Safe surgical procedure non -technical performance parameters- a review.

Share

There are 3 major areas in surgical care : (i) diagnosis and decision regarding surgical requirement and options; (ii) performance of the surgery including technical and non-technical aspects; and (iii) post-operative care.

Diagnosis and decision making relates to a careful clinical assessment including history, thorough examination, ordering/viewing of diagnostic tests and discussion with the patient regarding the surgical diagnosis, requirement / no requirement for surgery , options, expectations and risks.

The performance of surgery is broadly viewed in 2 areas.

One is technical excellence i.e. was the procedure correctly performed with minimal complication and a good outcome. Deficiencies in this area fall in the areas of lack of  : (i) knowledge, (ii)surgical competence,(iii) care , and (iv) cognitive and memory functions -impairment.

The second area relating to the performance of the surgery relates to non-technical aspects. This area has been increasingly recognised by regulators such as medical boards and colleges of surgery as being of at least equal importance. It is an area where a deficiency is often complex, difficult to recognise and measure and , unfortunately often resistant to intervention. 

Technical area deficiencies can be corrected with further training, course -work, mentorship, at times imposed in the form of Conditions or Undertakings by the regulators. The outcomes here are generally excellent with a surgeon resuming excellent practice.

Non-technical area deficiencies on the other hand are not as simple. These areas are recognised by hospital staff and colleagues.The surgeon may be 'difficult', 'arrogant', 'argumentative',intimidating' etc and such areas of concern result in conflicts in hospitals and more importantly poor surgical team outcomes. The area of bullying/harassment etc is a non-surgical procedural manifestation of problems in this domain of function. This latter  area is a separate topic which has been addressed by  both regulators and the specialty colleges including the RACS.

The RACS has an excellent learning tool 'Safer Australian Surgical Teamwork(SAST) ( Professor Francis Lannigan -Chair SAST) available to all Fellows. It covers non-technical skills for anaesthetists, surgeons and  scrub practitioners ( ANTS, NOTSS and SPLINTS).

NOTSS ( via University of Aberdeen) identifies the tools and domains at a very practical level.

Good Surgical Practice ( RCS Eng - September 2014) aims to be a baseline of clear and assessable standards for surgeons and their practice.It is not a statutory code or a regulatory document but rather seeks to exemplify standards required of all doctors by the General Medical Council (GMC) in the context of surgery. It represents the profession's core values, the skills and attitudes that underpin professionalism to which all surgeons should aspire in order to deliver high quality care.

Good Surgical Practice (RCS Eng September 2014 ) defines 4 Domains encompassing all doctors registered with the GMC.These Domains are :(i) Knowledge, Skills and Performance in good standards of clinical practice, introduction of new techniques ; (ii) safety and Quality; (iii) Communication, partnership and teamwork ; and (iv0 Maintaining a trust including treating patients and colleagues fairly and without discrimination. Both the GMC and RCS Eng recognise care of the patient as being the first concern along with providing a good standard of care as do our national regulators.

Non -technical skills have been focussed on in this paper ( and in SAST ( RACS) ,NOTSS and SPLINTS ( University of Aberdeen, Dr Rhona Flin) 2013).These areas are :

1.SITUATION AWARENESS : Gathering of information; Understanding information and  Projecting and anticipating future state. In this domain examples include the following. Gathering information: watching a surgical procedure and NOT fixating on one task.In 'projecting and anticipating', the surgeon times requests for equipment appropriately and not late.Deficiencies in this domain are not conducive to an effective and functional OR environment.

2. DECISION MAKING: Considering options, Selecting and Considering options and Implementing and Reviewing decisions. Practical examples of deficiencies include asking for all equipment for each approach to be in OR and opened, not advising OR staff of a change in surgical approach midway through a case.

3. COMMUNICATION & TEAMWORK: Sharing information, establishing  a shared understanding, co-ordinating team activities , setting and maintaining standards, supporting others and coping with 'pressure'. Examples of concern in this domain include: effectively using non-verbal signals inappropriately, dealing inappropriately with interruptions from others, ignoring others' requests, not organising required equipment and opening sterile equipment trays indiscriminately , not coping with 'pressure' and noising to other's emotional outbursts and raising his/her voice unnecessarily.

The reader may recognise certain behaviours exemplified above. These may be detrimental to the harmony and efficiency of the team with adverse surgical patient outcomes resulting. Over the decades perhaps these behaviours were more 'accepted' - nowadays they are identified as significant concerns which may indicate impairment OR deficiencies in non-technical surgical skills.

These deficiencies are more difficult to remedy than technical skill deficiencies. The latter are often able to be corrected by an often regulatory mandated imposition of further training or mentoring process- the non-technical deficiencies may be more difficult to correct. They may relate to personality /psychological/ impairment issues and considerable focussing and personal re-direction by the surgeon is required. 

The reader may recognise that unacceptance of poor standards /performance in team members may result in a surgeon indicating his/her dissatisfaction in at times a strident fashion  , however, the concerns identified by the regulators and colleges relating to non-technical surgical deficiencies relates to a pattern of behaviour which the interested reader can study further in the resources referred to.

Identifying issues relating to BOTH technical AND non-technical performance  in surgeons ( and other staff) is important for surgeons, hospital MAC members /administrators, surgical trainers and mentors, medical regulators and colleges. Identifying these issues before serial serious complications occur is the preferred course of action.Avoiding regulatory  mandatory intervention too is preferred. Managing technical deficiencies may require external teaching and mentoring .The non-technical deficiencies are both difficult to identify accurately as the surgeon may be labelled as ' always difficult' etc and requires action by the surgeon him/herself personally along with  external experienced assistance and review.

Texts on the subject include: 'Smart Surgeons, Sharp Decisions', 'Safety at the Sharp End', ' Enhancing Surgical Performance', ' Cultivating a Thinking Surgeon' , 'Developing the Wise Doctor',  'Reflection for medical Appraisal' ( Della Fish),'Thinking Fast and Slow' etc. These texts cover issues of non-technical skills important for a surgeon operating to avoid errors and improve performance.

This paper is general and academic in nature. The opinions expressed are those of the author.Individual practitioners should seek personalised advice in respect of surgical practice.

About the Author: Dr Michael Coroneos is a senior neurosurgeon with an interest in teaching and assessment of impairment.

Qualifications , Memberships and  Activities: Master CIME, FRACS, FACS, FRCS(EDIN)SN, FRCS(IRE), FRCS(ENG), FRCS(GLASG), FWAMS, MB BS (1st Class Honours 1980).

Memberships : Neurosurgical Society Australiasia and Qld, Member Australian Pain Society, Chair Education and Training WAMS ( World Academy of Medical Sciences).

Chairman ,Medical Advisory Committee and Medical Credentialing Conmmittee ; Member Patient Care Morbidity and Mortality Review Committee : Sunnybank Private Hospital, Healthscope.

Honorary Adjunct Associate Professor.

RACS 1st and 2nd line Mortality Assessor (QASM).

Member of Academy of Surgical  Educators (MASE).

Thursday 4 January 2018.