Marlot Kuiper

20 Connective Routines The promises of introducing a checklist in surgical care attracted global interest for multiple reasons. First of all, a pilot study performed in eight different hospitals worldwide had demonstrated that use of the checklist had significantly dropped mortality and complication rates – the checklist would thus improve safety and outcomes (Haynes et al., 2009) Secondly, the checklist was presented as a simple and cheap intervention. Surgeon Atul Gawande even heralded checklists to be “the biggest clinical invention in thirty years” in his best-selling book the Checklist Manifesto (2009). Thirdly, implementing a checklist would generate substantial cost savings (Seme et al., 2010). And last but not least, a checklist would improve teamwork and communication in multidisciplinary surgical teams (Bliss et al., 2012). Recent numbers show that this simple but ground-breaking solution to solve surgical problems and improve care delivery over the years has been implemented in more than 4000 institutions around the globe (Aveling et al., 2015; Pugel et al., 2015; Sendlhofer et al., 2015). 1.3 The implementation problem However, about a decade after the first introduction of safety checklists in the surgical domain, this idea of standardization has been pigeonholed the “Saga of high hopes followed by dashed expectations” and even the “Boulevard of broken dreams” (Urbach, 2015). Disappointing implementation rates have again prompted headlines that emphasize failure: “Not all surgeons follow checklists that prevent bad mistakes” (Wilson, 2016, May 26). Despite all good intentions, the surgical domain seems to be stuck with what is often called an ‘implementation problem’: “Eminently sensible quality and safety interventions— promoted by opinion leaders, endorsed by health quality organisations, and supported by impressive results in promising early studies—too frequently fail to perform as expected when they are introduced into routine care” (Urbach, 2015, p. 215). The next phase in the patient safety debate thus moved from solving mistakes as such towards ‘solving implementation problems’. From the idea that checklists are simple and cheap solutions to transform professional practice, flowed instrumental implementation strategies that focus on optimizing the implementation process. In implementing ‘simple’ checklists in health care, the comparison with implementing standards in product manufacturing sectors like the food and automobile industry is no exception (Gawande, 2007, 2009; Nicolay et al., 2012). However, there is a world of difference between manufacturing