Marlot Kuiper

310 Connective Routines Summary Background and Research Question This thesis focuses on standardization in healthcare. While medical doctors make it to the newspapers every now and then because of so-called ‘miracle operations’, they also regularly damage their professional reputation by making preventable mistakes like wrong side surgery or mixed-up patient identities. This leaves us with the question why ‘simple’ procedural tasks go wrong, while complex, innovative procedures succeed. This dissertation analyses if and how standardization is a means to reduce mistakes, and improve the quality of service delivery. The context of professional service delivery has changed drastically in recent years. Care delivery has become more complex, for instance because of multi- morbidity, new technologies, and evidence based knowledge that has to be translated into treatment plans for individual patients. Besides, trust in the professions and their services is no longer guaranteed. Publicly exposed incidents prompted both a political and public demand for more transparency and accountability. On top of this, these increasingly complex cases have to be treated in a policy context characterised by budgetary restraint and collaboration beyond professional borders. In short, various developments put professionalism under pressure. New professional standards like guidelines, protocols, and checklists have been implemented as simple and cheap solution to reduce medical mistakes and improve the quality of service delivery. However, the professional reality at the frontline proves more complicated. Checklists not automatically become new professional routines. The medical field sees itself confronted with a so-called ‘implementation gap’. Still, how standards actually work remains unknown. The standardization of professional work is being studied from multiple disciplines, and with varying research perspectives. Standards and their effects are approached differently from each of these perspectives. In the medical domain and the field of implementation science, standards are mostly seen as technical instrument that if implemented well - will lead to desired effects. From a sociological perspective, standards are seen as complex social instruments that will affect existing relationships. At first, professional standards were seen as a way to further professionalize and gain legitimacy. However, standardization makes practices measurable and comparable, and herewith allows for external