Week 12: Problem-Solving Fundamentals 問題解決入門
Time: 4 minute video
Category: Improvement 改善
Some problems are obvious. They interrupt the day, and everyone notices. Others stay in the background. A delay here. An extra explanation there. One more step that should not be needed. Each one seems small, but repeated every day, they quietly drain time and energy. This week’s video introduces PDSA, a practical method used in healthcare improvement. It helps leaders define the problem with facts, test one small change, and learn what actually works before changing more.
有些問題很明顯，一出現大家就看見。也有些問題藏在日常裡。這裡多等一下，那裡多解釋一次，流程裡又多了一個其實不需要的步驟。每一件看起來都不大，但每天重複，就會悄悄消耗時間和精力。本週影片介紹 PDSA，這是一個很實用、也很符合醫療改善思維的方法。它幫助主管先用事實把問題講清楚，再先試一個小改變，看看什麼真的有效，再決定要不要進一步調整。
English Version
中文版 (AI)
Summary of Video
Why does this matter for leaders at KFSYSCC?
Leaders do more than respond to problems. They shape the systems people work in every day. In a hospital, many problems are small but repetitive: an incomplete request, a delayed handoff, a queue that keeps building, or the same clarification given again and again. These patterns consume time, create frustration, and slowly wear people down. When the same issue keeps returning, telling people to “be more careful” is usually not enough. Leaders need a practical way to understand the pattern, test a small change, and learn what actually improves the work.
When would you use this?
Use PDSA when a familiar problem keeps coming back and the team is tired of working around it. It is especially useful when people can feel the friction, but the cause is still not fully clear; when the team wants to improve something, but a large change feels risky; when you want to test an idea before redesigning the whole process; or when the issue seems minor, but the cost adds up day after day.
What are the key phrases from this video?
Quiet problems are still costly
Facts before opinions
Test small before scaling
PDSA: Plan → Do → Study → Act
See the process, not just the person
Change one thing at a time
How would you describe this tool in 30 seconds?
PDSA is a practical way to improve repeated problems without overreacting. First, define the problem with facts. Then choose one small change and test it in a limited setting. Next, study what happened, not just what you hoped would happen. Finally, decide whether to keep the change, adjust it, or stop it and try a better idea. The goal is not a perfect answer on the first try. The goal is to learn quickly and improve step by step.
影片摘要
為什麼這對和信醫院的領導者很重要？
主管不只是處理問題，也是在塑造大家每天工作的系統。在醫院裡，很多問題看起來不大，卻會一直重複發生，例如需求資料不完整、交接延後、排隊越來越長，或同樣的事情一再被重複說明。這些模式會耗掉時間，增加挫折感，也會慢慢消耗團隊的力氣。當同樣的問題一直回來，光是提醒大家「要更小心」通常不夠。主管需要一個務實的方法，能看懂問題的模式、試一個小改變，並且學到什麼真的能改善工作。
什麼時候會用到這個工具？
當一個熟悉的問題一再出現，團隊也已經厭倦一直繞著它工作時，就很適合用 PDSA。特別是當大家都感受到卡住的地方，卻還不完全知道真正原因；當團隊想改善，但直接大改風險太高；當你想先測試一個想法，而不是一次重做整個流程；或當問題看起來不大，卻每天都在累積代價時，PDSA 都很有幫助。
這支影片的關鍵句是什麼？
安靜的問題，代價也不小
先看事實，不先下判斷
先做小測試，再考慮擴大
PDSA：Plan → Do → Study → Act
先看流程，不只看個人
一次只改一件事
用 30 秒怎麼描述這個工具？
PDSA 是一個很務實的方法，幫助團隊改善反覆出現的問題，而不是一下子做太大的反應。先用事實把問題講清楚，再選一個小改變，在有限範圍內先試一次。接著看實際發生了什麼，不只是看原本希望會發生什麼。最後再決定這個改變要保留、調整，還是停止後改試更好的做法。目標不是第一次就找到完美答案，而是快速學習，逐步改善。
Scripts for Leaders
Keep these short. The goal is not to sound impressive. The goal is to make work easier, calmer, and clearer.
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Let’s define the problem with facts first.
Last week, this happened on four of five days, usually before 11 AM.
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What keeps repeating here?
Is it the same place, the same time, or the same step?
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What is one likely cause we can test first?
Let’s choose one, not five.
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Let’s not redesign the whole process yet.
