With his teams intact he will dispute the mastery of healthcare

The general, unable to control his irritation, will launch his men to the assault like swarming ants, with the result that one-third of his men are slain, while the town still remains untaken. Such are the disastrous effects of a siege.

Therefore the skillful leader subdues the enemy's troops without any fighting; he captures their cities without laying siege to them; he overthrows their kingdom without lengthy operations in the field.

With his forces intact he will dispute the mastery of the Empire, and thus, without losing a man, his triumph will be complete. This is the method of attacking by stratagem.

From "Sun Tzu on the Art of War - The Oldest Military Treatise in the World"

Translated from the Chinese By Lionel Giles, M.A. (1910)
 

Discussion:

Another favourite phrases, naturally go and need no explanations. It is no wonder, ancient Chinese said "The highest physician cures the nation."

Translation:

The physician, unable to figure out what to do, will request the whole body inspection with batteries of examinations, with the result that one-third of the tests are found irrelevant, while the cause of the symptoms still remains unknown. Such are the disastrous effects of an admission.

Therefore the skilful physician subdues the patient's anxiety without any prescription; he treats their symptoms without admitting them to the hospital; he overcomes their diseases without lengthy operations in the theatre.

With his teams intact he will dispute the mastery of healthcare, and thus, without dropping out a patient, his job will be complete. This is the method of attaining by stratagem.

Ray Murakami

The highest form of medicine is to break the disease's pathogens

Sun Tzu said: In the practical art of war, the best thing of all is to take the enemy's country whole and intact; to shatter and destroy it is not so good. So, too, it is better to recapture an army entire than to destroy it, to capture a regiment, a detachment or a company entire than to destroy them.

Hence to fight and conquer in all your battles is not supreme excellence; supreme excellence consists in breaking the enemy's resistance without fighting.

Thus the highest form of generalship is to balk the enemy's plans; the next best is to prevent the junction of the enemy's forces; the next in order is to attack the enemy's army in the field; and the worst policy of all is to besiege walled cities.

From "Sun Tzu on the Art of War - The Oldest Military Treatise in the World"

Translated from the Chinese By Lionel Giles, M.A. (1910)
 

Discussion:

It goes naturally and needs few explanations. It matches the current emphasis on preventative medicine, community and outpatient care and non-invasive treatments. However, to call an operation "the worst policy of all" would be too harsh, so I changed it to "the least favourable policy of all" and referred to the most risky type of operation.

Translation:

It is generally recognised: In practice of healthcare, the best thing of all is to make full recovery with the whole body parts intact; to dissect and destroy the affected part is not so good. So, too, it is better to recover an organ entire than to remove it, to recover a tumour, a tissue or a cell entire than to destroy them.

Hence to perform and succeed in all your operations is not supreme excellence; supreme excellence consists in healing the disease's symptoms without operating.

Thus the highest form of medicine is to break the disease's pathogens; the next best is to prevent the junction of the disease's factors; the next in order is to treat the disease's symptoms in the outpatient setting; and the least favourable policy of all is to perform an operation under general anaesthesia.

Ray Murakami

Wise medical director makes a point of eliminating preventable medical errors

Hence a wise general makes a point of foraging on the enemy. One cartload of the enemy's provisions is equivalent to twenty of one's own, and likewise a single picul of his provender is equivalent to twenty from one's own store.

Now in order to kill the enemy, our men must be roused to anger; that there may be advantage from defeating the enemy, they must have their rewards.

Therefore in chariot fighting, when ten or more chariots have been taken, those should be rewarded who took the first. Our own flags should be substituted for those of the enemy, and the chariots mingled and used in conjunction with ours. The captured soldiers should be kindly treated and kept. This is called, using the conquered foe to augment one's own strength.

In war, then, let your great object be victory, not lengthy campaigns. Thus it may be known that the leader of armies is the arbiter of the people's fate, the man on whom it depends whether the nation shall be in peace or in peril.

