Marlot Kuiper

151 How standards work out in medical teams: On routine dynamics understandings of the checklist diverge, for example with regard to the ‘evidence base’ of the checklist and its potential for improving teamwork. The subjective understanding of the individual anaesthesiologist is that the checklist reduces medical mistakes and enhances teamwork. The subjective understanding of the orthopaedic surgeon on the contrary, is that the evidence base of the checklist is too thin, that he doesn’t need a checklist to improve patient safety, but he acknowledges the importance of the checklist with regard to accreditation. These findings thus also show that even the individual guiding principles consist of different sub ideas that motivate professional behaviour. Besides the different subjective understandings both within and between these individuals, there are also more congruent ideas. For example, the subjective understandings regarding teamwork of the anaesthesiologist and the scrub nurse overlap. They both consider the checklist a teamwork facilitator. The abstract pattern “the checklist is there for accreditation” is an understanding that is held by all three routine participants. If individual understandings of what the routine is overlap, it becomes more likely that these understandings firmly embed in the collective understanding, and hence, steer practices. Next, figure 11 represents a simplified interrelation of the ostensive ideas of three individuals with the same professional background. The figure shows that also within professional segments, in the example anaesthesia, ostensive patterns might be shared (“checklist improves teamwork”) but also, that ostensive aspects might diverge and even contrast “checklist reduces medical mistakes” versus “there is no proof the checklist reduces medical mistakes”. The envisioned checklist routine is often portrayed as pretty straightforward (see also chapter 2). The findings show however, that “the routine in principle” does not exist. Understandings of the checklist are not only multiple, they are also contested. Individuals know or assume portions of the envisioned routine, such as their own ideas and parts that are shared, but they are mostly not aware of understandings that others hold as a guiding principle, so all is known to none (see also Weick and Roberts (1993, p. 365)). The next section discusses how the (diverging) ostensive aspects translate into collective understandings and practice. 5