question - Assignment Essays

1-2 paragraphs, no plagiarism, original work

Reflect on the articles/video from this week regarding teamwork, team training and checklists. Share an example of how you currently use or have participated in teamwork training or the use of checklists.

Neither magic bullet nor a mere tool: negotiating
multiple logics of the checklist in healthcare quality
improvement
David Kocman1,2, Tereza St€ockelov�a2, Rupert Pearse3

and Graham Martin1,4

1SAPPHIRE Group, Department of Health Sciences, College of Life Sciences, University of
Leicester, Leicester, UK
2Institute of Sociology of the Czech Academy of Sciences, Prague, Czech Republic
3William Harvey Research Institute, Queen Mary, University of London, London, UK
4The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge,UK

Abstract Over two decades, the checklist has risen to prominence in healthcare
improvement. This paper contributes to the debate between its proponents and
critics, making the case for an Science and Technology Studies-informed
understanding of the checklist that demonstrates the limitations of both the
“checklist-as-panacea” and “checklist-as-socially-determined” positions. Attending
to the checklist as a socio-material object endowed with affordances that call upon
clinicians to act (Allen 2012, Hutchby 2001), the study revisits the efforts of a
recent improvement initiative, the Enhanced Peri-Operative Care for High-risk
patients trial. Rather than a singularised simple tool, this study discusses four
different and relationally enacted logics of the checklist as a stop and check tool, a
clinical prompt, an audit tool and a clinical record. Each logic is associated with
specific temporality, beneficiaries, relationship with material forms, and
interpellates (Law 2002) clinicians to initiate specific actions which can conflict.
The paper seeks to make the case for intervention to improve such tools and
consciously account for the consequences of their design and materiality and calls
for supporting such settings and arrangements in which incoherences collected in
tools can be locally negotiated.

Keywords: checklist, healthcare improvement, affordances, multiple logics, socio-material
infrastructures

Introduction

In the new millennium, the checklist rose to global prominence in a series of well delivered
pilot projects followed by the WHO recommending that all hospitals use this device in surgery
(Haynes et al. 2009). In the UK, by 2012, around 2000 institutions had tried the checklist in
daily practice for procedures in specialisms ranging from surgery and anaesthesia to childbirth
and swine flu (Anthes 2015). A best-selling apotheosis of an effort to promote the checklist
was Atul Gawande’s (2010) The Checklist Manifesto which placed the checklist within the

Published by John Wiley & Sons Ltd., 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA

Sociology of Health & Illness Vol. 41 No. 4 2019 ISSN 0141-9889, pp. 755–771
doi: 10.1111/1467-9566.12861

wider arena of quality improvement, insisting that doing simple things right and consistently
can fix many problems and challenges of modern medicine characterised by an ever-increasing
complexity. Simple tools such as checklists were argued to provide far better outcomes than
any individual pill or the best-trained surgeon (Gawande 2015). The turn to improving care
through checklists was further underpinned by strong theoretical framing in systems thinking,
behavioural psychology and epidemiology (Waring et al. 2016, Zuiderent-Jerak and Berg
2010) combined with rigorous process control adopted from the manufacturing sector (Hales
and Pronovost 2006, Jammer et al. 2015, Parry 2014, Pronovost et al. 2006). While some
research reported mixed messages about its effectiveness (Treadwell et al. 2014, Urbach et al.
2014), quality improvement in healthcare, with its emphasis on low-tech strategies and mun-
dane artefacts and formal tools to ensure behavioural change (Marshall et al. 2013, Parry
2014, Perla et al. 2013), provided a fruitful platform for the checklist’s rise as a simple yet
powerful instrument for standardising clinical practice and improving healthcare outcomes.

The rise of the checklist has not passed unnoticed by sociology. Critical examinations
pointed out that the checklist may have been regarded by too many as a “magic bullet” ready
to effect positive change irrespective of context (Dixon-Woods et al. 2012). Such critique,
often drawing on ethnographic insights into how clinical tools work in their environments,
argued against attributing improved outcomes solely or primarily to the checklist (Bosk et al.
2009). Some argued that promoting checklists as a powerful solution to complex problems
was an oversimplification and a distraction (e.g. Catchpole and Russ 2015) – technical solu-
tions could not resolve complex social problems such as behavioural change in healthcare set-
tings (e.g. Bosk et al. 2009). Arguably, the key point made by these authors is not that
checklists do not work, but that they do not work alone. Unlike checklist enthusiasts, critics
showed how success of improvement initiatives, rather than technical fixes, relied on an inter-
play of social factors, cultural values, practices and negotiations. All along, it was arduous
work, often laden with emotions (Aveling et al. 2013, Dixon-Woods and Martin 2016, Dixon-
Woods et al. 2012).

