Monitoring, Adaptation and Response

General practitioners and other primary care professionals are of course constantly engaged in monitoring patients but a safety strategy of this nature represents a broader attempt to enhance the capacity to detect deterioration and other problems

in the delivery of healthcare to the wider population. As examples we consider one proposal targeted at professionals and a second one aimed at developing a more collaborative culture to help primary care professionals adopt a more patient centred approach and enhance teamwork.

Developing a More Systematic Approach to Watching and Waiting

Time is an essential means of managing risk in primary care. A general practitioner may know from the presenting symptoms that there is a small chance that this is a cancer or other serious complaint; but to refer everyone with such symptoms is neither feasible nor good practice. Instead, they ask the patient to watch and to monitor any change. The use of time is central to the doctor's routines and practice management. Over time diseases and circumstances evolve and a problem encountered at one time will not be the same at a later point. Taking more time solves many health problems in general practice; some will simply resolve, regardless of the diagnosis or intervention, while others will manifest a much clearer symptom pattern. In a significant number of cases, the best way to deal with a situation is just to monitor its development and refrain from clinical intervention. Waiting is paradoxically often more valuable than acting immediately, provided both patient and doctor collaborate in the monitoring of symptoms and trust is maintained on either side. While this strategy is well known and implicitly accepted by both doctors and patients the use of time as a strategy for management has seldom been explicitly studied.

The development of the Tempos Framework (Amalberti and Brami 2012) reflects the importance of time management in primary care. Five time scales termed 'Tempos' requiring parallel processing by GPs are distinguished in the framework: (1) disease's Tempo (unexpected rapid evolutions, slow reaction to treatment); (2) office's Tempo (day-to-day agenda and interruptions); (3) patient's Tempo (time to express symptoms, compliance, emotion); (4) system's Tempo (time for appointments, exams, and feedback) and (5) physician's Tempo (time to access knowledge). This framework (Table 9.1) may serve as a basis for detecting adverse events and recovery, as well as improving adverse event analysis (see Chap. 6).

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