September 9th, 2013

Nontechnical Skills Matter in the Cardiac Operating Room


CardioExchange’s Harlan Krumholz interviews Joyce A. Wahr, lead author of the AHA’s new scientific statement on the importance of human factors and teamwork in performing cardiac surgery.

Krumholz: What are the most important insights from this scientific statement?

Wahr: First, we now have strong evidence that nontechnical skills (teamwork and communication) play a critical role in patients’ surgical outcomes. Second, surgical teams can improve these skills and reduce human error with a few simple interventions. The statement reviews the data showing that team training and the use of briefings/checklists can actually improve outcomes. Traditionally, medical and surgical training has focused on development of intellectual acumen and technical skills. We have only recently realized that complex medical environments, in which highly trained subspecialists interact with one another and use sophisticated technology (e.g., cardiac surgery), resemble those in other high-risk, complex industries. In aviation, nuclear power, and the military, the importance of teamwork training and nontechnical skills (such as communication, cooperation, coordination, and conflict resolution) has been emphasized for decades.

Krumholz: Are the findings relevant outside the operating room?

Wahr: The findings are relevant to every healthcare team regardless of its makeup or location in the healthcare system. Although we focused on studies addressing the challenges of reducing human error and improving patient safety in the cardiac and other surgical operating rooms, the concepts in these studies are broadly applicable—they have been studied in emergency departments, obstetrical units, medical intervention suites, and other healthcare settings.

Krumholz: What single change would have the biggest effect on patient safety?

Wahr: We would like to see all unit directors, department chairs, and hospital safety officers institute team training in their units. Excellent healthcare team-training tools exist—they simply need to be used. We also would like to see every cardiac surgeon lead a briefing with his or her team before every operation. Data show that such briefings improve many aspects of teamwork, including team members’ willingness to speak up. Briefings/checklists, together with team training, are the two distinct interventions that have improved surgical patient outcomes in large studies.


What’s your view about the potential for team training and presurgical team briefings to improve the safety of cardiac surgery?

3 Responses to “Nontechnical Skills Matter in the Cardiac Operating Room”

  1. Edward Bender, MD says:

    Could not agree more. This became particularly evident with the development of TAVR, in which so many specialists are treating such ill and frail patients. This was recently best exemplified by the approach that David Brown (cardiologist) and Mike Mack (cardiac surgeon) demonstrated at a recent international meeting during a live TAVR case (not that I’m a fan of live cases during meetings). Although I don’t remember the anesthesiologist and the non-physician personnel in the operating room, everyone was part of the process. All processes (routine or critical) were vocalized as if the operating room was the cockpit of a 747. Potential issues were discussed and everybody was assigned a potential activity should a particular problem arise. We should (and we try) to follow the same processes in every cardiac case, be it complex or routine. I think everybody goes into the case with the plan that the goal is to improve the health of the patient but with the realization that virtually every step of the procedure can produce a fatality.

  2. Watch the NFL- they huddle, play call, scheme, and audible(gestures and verbalization).
    As an interventionalists/proceduralist, after the scripted timeout I present the history, the readiness of the patient, indications for the procedure, anticipated findings and if hypothesis proven- proposed remedy. If unexpected findings- an in-procedure timeout to reframe the new information.

  3. Karen Politis, MD says:

    1.Cultivating an open atmosphere – listening to people’s suggestions. 2.Making a point of referring to patients with their names instead of “the gall bladder”.
    3.Keeping the whole team informed on the what we will be doing next.
    4.Being humble and admitting mistakes, but also being decisive when necessary – shouldering the uncertainty.
    5.Trying to keep the atmosphere relaxed, but efficient.
    And as the granddad of human factors, James Reason says, ensuring safety is dealing with “one damn thing after another”.