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The effects of aviation-style non-technical skillstraining on technical performance and outcome in theoperating theatre
P McCulloch,1 A Mishra,1 A Handa,1 T Dale,2 G Hirst,2 K Catchpole1
See Commentary, p 91
c Additional material ispublished online only at http://qshc.bmj.com/content/vol18/issue2
1 Nuffield Department ofSurgery, University of Oxford,Oxford, UK; 2 Atrainability Ltd,Guildford, UK
Correspondence to:Mr P McCulloch, NuffieldDepartment of Surgery, 6thFloor, John Radcliffe Hospital,Headley Way, OxfordOX3 9DU, UK;firstname.lastname@example.org
Accepted 30 December 2008
ABSTRACTUnintended harm to patients in operating theatres iscommon. Correlations have been demonstrated betweenteamwork skills and error rates in theatres. This was asingle-institution uncontrolled beforeafter study of theeffects of non-technical skills training on attitudes,teamwork, technical performance and clinical outcome inlaparoscopic cholecystectomy (LC) and carotid endarter-ectomy (CEA) operations. The setting was the theatresuite of a UK teaching hospital. Attitudes were measuredusing the Safety Attitudes Questionnaire (SAQ).Teamwork was scored using the Oxford Non-TechnicalSkills (NOTECHS) method. Operative technical errors(OTEs), non-operative procedural errors (NOPEs), compli-cations, operating time and length of hospital stay (LOS)were recorded. A 9 h classroom non-technical skillscourse based on aviation Crew Resource Management(CRM) was offered to all staff, followed by 3 months oftwice-weekly coaching from CRM experts. Forty-eightprocedures (26 LC and 22 CEA) were studied beforeintervention, and 55 (32 and 23) afterwards. Non-technical skills and attitudes improved after training(NOTECHS increase 37.0 to 38.7, t = 22.35, p = 0.021,SAQ teamwork climate increase 64.1 to 69.2, t = 22.95,p = 0.007). OTEs declined from 1.73 to 0.98 (u = 1071,p = 0.009), and NOPEs from 8.48 to 5.16 per operation(t = 4.383, p,0.001). These effects were stronger in theLC group than in CEA procedures. The operating time wasunchanged, and a non-significant reduction in LOS wasobserved. Non-technical skills training improved technicalperformance in theatre, but the effects varied betweenteams. Considerable cultural resistance to adoption wasencountered, particularly among medical staff. Debriefingand challenging authority seemed more difficult tointroduce than other parts of the training. Further studiesare needed to define the optimal training package, explainvariable responses and confirm clinical benefit.
We studied personnel performing laparoscopiccholecystectomy (LC) and carotid endarterectomy(CEA) procedures in the theatre suites of a majorUK teaching hospital. These procedures wereselected to minimise difficulties in evaluatingperformance caused by variations in the operativeprocedure. All CEA operations were performed inone theatre while the LC procedures were mostlydone in three others, one of which was designateda day-case theatre. All CEA operations wereelective or semielective procedures performed ordirectly supervised by consultant vascular sur-geons. About 20% of LC were performed byexperienced trainees without supervision, and asimilar percentage were hot procedures. There
were no major differences in availability andquality of equipment between the LC theatresexcept that intraoperative cholangiography wasdifficult to perform in the day-case theatre. Theconsultant surgical and anaesthetic staff and seniortheatre nurses were largely constant throughoutthe study, but junior staff turnover was relativelyhigh, typical of UK practice. The day-case theatrewas situated in a different hospital from the othertheatres; the nursing staff in this theatre werepredominantly trained in the Philippines, whereasmost staff in the other theatres were UK-trained.The core CEA team had considerable experience ofworking together, and the senior members had allbeen trained by the same senior vascular surgeonwhen the CEA operation was first practisedregularly at the hospital. We aimed to studyconsecutive cases but made exceptions due torefusal of consent (one case) or unavailability ofresearch staff (three cases). After the intervention,we also excluded cases where there were fewerthan two members of the theatre team who hadattended the classroom part of the training course(six cases).