From "Sun Tzu on the Art of War - The Oldest Military Treatise in the World"

Translated from the Chinese By Lionel Giles, M.A. (1910)
 

Discussion:

It was not easy to translate this last part of the second chapter, but they made senses when they were translated in the contexts of: preventing medical errors; preventive health intervension; improving emergency department throughput utilising inpatient facilities; and health reform by performance innovation. For the impact of preventable medical errors, the reference was the famous "To Err is Human: Building a Safer Health System" by the US Institute of Medicine.

 

Translation:

Hence a wise medical director makes a point of eliminating preventable medical errors. The deaths from preventable medical errors may reach tens of thousands cases and the total cost incurred may reach tens of billions dollars.

Now in order to fill the bed, our staff must be assigned to a patient; that there may be advantage from freeing beds, they must have their rewards.

Therefore in emergency treatment, when ten or more beds are taken from high dependency units  those should be awarded who took the first. ER patients should be transferred to beds from the units and new patients should be admitted. The captured beds should be carefully treated and kept. This is called, using inpatient facilities to enlarge emergency room capacity.

In health reform, let your great object be performance innovation, not lengthy campaigns. Thus it may be known that the leader of hospitals is the director of the people's welfare, the person on whom it depends whether the nation's health system shall be in peace or in peril.

Ray Murakami

Accessibility to high quality care causes health premiums to go up

On the other hand, the proximity of an army causes prices to go up; and high prices cause the people's substance to be drained away. When their substance is drained away, the peasantry will be afflicted by heavy exactions. With this loss of substance and exhaustion of strength, the homes of the people will be stripped bare, and three-tenths of their income will be dissipated; while government expenses for broken chariots, worn-out horses, breast-plates and helmets, bows and arrows, spears and shields, protective mantles, draught-oxen and heavy wagons, will amount to four-tenths of its total revenue.

From "Sun Tzu on the Art of War - The Oldest Military Treatise in the World"

Translated from the Chinese By Lionel Giles, M.A. (1910)

Discussion:

What is the equivalent for the proximity of an army in the health context is another difficult question. It should be something can be paired with the inefficiency in hospital care as another significant financial challenge in health management. Technical and financial advancements are improving accessibility to high quality care, but they are also pushing up national expenses on healthcare. So it is selected as another major challenge in health delivery comparable to the proximity of an army.

Translation:

On the other hand, the accessibility to high quality care causes health premiums to go up; and high premium causes the people's substance to be drained away. When their substance is drained away, the commerce will be afflicted by decreased demands.With this loss of substance and exhaustion of demand, the homes of the people will be stripped bare, and three-tenth of their income will be dissipated; while government expenses for healthcare, pension, welfare, nursing care and unemployment and disability benefits will amount to four-tenth of its total revenue.

Ray Murakami

The skilful surgeon does not operate a patient for the second time

The skillful soldier does not raise a second levy, neither are his supply-wagons loaded more than twice. Bring war material with you from home, but forage on the enemy. Thus the army will have food enough for its needs. Poverty of the State exchequer causes an army to be maintained by contributions from a distance. Contributing to maintain an army at a distance causes the people to be impoverished.

From "Sun Tzu on the Art of War - The Oldest Military Treatise in the World"

Translated from the Chinese By Lionel Giles, M.A. (1910)

Discussion:

The concept of "foraging on the enemy" requires careful consideration in translation. As the philosophy of Sun Tzu was acquiring the whole capacity of the enemy to enlarge your own advantage rather than destroying it, "foraging on the enemy" would never mean an outright plunder which would eventually cause rebels against invaders and make the control over the territory difficult. The main point is that the shift of resources from being used up by the enemy to supporting the friendly army. Thus it can be translated to shifting the resource from used up by inefficient management of care to supporting innovations of healthcare delivery.

