non-technical skills in the ornon-technical skills defined “behavioural aspects of performance in...

@jmrobertsonAPACVS 37th Annual Meeting

April 5, 2018

Non-Technical Skills in the OR

Jamie M. Robertson, PhD, MPHAssistant Director of Simulation-Based Learning

STRATUS Center for Medical SimulationBrigham and Women’s Hospital

Instructor in Emergency MedicineHarvard Medical School


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Nothing to disclose


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Objectives

• Discuss behavioral marker systems that have been developed to rate surgeons’ non-technical skills.

• Review non-technical skills required by surgeons in the operating room.


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Non-technical skills defined

“Behavioural aspects of performance in the operating room which underpin medical expertise, use of equipment and drugs. They are cognitive (e.g. situation awareness, decision making) and social (e.g. communication & teamwork, leadership) skills”

Yule et al Surgery 2006;139:140-149


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Some complications are due to non-technical skills

Observation and assessment key to improvement


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Situation Awareness, Decision Making, Teamwork, Leadership


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Situation Awareness

Decision Making

Teamwork

Leadership

These are critical competencies for high performance


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Defining Situation Awareness

January 2014

• “…the perception of the elements in the environment within a volume of time and space, the comprehension of their meaning, and the projection of their status in the near future”

• “Knowing what is happening around you”

Endsley, M.R. (1995). Human Factors 37(1), 32–64


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PERCEPTIONof data and the elements of the

environment (level 1)

COMPREHENSIONof the meaning

and significance of the situation

(level 2)

PROJECTIONof future states

and events

(level 3)

DECISION ACTION

SITUATION AWARENESS

State of theenvironment/

system

Mica Endsley’s 3-level model of Situation Awareness (1995)


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Observing Situation Awareness is challengingLimitations:• Much of SA is cognitive (inside the brain)• Must be partly inferred from observing outward

indicators of cognitive processes• Moment-moment; dynamic• Context/role/task specific

Observer biases:• Your assumptions may change based on feedback• Highly subject to hindsight bias• Dependent on situational awareness of the

observer• Your observations may not be consistent with self

report or peer observation


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Decide what to doSelect course of action

Situation AssessmentWhat is the problem? How much time is available?

What is the risk?

Implement course of action


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Focus on Intraoperative

• ‘Gloves on – scrubbed up’

• Influenced by pre-surgery decision making and planning

• Mainly routine – but can be unexpected events

• Characterised by:

- Dynamic risks

- Time constraints

- Resource constraints


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Types of Decision Making

• Analytical (option comparison)

• Rule-based (procedures)

• Recognition-primed (pattern-match)

• Creative (new solution)


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Communication failures in the OR can lead to patient injury

Info not transmitted or inaccurately received (n=60 cases) Greenberg et al Surgery 2007

Less info shared = greater chance of complication (n=293) Mazzocco et al AJS 2009

Communication failures in 24% of closed claimsRogers et al Surgery 2006


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Communication & Teamwork – NOTSS Definition • Skills for working in a team context to ensure

that the team has an acceptable shared picture of the situation and can complete tasks effectively

• Elements in NOTSS– Exchanging information

– Establishing a shared understanding

– Co-ordinating team activities


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Communication breakdowns

• Injury to patients– 60 cases of communication breakdown:

– 49% information not transmitted

– 44% info communicated but inaccurately received

– 7% info communicated but not received

Greenberg et al Surgery 2007


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Barriers to exchanging informationInternal

• Noise

• Low Voice

• Separation in space and time

• Lack of visual cues

– body language, eye contact, gestures, facial expressions etc

External

• Language difference

• Culture

• Motivation

• Expectations

• Past Experience

• Status

• Emotions / Moods


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Teamwork failures

– Teamwork failures related to technical errors in 31 cardiac cases (planned sequence of events fail to meet goal)

El Bardissi et al EJCS 2008


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Fundamentals of effective team coordination:

• Understand roles

• Task clarity

• Sequencing

• Deliberate practice

• Expertise

• Synchrony


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Leader

Aware of limitations

Can be wrong

Seeks advice

Supportive

Extracts performance

Commander

Infallible

Omnipotent

Doesn’t need advice

Intolerant of failure

Expects obedience


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Simple Things Matter

• Doing as you expect other people to do

• Expecting others to do as you do

• How you behave when no-one’s watching

• Deviance from Standard Protocol


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Creating the right environment

• Simulated OR with surgeon about to cut a blood vessel

• Students randomized to two groups:

– “Your opinion is important.”

• 23 of 28 (82%) spoke up

– “Do what I say. Save questions for next time.”

• 8 of 27 (30%) spoke upSalazar et al, JACS, 2014


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April 5, 2018

Thank you!

Contact: [email protected]

@jmrobertson

NOTSS Information: www.notss.org

mailto:[email protected]

http://www.notss.org/

non-technical skills in the ornon-technical skills defined “behavioural aspects of performance in...

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