Connective Routines: An Ethnographic Analysis of how Professional Standards Work in Medical Practice

Abstract

This dissertation analyses if and how standardization is a means to reduce mistakes and to improve the quality of surgical care delivery. This is highly relevant, given the challenges of present-day professional service delivery: the delivery of (surgical) care is complex, quality expectations have risen, medical professionals cannot make mistakes, trust in medical professions is no longer guaranteed. New professional standards such as checklists are implemented as simple solutions to cope with these challenges. However, checklists are not automatically turned into new professional routines on a day-to-day basis. Although so-called ‘implementation gaps’ are well-known, we hardly know how standards actually work. This dissertation analyses how new professional standards work, by looking at the way in which they make connections – or not. First, connections between people prove to be of crucial importance. Checklists are not ‘simple’ solutions, as team members have different ideas about checklists and what they mean for professional action. Secondly, connections between routines matter. Professionals have to deal with multiple, sometimes conflicting standards – they must set priorities and fit standards to the situation at hand. Thirdly, connections between artefacts, i.e. the (material) manifestations of standards, matter for whether checklists become workable. Whether they are used digitally or not, for example, makes a difference. This dissertation concludes that professional standards work if they are actively made to work. If and when connections are brought into existence, in teams, in workflows and in workable artefacts, new ways of working become reality. Working with standards calls for professional responsiveness.