Marlot Kuiper

128 Connective Routines Slemmer acknowledged that it remained difficult to translate ‘general guidelines’ to local circumstances: “We have all this detailed information, and now what?” At the time, the implementation of the checklist was considered a more or less “linear process” that would, if well-prepared, lead to the adoption of the new standard. As indicated in the policy document, an explicit purpose of the checklist for Plainsboro was to create a routine in which teamwork is key in reducing medical mistakes and preventing complications. In short, the checklist routine envisioned three main things: improved teamwork, a reduction of surgical mistakes, and accreditation of the hospital. From the policy document, these can be considered the three ‘basic’ understandings of the checklist. To prepare the staff for its introduction, information about the checklist was shared during staff meetings and through e-mails and the software system. Posters were put up in the operating theatres as a reminder. Three years after its introduction, the hospital performed a retrospective cohort study to measure if the implementation of the checklist “had worked.” In their study, researchers from Plainsboro measured if indeed the checklist had led to a reduction of in-hospital mortality. Although the study found a correlation between the two, a striking result of the study that drew attention was that compliance did not exceed “average”. The numbers of this self-evaluating study indicated that the checklist was used in practice, but also that there were “barriers” for fully incorporating them. Exploratory conversations with various key actors revealed that the hospital was having a hard time in finding clues for what they called “lacking implementation.” Possible explanations remained rather general; “It is something cultural I guess” or “The staff wasn’t well- prepared enough.” By looking at routines, I was open to a more social and situational explanation of how standards work.