Marlot Kuiper

178 Connective Routines thus referring to their professional judgment, in which complexity is prioritized over more standard procedures. Others claimed that it actually is a matter of “which surgeon shouts the loudest”, with which they mean that some surgeons clearly express their impatience and pressure the anaesthesiologist to start in their theatre. Often, as a consequence, the more calm and understanding surgeon has to wait. To which an anaesthesiologist subsequently added: “Actually…that’s not okay.” Still, at the start of the day, the decision that the anaesthesiologist is about to take is unknown to the surgeons. They can either wait and see what happens, or, as the observation note shows, anticipate on the situation. However, they can only anticipate on the information that the anaesthesiologist ‘might be late’. The two professionals in the observation note responded in two different ways. The surgeon in OR7 decided not to wait, by already at 7.50 performing the briefing with the attending anaesthesiologist in training. The surgeon in OR8 also decided not to wait, but then by also being late himself, for example by taking some more time for final preparation of the operation or visiting patients at the holding and marking surgical sites. Anticipation on insufficient information however, might be unfortunate for the progress and quality of the program. Performing the briefing without the anaesthesiologist as the surgeon in OR7 did, might lead to information deficits and eventually delays. (This specific situation is further illustrated in 6.4.2.). Being late anyway, like the surgeon in OR8 did, might even instigate more waiting time, and thus a delay of the program, since the anaesthesiologist did not find anyone in the theatre and decided to go for a cup of coffee instead. Anaesthesiologist and/or surgeon availability is a common problem. Comparable practicalities emerged for example with “two-part surgeries,” where two different surgeons perform different parts of the intervention (for example, a breast mastectomy followed by reconstruction), but have to be present for the briefing and time-out together. This routine required professionals to wait for another and interrupt and align their tasks, which proved a time consuming effort. In these instances the checklist routine interfered with existing workflows, which means that professionals have to improvise and decide “on the spot.” This might imply that the action patterns that emerge deviate from the “rule” as inscribed in the artefact. Nonetheless, these instances of “non-compliance” might very well be best solutions for the situation at hand. Paragraph 6.5 provides more detailed descriptions of how professionals deal with such demands.