Spoken word does not carry far enough: hence the institution of prompts and checklists

The Book of Army Management says: On the field of battle, the spoken word does not carry far enough: hence the institution of gongs and drums. Nor can ordinary objects be seen clearly enough: hence the institution of banners and flags.

Gongs and drums, banners and flags, are means whereby the ears and eyes of the host may be focused on one particular point.

The host thus forming a single united body, is it impossible either for the brave to advance alone, or for the cowardly to retreat alone. This is the art of handling large masses of men.

In night-fighting, then, make much use of signal-fires and drums, and in fighting by day, of flags and banners, as a means of influencing the ears and eyes of your army.

A whole army may be robbed of its spirit; a commander-in-chief may be robbed of his presence of mind.

Now a soldier's spirit is keenest in the morning; by noonday it has begun to flag; and in the evening, his mind is bent only on returning to camp.

A clever general, therefore, avoids an army when its spirit is keen, but attacks it when it is sluggish and inclined to return. This is the art of studying moods.

Disciplined and calm, to await the appearance of disorder and hubbub amongst the enemy:--this is the art of retaining self-possession.

To be near the goal while the enemy is still far from it, to wait at ease while the enemy is toiling and struggling, to be well-fed while the enemy is famished:--this is the art of husbanding one's strength.

To refrain from intercepting an enemy whose banners are in perfect order, to refrain from attacking an army drawn up in calm and confident array:--this is the art of studying circumstances.

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:

This part was translated referring Improving patient safety in the operating theatre – teamwork and communication from The Health Quality & Safety Commission New Zealand and WHO surgical safety checklist and implementation manual. Creativity was required in translating the word "enemy" as in operation theatre there are no apparent enemies.

Translation:

The Book of Health Management says: On the theatre of operation, the spoken word does not carry far enough: hence the institution of prompts and checklists. Nor can ordinary objects be seen clearly enough: hence the institution of visual aids and markers.

Prompts and checklists, visual aids and markers, are means whereby the ears and eyes of the team may be focused on one particular point at a time.

The team thus forming a single united body, is it impossible either for the brave to advance alone, or for the cowardly to retreat alone. This is the art of handling a multi-professional team.

Before the induction of anaesthesia, make use of “sign in” checklist, before the incision of the skin, of “time out” checklist and before the patient leaves the operating room, of “sign out” checklist as a means of confirming completion of tasks by the ears and eyes of your surgery team.

A whole team may be affected in its spirit; a chief surgeon may be affected in his presence of mind.

Now a team's spirit is keenest in "sign in"; by "time out" it has begun to flag; and in "sign out", its mind is bent only on returning to station.

A clever surgeon, therefore, avoids a team's too eagerness when its spirit is keen, but cautions it when it is sluggish and inclined to return. This is the art of studying moods.

Disciplined and calm, to await the appearance of disorder and focus amongst the site:--this is the art of retaining self-possession.

To be near the area while the operating time is still far from the limit, to wait at ease while the aid is toiling and struggling, to be well-oxygenated while the bleeding is controlled:--this is the art of husbanding one's strength.

To refrain from intercepting a team member whose points are in perfect order, to refrain from attacking an objection drawn up in calm and confident way:--this is the art of studying circumstances.

Ray Murakami

In incision and surgical removal be like fire, in watchful waiting like a mountain

In war, practice dissimulation, and you will succeed.

Whether to concentrate or to divide your troops, must be decided by circumstances.

Let your rapidity be that of the wind, your compactness that of the forest.

In raiding and plundering be like fire, in immovability like a mountain.

Let your plans be dark and impenetrable as night, and when you move, fall like a thunderbolt.

When you plunder a countryside, let the spoil be divided amongst your men; when you capture new territory, cut it up into allotments for the benefit of the soldiery.

Ponder and deliberate before you make a move.

He will conquer who has learnt the artifice of deviation. Such is the art of maneuvering.

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:

In pathway management, there is no plundering countryside or capturing new territory. So they are translated into achieving a positive outcome and receiving new resources respectively.

Translation:

In healthcare, practice personalisation, and you will succeed.

Whether to concentrate or to divide your regimens, must be decided by circumstances.

Let your swiftness be that of the wind, your calmness that of the forest.

In incision and surgical removal be like fire, in watchful waiting like a mountain.