In this paper, we contribute to this debate between proponents and critics of the checklist.
We suggest that this debate risks generating conceptualisations that oscillate between viewing
the checklist in healthcare improvement as either a “magic bullet,” or a “mere tool,” animated
(and dominated) by social forces. We argue that to understand the role and power of checklist
in today’s healthcare, we need to attend to its materiality in action. To do so, we mobilise
insights from Science and Technology Studies (STS) about how mundane artefacts act, and
are acted upon, in socio-material arrangements of healthcare. In particular, we draw on the
work of Davina Allen on the “affordances” of tools (Allen 2012, Allen et al. 2016, Hutchby
2001, Petrakaki et al. 2016) and expand it using the notion of “multiple logics” (Law 1994).
With this analytical sensitivity, we revisit ethnographic data collected as part of an evaluation
of a recent initiative in the British National Health Service (NHS) aimed at improving emer-
gency surgery. Our findings show that in everyday improvement practice, clinicians did not
engage with a “simple checklist” endowed with a single set of affordances. We argue that the
affordances of the checklist clustered to identifiable different logics inscribed in larger infras-
tructures of healthcare (and beyond). We show different versions of the checklist that were
relationally enacted at different times: the checklist was at one time a stop and check tool, at
another time a clinical prompt, an audit tool, or a clinical record. At the sharp end of improve-
ment projects, we also observed an interplay between the logics. This interplay at times cre-
ated practical tensions for clinicians. Both proponents and critics tend to understand tensions
and uncertainties around the checklist as a function of clinical resistance, ignorance or mis-
managed projects. We suggest, rather, that tensions were part of the checklist’s materiality
whereby different logics prompted clinicians to undertake specific actions, within a specific
© 2019 Foundation for the Sociology of Health & Illness

756 David Kocman et al.

temporality and for specific beneficiaries. These actions, timescales and audiences were not
always incompatible. But often they also created frictions that needed to be negotiated by clin-
icians in everyday encounters. This allows us to see practical tinkering with the checklist not
as singular enactments but as patterned activity whereby the logics are further stabilised (or
not) in healthcare. Our findings have implications for understanding the ways improvement
tools shape clinical actions.

After further revisiting the checklist debate to add a third theoretical perspective in the next
section, and accounting for our methods, we outline findings about how hospital-based
improvement teams in our study used a specific tool, which followed the checklist format, the
pre-operative “boarding card.” In the concluding discussion, we highlight implications for the-
ory and practice.

Bringing STS to the checklist debate

The rise of the checklist in medical practice provoked a critical response from sociologists and
clinicians who pointed out that the checklist enthusiasts and the WHO recommendations may
have overstated the significance of the checklist (e.g. Aveling et al. 2013, Dixon-Woods et al.
2011). Critics revisited one of the successful studies cited by those promoting the checklist,
the Keystone improvement programme in Michigan, US, which reported a large and sustained
reduction in rates of catheter-related blood stream infections in Intensive Care Units (Pronovost
et al. 2006). The triumph, which led to 50 per cent reduction in deaths, was ascribed by some
to the checklist. The response argued that “the mistake of the simple checklist story was in the
assumption that a technical solution (checklists) can solve an adaptive (sociocultural) problem”

(Bosk et al. 2009: 444). Arguably, checklists were but one component in the composite reality
of healthcare, which was “messier” and more complex than checklist proponents imagined.
Improvements that worked involved the creation of social networks with a shared sense of
mission, whose members were each able to reinforce the efforts of the other to cooperate with
the interventions. An ex post reconstruction of the Michigan project confirmed that the success
of Keystone dwelled in reframing clinical issues as a social problem which involved human
action and behaviour, creating social networks to generate a wide buy-in, and using persuasive
techniques such as storytelling and “hard data” (Dixon-Woods et al. 2011).

Both advocates and critics deployed specific notions of agency in their understanding of the
checklist and the role of the context in affecting success of medical actions. Advocates called
the checklist a simple and powerful improvement tool, and promoted it as an effective way of
managing complexity. To them, success was inherent to the tool while failure may occur as an
effect of external influences, namely people mishandling the checklist. If used wisely, check-
lists are said to be able to reduce ambiguity and enable clinicians to perform required tasks
consistently (Gawande 2007, Walker et al. 2012). Critics suggest that, rather than a magic bul-
let, the checklist is dependent for success on the social context of its use. Where advocates of
the checklist understood success a function of the checklist and failure a social outcome, critics
pointed out that, in fact, both failure and success are determined by the interplay of social fac-
tors, cultural values, practices and negotiations. In these accounts, the checklist becomes unin-
teresting compared to the forces that animate (or inhibit) it. Nonetheless, both camps agreed
that investing in “social contexts,” namely in interventions such as education and coaching of
clinicians (Low et al. 2012) and effective leadership (Conley et al. 2011), need to be under-
stood as key to successful improvement (Bosk et al. 2009, Brown and Calnan 2011). After
all, both agree that “the main challenge to [implementation] lies within us” (Low et al. 2012:
1030).

