The influence of non-technical performance on technical outcome in laparoscopic cholecystectomy

Introduction: Evidence from other professions suggests that training in teamwork and general cognitive abilities, collectively described as non-technical skills, may reduce accidents and errors. The relationship between nontechnical teamwork skills and technical errors was studied using a behavioural marker system validated in aviation and adapted for use in surgery. Method: 26 elective laparoscopic cholecystectomies were observed. Simultaneous assessments were made of surgical technical errors, by observation clinical human reliability assessment (OCHRA) task analysis, and nontechnical performance, using the surgical NOTECHS behavioural marker system. NOTECHS assesses four categories: (1) leadership and management, (2) teamwork cooperation, (3) problem-solving and decisionmaking, (4) situation awareness. Each subteam (nurses, surgeons and anaesthetists) was scored separately on each of the four dimensions. Two observers - one surgical trainee and one human factors expert - were used to assess intra-rater reliability. Results: The mean NOTECHS team score was 35.5 (95% C. I. +/- 1.88). The mean subteam scores for surgeons, anaesthetists and nurses were 13.3 (95% C. I. +/- 0.64), 11.4 (95% C. I. +/- 1.05), and 10.8 (95% C. I. +/- 0.87), respectively, with a significant difference between surgeons and anaesthetists (U = 197, p = 0.009), and surgeons and nurses (U = 0.134, p <= 0.001). Inter-rater reliability was found to be strong (a = 0.88). There were between zero and six technical errors per operation, with a mean of 2.62 (95% C. I. +/- 0.55), which were negatively correlated with the surgeons situational awareness scores (rho = - 0.718, p < 0.001). Conclusions: Non-technical skills are an important component of surgical skill, particularly in relation to the development and maintenance of a surgeon's situational awareness. Experience from other industries suggests that it may be possible to improve the ability of surgeons to manage their own situation awareness, through training, intraoperative briefings and intraoperative workload management. In the future, it may be possible to use non-technical performance as a surrogate measure for technical performance, either for early identification of surgical difficulties, or as a method of evaluation by which non-surgically trained observers.