Marlot Kuiper

261 Conclusion Professional standards work if they are actively made to work. Standards work if connections already exist and are brought into existence, both in teams, in workflows and by way of workable artefacts. Professional standards are dynamic; both in terms of ideas, performances, and the artefacts that represent them. Standards require responsiveness, rather than ‘standardized responses.’ Working with standards requires on the spot decisions; they only work when professionals deal with multiple, sometimes conflicting demands, set priorities and tailor solutions. In performance-oriented contexts, there is much emphasis on transparency and accountability. Standards work to account for actions, and gain legitimacy and accreditation. In practice however, this leads to two different activities within the same routine. Neat registration of the checklist serves the purpose of accountability, while flexible performances work to ‘do patient safety’ at the frontline. The two are usually disconnected: how standards ‘work’ differs from how they are ‘recorded’ to work. Artefacts can support working with standards, but creating workable artefacts is a complex, political matter. If artefacts limit flexibility, they will reinforce feelings of ‘controlled professionalism’. If artefacts afford (too) many and different options for use, their purpose remains unclear and they will be left untouched. Although artefacts are introduced in professional contexts to model a new (safety) routine, professionals also actively use them to restructure social connections, for instance by actively using or refusing them. Hence, they are powerful tools rather than technical instruments. ‘Implementers’ often hold the assumption that implementing standards leads to outcomes that are comparable, uniform, and transparent. From an instrumental perspective, standards such as checklist might be seen as (re)organising work and establishing new connections, as they become new routines for treating cases. This thesis has shown that it is much more, and different than that. New professional standards not ‘automatically work’. This means that ‘hybridity’, a natural interweaving of an organisational logic with a professional logic, is no automatic outcome of a standard to improve performance and reduce mistakes, but an ongoing context-dependent process. When talking about routines on a daily basis, people easily state “That work is routine”. From this study I would conclude quite the opposite: “That routine is (hard) work.” 8