What is one small change we can test this week?
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How will we know whether this helped?
What number or behavior will we watch?
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Let’s run this test for one week.
We’ll review the result next Friday at 4 PM.
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Let’s pause before we blame someone.
I want to understand the process first, then decide what needs to change.
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This test helped a little, but not enough.
Let’s adjust it and run one more small cycle.
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defining the problem too vaguely
blaming a person before understanding the process
changing too many things at the same time
running a test without studying the result
給主管的對話腳本
這些句子請盡量簡短。目標不是「講得很厲害」，而是讓工作更順、更穩、更清楚。
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我們先用事實把問題講清楚。
上週五個工作天裡，這件事有四天都發生，而且大多在早上 11 點前。
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這裡重複出現的是什麼？
是不是同一個地點、同一個時間，或同一個步驟？
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哪一個原因最值得先測試？
我們先抓一個，不要一次抓五個。
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我們先不要急著重做整個流程。
這週可以先試哪一個小改變？
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我們怎麼知道這個改變有沒有幫助？
要看哪個數字，或觀察哪個行為？
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我們先試一週。
下週五下午 4 點，我們一起回頭看結果。
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我們先不要急著怪人。
我想先看清楚流程出了什麼問題，再決定要改什麼。
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這個測試有一點幫助，但還不夠。
我們調整一下，再做一輪小測試。
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問題講得太模糊
還沒看懂流程，就先怪人
一次改太多事情
有做測試，卻沒有回頭看結果
Supporting Research
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Healthcare improvement research consistently supports a systems view. When errors, delays, or workarounds keep repeating, the cause is often found in the process, not only in individual performance. AHRQ’s PSNet emphasizes looking for underlying system causes so the same problems are less likely to recur. PDSA is also widely used in healthcare because it allows teams to test changes on a small scale, learn quickly, and refine their approach before broader implementation. Reviews suggest that the method is broadly accepted in healthcare improvement, although the quality of execution matters.
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PDSA is simple, but it is not automatic. A small test does not guarantee a good result. The method works best when the problem is clearly defined, the test is narrow enough to learn from, and the team actually studies what happened. Reviews also suggest that PDSA is weaker when teams skip the Study step, test too many changes at once, or move forward without a clear measure of success.
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At KFSYSCC, we use problem-solving to make repeated work problems clearer, smaller, and more manageable. We start with facts, avoid early blame, test one change at a time, and review what actually happened in daily work. The goal is not a dramatic fix. The goal is a practical improvement that fits real hospital operations and can be sustained over time.
支持性研究
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醫療改善研究一再支持「系統觀點」。當錯誤、延誤或各種臨時補救做法一再出現時，原因常常不只是在個人表現，更常是在流程本身。AHRQ 的 PSNet 也強調，要先找出底層的系統原因，才能降低同樣問題一再發生的機會。PDSA 在醫療現場也被廣泛使用，因為它讓團隊可以先做小規模測試、快速學習，再根據結果調整後擴大。回顧研究也指出，PDSA 在醫療改善中是被廣泛接受的方法，只是執行品質會明顯影響成效。
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PDSA 很簡單，但不代表用了就一定有效。小測試本身也不保證會有好結果。這個方法最有用的時候，是問題定義得夠清楚、測試範圍夠小、而且團隊真的有回頭看發生了什麼。研究回顧也提醒我們，若團隊跳過 Study 這一步、一次測太多改變，或沒有清楚的判斷指標，就比較難得到真正有用的結果。
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在和信，我們用問題解決的方法，讓反覆出現的工作問題變得更清楚、更小，也更容易處理。我們先從事實開始，不太早怪人，一次只測試一個改變，然後回頭看它在日常工作裡到底產生了什麼結果。目標不是做一個很戲劇化的大改革，而是在真實的醫院運作中，找到一個做得到、用得住、也能持續的改善。
Bonus Clips
加碼影片
If you want a quick outside perspective, here are three videos that reinforce this week’s lesson:
如果你想快速聽聽外部觀點，以下三支影片會呼應本週課程的重點：
References
AHRQ PSNet: Root Cause Analysis
AHRQ PSNet: Systems Approach
IHI: How to Improve – Testing Changes
https://www.ihi.org/library/model-for-improvement/testing-changes
IHI: Model for Improvement
Taylor et al. (2013/2014). Systematic review of the application of PDSA cycles