Marlot Kuiper

238 Connective Routines 7.8 To conclude This chapter focused on the question: “How do artefacts affect how standards work in medical teams?” Hospitals are urged by for instance inspectorates and accreditation boards, to implement standards that enhance quality and safety of service delivery. They do so by introducing a multitude of artefacts that represent these standards. The findings of this chapter illustrate that these artefacts form a dynamic arrangement, in which artefacts are constantly changed. The process in which artefacts are added and changed to improve compliance is political. Only a few – and usually not those who work with the checklist at the frontline - have the power to amend artefacts that prescribe how work should be conducted and where responsibilities lie. Although artefacts are introduced as representation of the envisioned routine, the various dynamic artefacts with their various possibilities and limitations for use, make a collective understanding of what the checklist is all the more complicated. Rule-embedded artefacts influence or strengthen ideas in different directions, for instance ‘bureaucratic software tools’ that enhance notions of the checklist as an organisational burden, or a paper checklist that enhances the idea of a check list rather than a tool for memory support. Besides, other artefacts mediate routines. The setting and furniture in the operating theatre act as boundaries to actively incorporate the checklist as a team effort. Hence, routine dynamics and interactions cannot be fully understood without a focus on the material that actively shapes behaviour in complex settings. Building on the previous chapters, the findings of this chapter urge for a shift from the instrumental implementation of artefacts to a consideration of the social and situated performances of routines, to ultimately be able to introduce artefacts that better correspond with professional practice and actually support professionals in increasing patient safety. Nonetheless, creating workable artefact proves difficult. Working with artefacts should be a matter or ‘trial and error’ to see what works best in specific contexts, in specific times.