Intraoperative Assessment of Non-Technical Skills for Surgeons (NOTSS) and Qualitative Description of their Effects on Intraoperative Performance.

OBJECTIVE: The aims of this study were (1) to evaluate the feasibility of using the Non-Technical Skills for Surgeons (NOTSS) rating tool in assessing surgeons' non-technical skills behaviors in live operations, and (2) to describe the effect of NOTSS on intraoperative performance. SETTING DESIGN: This study was conducted in an academic hospital in North America. Two observers independently conducted direct non-participant observations using the NOTSS rating tool to assess non-technical skills, and to document examples of effective or ineffective non-technical skills behaviors. Observers took field notes to document non-technical skill gaps that were not captured by the NOTSS rating tool, and situations or scenarios that presented challenges for accurate assessment. Interclass correlation estimates and 95% confidence intervals were calculated to assess the validity of the NOTSS rating tool. Deductive thematic qualitative data analysis was used for field notes and NOTSS behavior descriptions. PARTICIPANTS: Participants were general surgeons performing either minimally invasive (robotic assisted or laparoscopic surgery), or open procedures. RESULTS: We observed 18 surgeries, involving 6 surgeons, 11 residents and one fellow resulting in 37 hours of direct observations. The mean NOTSS score was 3.8 (SD 0.41) for situation awareness, 3.75 (SD 0.47) for decision-making, 3.71 (SD 0.39) for communication and teamwork, and 3.76 (SD 0.38) for leadership. The inter-rater reliability ranged between 0.65 and 0.80 for each NOTSS categories. The observers documented examples of effective non-technical skills behaviors and examples of behaviors that need improvement. Furthermore, we described the effect of each observed behavior on intraoperative performance. One challenge to NOTSS use in live surgery was that observers had to infer situation awareness, decision-making, and coping with pressure as these were not easily observed without attending surgeons articulating their underlying thought process. CONCLUSION: The use of the NOTSS tool in live surgery is a valid and practical tool to document observed behaviors and their effect on intraoperative performance in order to provide constructive feedback to surgeons. One notable limitation is that without specific articulation by the surgeon of their underlying thought process the observer must infer specific elements. By documenting specific real-world events with high inter-rater reliability and adequate surgeon score variation the process can be used to provide useful feedback for improvement.

Entrustable Professional Activity-Based Summative Performance Assessment in the Surgery Clerkship.

OBJECTIVE: The objectives of this study were to 1) assess the performance Entrustable Professional Activities (EPAs) when integrated into the summative assessment of third-year medical students on the surgery clerkship and 2) to compare EPAs to traditional clinical performance assessment tools. DESIGN: EPA assessments were collected prospectively from a minimum of 4 evaluators at the completion of each surgical clerkship rotation from November 2019 to June 2019. Overall EPA-based clinical performance scores were calculated as the sum of the mean EPA score from each evaluator. A rating of overall clinical performance called the clinical performance appraisal (CPA) was also collected. EPA ratings were compared to the CPA score, National Board of Medical Examiners exam score, objective structured clinical exam scores, and final clerkship grade. SETTING: Northwestern Memorial Hospital, a tertiary care teaching institution in Chicago, IL. RESULTS: Overall, 446 evaluations (111 students) were included in the analysis. The aggregate EPA scores ranged from 11.6-24.0 (mean 19.9 ± 2.0), and the CPA scores ranged from 4.4-9.0 (mean 7.6 ± 0.7). The variance among learners in EPA scores was significantly higher than CPA scores (p < 0.001). The aggregate EPA scores correlated well with CPA scores (Spearman's rho 0.803) but had lesser, positive correlations with the objective structured clinical exam (rho 0.153) and National Board of Medical Examiners (rho 0.265) scores. When all EPA scores were included in ordinal logistic regression, only EPA 6, oral presentation of patients, was independently associated with students' final grades (OR: 10.05, 95%CI 1.41-71.80; p = 0.02). CONCLUSION: Integration of EPAs for use in clinical performance assessment of medical students is feasible within a surgery clerkship. Compared to a global clinical performance assessment, EPA-based assessment provided better discrimination of clinical performance among learners. Use of EPAs may better identify advanced learners and those that need additional time.

NCCN Guidelines Insights: Genetic/Familial High-Risk Assessment: Colorectal, Version 2.2019.

Identifying individuals with hereditary syndromes allows for improved cancer surveillance, risk reduction, and optimized management. Establishing criteria for assessment allows for the identification of individuals who are carriers of pathogenic genetic variants. The NCCN Guidelines for Genetic/Familial High-Risk Assessment: Colorectal provide recommendations for the assessment and management of patients with high-risk colorectal cancer syndromes. These NCCN Guidelines Insights focus on criteria for the evaluation of Lynch syndrome and considerations for use of multigene testing in the assessment of hereditary colorectal cancer syndromes.

