眼見為憑 👀：繼策略性焦點後，Biodesign 的下一步

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兩位希望做出創新變革的朋友，聯絡了同一名王醫師，甲向王醫師約了訪談，乙則詢問王醫師是否能在下次他進行開胸手術時在旁觀摩、並參與術後恢復過程。誰可能獲取更精闢的洞見呢？

To see is to believe.

兩位滿腔熱血、希望做出創新變革的朋友，都在試著找到改善開胸手術的新契機。他們聯絡了同一名王醫師，甲向王醫師約了訪談，乙則詢問王醫師是否能在下次他進行開胸手術時在旁觀摩、並參與術後恢復過程。甲和乙都從各自的訪談和拜訪中獲得了許多重要的發現，但實際參與開胸手術並眼見過程中效率低落的環節、風險與危機、手術當下和術後恢復時醫師和病人所經歷的壓力與痛苦的乙，將會更加掌握得以改善術中術後狀態的機會；僅僅聽或閱讀醫師描述手術的過程，很難完整地窺見真實的情境下所發生事件的特徵和脈絡。

Photo by Piron Guillaume on Unsplash

決定策略焦點之後，我們必須定義清楚「重要的臨床問題」是什麼，才有辦法繼續往解決方案邁進。我們可以善用觀察技巧，來找出醫療上流程、處置、事件所存在的問題，並以「需求」的角度來描述，而這正是 Biodesign 創新的基石。醫療體系中的需求族繁不及備載，關鍵在於哪些問題是真正重要的呢？有些問題在真實世界顯而易見，有些卻隱匿在你我身邊；一個很不錯的切入方法學，是透過「客觀」且「直接」的臨床觀察，包含了三大步驟 👇
1️⃣ 觀察一個特定的臨床情境 ➡ 譬如在急診的新進住院醫師努力試著幫病人插管，導致病人血氧濃度下降。
2️⃣ 找出和這個臨床情境有緊密關聯的問題 ➡ 對於經驗較少的年輕急診醫師來說，可能需要更長的時間才能成功插上管，對病人的狀況影響甚鉅。
3️⃣ 將觀察者對於問題的理解，轉化為需求 ➡ 在急診如何讓資歷較淺的急診醫師縮短插管的時間。

「觀察」與「問題」論述是不一樣的，雖然都需要用精雕細琢的語言來做表達，前者是創新仔在臨床觀察的過程中目睹的單一事件，後者則是在臨床照護過程中反覆且持續發生的疑慮、不確定性、阻礙，兩者最終會形成「需求」論述，定義出為了解決某個特定問題所需要發生或改變的成果。以前面的例子來說，我們需要透過進一步的觀察及所收集的資料，來瞭解插管成功所需時間較長的這個問題，是只發生在住院醫師身上，還是其他職類或級別的醫療人員也可能遇到（如資深醫師、救護員等）；把觀察轉為問題的論述，也需要驗證、測試，例如我們原本假設住院醫師插管花的時間比較多是因為技術不夠熟練，但如果事實上原因是出在病人解剖構造的變異導致困難插管，並非改善插管技術就能解決，那就等於把金錢、時間、精力投注在其實不存在的需求上。此外，現在設定的 Outcome 目標是插管時間，但臨床上更重要的可能需要再明確、與醫學相關一點，譬如減少插管過程中血氧飽和濃度下降的程度。因此，觀察的流程中，在把問題梳理清楚、轉譯成需求之前，我們需要不斷去驗證想法的實確性。

透過各方觀察視角，挖掘問題

在健康照護情境中直接做觀察，能讓我們有機會找出臨床上重要的問題，即便我們原本就對於某個需求抱有特定想法，實際觀察能讓我們辨識這個想法的真實性。特別當創新者本身就是醫師的時候，因為對於自身專業領域有相當豐富的經驗和相對強烈的定見，如果沒有做驗證，頗容易會開發出技術上挺有意思、但對問題的受眾來說無法搔到癢處、直接解決問題的醫材，或是遺漏了還沒被辨識出來的關鍵問題。藉由觀察，我們快速且客觀地測試對於這個問題、需求所牽涉到的利害關係人而言，我們所定義的問題的重要性足夠到值得我們投入資源去找出它的解決方案。

找出問題最好的起手式是在策略焦點的臨床領域觀察病人照護的流程，從病人、醫師、護理師、其他醫療體系中有關的人員的角度來思量，去發掘現有模式中不足或受限的地方，在流程的每個階段仔細詢問每個相關人士、觀察每處環節，確保不會掛一漏萬，並從多方觀點來描繪問題的樣貌，對問題的本質既見樹又見林。舉例來說，觀察病人去醫院做手術的過程，不只是要去認識手術的種類、怎麼做、用了什麼器械，更要瞭解在整個流程中病人、醫師、醫院其他人員的體驗是什麼。