Let your plans be deep and encompassing as darkness, and when you move, proceed like a lightning bolt.

When you achieve a positive outcome, let the praise be distributed amongst your team; when you receive new resources, cut it up into allotments for the benefit of the soldiery.

Ponder and deliberate before you make a move.

He will conquer who has learnt the articulation of variances. Such is the art of pathways.

Ray Murakami

Cannot enter into alliances until acquainted with neighbour facilities

We cannot enter into alliances until we are acquainted with the designs of our neighbors.

We are not fit to lead an army on the march unless we are familiar with the face of the country--its mountains and forests, its pitfalls and precipices, its marshes and swamps.

We shall be unable to turn natural advantage to account unless we make use of local guides.

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:

In the shared care contexts, administrating care plans and pathways requires not only internal knowledge and understanding of resources and issues within the hospital, but also external alliances and liaison with neighbouring facilities and local practitioners.

Translation:

We cannot enter into alliances until we are acquainted with the designs of our neighbour facilities.

We are not fit to lead an army of orders unless we are familiar with the faces of the hospital--its departments and wards, its problems and issues, its risks and hazards.

We shall be unable to turn community advantage to account unless we make use of local general practitioners.

Ray Murakami

Managing a clinical pathway with an undisciplined multitude is most dangerous

Maneuvering with an army is advantageous; with an undisciplined multitude, most dangerous.

If you set a fully equipped army in march in order to snatch an advantage, the chances are that you will be too late. On the other hand, to detach a flying column for the purpose involves the sacrifice of its baggage and stores.

Thus, if you order your men to roll up their buff-coats, and make forced marches without halting day or night, covering double the usual distance at a stretch, doing a hundred LI in order to wrest an advantage, the leaders of all your three divisions will fall into the hands of the enemy.

The stronger men will be in front, the jaded ones will fall behind, and on this plan only one-tenth of your army will reach its destination.

If you march fifty LI in order to outmaneuver the enemy, you will lose the leader of your first division, and only half your force will reach the goal.

If you march thirty LI with the same object, two-thirds of your army will arrive.

We may take it then that an army without its baggage-train is lost; without provisions it is lost; without bases of supply it is lost.

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:

A physician does not have full authority to hospital staff but has it for the orders made by the physician. So the army of soldiers are translated into the army of orders.

Translation:

Managing a clinical pathway with an army of observations and interventions is advantageous; with an undisciplined multitude, most dangerous.

If you set a fully specified army of orders in every detail in order to snatch an advantage, the chances are that you will be too late. On the other hand, to detach an ongoing column of an active pathway for the purpose involves the sacrifice of its already dispensed solution bags and supplies.

Thus, if you order your observations and interventions to roll over their cutoffs, and make forced STATs without halting day or night, covering double the usual stint at a stretch, doing a hundred rounds in order to wrest an advantage, the leaders of all your three divisions will fall into the hands of the illness.

The stronger staffs will be in front, the jaded ones will fall behind, and on this care plan only one-tenth of your army of orders will reach their outcomes.

If you march fifty rounds in order to outperform the clinical indicators, you will lose the leader of your first division, and only half your staff will reach the goal.

If you march thirty rounds with the same object, two-thirds of your army of orders will be achieved.

We may take it then that an army of orders without sufficient nursing carts is lost; without provisions it is lost; without bases of supply it is lost.

Ray Murakami

In treatment, the physician receives his authority from the patient

Sun Tzu said: In war, the general receives his commands from the sovereign.

Having collected an army and concentrated his forces, he must blend and harmonize the different elements thereof before pitching his camp.

After that, comes tactical maneuvering, than which there is nothing more difficult. The difficulty of tactical maneuvering consists in turning the devious into the direct, and misfortune into gain.

Thus, to take a long and circuitous route, after enticing the enemy out of the way, and though starting after him, to contrive to reach the goal before him, shows knowledge of the artifice of DEVIATION.

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:

After some considerations this chapter's title manoeuvre was translated into (clinical) pathway.

Translation:

In treatment, the physician receives his authority from the patient.

Having collected staff and examined shifts, he must blend and harmonise the different elements thereof before pitching his team.

After that, comes clinical pathway, than which there is nothing more difficult. The difficulty of clinical pathway consists in turning the devious into the direct, and outlier into gain.