Translation:

The skilful surgeon does not operate a patient for the second time, neither are his supply-wagons for an operation loaded more than twice. Fund operational expenses from capitation, but fund extras on innovations in efficiency and effectiveness. Thus the hospital will have capacity enough for increasing health needs. Poverty of the State exchequer causes a hospital to be maintained by contributions from the general public not directly benefiting from healthcare. Contributing to maintain an hospital not servicing them directly causes the people to be impoverished.

Ray Murakami

Effectiveness has never been seen associated with long admissions

Thus, though we have heard of stupid haste in war, cleverness has never been seen associated with long delays. There is no instance of a country having benefited from prolonged warfare. It is only one who is thoroughly acquainted with the evils of war that can thoroughly understand the profitable way of carrying it on.

From "Sun Tzu on the Art of War - The Oldest Military Treatise in the World"

Translated from the Chinese By Lionel Giles, M.A. (1910)

Discussion:

Administrative targets such as "Shorter stays in the emergency department" are often criticised that they does not necessarily reflect the true efficiency of healthcare provided there and sometimes encourage superficial achievement by sacrificing quality, safety or satisfaction of patients. However, it is so true that there is no instance of a country having benefited from prolonged warfare even against diseases.

Translation:

Thus, though we have heard of initiatives for shortened stays in hospitals, effectiveness has never been seen associated with long admissions. There is no instance of a health system having benefited from prolonged hospital stays. It is only one who is thoroughly acquainted with the adverse effects of hospitalisation that can thoroughly understand the profitable way of carrying it on.

Ray Murakami

In actual treatment, if discharge is long in coming

When you engage in actual fighting, if victory is long in coming, then men's weapons will grow dull and their ardor will be damped. If you lay siege to a town, you will exhaust your strength. Again, if the campaign is protracted, the resources of the State will not be equal to the strain. Now, when your weapons are dulled, your ardor damped, your strength exhausted and your treasure spent, other chieftains will spring up to take advantage of your extremity. Then no man, however wise, will be able to avert the consequences that must ensue.

From "Sun Tzu on the Art of War - The Oldest Military Treatise in the World"

Translated from the Chinese By Lionel Giles, M.A. (1910)

Discussion:

There is no need to discuss much about the implications of prolonged hospital stays as well as protracted military campaigns.

Translation:

When you engage in actual treatment, if discharge is long in coming, then staff's focuses will grow dull and their ardour will be damped. If you run over capacity of a hospital, you will exhaust your strength. Again, if the admission is protracted, the resources of the teams will not be equal to the strain. Now, when your focuses are dulled, your ardour damped, your strength exhausted and your expenditure spent, adverse events and complications will spring up to take advantage of your extremity. Then no practitioners, however wise, will be able to avert the consequences that must ensue.

Ray Murakami

The cost of providing healthcare services for 100,000 people

Sun Tzu said: In the operations of war, where there are in the field a thousand swift chariots, as many heavy chariots, and a hundred thousand mail-clad soldiers, with provisions enough to carry them a thousand li, the expenditure at home and at the front, including entertainment of guests, small items such as glue and paint, and sums spent on chariots and armor, will reach the total of a thousand ounces of silver per day. Such is the cost of raising an army of 100,000 men.

From "Sun Tzu on the Art of War - The Oldest Military Treatise in the World"

Translated from the Chinese By Lionel Giles, M.A. (1910)

Discussion:

I referred to the statistics of the healthcare expenditures par capita of the OECD countries to have realistic order of the magnitude for expenditure per day for the healthcare of 100,000 population. I was amazed by how easily the description for the army of 100,000 men can be translated into the one for healthcare for 100,000 population.

Translation:

From the statistics: In the operation of healthcare, where there are in the hospital a thousand outpatient visits, as many acute inpatient beds, and a hundred thousand catchment population, with provision enough to provide full 24 hours a day, 7 days a week and 365 days a year services, the expenditure at back offices and at the front, including hospitality for the guests, small items such as pens and paper, and sum spent on scrubs and linens, will reach the total of hundreds of thousands dollars per day. Such is the cost of providing healthcare services for 100,000 people.

Ray Murakami