PROBLEMCurrent evidence suggests that modern healthcarecauses unintentional harm to between 3% and 16%of hospital inpatients.1 2 The factors implicatedinclude organisational complexity, reliance onpotentially dangerous high-technology equipmentand the lack of systematic communications andteamwork training for staff.3 4 The operatingtheatre is reportedly the environment wherepatient harm is most likely.5 Theatre work isperceived as stressful by staff,6 and communicationbetween team members as flawed and difficult.7
Reports on high-profile disasters in surgery such aswrong organ removal or the Bristol cardiac surgeryincident have stressed the major role of teamworkand communication problems in bringing theseabout.8 Reviews of practice in high-reliabilityindustries such as aviation, nuclear power andoffshore oil production emphasise the need fortraining in principles of teamwork and freecommunication to reduce the risks of error,9 andstudies in healthcare show that such trainingimproves safety culture and attitudes across arange of specialty settings.10 11 We were aware that,like most large hospitals, our local Trust hadexperienced major intraoperative incidents such awrong organ removal in the recent past.Observational studies in paediatric cardiac surgeryhave shown (a) a clear association between the
Qual Saf Health Care 2009;18:109115. doi:10.1136/qshc.2008.032045 109
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accumulation of minor errors in an operation and theoccurrence of a major incident with potentially seriousimplications for the patient12 and (b) a convincing correlationbetween the quality of theatre team non-technical skills andthe number of technical errors which occurred.13 The environ-ment in which these studies were conducted is highly unusual,and in particular combines extremely high risks of adverse orfatal outcome with an absolute need for close cooperationbetween anaesthetists, surgeons and perfusionists in the heartlung bypass process. A study of non-technical skills andtechnical errors in LC in our theatre suite, however, showedevidence of deficiencies in both technical and non-technicalskills of the same order as that seen in the cardiac environment,and confirmed the association between them.14 The hypothesisthat improvements in theatre team non-tech skills couldsubstantially reduce errors and adverse outcomes of surgeryhas become widely accepted, but the evidence supporting thishypothesis is currently scanty.
Studies of theatre teamwork, communication and safety havebeen largely observational, focusing on the development ofmethodology1517 and on the correlations between non-technicalskills and adverse events.13 18 19 Only one major interventionalstudy has attempted to evaluate non-technical skills training inhospitals,20 reporting a reduction in clinical errors in emergencyrooms. No similar study of theatre teams has been reported. Wefelt that the postulated benefits of non-tech skills training fortheatre teams merited further study. Based on our reading, weexpected we might, through aviation-style CRM teamworktraining, be able to improve teamwork in theatre teams, andthereby reduce technical errors and misunderstandings. Wetherefore hoped to see reductions in the number of potentiallysignificant errors and mishaps in theatre with potential forharm to patients, and perhaps to observe improvements in someclinical outcome measures. We therefore undertook a single-institution beforeafter study of a non-technical skills teamtraining intervention.
KEY MEASURES FOR IMPROVEMENTWe first observed performance and outcomes in a series ofoperations, then introduced a training intervention, and finallyconducted a second observation period. The three phases lasted6, 3 and 6 months respectively. We initially agreed to observe atheatre team from another specialty without providing an
intervention, but this team withdrew after some initialobservations due to sensitivities over their perception thatinvolvement called into question their current performance. Thestudy was therefore an uncontrolled beforeafter interventionstudy. Our hypothesis postulated an effect of teamworktraining starting with improved attitudes, knowledge andperformance in terms of teamwork and communication, leadingto a reduction in unsalvaged technical errors, misunderstand-ings and omissions, and via this route to less imperfect technicalresults and ultimately less complications. We therefore designedour outcome measures to evaluate a chain of evidence linkingteamwork training via improved teamwork attitudes, skills andperformance to reduced technical errors, untoward events andadverse outcomes. We therefore measured attitudes, knowledgeand behaviour relating to workplace teamwork and safety, andrecorded technical and procedural errors by the theatre teammembers. We also counted complications and critical incidentreports and measured operating time and length of hospitalstay. Ethical approval for the study was obtained from theMilton Keynes LREC (ref no 04/Q1603/35). Informed consentwas sought from all staff involved in the operations studied, andfrom the patients undergoing them.
METHODS FOR EVALUATIONObservations were made by researchers (AM and KC) present intheatre throughout each operation. Both had more than 2 yearsexperience in theatres as