Original article Box 1 A tale of a natural network and propagation of a sticky idea57 59 By the late 1980s, important technological advances provided the potential for safer anaesthesia with devices such as pulse oximeters and capnographs. When anaesthetists requested access to these, they were ignored by administrators. Frustrated, a meeting was called in Australia of influential clinicians. The idea had such natural appeal that 63 of 65 people invited attended the meeting in May 1987, the majority of whom represented hubs of natural networks interested in subjects allied to safety and monitoring. All had to pay their way to the meeting which was called at short notice and not under the auspices of any professional college, society or association. Everyone who was asked to present a paper did so and provided copy for the 36 manuscripts which were published 10 months later.57 These recommended minimum standards which were endorsed by the relevant professional bodies at national, and, later, international levels. Despite opposition from administrators, oximeters were introduced for every anaesthetised patient and capnographs for every intubated and/or ventilated patient. The idea ‘‘tipped,’’ and it became unacceptable to conduct anaesthesia in developed countries without the use of these devices. An analysis of 4000 incidents and 1200 medicolegal reports over the period 2000–2005 revealed not a single case of hypoxic brain damage or death due to inadequate ventilation or undetected oesophageal intubation, problems which had plagued anaesthesia until the late 1980s.59 This is an example of quadruple-loop learning (at personal, organisational, national and international levels),53 and a bottom-up initiative which gained traction by harnessing some of the natural properties of a sociotechnical system. problems will continue to emerge at the leading edge of medical advances. The plethora of new errors associated with the introduction of computer order entry provide an example.63 Problems to address initially could be those clearly shown to be widespread, costly and amenable to mitigation by proven interventions of reasonable cost– and risk–benefit.54 64 65 Once a problem that needs to be addressed has been identified, a meeting should be arranged to develop a tool to address it. Modest funding should be provided for two or three acknowledged experts to attend and present reviews of the relevant information. A public invitation should be issued to all with an interest in the area. In this way, the natural hubs of existing networks relevant to the problem can be gathered together to strengthen existing links between networks and establish new ones, thereby facilitating the ongoing generation of effective solutions to the particular problem. Ideal tools should: explain the underlying principles; outline the necessary tasks; record that they have been done; facilitate audit; and promote dissemination, stickiness and use of the principles in question. They should be endorsed by the relevant professional organisations as clinical standards, with a requirement that they should be used whenever appropriate. Their design should make compliance easy, and clinicians should be involved in their design to facilitate this. Documented justification of non-compliance should be required. The underlying rationale for the tool, and the process by which it was developed, should be published (ideally in the peer-review literature) and made available on the internet; a plain language version should be developed for patients and lay- carers. The tool should be refined over time on the basis of feedback from those who use it. Natural surveillance and collegial behaviour A transparent process is needed for identifying persistent non- compliance with these tools, with a view to progressively improving standards. It has been shown that formal surveillance may be acceptable to practising clinicians.66 67 We recommend a peer-review audit. This is practical because much routine clinical practice involves the following of pathways and algorithms by individual clinicians through habit, so it is possible to identify the routine practices of most clinicians by reviewing as few as 10 or 20 medical records. We propose that peers review each other’s compliance with agreed tools on a regular basis, as part of normal professional practice, and accreditation agencies can then randomly check for evidence of tool use. This would provide a transparent process for identifying persistent non-compliance with standards and an objective basis for opening discussions to understand and address the issues. CONCLUSION There is now compelling evidence and widespread acceptance that there are problems in healthcare that must be addressed and that current approaches to addressing them are inade- quate.68 Education, persuasion and attempts to change practice through existing hierarchical structures have largely failed in the face of the entrenched opposing forces of clinical autonomy and the traditional tolerance of individual and regional variations in practice.11 Evidence-based practice is overdue. It is time to do something different. We recommend harnessing the natural properties of the sociotechnical system that comprises healthcare, and guiding the existing practices which come naturally to clinicians, so that these can be developed and used to promote continuous quality improvement with effective self-regulation.50 Clinicians, like other professionals, work best when they are allowed to flourish in groupings of their own interests and preference, are empowered rather than directed, and nurtured and influenced by their peers rather than controlled by others. They are likely Box 2 Joanna Briggs Institute for Evidence-Based Healthcare—another self-propagating network This organisation was formed in 1996 with a single corporate member. It was not under the auspices of any professional body but has alliances with several as well as with hospitals and universities. Within a decade it had 26 centres in 15 countries, with members in 48 countries, and 2000 corporate members. The core business is the generation of annually updated evidence-based guidelines based on systematic literature reviews. There are now 1200 systematic reviews and 200 packages of guidelines which can be compiled, using software available for members, into customised clinical practice manuals. Software is also available for clinical audit, benchmarking and tracking evidence of practice change. There are now plans to harness the concepts and networks to complement international and national collaborations for translating evidence into practice. 40 Qual Saf Health Care 2009;18:37–41. doi:10.1136/qshc.2007.023317