Marlot Kuiper

221 St. Sebastian’s At St. Sebastian’s, they did not employ the strategy of introducing more artefacts, rather, the strategy was to alter the paper checklist in such a way that performances would be improved. Altering artefacts involved two sub strategies; (1) clearly spelling out responsibilities – this strategy links to the alteration in Plainsboro’s software system, and (2) further demarcating the checks to prevent extensive conversations. The following observation note illustrates how the strategy of altering artefacts was performed by the manager of the surgery department and the chair of the anaesthesiologists. I’m in the staff room of St. Sebastian’s. I just refilled my cup of coffee for the third time that day. I am shadowing anaesthesiologist dr. Herbers, and we have to wait for the operation to be finished. There are more colleagues in the room, some chatting, some behind their computer screen. Then mr. Bakker enters the staff room, who introduces himself as the manager of the surgery department. He has an appointment with dr. Laarakkers, the chair of the anaesthesiologists group. Dr. Laarakkers is still in the theatre reviving a patient. As I introduced myself as a researcher, we get into a conversation about the subject. Mr. Bakker states that coincidentally, the appointment he has with dr. Laarakkers is about optimizing the checklist and he invites me to listen in. Dr. Laarakkers enters the staff room. “Sorry you had to wait, it took a while to wake him up” he laughs. They get seated behind the computer, and dr. Laarakkers opens the file with the checklist. “I’ve been thinking about how to further demarcate responsibilities” he starts off. In the conversation that follows, dr. Laarakkers and mr. Bakker are mostly deliberating about responsibilities, in which they aim to indicate more clearly what has to be done by who, and who’s responsible. Their assumption is, that when responsibility has not clearly been indicated, no one will feel responsible. Clearly indicating responsibilities, will facilitate ‘compliance’. Besides more clearly disentangling responsibilities, the conversation concentrates around ‘focusing the conversation’. In chapter 6 I described how dr. Herbers 7