Category Archives: analysis

I got one right

Throughout my blog, I have argued time and again that the development and practice of cognitive ability is one of the key enablers or detractors of personal and organizational performance.   I have encouraged my readers to focus on improving their cognitive skills as a means of empowering improved decision making capabilities.

When I was in undergraduate business school years ago, we were required to subscribe to and read the Wall Street Journal on a daily basis. That assignment started a discipline that has endured through my career.  One of the reasons that I read the Wall Street Journal daily is that its healthcare industry coverage is as good as any.  In addition, The Wall Street Journal is intellectually stimulating on many levels.  For example, one of the things that has been shown to improve cognitive ability is vocabulary study.  Rarely a day goes by that I do not see at least one word in the journal that I cannot define.  I look these words up and record their definition.  When I find myself with nothing to do, I get my list out.  More often than not, these words are found on the Journal’s editorial pages that are written by some of the smartest people alive.

My article on career development has been very popular.  I am honored and humbled by the number of people following my work that are genuinely interested in developing their careers and advancing in organizations.  The comments, feedback and suggestions this article stimulated have been inspiring to me and motivate me to find suggestions and recommendations that will be helpful to my readers.

Many of us know and are motivated by the stimulation that comes from affirmation.  In my article on career advancement, I argue for the development of cognitive ability as a means of building a foundation from which you may advance your career.  One of the things that fascinates me about universities and the people that work there is that regardless of the subject, how arcane or trivial it may seem to be, there is a professor at some university somewhere that is an expert on the subject.  We are so blessed and our society and life is so enriched to have these geniuses among us.

An article that appeared in the Wall Street Journal on June 5, 2017 is a very good example of what I’m talking about. This article confirms my theory that the development of cognitive ability is a critical success factor when it comes to roles and responsibilities requiring the incumbent to be able to do their own thinking.  I had no idea that for many years this very characteristic has been under study.  Not only that, there is a ranking of the degree to which various university programs are or are not successful in developing cognitive skills among their students.  It is very sad and some may argue disingenuous that these data are not readily available to people considering one academic program over another.

The  article title is:  Exclusive Test Data: Many Colleges Fail to Improve Critical-Thinking Skills

So I’m vindicated.  The admonition of this is that all of us can benefit from  focus on continuous cognitive ability improvement.  So what are you waiting for?  How much more evidence do you need to be convinced that among the highest and best uses of your time is investment in yourself?

Please feel free to contact me to discuss any questions or observations you might have about these blogs or interim executive services in general.  As the only practicing Interim Executive that has done a dissertation on Interim Executive Services in healthcare in the US, I might have an idea or two that might be valuable to you.  I can also help with career transitions or career planning.

The easiest way to keep abreast of this blog is to become a follower.  You will be notified of all updates as they occur.  To become a follower, just click the “Following” link that usually appears as a bubble near the bottom this web page.

There is a comment section at the bottom of each blog page.  Please provide input and feedback that will help me to improve the quality of this work.

This is original work.  This material is copyrighted by me with reproduction prohibited without prior permission.  I note and  provide links to supporting documentation for non-original material.

If you would like to discuss any of this content or ask questions, I may be reached at ras2@me.com. I look forward to engaging in productive discussion with anyone that is a practicing interim executive or a decision maker with experience engaging interim executives in healthcare.

Best of luck – Ray Snead

More sadistics

In my last blog post, I made a grievous, amateur error.  I will be lucky if UAB does not repossess my degree.  I made the most common mistake know in the world of statistics.  I said, “and does the thing I think is causing what I am seeing really have anything to do with it?”

If you ever learn anything about statistics, it must be that no amount of statistical analysis can prove a cause and effect relationship between anything.  All you can prove with statistics is that things are ASSOCIATED with each other.  The best example of this I can think of is the debate around smoking and disease.  As far as I know, no one has proved a direct link or causal effect between smoking and disease.  No scientist can explain why some smokers get disease and others do not.  No one can explain why one smoker gets cancer while another gets heart disease.  No one knows exactly what about tobacco is unhealthy.  No one can explain how George Burns lived to be 100 years old smoking a cigar every day.  Of course smoke has bad chemicals in it but so does the air we breathe and almost everything we consume, especially since the government approved drugging livestock and feeding them (and us) genetically altered food.  We do know with a very high degree of certainty that there is a strong ASSOCIATION between smoking and disease.  We just cannot explain the causal factor(s).  If we could, we would do something about it.  I never did believe the attacks on the tobacco industry were justified because no one can prove cause.  The attacks are about money and not much else.  The tort liability vested upon tobacco manufactures served only to raise the price of the product while creating a windfall for States that as far as I know have not spent much if anything of the appropriated funds they received on smoking prevention.  If the government is really serious about smoking, it would not give Medicaid cards out to smokers.  For that matter, it would use EBT to incentivize people to engage in more healthy lifestyles in order to reduce Medicaid expenditures down the road but that is the topic for another blog.

