Marlot Kuiper

157 How standards work out in medical teams: On routine dynamics routine, as these ideas and performances are created and amended in a context in which professionals constantly have to perform multiple routines and assess the time and effort that is needed to perform actions in particular situations. So, even if a doctor thinks “the checklist improves teamwork”, performances are not necessarily accordingly. Each guiding principle has to be assessed, in terms of the relative time and effort it takes to perform the checklist in a particular situation. To put an example, if the program is on schedule, and no patient is waiting for an epidural, the “improves teamwork principle” will guide an anaesthesiologists’ behaviour (initiating and extensively performing the checklist). If, on the contrary, time pressures are fierce and more tasks are waiting, the checklist might very well not be performed according to principles regarding teamwork or safety. Secondly, the findings of this chapter suggest that the checklist routine (the abstract model and concrete performances) is affected by the connection with various artefacts. For example, the ‘soup protocol’ artefact, is an interesting one as it clearly represents some of the ostensive aspects that are held by individuals. As argued, individuals mostly know their own guiding principles, and at best assume those of others. Because ostensive understandings are physicalized through the soup protocol artefact, they become easy to share. Individuals can therefore become aware of other understandings and herewith align and create a firm shared, collective understanding. Because the artefact is anonymous and ‘floating around’ professionals can distance themselves from it, while uniting at the same time: the collective abstract pattern becomes that intensive control is a burden. Moreover, the message that is communicated through this artefact, builds on the argument above: surgical care is not only about ‘the soup’, but about many, many more. So rather than a mere recursive cycle of ostensive and performative aspects, these findings lay bare how artefacts might influence this dynamic. In chapter 7, there will be explicit attention for the role of artefacts in shaping routines. These latter explanations that hint on prioritizing activities and the influence of artefacts, lay bare the analytical limitations of this chapter. A focus on internal routine dynamics does provide us with sufficient understandings of how ostensive aspects evolve into practices. At the same time, internal routine dynamics only provide us with partial explanations, as the interaction of routines and artefacts strongly influence these internal routine dynamics. I’ll therefore expand the analytical focus in the next chapter. 5