Post on 08-Aug-2020
@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
@jmrobertsonAPACVS 37th Annual Meeting
April 5, 2018
Nothing to disclose
@jmrobertsonAPACVS 37th Annual Meeting
April 5, 2018
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.
@jmrobertsonAPACVS 37th Annual Meeting
April 5, 2018
@jmrobertsonAPACVS 37th Annual Meeting
April 5, 2018
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
@jmrobertsonAPACVS 37th Annual Meeting
April 5, 2018
Some complications are due to non-technical skills
Observation and assessment key to improvement
@jmrobertsonAPACVS 37th Annual Meeting
April 5, 2018
Situation Awareness, Decision Making, Teamwork, Leadership
@jmrobertsonAPACVS 37th Annual Meeting
April 5, 2018
@jmrobertsonAPACVS 37th Annual Meeting
April 5, 2018
Situation Awareness
Decision Making
Teamwork
Leadership
These are critical competencies for high performance
@jmrobertsonAPACVS 37th Annual Meeting
April 5, 2018
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
@jmrobertsonAPACVS 37th Annual Meeting
April 5, 2018
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)
@jmrobertsonAPACVS 37th Annual Meeting
April 5, 2018
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
@jmrobertsonAPACVS 37th Annual Meeting
April 5, 2018
@jmrobertsonAPACVS 37th Annual Meeting
April 5, 2018
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
@jmrobertsonAPACVS 37th Annual Meeting
April 5, 2018
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
@jmrobertsonAPACVS 37th Annual Meeting
April 5, 2018
Types of Decision Making
• Analytical (option comparison)
• Rule-based (procedures)
• Recognition-primed (pattern-match)
• Creative (new solution)
@jmrobertsonAPACVS 37th Annual Meeting
April 5, 2018
@jmrobertsonAPACVS 37th Annual Meeting
April 5, 2018
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
@jmrobertsonAPACVS 37th Annual Meeting
April 5, 2018
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
@jmrobertsonAPACVS 37th Annual Meeting
April 5, 2018
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
@jmrobertsonAPACVS 37th Annual Meeting
April 5, 2018
@jmrobertsonAPACVS 37th Annual Meeting
April 5, 2018
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
@jmrobertsonAPACVS 37th Annual Meeting
April 5, 2018
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
@jmrobertsonAPACVS 37th Annual Meeting
April 5, 2018
Fundamentals of effective team coordination:
• Understand roles
• Task clarity
• Sequencing
• Deliberate practice
• Expertise
• Synchrony
@jmrobertsonAPACVS 37th Annual Meeting
April 5, 2018
@jmrobertsonAPACVS 37th Annual Meeting
April 5, 2018
@jmrobertsonAPACVS 37th Annual Meeting
April 5, 2018
Leader
Aware of limitations
Can be wrong
Seeks advice
Supportive
Extracts performance
Commander
Infallible
Omnipotent
Doesn’t need advice
Intolerant of failure
Expects obedience
@jmrobertsonAPACVS 37th Annual Meeting
April 5, 2018
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
@jmrobertsonAPACVS 37th Annual Meeting
April 5, 2018
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
@jmrobertsonAPACVS 37th Annual Meeting
April 5, 2018
@jmrobertsonAPACVS 37th Annual Meeting
April 5, 2018
@jmrobertsonAPACVS 37th Annual Meeting
April 5, 2018
@jmrobertsonAPACVS 37th Annual Meeting
April 5, 2018
Thank you!
Contact: jmrobertson@bwh.harvard.edu
@jmrobertson
NOTSS Information: www.notss.org