If you are now boiling mad at me for making these assertions, I have you where I want you to make a point about statistics that you might remember.  To cite just one example, there is similar controversy about diet drinks.  There have been a number of studies that show that diet drinks may be as bad or worse for your health than cigarettes.  “Researchers from the University of Texas found that over the course of about a decade, diet soda drinkers had a 70% greater increase in waist circumference compared with non-drinkers. (1)”.  “Drinking one diet soda a day was associated with a 36% increased risk of metabolic syndrome and diabetes in a University of Minnesota study.  Metabolic syndrome describes a cluster of conditions (including high blood pressure, elevated glucose levels, raised cholesterol, and large waist circumference) that put people at high risk for heart disease, stroke, and diabetes (2).  “Using diet soda as a low-calorie cocktail mixer has the dangerous effect of getting you drunk faster than sugar-sweetened beverages, according to research from Northern Kentucky University.  The study revealed that participants who consumed cocktails mixed with diet drinks had a higher breath alcohol concentration than those who drank alcohol blended with sugared beverages.  The researchers believe this is because our bloodstream is able to absorb artificial sweetener more quickly than sugar (3).  “Just one diet soft drink a day could boost your risk of having a vascular event such as stroke, heart attack, or vascular death, according to researchers from the University of Miami and Columbia University.  Their study found that diet soda devotees were 43% more likely to have experienced a vascular event than those who drank none. Regular soda drinkers did not appear to have an increased risk of vascular events.(4)”  All of these citations were from just one article.  If you do not believe me, do your own internet search.  This makes me wonder why the government and the tort lawyers are not after the soft drink industry if its products CAUSE all of these maladies?

Now I am going to bring back nightmares from your college statistics course by reminding you about something you forgot long ago.  Remember regression?  For those of you that have not been initiated, regression is a procedure utilized to determine the degree of ASSOCIATION between things.  In a simple regression, you are looking at two things (an independent and a dependent variable).  In a multiple regression, you are looking at multiple things (one dependent and multiple independent variables).  I know some of you are thinking that the only kind of regression you understand is what happens when people are appointed to C-Suite roles in healthcare organizations but bear with me for a minute.  Among the various statistics produced as a result of a regression analysis is the effect size measurement of R Squared.  The R Squared statistic is alternatively described as the coefficient of determination or correlation coefficient.  Start dropping these terms at a cocktail party and watch how fast people start treating you like you have the plague.  What this statistic describes is the degree of association among the variables.  Its values range from 0 to 1 or 0% to 100%.  If there is no association between the variables, the correlation coefficient will be low.  If there is a perfect ‘fit’ (in other words when one variable zigs, the other zigs by the same magnitude. They also zag together) between the variables, the correlation coefficient will be 100%

People that fall into the trap of believing that statistics prove cause and effect would draw the incorrect conclusions from the following examples of extremely high statistical associations.  These associations are described as spurious correlations where the statistics say that things that cannot be related are associated with each other.  Uninformed analysts or liars would infer or imply that there is a causal effect.  What do you think about these examples?

US spending on space, science and technology correlates with suicides by hanging.  The correlation coefficient is 99.79%  Maybe people are actually killing themselves when they come to the full realization about how much money the government is blowing.

Per capita cheese consumption is very strongly associated with the number of deaths occurring when people became entangled in their bed sheets.  R Squared = 94.71%

There is an association between the per-capita consumption of margarine and the divorce rate in Maine.  The coefficient of determination is 99.26%.  Some would conclude that in order to eliminate divorce in Maine, all we have to do is outlaw the consumption of margarine.

Drownings resulting from falling out of a fishing boat can be explained by the marriage rate in Kentucky (R Squared = 95.2%)  In other words, in order to eliminate drownings in fishing accidents, we need to outlaw marriage in Kentucky.  I guess the Supreme Court recently took care of that.  I would recommend that fishermen start wearing life vests.

There are a number of examples of spurious correlations on the internet.  The point of these examples is to sensitize you to the fact that statistics do not and can not PROVE cause and effect.  Sometimes associations found in statistical analyses are spurious.  This is why you are paid the big bucks – to understand what you are looking for, to not fall into this trap and to apply cognitive analysis to anything you see to prevent you from drawing the wrong conclusion(s).

As I have said before, as leaders we are not paid for what we do.  We are paid for what we know and more than anything, we are paid for our decision making capability.  My point in writing this is to argue for the use of more analysis and evidence in executive decision making in healthcare administration.  They even have a Doctorate of Science Program at The University of Alabama at Birmingham that focuses on this very concept.

