U.S. Air Force surgeons Dr. Patrick Miller (left), Dr. Michael Hughes (right), and surgical technician SrA Ray Wilson from the 379th Expeditionary Medical Squadron, repair the ruptured achilles tendon of a servicemember on March 11, 2003. The doctors are performing this surgey at a field hospital in a foward-deployed location. (U.S. Air Force photo by SSgt. DERRICK C. GOODE)(RELEASED)
Featured photo credit: Wikipedia | CC

Hospital operating rooms (ORs) are complicated and stressful environments in which to work. First of all, the patient being operated is totally dependent on the surgical team to get him or her safely through the procedure, hopefully with the desired outcome. In addition, OR teams are made up of different types of medical professionals (surgeons, nurses, anesthetists, technicians) each with their own critical tasks to perform if the operation is to be successful.

ORs require superb teamwork to run well. If not run well, they can be downright dangerous. Highly functioning operating room teams minimize human error and maximize successful outcomes—more patients live. Poorly functioning teams have more adverse events and deaths. Operating room teams’ effectiveness at working together even affects surgeons’ technical performance—the actual surgery.

George Whittaker, Dr. Kamran Ahmed and their colleagues at King’s College London and Guy’s and St. Thomas’s NHS Foundation Trust performed a literature search for nontechnical skills (NTS) assessment tools in articles published between 1946 and August 2015, as described in “Teamwork Assessment Tools in Modern Surgical Practice.” After winnowing 994 articles to 25 that met the inclusion criteria, they came up with eight assessment tools for various healthcare professionals, such as surgeons, anesthesiologists, and operating room staff.

One of the best is the Nontechnical Skills for Surgeons (NOTSS), which evaluates the non-technical skills of individuals during operating, rating three elements in each of four categories, as follow. This tool has high levels of validity (it measures what it says it does, acceptability and inter-observer reliability (different observers rank this tool about the same). Here is what is measures:

1. Situation Awareness

  • Gathering information: Do team members anticipate equipment needs? Does my neurosurgeon have the correct tools to cut open my head?
  • Understanding information: Do the team members not only know the information but the implications of the information?
  • Projecting and anticipating future state: Does the team know what to do if my artery is accidentally cut?

2. Decision-making

  • Considering options: Do team members take an active part in solving problems?
  • Selecting and communicating options: Do they suggest solutions, such as alternative equipment?
  • Implementing and reviewing decisions: Does the team do preoperative briefings and postoperative debriefings AND use the information to improve subsequent surgeries?

3. Communication and teamwork

  • Exchanging information: Will the person at the lowest level in the hierarchy feel safe in telling the surgeon he’s about to operate on the wrong leg?
  • Establishing a shared understanding: Is the equipment provided the same as is needed?
  • Coordinating team activities: Will the senior nurse cover for the junior scrub nurse?

4. Leadership

  • Setting and maintaining standards: Does the leader, usually the surgeon, establish standards for operating room conduct and support, and follow them himself?
  • Supporting others: Does the surgeon have his team members’ backs?
  • Coping with pressure: Does the surgeon react with equanimity if there’s an emergency. Or does s/he scream and throw instruments?

As with most organizations and individuals, surgeons and surgical teams cannot assess their effectiveness as a team, which is why they can benefit from a nontechnical skills (NTS) assessment.


Why isn’t this standard practice?

As I read this article, I clicked on the supporting articles and was thrilled to have found a systems approach to measure surgical teams. Then I stopped, wondering why this isn’t standard practice in operating rooms. After all, the process follows the medical model:

  1. Take a baseline measurement, e.g., a glucose level;
  2. Design and implement an intervention for the results you want, give insulin;
  3. Measure the effect of the intervention, updated glucose level; and
  4. Repeat until you get the result you want.

Since high functioning teams are critical to high-quality patient care, what about using this process as part of a hospital’s accreditation? Is it because although the testing fits in with physicians’ Culture of Straight A’s, it conflicts with physicians’ desire for autonomy and the culture of competition, honed since undergrad days?

Effective surgery teamwork is fundamental to health and safety

Before undergoing an elective operation, ask your surgeon if his or her surgical team has participated in a nontechnical survey and whether they have used the results to improve the system. The answer you get might just save your life.


  1. Thank you, George, for your thoughtful comments. In addition to trainees, I’d like to see assessments on medical school faculty and private sector operating room teams. Imagine this information being available to patients to assist them in choosing their surgeons.

  2. Very insightful article, I fully agree that teamwork training and assessment should be a mandatory part of any surgical curriculum. As awareness of the impact that teamwork and communication skills have on patient outcomes increases, I hope educational bodies begin to implement methods of ensuring that surgical trainees achieve a safe level of non-technical competency.


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