Neither magic bullet nor a mere tool 757

This accentuation of the social and organisational context in both the “magic bullet” story
and its critique has meant that the question of the materiality of the checklist remains under-
researched and under-theorised. To advance the debate, we turn to STS, and more specifically
to Davina Allen’s call for considering how “affordances” of mundane technologies, such as
the checklist, relate to the socio-material infrastructure into which they are introduced (Allen
2012: 461). Despite its contested ontology (Parchoma 2014), the concept of affordances has
been widely used in studies of medicine (Allen 2012, Petrakaki et al. 2016) and other areas
(Koed Madsen 2015, Leonardi 2011, Zammuto et al. 2007). Following Hutchby, affordances
refer to the “functional and relational aspects which frame, while not determining, the possibil-
ities for agentic action in relation to an object” (Hutchby 2001: 444, emphasis added). We
may think of affordances as material ways of calling upon clinicians: as “interpellating” them
towards certain actions and not others (Law 2002). How strong these interpellations become
remains open to interactional negotiations where other elements, both human and non-human,
intervene. In that respect, affordances come close to the classic STS notion of “materiality” in
conveying the idea that technologies exercise agency in the sense they matter more than mere
containers for human intentions and meaning (Latour 2005) – while emphasising that any such
agency is emergent, rather than inherent to the technology. The checklist as a socio-material
object not only emerges in actual enactments, it also has specific consequences in those
enactments.

To advance the debate about checklist and its affordances, one of the stories STS have told
consistently about objects and technologies, from aircrafts (Law 2002) to bush pumps (de Laet
and Mol 2000) and electronic patient records (Petrakaki et al. 2016), is that they are rarely
“singularised” – well bounded and organized along a single logic (Berg 1997). The STS sto-
ries then often use the notion of “logic” in plural, referring to multiple versions of an object,
each providing it and those around it with an operational framework for action or a “mode of
ordering” (Law 1994). There is no space for technological (or social) determinism (Latour
2005). Each logic can be associated with a different temporality, prescribe specific action and
a beneficiary of that action, require an action of a particular speed and rhythm, and make vari-
able demands of others’ actions. Logics also have an emergent quality. They do not pre-exist
“practice,” yet they pre-exist individual practices in the sense of having been enacted in myr-
iad ways before their next enactment. As such they may be learned about and inscribed into
tools. We explore the materiality of the checklist through its various logics that may entangle
and disentangle those around it, and may also conflict with each other. The checklist, like
other technologies, may then perform in incoherent ways (Law 2002).

The case: checklist as part of the EPOCH trial

The Enhanced Peri-Operative Care for High-risk patients (EPOCH) trial, launched in 2014,
was a major national project to improve emergency general (abdominal) surgery in the UK,
with 96 NHS hospitals participating in 15 clusters over an 18-month period. The trial intro-
duced a 36-node list of clinical interventions organised in a care pathway which set out the
ideal routemap for pre-operative, intra-operative to post-operative care and patient discharge
(Pearse 2014). Implementation of the pathway was supported by a range of strategies and tools
devised to that end, and shared by the trial coordinators with participating improvement teams.
Clinicians-turned-quality-improvement-leads were prompted to combine evidence-based clini-
cal practice with thinking about “softer skills” of persuasion, taught how to understand varia-
tion in data, and how to build up knowledge about instigating change. The care pathway was
also subdivided into several “bundles” for ease of implementation and evaluation; the trial
© 2019 Foundation for the Sociology of Health & Illness

758 David Kocman et al.

coordinators encouraged improvement teams to use tools such as a “boarding card” to imple-
ment a specific bundle of clinical actions into everyday surgical care.

The “boarding card” was a checklist-based tool born out of a list of recommendations pub-
lished in 2011 by the RCS (2011) and later systematised into a care pathway (Odor and Gro-
cott 2016, Pearse et al. 2011). The recommendations were also translated into a prototype
“boarding card” tested in an improvement project in southern England (see Figure 1), and
widely circulated across clinical communities (Richards et al. 2016). The EPOCH trial coordi-
nators encouraged participating hospital teams to adapt the “prototype” boarding card to fit
their local improvement needs. As such, the individual checklist-based tools varied in detail
while incorporating all interventions included in the pre-operative bundle of the pathway.

Data and methods

Data used in this paper come from a qualitative sub-study in six hospitals which ran concur-
rently with the EPOCH trial. The trial itself followed a stepped wedge cluster randomisation
format with gradual activation of clusters of hospitals into the trial. The six sites selected for
the sub-study were activated at various points, allowing for differences in length of engage-
ment. Consequently, the volume of collected data ranged from 20 interviews and 54 hours’
observation in Site 2 to four interviews and 18 hours’ observation in Site 6. Across all six
sites, 54 interviews and over 200 hours’ observation were undertaken. Interviews, mainly with

Figure 1 The prototypical emergency surgery “boarding card.” Source: Richards et al. (2016). [Colour
pictures can be viewed at wileyonlinelibrary.com]

Neither magic bullet nor a mere tool 759

senior clinicians in surgery, anaesthesia and critical care who acted as implementation leads,
focused on capturing key nodes of decision-making, factors affecting implementation, actors
involved and their understandings, and the implementation tools and strategies they chose to
deploy. Observations covered visits to regional meetings organised by the trial coordinators,
local teams’ implementation meetings, and various gatherings called by the improvement teams.