Please feel free to contact me to discuss any questions or observations you might have about these blogs or interim executive services in general.  As the only practicing Interim Executive that has done a dissertation on Interim Executive Services in healthcare in the US, I might have an idea or two that might be valuable to you.  I can also help with career transitions or career planning.
The easiest way to keep abreast of this blog is to become a follower.  You will be notified of all updates as they occur.  To become a follower, just click the “Following” link in the menu bar at the top of this web page.
This is original work.  This material is copyrighted by me with reproduction prohibited without prior permission.  I note and  provide links to supporting documentation for non-original material.

If you would like to discuss any of this content or ask questions, I may be reached at ras2@me.com. I look forward to engaging in productive discussion with anyone that is a practicing interim executive or a decision maker with experience engaging interim executives in healthcare.

Are you into ‘sadistics’?

Statistics – the one discipline that almost anyone that has ever been forced through does everything in their power to forget anything they learned as soon as they can.  I used to be a member of this crowd.  In fact, the first statistics course I encountered in undergraduate school nearly ended my college career.  The D I received in that course remains my proudest academic achievement.  For a number of years, I thought my sadistical torture was over and behind me.  Then I enrolled in a post graduate program at The University of Alabama at Birmingham and much to my chagrin, in order to finish a doctorate program I was going to have to complete five more statistics courses including an Applied Multivariate Statistics for Health Administration course.  The icing on the cake was the requirement that my dissertation be based on statistically valid research.  By the time I completed my doctorate degree, I fully understood the meaning of evidence-based leadership in healthcare administration.

What I have learned about ‘sadistics’ is that it is not nearly as complicated and intimidating as most people think.  In fact, to prove my degree of neurocognitive disorder, I will admit that I now study quantitative methods for fun.  They got to me at UAB.  As I learn better the application of the discipline, I cannot get enough knowledge or understanding of it.  For example, I am currently trying to get my head around Chua’s incredible article on Normative Decision Theory and its application to healthcare administration and strategy development.  Pretty good stuff for those of you that are interested in making yourselves better at what you do.

For the most part, statisticians are interested in understanding if this thing is different from that thing or if there is some kind of relationship between two or more things.  Some of them even try to make sense of the magnitude and frequency of the vibration (variance) of things.  They waste time trying to figure out what the probability might be that they are drawing the correct conclusion from what they are seeing.  Why anyone in healthcare administration would care about such a trivial concept escapes me.  One of the things that statisticians are obsessed with that does have profound application in healthcare administration is what they call ‘effect’ or more precisely, isolation of effect.  In other words, what the hell is happening and does the thing I think is causing what I am seeing really have anything to do with it?

As healthcare administrators, we spend a lot of (too much) time looking at data.  What we really need is information.  What in the data is relevant?  Is the change we are seeing in the data significant or is the change within the realm of expected normal variation?  Two of the worst mistakes we can make as leaders are to fail to react to data that is telling us something is not right or reacting to something when there is no legitimate reason for concern.  For those of you sensing statistical ghosts, I am talking about type I and type II (alpha and beta) errors.

The CMS is increasing its focus on payment for outcome instead of payment for throughput.  In this process, the risk associated with outcomes that vary (variance) from the expected outcome that will be the basis of reimbursement and that risk will be borne solely by the provider.

Those of you that follow my blog regularly know that I frequently digress and I am feeling the need to digress right now.  Sometimes, my digressions devolve to rants and I am feeling one coming on.  I have heard about all I care to hear about population health management and integrated delivery systems.  The largest part the cost of an episode of illness in most cases is the hospitalization.  Leadership teams are distracted into grandiose fantasies of managing the health of large populations.  The hypocrisy of this is that the same leadership teams cannot find the courage, will  or means to manage the population under their direct control.  If there were ever a group of people that know how to utilize healthcare benefits, it is healthcare workers.  Healthcare groups routinely utilize healthcare benefits at higher rates than their non-healthcare counter-parts.  What I do not understand is why provider organization leaders I have worked with in multiple organizations go to meetings to obsess over medical homes and population health management while they fail or refuse to do anything about the inappropriate utilization that is occurring right under their noses.  One leader I worked with was talking about medical homes before most people had any idea what a medical home was.  In spite of the fact that the organization had all of the resources necessary to develop and implement medical homes for their employees, they did nothing to demonstrate what a medical home was or what it might accomplish while the leaders were running up and down the road selling the idea to other organizations.  The message I was hearing was, “We are not doing anything about our medical costs and utilization but trust us, we will help you manage yours.”  Why would anyone expect to be believed while doing this?  I postulate that if you are the low cost, high quality provider, organizations needing the services you provide will be blazing a path to your door.  If you are not a low cost, high quality provider, either your organization will be left behind, it will become a part of a larger organization with utilization management capabilities or someone else will be running it.  I do not believe that the responsibility to achieve better outcomes and cost can be outsourced.

