Marlot Kuiper

272 Connective Routines to employ more artefacts to model the routine not per se is the most desirable one. Implementation Science Finally, even though this dissertation did not focus on ‘implementation’, the findings of this study might be of interest for implementation scholars. First and foremost; checklists are not simple tools. Therefore, developing an implementation strategy is not easy. Though it might be worthwhile to distil factors that influence implementation processes, scholars should not overlook that they are interrelated in many complex ways. Individual factors cannot be understood without a consideration of social relations for example. Next, this study makes a plea for a more holistic research design when studying ‘effective implementation’ of standards. In the theoretical section on routine interactions (3.4.3) I discussed how many studies on the implementation of the Surgical Safety Checklist focused on ‘compliance’ and how these empirical studies were confined to either registration numbers, or isolated observation of the checklist performance. By considering the multiplicity of routines, I have been able to answer questions like: Why wasn’t the anaesthesiologist there? Why did the surgeon already start with the briefing? Questions that would otherwise have remained unanswered. By observing just the performance of the checklist in the operating theatre, and herewith neglecting the interaction with other routines, these instances would have been reported as ‘non-compliant’. A focus on interacting routines makes me conclude that the term ‘non-compliance’ has too much weight in talking about patient safety. Compliance is closely associated with strict rule-following behaviour, while the complex nature of surgical care requires professionals to be responsive to (conflicting) routine demands. Thirdly, general lessons like: “A system that holds people accountable for improper behaviour or use of the initiative should be considered” (Russ et al., 2015, p.89)” will always remain general lessons. In looking for ways to make standards ‘work’, implementation should not be seen as a linear process, but a constant and dynamic process in which what works best is tight to specific contexts and will only gain meaning through contextualized actions. 8.6.2 Methodological implications This dissertation makes a case for ethnographic sensibility in both Public Administration and healthcare/patient safety research. I started this dissertation