The overall ethnographic framework focused broadly on challenges to implementation and
was not designed to collect systematic data on the checklist. When revisiting the collected
material for the purposes of this paper, only data from Site 2 and Site 5 were utilised, as
improvement teams in these sites attempted extensively to deploy boarding cards to improve
emergency surgery. Data from the remaining sites did not allow for a detailed account of local
tinkering with the checklist; they are reported in other outputs (Martin et al. 2017). As part of
the original ethnography, all interviews were digitally audio recorded, and field notes recorded
in a diary at the time of observation, or as soon as possible afterwards. Interview recordings,
fieldnotes and within-team debriefs discussing the data collected were then professionally tran-
scribed. Analysis of data was based on the constant comparative method (Charmaz 2007) but
informed by theoretical concepts arising from the literature and from discussion within the
team. This process allowed the analytical construction of four logics of the checklist: some,
such as the logics of “audit” and “stop and check,” had already existed in different strands of
literature and were also observed in the field. Others, such as the checklist as a clinical record
and the checklist as a prompt, emerged because the interviews and observations offered other
and more nuanced positions. The authors then critically reflected on the autonomous status of
individual logics but also weighted their presence and gravity in interactions between clinicians
and the checklist. Separating analytically the range of domains within which logics operated
informed this process, as some logics, namely “stop and check” and “prompt,” were alike in
terms of aims and beneficiaries and only differed in temporality and rhythm (see Table 1).

Ethical approval was given by a NHS Research Ethics Committee, and clearance was provided
by the research governance office of each participating organisation before fieldwork began.

Findings

Invariably, for clinicians, the boarding card represented a “singularised” tool with a common
name, printed on a single sheet of paper, which was simple to use and brought together the
best of improvement science and clinical knowledge in emergency surgery.

The boarding card. Dead easy. People like it, it focuses the mind. It’s been great. (Consul-
tant in intensive care and anaesthetics, Hospital 5)

Despite the perceived simple nature and singularity of the tool, we account for four different
logics that could be identified in interactions between clinicians and the boarding card: stop
and check; prompt; audit; and clinical record (see summary in Table 1). After their empirical
exposition which follows we then attend to the ways clinicians navigated their improvement
work through the various, sometimes conflicting, demands posed by the interplay of logics.

Checklist as a stop and check

Similarly to aviation where the idea of the checklist originated (Clay-Williams and Colligan
2015), the stop and check logic required clinicians to pause and check whether a set of
© 2019 Foundation for the Sociology of Health & Illness

760 David Kocman et al.

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Neither magic bullet nor a mere tool 761

interventions specified on the checklist form had been completed. As such, the checklist was
designed to become an important tool to remind an individual – the clinician holding the
boarding card in their hands – to check whether either they or colleagues had done what they
were meant to. The guiding question was “has this been done?”, “have we missed anything
important?” in pre-operative assessment and decision-making:

It’s all about optimising the physiology of a patient going for laparotomy. [. . .] So [here we
have] highest early warning score in the last 6 hours, [then] systemic inflammatory response
syndrome, so this is the patient tachycardia, what’s their white count et cetera. [. . .] Antibi-
otics, have they been given yet, is the patient consented, cross-matched, evidence of coagu-
lopathy, and then there’ll be a predicted mortality. (Consultant surgeon, Hospital 2)

The positive argument for using the checklist to stop and check bore the imprint of Gawande
and the “human factors” community about how human fallibilities (e.g. cognitive capacity,
memory) in pressurised, complex organisations can give rise to “non-compliance.” The
EPOCH improvement leads promoted checklists as a means of managing complexity and, in
doing so, translated these arguments into their local environments.

It may be that you forgot to take the temperature because you had other things on your
mind, and so having the flowchart and the tick boxes, you just go “Oh, I haven’t ticked that
box, what was that one, oh, that was the temperature one, oh, quickly do that.” (Consultant
anaesthetist, Hospital 2)

The “temporality” of the stop and check logic was thus looking back before the next clinical
step could begin. Stopping and checking required that clinicians craft dedicated time and space
for doing so. Local improvement teams introducing the boarding card followed the guidance
and located this opportunity in the period immediately before a theatre was to be booked for
operation. To support this pause of self-reflection and to ensure clinical interventions on the
boarding card were given attention by clinicians, theatre booking systems in Hospital 2 were
amended, and administrators and theatre coordinators were instructed not to book operations
unless all interventions on the boarding card had been completed.

