Marlot Kuiper

145 How standards work out in medical teams: On routine dynamics It is 11.00am when I am at Plainsboro’s surgery department for a day of outpatient gynaecology treatment. ‘Outpatient’ means that patients come in for a surgical intervention and go home on the same day. Mostly, they leave shortly after the intervention. Interventions are not that complex, and follow-up on each other quite fast. Three patients have already been operated, and the third patient just entered the OR for a removal of an IUD (a hormonal intra-uterine device, or coil). Before the surgeon has scrubbed or performed the time-out procedure, he sits behind the computer screen in the corner of the theatre. I: “What is it you are doing right now?” Surgeon: [laughing] “I am ticking off boxes so I can continue.” After the time-out boxes are ticked-off in the software system, the surgeon leaves to scrub. When he returns he walks towards the operating table and does the time-out with the patient. This observation note reflects how two action flows emerge in the checklist routine. The ‘rule’ is that professionals perform the SSC, and after they did so, register this performance in the software system. Interestingly, in many cases, the registration of the routine is done before the actual checking routine has been performed. Ticking off boxes appears as something different from what they do with patients. Ticking off boxes doesn’t necessarily imply that there has been – or will be – actual checking with the patient. It shows that the registration of the checklist is consistently done, be it before or after the actual checking. There are three reasons for the emergence of this pattern. The first reason is a practical one. The software system has to give professionals ‘green light’ to continue. Only when all boxes are ticked-off, the system allows to proceed with the next patient. Also the next reason, is a practical one. When the gynaecologist was behind his computer ticking off the boxes, the team members from anaesthesia were preparing the patient for the operation. They help the patient onto the surgical table, and install the devices that they need to put the patient in the right position. Already ticking off the boxes herewith appeared as an effective use of ‘spare time’. The surgeon had to wait for the patient to be ready anyway, and by already fulfilling the administrative tasks, he can smoothly resume the program later on. 5