1. WORKSHOP Surgical Errors and Assessment of Non- Technical Skills for Surgeons (NoTSS) Jonathan Beard Eleanor Robertson

2. Aims of Workshop To enable you to understand the non- technical skills which underpin good intra-operative performance and how these can be observed and rated

3. Incidence of Adverse Events in Healthcare 10 - 15 % patients* 50% surgical 50% in the operating room 50% preventable Most due to human factors *Vincent BMJ 2001

4. Mortality Comparisons US airlines:5 years (2001-2006) = zero US Healthcare:250-500,000 deaths from medical errors* Equivalent to a Boeing 747s crashing every week *JJ Nance ‘Why hospitals should fly’ 2008 “How did that mountain goat get into this cloud?”

5. 1.Surgery on wrong body part 2.Surgery on the wrong patient 3.Wrong procedure 4.Foreign body left behind in patient (e.g. retained swab/instrument) 5.Intra-op or immediate post-op death in ASA 1 patient Surgical “Never Events”

7. Results – All Sites BaselineChecklistP value Cases 37333955- Death 1.5%0.8%0.003 Any Complication 11.0%7.0%<0.001 SSI 6.2%3.4%<0.001 Unplanned Reoperation 2.4%1.8%0.047

8. What Kind of Team do we Have? A: Expert Team Same team every time Highly skilled individuals Stable membership Clearly defined roles and skill sets B: Team of Experts Ad Hoc Highly skilled individuals Fluid membership Multiple crews

9. ‘Miracle on the Hudson’ Flight crew manages to land plane on the Hudson river minutes after take-off from LaGuardia Airport with no loss of life after catastrophic engine failure due to bird strike. Avoiding Disasters

10. How Good are You at …………. Coping when things go wrong? Coping with uncertainty? Accommodating change? Waiting for things? Dealing with distractions? Supporting juniors in theatre? Speaking up if you see a potential problem?

11. Danger signs H ungry A ngry L ate T ired x8 times more likely to have an accident HALT!

12. Effect of rudeness Rudeness effects subjects and onlookers in performance of routine and creative tasks working memory Porath & Erez Organizational behaviour and Human decision processes 2009 109:29-44 Effect of Rudeness

13. Project sponsors: Royal College of Surgeons of Edinburgh (RCSEd) NHS Education for Scotland (NES) Developing a behaviour rating system to assess surgeons intra-operative skills: The NOTSS project (2002-2008))

14. Task analysis (2003-2005) Literature, survey, observations, cognitive interviews 150 skills emerged Taxonomy design and development (2005-2006) 150 skills sorted by 4 panels of attending surgeons Taxonomy and behavior markers written Evaluation (2006-2008) Reliability - using video scenarios (n=44 attending) Usability testing in the OR Implementation (2008- 2014) NOTSS debriefing in OR and simulated OR Masterclass curriculum Reliability, validity and acceptability tested in Sheffield*and South Yorkshire NOTSS Development

15. CategoriesElements Situation Awareness Gathering Information Understanding Information Projecting and anticipating future state Decision Making Considering options Selecting and communicating option Implementing and reviewing decisions Communication and Teamwork Exchanging information Establishing a shared understanding Co-ordinating team LeadershipSetting and maintaining standards Coping with pressure Supporting others NOTSS Skills Taxonomy Yule et al (2006) Surgery, 139, 140-149 Yule et al (2006) Medical Education, 40, 1098-1104

16. Behaviours Communication & Teamwork Situation Awareness Leadership NOTSS Gathering Information Projecting and anticipating future state Decision Making Understanding information Positive: Verbalises what equipment may be required later in operation Negative: Waits for a predicted problem to arise before responding Category Element Behaviour

17. NOTSS rating scale 1 Poor Performance endangered or potentially endangered patient safety, remediation is required 2 Marginal Performance indicated cause for concern, considerable improvement is needed 3 Acceptable Performance was of a satisfactory standard but could be improved 4 Good Performance was of a consistently high standard, enhancing patient safety N/A Skill was not required in this scenario

18. ISCP NoTTS Form Assessment can be undertaken by Consultant Surgeons, Anaesthetists and Senior Nurses Assessment cannot be undertaken unless training has been undertaken (NoTTS in a box) Form on ISCP website has drop- down performance descriptors Documentation of feedback and action plan is mandatory

19. Task: NOTSS Rating

20. What are Your Impressions? Did his behaviour enhance theatre safety? Were the team prepared for the operation? Did he utilise his team well? Did he lead? Would you want to work for him?

22. What Would You Do?

23. Instructions for NoTSS Rating Exercise raters - Cognitive skills Watch the following scenario unfold in the operating room Note down any good or poor behaviours you observe using the sheet provided Rate the operating surgeon using the 1-4 rating scale in NoTSS Discuss your observations when the scenario has finished What actions do you suggest?

24. Improving Team Performance Role clarity (own and others) Leadership / followership Common understanding of goal Shared mental models Improving communication Workload / task coordination Theatre Team Training in human factors required for all members of the surgical team

25. Summary Human error responsible for most surgical errors WHO Checklist reduces the risk of adverse events Team Training (CRM) improves team performance NoTSS is a reliable, valid and acceptable way of assessing a surgeon’s non-technical skills Principle aim is to aid learning through constructive feedback Get trained!

26. NoTSS in a box: http://www.rcsed.ac.uk/education/educational- resources/non-technical-skills-for-surgeons-(notss).aspx