Marlot Kuiper

136 Connective Routines people do. Was it research even? Mostly, they were interested in one thing: Does it work? Or, as an orthopaedic surgeon in St. Sebastian’s put it: “We are doing it and stuff.. but there’s never been a baseline measurement, so we don’t even know if it actually works!” Not knowing if it actually works resulted in a more resistant attitude towards the checklist (ostensive). Various professionals I talked to argued that it has not been proved that the Surgical Safety Checklist indeed affects outcomes; “The evidence base is too thin.” As a result, performances become more ‘slack’. Performing the checklist routine is something professionals are expected to do, but at the same time they are not sure whether it reaches its goal. ‘Goal’ is stated here as singular, as in the conversations it showed that most respondents only assigned the goal of ‘mistake reduction’ to the checklist. Most of the time when talking about the checklist, respondents narrowed down the conversation to specific cases. They talk about a safe surgery, a safe intervention on their patient. In distributing the scarce amount of time in the operating theatres, surgeons are even inclined to compete with peers; “My patient needs to go first”. They are busy with doing what’s best for what they consider ‘their patient’. Whereas in the introduction module for new employees the goal to “optimize processes” was clearly communicated, in practice individuals not so much bother about optimizing workflows. Rather, they treat individual cases and just want to perform a safe surgery. And needless to say, that is exactly what that individual patient is expecting them to do. Only those who had been involved in the development or implementation of the checklist in some way, identified broader goals of the checklist – such as improving teamwork, i.e. creating connections. While we were drinking coffee in the staffroom waiting for another operating to finish, an anaesthesiologist working at St. Sebastian’s expressed his enthusiasm for the checklist and identified himself as a ‘frontline leader’. He had been involved in implementing the checklist at St. Sebastian’s, and as an “early adopter” of the checklist, he particularly considered his role to engage others and “get them on board”. Put differently, his aim was to anchor this broader ostensive pattern of the checklist. The ideas prevailing under those involved in the implementation process thus differed from those who are expected to work with the checklist in daily practice. ‘Early adopters’ had no doubts about the checklists’ evidence base and endorsed Gawande’s (2009) idea that “The checklist works, as long as it is implemented