Thus, to take a long and circuitous route, after enticing the infection out of the way, and though starting after predisposed conditions, to contrive to reach the goal before onset of those conditions, shows knowledge of the artifice of VARIANCE ANALYSIS.

Ray Murakami

Just as water retains no constant shape, so in healthcare, no constant conditions

Military tactics are like unto water; for water in its natural course runs away from high places and hastens downwards.

So in war, the way is to avoid what is strong and to strike at what is weak.

Water shapes its course according to the nature of the ground over which it flows; the soldier works out his victory in relation to the foe whom he is facing.

Therefore, just as water retains no constant shape, so in warfare there are no constant conditions.

He who can modify his tactics in relation to his opponent and thereby succeed in winning, may be called a heaven-born captain.

The five elements (water, fire, wood, metal, earth) are not always equally predominant; the four seasons make way for each other in turn. There are short days and long; the moon has its periods of waning and waxing.

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:

This part is rather straight forward translation. However, the last paragraph may well stay as it is but a trial was made to put it into the context of the whole system approach in the healthcare.

Translation:

Treatment designs are like unto water; for water in its natural course runs away from high places and hastens downwards.

So in treatment the way is to avoid what is contraindication and to look at what is indicating.

Water shapes its course according to the nature of the ground over which it flows; the practitioner works out the care plan tailored to the patient conditions which the team is facing.

Therefore, just as water retains no constant shape, so in healthcare there are no constant conditions.

Those who can modify their care plan in relation to patient's needs and thereby succeed in treatment, may be called an excellent healthcare performance.

The five elements (medicine, surgery, nursing, allied health, administration) have no fixated priorities; the acute and chronic make way for each other in turn. There are short stays and long; the health demand has its periods of waning and waxing.

Ray Murakami

Do not repeat the treatment which have gained you one good result

Though according to my estimate the soldiers of Yueh exceed our own in number, that shall advantage them nothing in the matter of victory. I say then that victory can be achieved.

Though the enemy be stronger in numbers, we may prevent him from fighting. Scheme so as to discover his plans and the likelihood of their success.

Rouse him, and learn the principle of his activity or inactivity. Force him to reveal himself, so as to find out his vulnerable spots.

Carefully compare the opposing army with your own, so that you may know where strength is superabundant and where it is deficient.

In making tactical dispositions, the highest pitch you can attain is to conceal them; conceal your dispositions, and you will be safe from the prying of the subtlest spies, from the machinations of the wisest brains.

How victory may be produced for them out of the enemy's own tactics--that is what the multitude cannot comprehend.

All men can see the tactics whereby I conquer, but what none can see is the strategy out of which victory is evolved.

Do not repeat the tactics which have gained you one victory, but let your methods be regulated by the infinite variety of circumstances.

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 protection of population against epidemics is often misunderstood by the general public. Each time an epidemic of an exotic and deadly disease in foreign country floods news media, people often are panicked as though the disease mentioned is just outside of their doorsteps. However, such a news  scrum rarely encourages people to immunise against known but potentially deadly diseases. Sun Tzu's tricks on how to deceive enemies, which interestingly correspond to tactics to battle against contagious pathogens, also remind us on difficulties of publicising population health policies including epidemic prevention.

Translation:

Though according to the expert's estimate the outbreaks of infection exceed our immunisation in number, that shall advantage them nothing in the matter of quarantine. I say then that quarantine can be achieved.

Though the pathogen be stronger in numbers, we may prevent it from spreading. Scheme so as to discover its patterns and the likelihood of their spread.

Cultivate it, and learn the principle of its activity or inactivity. Force it to reveal itself, so as to find out its vulnerable spots.

Carefully compare the emerging pathogen with the already known, so that you may know where strength is superabundant and where it is deficient.

In making tactical population protection, the highest pitch you can attain is to isolate them; isolate your population, and you will be safe from the prying of the subtlest contacts, from the infection of the most contagious strains.

How protection may be produced for people out of the disease's own pathogens--that is what the multitude cannot comprehend.

All people can see the treatment whereby the medicine conquer, but what none can see is the strategy out of which treatment is evolved.

Do not repeat the treatment which have gained you one good result, but let your methods be regulated by the infinite variety of circumstances.

Ray Murakami