Checklist as a prompt

The second logic of the pre-operative checklist – checklist as a clinical prompt – also related
to individual clinicians considering clinical interventions. Individually and as a bundle, all
interventions on the boarding card made sense to clinicians who deemed them a good standard
of care in high-risk emergency surgery. Still, for any individual patient, they may not have
deployed every single intervention. The EPOCH trial aimed to reduce variation in care. To that
end, the checklist was designed as a tool to instil sameness. Both “stop and check” and “clini-
cal prompt” logics had a role in this effort – both prescribed actions to be taken by clinicians.
Where they differed was temporality and rhythm. The stop and check logic operated retrospec-
tively and required clinicians to slow down to recall and reflect, whereas as a prompt the
checklist mainly called to action prospectively what might not otherwise happen.

I’m interested that [clinical interventions] are done. Ultimately we’re interested that it’s
done. It would be a bonus if the checklist has actually been completed; but I think the
checklist, from my point of view, is a prompt for people. (Research nurse, Hospital 2)

762 David Kocman et al.

Some clinicians felt that the checklist as a prompt was there to provide guidance to junior doc-
tors in particular. Others had in mind those providing cover on an early morning shift and
those who may otherwise forget or resist taking specified clinical interventions.

Checklists are good, tick boxes are good, because when people are in a stressful situation or
if they’re tired or if there are lots of other pressures going on and they’re being torn in lots
of different directions to do lots of different jobs by lots of different people, that people
don’t perform well and checklists are a safety mechanism and can really help in that situa-
tion. (Consultant intensivist, Hospital 2)

Taken seriously, the checklist was meant to ensure a set of concerted clinical interventions
took place every time, everywhere. As such it demanded all clinicians, irrespective of senior-
ity, to be obedient in enacting all prescribed interventions deemed right and proper in pre-
operative care.

The more we do it, the easier it will get, the more it becomes established into the fabric of
what we do and the easier it will be. But I think in the early days mainly to use it as a
prompt and then for the resistant cases we’ll need to use a taser and then people will
develop an aversion to tasers and will start to do it; even the more reluctant members will
start to do it. (Consultant anaesthetist, Hospital 2)

The ideal user of the checklist was therefore a clinician who subscribed to the call of quality
and safety to eradicate variation in care. The checklist as prompt had no expiry date: it was
not to be overridden by years of clinical experience or by established routinisation of actions.

[W]e all think we know better, we all think we know how to give an anaesthetic, but really, do
we? There’s nothing, there’s no evidence to suggest that. All the evidence suggests [the need
to] minimise variation in practice. And I think – essentially it’s a checklist, isn’t it, and that’s
[what] these things are doing. (Consultant in intensive care and anaesthetics, Hospital 5)

Together with the logic of checking, prompts to action were framed as important and indis-
pensable to everyday work even for the most experienced of clinicians, since no-one was
deemed immune to the risk of errors and workarounds. When clinicians argued that the check-
list helped in dealing with manifold pressures of the workplace, another echo of arguments
from Gawande’s Manifesto could be heard across improvement teams.

Checklist as an audit tool

Thirdly, improvement teams introduced the boarding card as an audit tool to monitor the
implementation of the pre-operative bundle. As such they felt its format allowed for an easy
administration, collection and checking to provide information about compliance with newly
rolled out processes. The compliance was in turn seen as a precondition of improved out-
comes. Therefore, with respect to audit, the prime action associated with the checklist was
recording. Where the stop-and-check asked clinicians to initiate a mental verification of their
past actions and the prompt logic asked them to act, the audit logic required clinicians to
write, tick, and record for the sake of a distant reader. Thus, the beneficiary also changed.
Recording for audit did not benefit the clinician and their immediate actions, but a third party
who at some point might collect and audit the checklists.

Neither magic bullet nor a mere tool 763

The defining feature of the audit logic was the presumption of a close link between what
was recorded and what had happened. As long as the checklists were filled in, clinical inter-
ventions listed on the boarding card were deemed actioned. Conversely, the improvement leads
often repeated the assumption that “what is not recorded has not happened.”

We’ve discussed this, and in my mind if the data is not there, it hasn’t been done. (Consul-
tant anaesthetist, Hospital 2)

Outside the audit logic, clinicians were ready to problematise such an assumption as simplistic.
They could readily recall how actions and recording of those actions were in fact spatially and
temporally dissociated, and could take place independently of each other. Clinicians knew that
at times, such as in situations of conflicting pressures, prescribed interventions were difficult to
complete. Their experiences also suggested that, at other times, recording was implausible or
even impossible. Practical dissociation between clinical actions and their recording for audit
also meant that, at least in principle, action could take place even when the associated record-
ing did not (or vice versa).

