MUSHIN: “absence of discursive thought and judgment, so the person is totally free to act and react towards an opponent without hesitation and without disturbance from such thoughts. At this point, a person relies not on what they think should be the next move, but what is their trained natural reaction, or what is felt intuitively. It is not a state of relaxed, near-sleepfulness, however. The mind could be said to be working at a very high speed, but with no intention, plan, or direction.”
http://en.wikipedia.org/wiki/Mushin
MUSHIN NO SHIN is a Zen expression meaning “mind without mind.” Also referred to as a state of “no-mindness” the idea is to allow ourselves to look and see without the constraints which our personal bias and experience filters and subconsciously interprets. It is a state of mind in which our environmental awareness is enhanced and our instinct to focus and allow innate and social pressure to define what we see is reduced.
The observations of Solomon Asch, Gregory Berns and others that we see what our peer group tells us to see is thus extended to what we see is limited by the collective “wisdom” of our conflict resolving nature, whether the challenge is derived from a group or ourselves.
As Japanese warriors and now martial artists prepare for battle, they seek to achieve a state of MUSHIN so that they are totally free to act towards their opponent not by what they think rather what they intuitively believe.
A reference to the state of mind acquired by Japanese soldiers during combat as an opening to a analysis of a document on clinical care might seem a bit zealous, but the comparison remains—like it or not, the clinical care model has changed, and as health care warriors and patient advocates, survival depends on how quickly we choose to pick up the sword. The difference is that the mind of the physician had better well be set with a clear intention, plan, and direction.
For our purposes then, let us have an open mind not framed by our current way of doing things, how they have been done before, or even a consequence of our comfort and bias. Consider the course set: tenets of our approach to clinical quality and high-value care are to place the patient at the axis, and embed the patient journey and experience into the operating model. Such becomes our common and shared vision and purpose, as we look to establish collective/coordinated actions in support of our goals.
Our method of leadership is to establish a learning culture, as opposed to one of judgment. We look to attack process (not people) and shift focus from the individual to process variation. We prioritize goal categories, guide and support the team, and provide them with tools and resources. We aspire to create an execution-driven, accountable culture, with the utmost patient care and outcomes as the goal.
Our arsenal contains two powerful motivators to engage clinical quality improvement:
- the desire to do what is best for our patients
- accurate, validated data
The latter is both robust and transparent, and will support our efforts to adopt Brent James’ words to “analyze data without impugning the motives or professional capability of our clinicians and broader care delivery team.”
LEAN principles support the belief that if we base relationships with clinicians on high-quality clinical outcomes, cost improvements will follow–thus supporting the value proposition. Our focus, then, is to create an infrastructure, along with tools to support capability and future enhancements (not necessarily capacity). We know that eliminating variations in the processes of care will improve clinical outcomes. Local experience supports the “Surviving Sepsis Campaign,” as laid out by the Society of Critical Care Medicine, as well as other broader experience. Those outcome measures range from mortality to complication rate and length of stay, and may all be significantly impacted by adoption of best practice protocols.
“Marcus Welby is dead and gone and not coming back.” Ronald Hempling, MD, 2013.
Let us not minimize the disruptive impact of the reality that we do not know our patients as well as we once did. The physician who engages a direct care relationship with his or her patients throughout the continuum of care (delivery room through nursing home) is no longer the norm. The result is increased handoffs and communication gaps, which we have failed to effectively address. The typical four-day average hospital length of stay further complicates the problem.
We are challenged to develop and implement a new model of care, built around the complex needs of our patients and a refreshed application of our tools. The electronic health record (EHR), while admittedly cumbersome, to a large extent has been victimized (not realizing its full capability) by our failure to adapt legacy workflows, approaches, as well as by bias and culture. No longer is everything that our physicians need to know contained in the pocket-sized Merck Manual or 5-Minute Clinical Consult, nor even the most recent version of Harrison’s Manual of Medicine. There is much more to know, many more tasks to complete, and checklists to satisfy, in support of core and value-based purchasing measures, lest we not forget adherence to best practice protocols, and many more tools to apply in support of care. The art of medicine needs both a fresh look and orientation, as we look to coordinate and integrate all of the aforementioned tools and processes. At the same time, we may leverage the training and expertise of our nursing and other staff members, and the EHR, as we advance a model of team based care in the
inpatient environment. To again adopt Brent James, “we will bring protocol to workflow–making it easy to do the right thing, at the right time, all of the time.” Note: best practice adoption is not a technology problem; hence, there will not be a technologic solution. Physician decision-support tools, provided by the EHR, underscore its potential value, as we welcome technology as a member of the new team, based model of care. Like everyone else, technology will be fully utilized to add value to the team. Its core responsibility is to provide robust electronic tracking tools and decision support, which reinforces stratification of the patient’s conditions, as well as the clinician’s adoption of the requisite best practice bundle in real time.
Remember that the swarm theory centers on a collective body of individuals acting independently with a shared, or common, purpose. It is a group mindset, organized by shared objectives, to create a meaningful pattern of achievement. Understanding the goal categories (aka “wildly important goals” or “lagging measures”) allows the collective/coordinated action to succeed, driven by local leaders who are adaptable, evolvable, resilient, and sensitive to current and local conditions. The sometimes “messy power of complexity” requires the unprejudiced growth and unguided learning achieved by the network approach with a shared, or common, purpose and goal-achieving actions.
Care redesign requires a fresh look and clear mind–MUSHIN. While the discipline of LEAN methods is required, unlike a typical A3-focused problem statement construct, integrative thinking will lead us to a new model, which will look quite different than our current state. We seek to embrace precepts espoused by Berwick, James, and Deming; our focus is on process, in order to support our realization of exceptional care, and “triple aim” precepts.