Marlot Kuiper

126 Connective Routines 5.1 Introduction “You should research if the checklist actually works” – orthopaedic surgeon That is what an orthopaedic surgeon persuasively said to me when we were talking about this research project over a cup of coffee. Besides him, various actants showed a clear need to know ‘if the checklist works’, with which they presumably meant if it actually reduces in-hospital mortality. There is however a vital difference in studying if a checklist works, and studying how a checklist works. This chapter focuses on the latter – also to make sense of the strong presence of the first question in the field. By revealing insights on the internal dynamics of the checklist routine, I aim to answer the research question: How do standards work out in medical teams? In the previous chapters, I worked towards an analytical framework to study how standards work. In this chapter, I use this framework that conceptualizes routines as dynamic systems of ostensive and performative aspects to show how ostensive understandings of the surgical checklist – such as: ‘does it work?!’ – fuel performances, and how performances in turn, can instigate a change in ostensive patterns. Though recognizable as ‘the checklist routine’, it showed that the individual repetitions of the routine by surgical teams widely varied across contexts. In this chapter I therefore delve into the origins of varying routine performances and their encompassing drivers for change. The storyline of Plainsboro Teaching Hospital is the point of departure of this chapter. Insights from St. Sebastian’s are added to the analysis to show the bigger, overarching storylines, and highlight interesting differences. First, I will illustrate how new employees are introduced to Plainsboro, and how organisational ideas about the checklist are communicated to them. Next, I will show how a dynamic interplay of such ostensive dimensions unfolds in professional practice. The chapter is structured along the lines of three ‘basic’ abstract patterns that fuelled the performances in specific ways: improving teamwork, reducing medical mistakes, and maintaining accreditation. The final section of the chapter analyses the checklist as a dynamic system of interacting ostensive and performative aspects and draws some sub conclusions. The findings of this chapter show that there is no such thing as “the checklist”. The understandings of the checklist are multiple, and even these ‘basic understandings’ turn out complex and contested at the frontline. Building on