I did one [emergency laparotomy] recently. I realised that I still hadn’t filled out the check-
list form because the [patient] was about to die in front of me, so I didn’t get the checklist
done at the time. But I did it retrospectively [. . .] after theatre. (Consultant anaesthetist,
Hospital 2)

Yet when acting within the audit logic, irrespective of their experience with the practical dis-
entanglement between actions and recording, clinicians upheld the ideal of a tight coupling
between the two. Only such insistence, tenable or not outside audit, rendered checking compli-
ance through the means of the boarding card meaningful. It promised to inform the improve-
ment team whether implementation was a success or a failure. Thus, when a research nurse in
Site 2 was asked to retrieve the boarding card forms for 17 emergency laparotomies and found
that only seven had been completed, with only five in full, the local improvement team had a
generalised sense of failed clinical practice (not just record-keeping).

The ease with which counting could be done was a valued quality of the checklist in its
own right. Even though the improvement teams also used other more extensive performance
measures to harness knowledge about instilling change in emergency surgery, the allure of
auditability was strong among clinicians. They maintained praise of the boarding card as a
very “auditable tool,”

Being a tick box, [the boarding card] is very easily auditable. Because we can send one of
our med students away and say, “Count how many boxes have been ticked,” and we can
plot them on the timeline. We can have a monthly return; put them on a timeline. And what
I would love to see is mortality coming down as our intervention rate goes up. (Consultant
in anaesthetics and critical care, Hospital 2)

In Site 5, the improvement team discussed whether the boarding card should be incorporated
into an existing theatre booking form. In the discussion, one member of the team argued
against burdening clinicians with yet another form, and for merging the checklist with the the-
atre booking form. However, the promise of quick and easy auditability won the argument,
and the forms remained separate. This was because recording in the logic of audit was not
regarded as burdensome; rather it was constructed as integral to care and a supposedly syner-
gistic extension of the other logics of stop and check and prompt.
© 2019 Foundation for the Sociology of Health & Illness

764 David Kocman et al.

Checklist as a clinical record

On top of audit, some clinicians associated the emergency laparotomy checklist with another
way of recording clinical activity. In complex organisational arrangements such as healthcare,
clinical records have an indispensable role in decision-making, which often cannot proceed
without having specific recorded information at hand (Berg and Bowker 1997). This enabling
role in clinical decision-making was what distinguished clinical record from recording for
audit. Although both logics involved practices of writing in order to share information with
others, in audit these “others” were third parties auditing compliance. The checklist was also
meant to be relevant to clinicians and the unfolding process of care there and then. In this
respect, the boarding card was equipped to hold patient-specific, clinically relevant informa-
tion, most importantly the P-POSSUM score calculating the risk of mortality and morbidity,
across temporally and spatially separate teams.

There are possibly two or three registrars involved in seeing a patient at different times of
the patient journey. And things can slip . . . (General surgery registrar, Hospital 2)

Holding such information (such as body temperature or levels of arterial lactate) would also
reinforce the agency of the checklist: clinicians would be waiting for the records to inform
their actions, and require less coercion to engage with the checklist.

Contrary to these hopes, it soon transpired that, of all four logics, the logic of clinical record
was the least pronounced in the use of the boarding card. In an environment already populated
by a plethora of other forms containing a spectrum of measures that circulated in and out of
operating theatres, the boarding card as a record failed to interest clinicians. Although the
checklist followed patients through theatres, most of its items were also being recorded else-
where and thus seen as duplicate: for example, the calculated P-POSSUM score, which
EPOCH leads understood as a key measure to inform decision-making pre-operatively, was
recorded on the boarding card but also on the National Emergency Laparotomy Audit form
which, unlike the checklist, was mandatory for clinicians to complete and which sometimes
even served as a reference point for clinicians – i.e. it also served as a clinical record, leaving
this logic of the checklist redundant. As a result, no-one was really waiting for the checklist to
inform their decision-making. When put to action in the wider infrastructure of records, the
checklist ended up yielding comparatively little relevance to keep clinicians interested. As the
boarding card failed to move from one pair of hands to another it practically weakened the
logic of clinical record.

Dealing with incoherence

When the boarding card was introduced in participating sites, it was thought of as a singular
entity able to perform several roles, from allowing clinicians to stop and check to serving as a
clinical record. In practice, however, clinicians involved in the process of implementing the
tool started to experience uncertainties when revising the tool for the purposes of audit. The
materiality of the form, namely the way individual items on the form were formulated, sat well
with some logics and created tensions with others. Within the logic of prompt, clinicians inter-
acted with a sequence of reminders. As the boarding care conveyed “key words” referring to
familiar clinical interventions, the exact wording of sentences was of lesser importance. For
clinicians the checklist as a prompt simply read: “do the blood sugars,” “give antibiotics,”
“consent the patient” etc. Within the logic of audit, however, this was no longer the case and

Neither magic bullet nor a mere tool 765

the wording of individual prompts gained gravity. Clinicians needed to read the whole sen-
tences and consider more carefully what they meant rather than rely on key words understood
as a reminder of good practice and a prompt to action.