🧑‍🦰 病人

🔸 手術前，病人需要做哪些術前檢查、門診評估？
🔸 需要花多少時間去做手術的準備？
🔸 術前準備的項目包含哪些？
🔸 前一天晚上需要空腹禁食嗎？
🔸 術前準備對病人會產生任何負面或非預期的影響嗎？
🔸 病人到醫院後，需要去哪些地方、做哪些事、有怎麼樣的感受？
🔸 病人大約需要等多久才能做到檢查？
🔸 病人是坐輪椅、還是推床去手術室？
🔸 手術大概會做多久？
🔸 手術包含哪些步驟、每個步驟分別需要花多久時間？
🔸 手術需要全身麻醉嗎？
🔸 手術過程中、做完手術後、出院後，病人會有多大程度的疼痛或不適感？
🔸 術後照護的流程包含了哪些內容？
🔸 傷口需要多頻繁換藥、更換引流管？
🔸 手術需要留置導尿管嗎？
🔸 手術需要靜脈導管嗎？
🔸 手術有可能導致哪些併發症？
🔸 如果需要引流、放尿管、On IV，大概需要多長的時間？
🔸 術前準備、手術執行、術後照護的過程，有什麼其他替代方案嗎？
🔸 病人術後需要住院嗎？要住多久？
🔸 病人出院後會需要哪些面向的協助呢？
🔸 從手術完成到完全恢復到術前生活狀態，大概要多長的時間？

🧑🏻‍⚕️ 醫護人員（醫師、護理師、專科護理師等）

🔹 哪些人員會參與術前準備？
🔹 刀房裡會有哪些人員參與？他們各自的角色是什麼？
🔹 手術從開始到結束都是相同的幾位醫療人員負責進行嗎？
🔹 不同層級的醫院，參與人員的職級是一樣的嗎？
🔹 為什麼醫護人員的人力分配會如此安排？
🔹 這個進行方式成為標準流程的時間已經多久了？
🔹 在現行做法之前，手術是怎麼做的？
🔹 現行做法的主要限制和瓶頸有哪些？
🔹 手術中所用到的醫材、器械是否符合醫療人員的期待？
🔹 醫療人員是怎麼用醫材、器械來手術的？
🔹 醫療人員掌控、操作醫材的流暢度怎麼樣？有沒有遇到什麼困難？手術時或使用醫材時，需要多少助手或輔助的器械？
🔹 操作醫材的過程中，醫療人員有發生哪些錯誤嗎？
🔹 手術後，醫療人員要做哪些追蹤？
🔹 手術最常發生的併發症是什麼？
🔹 誰會負責處理併發症？處理得如何？

🏥 醫療體系相關人事物（如機構院所、健保或私人保險業者）

🔸 手術會花多少錢？
🔸 保險會給付手術多少比例？
🔸 這個手術是否有利潤？
🔸 哪些因素可能讓手術成本提高？
🔸 手術大約要花多少時間？
🔸 手術中哪個流程會耗上最多時間？
🔸 手術所需要花費多少資源？
🔸 手術需要使用到哪些硬體空間（如刀房）？
🔸 手術只能在手術房進行，還是也有機會是門診刀？
🔸 手術會需要用到哪些器械、裝備、耗材？它們的成本為何？如何影響獲利能力？
🔸 手術引發的併發症帶給醫療體系的風險為何？
🔸 誰會承擔或吸收手術引發併發症的費用？

由此可見，觀察整個臨床照護的生命週期才能顧及全局，只關注手術過程中用醫材的幾分鐘或幾十分鐘是不夠的，術前準備、術中做法、術後照顧的每個環節對問題的掌握都是必須，且要從各種角色的觀點來評估不同階段的狀況，像是做大腸鏡的病人最困擾的其實是前一天喝瀉藥灌腸的檢前準備，但醫師可能會認為最具挑戰性的部分是怎麼用腸鏡去看腸道某些死角的技術。只聽醫療人員說他們想要的人事時地物可能會有一定的誤導性，醫師「說的」、「要的」、「會付錢買單的」、「實際做的」很有機會存在天壤之別，因此百聞不如一見還是很有道理的，看醫師在特定情境下怎麼做、如何反應、問題如何發生，比只聽他們描述問題更有價值。透過觀察，我們也更加能夠察覺出被醫療人員視為理所當然的工作日常中被忽視的細節，像是超會做大腸鏡的腸胃科醫師在整個無痛檢查過程中會覺得病人已經睡著、不太會有不舒服的感覺，但卻不瞭解病人前一晚喝瀉藥時有多煎熬；觀察者因為目睹了術前中後的完整流程，得以發掘出被醫護人員忽略的問題及需求。當然，怎麼問問題、做論述也是門藝術，在觀察時問句所使用的語言必須讓受訪者清楚且中立地瞭解問題發生的脈絡，像是在冠心病病人心導管冠狀動脈氣球擴張術發明之前，心臟內外科醫師實在很難想像要怎麼不先暫停心臟搏動、繞道、開胸就能解決心肌梗塞，但透過不同觀看問題的方式，我們就能為不適合手術的病人提供氣球血管擴張手術的選項，最終成為冠狀動脈繞道手術的替代方式。

#CC

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