Towards safer, better healthcare: harnessing the natural properties of complex sociotechnical systems J Braithwaite,1,2,3 W B Runciman,4,5 A F Merry6,7 1 Institute of Health Innovation, University of New South Wales, Sydney, Australia; 2 Centre for Clinical Governance Research in Health, University of New South Wales, Sydney, Australia; 3 School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia; 4 Royal Adelaide Hospital, Joanna Briggs Institute and University of Adelaide, Adelaide, Australia; 5 Australian Patient Safety Foundation, Adelaide, Australia; 6 University of Auckland, Auckland, New Zealand; 7 Quality and Safety Committee of the World Federation of Societies of Anaesthesiologists, London, UK Correspondence to: Dr J Braithwaite, Centre for Clinical Governance Research, Faculty of Medicine, University of New South Wales, Sydney NSW 2052, Australia; j.braithwaite@unsw.edu.au Accepted 17 August 2008 This paper is freely available online under the BMJ Journals unlocked scheme, see http:// qshc.bmj.com/info/unlocked.dtl ABSTRACT Objectives: To sustain an argument that harnessing the natural properties of sociotechnical systems is necessary to promote safer, better healthcare. Methods: Triangulated analyses of discrete literature sources, particularly drawing on those from mathematics, sociology, marketing science and psychology. Results: Progress involves the use of natural networks and exploiting features such as their scale-free and small world nature, as well as characteristics of group dynamics like natural appeal (stickiness) and propagation (tipping points). The agenda for change should be set by prioritising problems in natural categories, addressed by groups who self select on the basis of their natural interest in the areas in question, and who set clinical standards and develop tools, the use of which should be monitored by peers. This approach will facilitate the evidence-based practice that most agree is now overdue, but which has not yet been realised by the application of conventional methods. Conclusion: A key to health system transformation may lie under-recognised under our noses, and involves exploiting the naturally-occurring characteristics of com- plex systems. Current strategies to address healthcare problems are insufficient. Clinicians work best when their expertise is mobilised, and they flourish in groupings of their own interests and preference. Being invited, empowered and nurtured rather than directed, micro- managed and controlled through a hierarchy is preferable. An important question facing contemporary health systems is how to reduce variability and iatrogenic harm.1 Many initiatives have been proposed in the belief that this is primarily a structural issue.2 3 They have taken the form of reorganisation4 and policy reforms,5 credentialling and accreditation,6 7 and directives to standardise care processes.8 9 However, at the heart of healthcare lie interactions between individual patients and clinicians. Improving communication and relationships, enhancing individual decision-making through evidence-based decision support10 and promoting patients’ involvement in and responsibility for their own care are also vital for safer, better care. We propose that stimulating the fundamental transformation needed to improve the safety and quality of healthcare will require harnessing the natural properties which emerge (often sponta- neously) at the interface between the socio (human behavioural) and technical components of complex systems.11 A bottom-up strategy led by clinicians is badly needed to balance the predomi- nantly top-down approaches which frequently result in only modest improvements which are difficult to sustain.12 Patient safety is what social Qual Saf Health Care 2009;18:37–41. doi:10.1136/qshc.2007.023317 Original article scientists call a ‘‘wicked problem’’—one that is messy, persistent and multidimensional.13 14 Politicians and bureaucrats seek to shape clinical practice by edict, whereas in reality it is shaped by the behaviours and attitudes of practising clin- icians. NATURAL PROPERTIES OF COMPLEX SYSTEMS Many complex systems have similar natural properties and behaviours (table 1); these have been identified in fields as diverse as mathematics,15 sociology,16 marketing science17 and psychology,18 and attempts made to apply them to health- care.19 20 Safety is a property which depends on good organisation, tools and infrastructure as well as on the behaviours of individuals (often in teams). The collective values and behaviours of these individuals comprise the culture of the system. Harnessing their undoubted industry, goodwill and energy, and supporting the natural processes by which they interact and cooperate, rather than constantly reorganising them, is the key to changing this culture.21 22 The emphasis should be on guiding the natural properties and behaviours of sociotechnical systems (see table 1) rather than imposing hierarchical structures and above-down instructions from people who do not actually work at the ‘‘coal-face.’’ ARTICULATING THESE NATURAL PROPERTIES Natural networks There are two types of network: those that are purpose-designed, funded and imposed by someone in authority (mandated networks), and those that are formed by relationships among clinicians which rest on mutual (often implicit) agreements to participate (natural networks).23 The former have assigned functions, and are necessary and appro- priate for the ‘‘hotel,’’ logistic and infrastructure requirements of healthcare. The latter underpin the health system’s purpose: to enhance health and deliver care. Natural networks respond poorly or not at all to conventional management or control measures. They emerge spontaneously and function with little or no externally imposed structure, but can exert powerful and pervasive influences on how systems actually perform and function, at ‘‘street level,’’ behind the formal organisational charts. They are webs of humans connected personally or via technologies, interacting in multiple ways. With the internet, natural networks of patients and their supporters are also increasing.24 Natural networks can be relatively simple or highly complicated,25–27 and individuals may tap into as many networks as there are problems to be 37