Take the case of a specific item of the boarding card, “patient warming.” As a clinical prompt,
it simply asked clinicians to remember that body temperature mattered and that it ought to be
checked. Ideally it would be taken seriously by a knowledgeable and skilled clinician who would
then determine a specific action based on their experience and clinical judgement. Compared to
the checklist as a prompt, the logic of audit rendered the manoeuvring space for individual action
narrower. Whereas a prompt could come in the form of a keyword which elucidated a range of
practical options, the wording of an audit question had a certain specificity built into it; and with
it came prescriptiveness: the checklist rendered some clinical actions more permissible than
others. A clinician used to the relative freedom of prompts, stemming from not being called upon
to account for every word, could then become preoccupied with what practice was implied by the
wording, and how it related to their and others actions.

[It says,] “Has active patient warming been undertaken?” Well, no it hasn’t. So you put
“no” in and it scores badly on the interventions. But, actually, it hasn’t been undertaken
because the temperature was 39 degrees [Celsius] and you’re not going to warm someone
who is boiling hot. So [it should really read], “Has avoidance of hypothermia been consid-
ered?” [That would mean], they’re cold, let’s do something about it. But yes it’s been con-
sidered but they’re hot so we’re not doing anything about it, but it’s still being considered.
(Consultant anaesthetist, Hospital 2)

A similar tension was observed in the case of other items on the checklist such as glucose manage-
ment and administering antibiotics. Each time, the tension manifested itself in terms of specificity
and permissiveness of clinical actions and triggered a realisation that prompts were also audit ques-
tions. This in turn could trigger critical reflection resulting in an intent to redesign the checklist in
order to resolve the tension and re-entangle the materiality of the checklist with a range of logics.

Glucose monitoring, we should be doing that for everyone. But it says, “Have you done
blood glucose monitoring? ‘Yes/No’.” We should do it for everyone. So that’s an easier one
to ask. [But] to do the low tidal volume, protective ventilation you need a ventilator that’s
quite a little bit more intuitive than a lot of the basic ventilators. You can do it, but it may
be more difficult and in difficult patients you may spend all your time fiddling with the ven-
tilator. So all we’re saying is “Has it been attempted?” and that gets us round the fudge of
having a ventilator that’s not up to purpose. (Consultant anaesthetist, Hospital 2)

Not all items of the boarding card were seen by clinicians as problematic; some questions,
such as those related to calculating a mortality risk score, consenting a patient and recording
an early warning score, were deemed to have universality and context specificity balanced –
they were to be actioned for all patients regardless of the specifics of the case. But in many
cases, the need for an easily completed form that could be audited and for an aide that would
prompt action and checking by the individual clinician were in tension.

Discussion

This study draws upon STS sensibilities to contribute to the existing debate about the
checklist and its role in healthcare improvement. It follows Davina Allen’s (2012, 2017) call
© 2019 Foundation for the Sociology of Health & Illness

766 David Kocman et al.

for examining the mundane technologies used in organising healthcare as socio-material
entanglements, and her rendition of the notion of affordances through which the technolo-
gies interpellate clinicians. In the case of the EPOCH “boarding card,” these interpellations
were observed to be less deterministic than implied by the notion of a simple checklist and,
at the same time, exercised more gravity than suggested by critics who may tend to focus
on the social shaping of clinical actions and tools. Rather than a singlularised simple tool,
this study identified four different logics of the checklist, each calling upon clinicians to ini-
tiate certain actions: the checklist as a stop and check required only minimum recording, as
it mainly asked clinicians to recount clinical steps so far; the checklist as a prompt required
clinicians to activate interventions listed as part of a clinical pathway; the checklist as an
audit tool expected them to provide ticks and numbers under all listed items; and the
checklist as a clinical record sought (though largely failed) to prompt them to write down
clinically relevant information, e.g. the mortality risk score, for colleagues to read and act
upon.

The tool coupled different logics, yet the multiplicity did not necessarily imply tensions.
For example, we did not detect tensions between the checklist as a stop and check tool and
a prompt; the materiality of the form in its specific format allowed both to be acted upon:
one was prospective, the other retrospective, and their temporalities complemented rather
than conflicted with each other. The ill-fated logic of clinical record was rendered irrelevant
not by other logics but by other recording devices, such as the National Emergency Laparo-
tomy Audit form, the anaesthetic form and the existing theatre booking form, circulating in
perioperative care. Practical use or non-use derived not just from the interaction of logics
with each other, however; they arose from interactions with clinicians and the ways the tool
was intertwined with the wider textures of healthcare. In this respect, apart from circulation
of forms, we saw improvement teams crafting an architecture of support for the checklist as
a stop and check by entrusting theatre administrators with the powers not to book opera-
tions unless all items on the checklist had been attended to. We also saw how a specific
gravity was associated with the checklist as an audit tool due to well-established “audit cul-
tures” (Strathern 2000) within healthcare which affected what the improvement teams
wanted the checklist to tell them about compliance and what format the checklist might
take. Most broadly, we saw the tool connected to (and formed by) the dreams of quality
improvement as a specific approach to realising healthcare, which animated clinicians’ will
to engage with the boarding card through a promise of improved outcomes further down
the line.