One of the fascinating aspects of healthcare cost is that a disproportionate amount of cost is concentrated in a relatively small number of resource intensive or catastrophic cases.  It is not unusual to see over half of the entire cost of a health plan was driven by less than five percent of the covered lives.  There is a lot in the press about the very high percentage of Medicare expenditures during the final two weeks of life.  The CMS is currently proposing to establish reimbursement for physicians to manage palliative care.  The point of this is that you do not have to manage the health of a population.  You have to case manage the cost that is being driven by a very small part of the population.  The question is who are the people?  What are their problems? Are resources being allocated efficiently for the best benefit of the patients?  In order to manage a population, we have to identify those at risk of becoming large claims and help them manage their conditions including medical costs incurred outside the hospital.  The other 95% will take care of themselves.

A good friend and classmate of mine was recently appointed CEO of a metropolitan safety net hospital.  Joe’s dissertation topic was on population health management so I suspicion he might know something about the topic.  If there were ever a population needing help managing their health, it is the people that utilize safety net hospitals.  What do you think one of the first things Joe did after arriving at the hospital?  He hired a Ph. D. statistician to head up his clinical quality department.  This is the difference between Joe and me.  Because of my background, experience and training, I tend to focus on helping the hospital reduce its cost by operating more efficiently.  Joe’s approach is to manage cost by stopping inefficient and inappropriate utilization of hospital services.  If we ever get a chance to work together, we are going to set some organization on fire.  We won’t make the cover of Rolling Stones but we might make the cover of Modern Healthcare.

Why would Joe do such a thing anyway?  Do you think it might be to have someone in his charge that could make sense of the mountain of data every hospital accumulates and give him some information that he can respond in ways that might improve patient outcomes and hospital costs?  I wonder if it might have anything to do with isolation of effects that are driving costs and outcome and focusing very limited resources in areas that might make a difference?  Do you think the application of quantitative methods might have some potential benefit to help prioritize initiatives that would make a material difference quickly?  Do you wonder how long it will be before Joe knows which of his physicians’ practice is too expensive for the hospital to afford?  Too often, leadership teams get drawn off their focus by trivial distractions that have little if any potential to make a lasting difference in the organization while issues that are costing thousands of dollars per day are ignored.  If you really want to get fancy, you can start thinking about variance and the analysis of variance or ANOVA as a means to understand the significance of the effect that is being observed.

A leadership team has a limited ability to focus because of a phenomenon that I describe as bandwidth constraint or not enough of us to go around.  The more items the leadership team takes up, its ability to provide concentrated focus on any particular item is degraded.  I have been frustrated by my failed efforts to get leadership teams to agree on what is important and resolve themselves to focus on a few high priority items that everyone agrees will make a significant difference if implemented while ignoring distractions.  A year later, the performance of the organization has failed to improve and most of the strategic initiatives remain incomplete and no one can remember what most of the time was spent on during the year.  Anyone that has ever hunted birds knows what usually happens when a rabbit runs between the dogs and the birds.  Where do you think this term ‘chasing rabbits’ came from anyway?

The world is changing quickly.  Our ability as leaders to make sense of what is happening around us and to discern how to respond effectively will define our potential for success.  One of the tools that can dramatically enhance this ability is to replace old skill sets that have little future potential with the skill sets necessary for survival in a different world.  Among these is quantitative methods.  The best part of this is that you do not have to know statistics but you need experts who do know statistics and who know how to mine ‘big data.’  If you are an occupant of most of the C-suite roles, you have become a generalist. We do not need the high technical knowledge required of many of those that report to us.  But you do have to have the correct resources in the organization if you plan to survive.

Throughout this article, I have interchanged the proper use of the word ‘statistics’ with a form that resonates with anyone that has ever been tortured by study of the subject; ‘sadistics’, a term coined by another classmate, Dr. Jim Burkhart that is currently the CEO of another large, municipal safety net hospital.

Please feel free to contact me to discuss any questions or observations you might have about these blogs or interim executive services in general.  As the only practicing Interim Executive that has done a dissertation on Interim Executive Services in healthcare in the US, I might have an idea or two that might be valuable to you.  I can also help with career transitions or career planning.
The easiest way to keep abreast of this blog is to become a follower.  You will be notified of all updates as they occur.  To become a follower, just click the “Following” link in the menu bar at the top of this web page.
This is original work.  This material is copyrighted by me with reproduction prohibited without prior permission.  I note and  provide links to supporting documentation for non-original material.