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Enhancing Surgical Performance


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Table of Contents


Intraoperative Performance, Non-Technical Skills and Surgical Safety
Surgical Skills
Non-Technical Skills
What Non-Technical Skills Are Not
Factors Influencing Surgical Performance
Surgical Error
About this Book

Human Factors: The Science Behind Non-Technical Skills
Human Factors Science
Evolution of Non-Technical Skills
Non-Technical Skills for Pilots
NOTECHS: Non-Technical Skills for Pilots
Non-Technical Skills in Other Industries
Non-Technical Skills in Health Care

Non-Technical Skills for Surgeons: The NOTSS Behaviour Marker System
NOTSS System
Underpinning Theory of Non-Technical Skills
Non-Technical Skills at Work in the Operating Room
New Developments with NOTSS Since the Taxonomy Was Published
Importance of NOTSS for Surgeons and Patients

Human Memory System
Model of Situation Awareness
Influencing Factors
Training Situation Awareness
Assessing Situation Awareness

Decision Making
Model of Intra-Operative Decision Making
Decision-Making Methods: What Shall I Do?
Factors Influencing Intra-Operative Decision Making
Training Surgeons' Intra-Operative Decision Making
Assessing Surgeons' Intra-Operative Decision-Making Skills

Teamwork and Communication
Exchanging Information
Establishing a Shared Understanding
Co-Ordinating Team Activities
Interventions to Improve Teamworking and Communication

Leadership in NOTSS
Setting and Maintaining Standards
Supporting Others
Coping with Pressure
Surgeons' Leadership Inventory

Performance-Shaping Factors
Stress in Surgery


Training Methods For Non-Technical Skills
Training Design and Development for Non-Technical Skills
Integrating Non-Technical Skills Training into Surgical Training
Training Modalities
Practical Matters and Future Possibilities

Assessing Non-Technical Skills in the Operating Room
Emergence of Non-Technical Skills Assessment
Principles of Assessment
Behavioural Marker Systems
Practical Issues and Problems with Behavioural Marker Systems
Current Methods for Assessing Surgeons

What Next? Development of Non-Technical Skills
Acquisition: Education in Patient Safety and Non-Technical Skills
Using, Developing and Enhancing Non-Technical Skills
Coaching and Debriefing Using Non-Technical Skills for Surgeons
Non-Technical Skills and Quality Improvement
Safety Management Systems
Safety Culture and Non-Technical Skills
Liability, Indemnity and Non-Technical Skills
Adverse Event Analysis and Non-Technical Skills
Demonstrating and Retaining Competence in Non-Technical Skills
Limits and Boundaries

About the Author

Edited by Rhona Flin, BSc, PhD, FRSE, FBPsS, holds the chair of Applied Psychology and is the director of the Industrial Psychology Research Centre at the University of Aberdeen in Scotland. She was involved in the NOTECHS project to develop a non-technical skills rating tool for pilots, and supervised the ANTS, NOTSS, SPLINTS and ANTS-AP projects. She was awarded the Roger Green Medal for Human Factors in Aerospace (Royal Aeronautical Society) and the John Bruce Medal for Behavioural Science in Surgery (Royal College of Surgeons Edinburgh). Her current research is on non-technical skills, surgeons' intra-operative decision making and senior managers' safety leadership. George G. Youngson, CBE, MBChB, PhD, FRCPEdin, FRCSEd is an emeritus professor of paediatric surgery at the Royal Aberdeen Children's Hospital and University of Aberdeen in Scotland. He is a past vice president of the Royal College of Surgeons of Edinburgh and is the founder of its Patient Safety Board. His interests and contributions have included re-configuration of children's surgical services in Scotland, surgical education, and clinical human factors as they affect surgical performance. He has been involved in the delivery of the NOTSS masterclass in various continents, including Asia, Europe, Africa and North America. Steven Yule, MA, MSc, PhD, is an assistant professor of surgery at Harvard Medical School in Boston, Massachusetts. Dr Yule is an Organizational Psychologist and Human Factors scientist. He has been involved in the development of a number of assessment tools including NOTSS, SPLINTS and the Surgical Leadership Inventory (SLI). He has led the development of curricula in non-technical skills for surgical trainees and practising surgeons in the United Kingdom and United States. Dr. Yule is the director of education & research at the STRATUS Center for Medical Simulation, Brigham and Women's Hospital in Boston, where the current research focus is on demonstrating the impact of surgeons' non-technical skills on process and outcomes, and implementing scalable interventions to enhance patient safety. He is the vice chair of the American College of Surgeons (ACS) committee on non-technical skills and also on faculty at both the Center for Surgery and Public Health and Ariadne Labs for Health System Innovation, at Brigham & Women's Hospital/ Harvard School of Public Health.


"Describes very well the process of thought, judgement, analysis and evaluation of risk by surgeons. It emphasises the role of the surgeon as a leader and setting up and maintenance of standards... This book explores a new dimension in the operating theatre environment. It is therefore a unique book."
-(BMA Council Chair's Choice, chosen by Dr Mark Porter, BMA Medical Book Awards 2016)

"I am in awe of the knowledge and deep understanding possessed [by the] ... contributors of this very important complementary set of skills that not only should but must be embraced by all surgical teams ..."
-Bruce Barraclough, Former President, Royal Australasian College of Surgeons

"It defines the types of decision making that surgeons make on a daily basis without necessarily being aware of how they reached those decisions. I believe having this insight will help improve performance."
-Professor Sir Norman S. Williams, Past President, Royal College of Surgeons of England

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