Moving back to the material specificity of the boarding card, particular tensions were
observed as a relational effect of the format of the checklist and its wording and the in/abil-
ity of clinicians to act. We noticed a tension between the logics of prompt and audit. What
seemed a simple and obvious form of wording for one purpose could complicate the check-
list’s use according to the other. As part of the checklist’s composition, the logic of prompt
allowed for certain flexibility, in contrast to the closed format of audit questions which
impacted on how they could be answered and what the answers meant. In audit, all words
on the form started to matter – and the wording could belie the checklist’s assumed utility
and ease of use. In audit specifically, the prime action demanded by the checklist was
recording for a third party rather than performing a clinical action there and then. This post-
poned use of the checklist in audit further complicated clinicians’ interaction with the tool
as it brought into play questions of evaluation of their performance, and of the improve-
ment project as a whole. Yet even when logics conflicted, it did not need to pose an irre-
solvable problem. As Allen notes, people interacting with technologies tend to “find ways
of managing the constraints and the possibilities that emerge from a technology’s

Neither magic bullet nor a mere tool 767

affordance” (Allen 2017: 3). In this respect, we witnessed clinicians tinkering with the
design of the boarding card – their strategy was to insert the notion of “consideration” –
“has X been considered” rather than “has X been done” – which would allow clinicians to
assert clinical judgement and render the checklist applicable as an audit tool at the same
time. It is worth noting that the ability to redesign the checklist was specific to the innova-
tive nature of the trial. As such it was conditional and locally crafted. Had the boarding
card been rolled out as part of a different initiative with a standardised format, clinicians
would need to deploy different coping strategies, such as workarounds, rather than direct
re-design.

Such incoherence, as others in STS literature have argued (Law 2002), was not in principle
a problem. On the contrary, it was key to resolving tensions in situations when responding to
some logics of the checklist led to a struggle to follow others. It also closely related to the
acknowledgement that the checklist required adaptation in dynamic and divergent clinical set-
tings, rather than being a fixed untouchable simply to be. This implied recognition that the
very simplicity of the “simple checklist” could, ironically, cause complications: what was sim-
ple for one logic needed to be carefully unravelled if the checklist was to work in another. In
more general terms, success or failure of the checklist was not only in the hands of clinicians;
it was also in the hands of the tools – their properties and affordances. In this respect our
study suggests to conceptualise the potential of checklists in such way to avoid the all too
familiar oscillation between welcoming checklists as simple and powerful tools and the sur-
prise when checklists turn out to be less helpful than anticipated in making change happen.
The key is in supporting settings and arrangements in which incoherences inscribed into tools
can be locally negotiated. This includes asserting the role of various human intentions in
moulding the materiality, and hence the affordances, of the checklist in a way that anticipates
its use, its interaction with other actants, and the interpellations that might follow – and thus
accommodates and reconciles divergent intended functions as far as possible. This is not to
argue that such devices can be “scripted” through meticulous design so that emergent agency
is designed out (cf. Oudshoorn and Pinch 2003), but it is to suggest that through iterative
development based on practical experience, better checklists – and better approaches to
improvement – are possible.

Conclusion

Previous sociological studies highlight social contexts as key to successful use of the checklist
in healthcare improvement. Our STS-informed study suggests that the checklist as a mundane
tool comes equipped with affordances that mediate rather than determine entanglements of
people and things in organising healthcare. Moreover, rather than a seemingly simple tool with
a singularised set of affordances, we identified four logics, each interpellating clinicians to
specific actions. When given the opportunity, clinicians managed constraints and negotiated
conflicts. In this respect, our study highlights the potential for improvement initiatives to nour-
ish formative reflexivity about the construction of checklists as part of the wider infrastructures
of improvement.

Address for correspondence: David Kocman, Social Science Applied to Healthcare
Improvement Research Group (SAPPHIRE), Department of Health Sciences, College of Life
Sciences, George Davies Centre, University of Leicester, University Road, Leicester LE1 7RH,
UK. E-mail: dk172@le.ac.uk

768 David Kocman et al.

mailto:

Acknowledgements

We are grateful to staff members in participating sites for their time and frankness in interviews. We are
also grateful to Janet Willars for her contribution to fieldwork in one of the case-study sites. The empirical
research was funded by the National Institute for Health Research (NIHR) Health Services and Delivery
Research (HS&DR) programme (grant number 12/5005/10). David Kocman and Tereza St€ockelov�a’s con-
tributions to the paper were funded by the Czech Science Foundation (grant number 15-16452S). Graham
Martin’s contribution was also supported by the NIHR Collaboration for Leadership in Applied Health
Research and Care East Midlands (CLAHRC EM). The views expressed are those of the authors and not
necessarily those of the NHS, the NIHR, the Department of Health, or the Czech Science Foundation.

Supporting information

Additional supporting information may be found online in the Supporting Information section
at the end of the article.

Appendix S1. Members of the EPOCH trial group.

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