Marlot Kuiper

192 Connective Routines 6.6.2 Implementation and (measuring) compliance are contextualized activities In the theoretical chapter of this thesis, I discussed the ‘implementation discourse’ that plays a vital role in the medical domain, and in which implementation of ‘simple’ checklists is often considered a rather technical process. In the previous chapter, I already explained the checklist to be a relational rather than a ‘simple’ technical matter. The findings of this chapter all the more show the complexity of embedding a checklist in daily routines. A checklist does not stand on its own, and this has implications for (1) implementing the checklist and (2) measuring compliance. First, a multitude of routines make the organisation of the implementation processes difficult. In the previous chapter, I showed how the social nature of working with standards was underestimated (this is an understatement) when the checklist was implemented. ‘Frontrunners’ at the frontline and the hospital board heralded the evidence base of the checklist and considered implementation of the checklist a rather simple and straightforward matter. Information provision and accurate preparation were considered the success factors in implementing the checklist. Indeed, there was information provision to the ‘intended users’ of the checklist, but from their perspective, e-mails about the checklist were considered just one out of many. As professionals receive many, many e-mails a day, they have to prioritize, and “administrative” e-mails easily slip from their attention. Moreover, sessions to spread the ostensive dimension of the checklist were organised, but some practicalities hindered a smooth transition of these ideas. For example, an anaesthesiologist in training at Plainsboro told me that she had to work night shifts at the two days these sessions were organised. She missed both of them, as she explained: “I’m not going back to the hospital just to attend such a meeting, as I can use every sleeping hour I can get..” It proves difficult to organise implementation processes in highly professional contexts that are characterised by multiple interacting routines, and participants that enter and leave the settings at different points in time. Meetings were organised to disseminate information about the checklist – that was considered ‘basic’ and straightforward. However, practicalities hindered attendance, so creating shared understandings was also difficult from a practical view. This might have caused a situation in which so many different understandings (chapter 5) could emerge already from the beginning.