NCCN Guidelines Insights: Genetic/Familial High-Risk Assessment: Colorectal, Version 3.2017.

The NCCN Guidelines for Genetic/Familial High-Risk Assessment: Colorectal provide recommendations for the management of patients with high-risk syndromes associated with an increased risk of colorectal cancer (CRC). The NCCN Panel for Genetic/Familial High-Risk Assessment: Colorectal meets at least annually to assess comments from reviewers within their institutions, examine relevant data, and reevaluate and update their recommendations. These NCCN Guidelines Insights focus on genes newly associated with CRC risk on multigene panels, the associated evidence, and currently recommended management strategies.

Genetic/Familial High-Risk Assessment: Colorectal Version 1.2016, NCCN Clinical Practice Guidelines in Oncology.

This is a focused update highlighting the most current NCCN Guidelines for diagnosis and management of Lynch syndrome. Lynch syndrome is the most common cause of hereditary colorectal cancer, usually resulting from a germline mutation in 1 of 4 DNA mismatch repair genes (MLH1, MSH2, MSH6, or PMS2), or deletions in the EPCAM promoter. Patients with Lynch syndrome are at an increased lifetime risk, compared with the general population, for colorectal cancer, endometrial cancer, and other cancers, including of the stomach and ovary. As of 2016, the panel recommends screening all patients with colorectal cancer for Lynch syndrome and provides recommendations for surveillance for early detection and prevention of Lynch syndrome-associated cancers.

A validated low-cost training model for suprapubic catheter insertion.

OBJECTIVE: To describe an anatomically correct simulator for use in suprapubic catheter (SPC) insertion training. METHODS: A scale reproduction of an adult male pelvis with bony landmarks and a subcutaneous fluid-filled reservoir was created using platinum cured silicone rubber. This model was evaluated by 6 expert urologists for content validity with a 16-item 5-point rating scale used to evaluate domains relevant to the simulator­physical attributes, realism of experience, realism of materials, and global rating. The simulator was used by 25 general surgeons from rural practices participating in a 2-day comprehensive specialized surgical skills course. RESULTS: The domains were scored between 1 and 5; 1 being "not at all realistic" and 5 being "highly realistic, no changes needed." The average expert ratings of the domains were 3.9 (physical attributes), 4.3 (realism of experience), and 3.9 (realism of materials). The simulator was rated more valuable as a training tool (4.5) compared with a testing tool (3.8) with an average global rating of 4.1. CONCLUSION: Experts and trainees reported high satisfaction with their experience using this simulator. Preliminary evidence suggests this simulator is a useful tool that can be integrated into training programs to facilitate learning this necessary urologic skill.

Staying alive: strategies for accountable health care.

The Patient Protection and Affordable Care Act signed into law in March 2010, has led to sweeping changes to the US health care system. The ensuing pace of change in health care regulation is unparalleled and difficult for physicians to keep up with. Because of the extraordinary challenges that have arisen, the public policy committee of the Society for Surgery of the Alimentary tract conducted a symposium at their 52nd Annual Meeting in May 2011 to educate participants on the myriad of public policy changes occurring in order to best prepare them for their future. Expert speakers presented their views on policy changes affecting diverse areas including patient safety, patient experience, hospital and provider fiscal challenges, and the life of the practicing surgeon. In all areas, surgical leadership was felt to be critical to successfully navigate the new health care landscape as surgeons have a long history of providing safe, high quality, low cost care. The recognition of shared values among the diverse constituents affected by health care policy changes will best prepare surgeons to control their own destiny and successfully manage new challenges as they emerge.

Development of an online morbidity, mortality, and near-miss reporting system to identify patterns of adverse events in surgical patients.

OBJECTIVES: To design a Web-based system to track adverse and near-miss events, to establish an automated method to identify patterns of events, and to assess the adverse event reporting behavior of physicians. DESIGN: A Web-based system was designed to collect physician-reported adverse events including weekly Morbidity and Mortality (M&M) entries and anonymous adverse/near-miss events. An automated system was set up to help identify event patterns. Adverse event frequency was compared with hospital databases to assess reporting completeness. SETTING: A metropolitan tertiary care center. MAIN OUTCOME MEASURES: Identification of adverse event patterns and completeness of reporting. RESULTS: From September 2005 to August 2007, 15,524 surgical patients were reported including 957 (6.2%) adverse events and 34 (0.2%) anonymous reports. The automated pattern recognition system helped identify 4 event patterns from M&M reports and 3 patterns from anonymous/near-miss reporting. After multidisciplinary meetings and expert reviews, the patterns were addressed with educational initiatives, correction of systems issues, and/or intensive quality monitoring. Only 25% of complications and 42% of inpatient deaths were reported. A total of 75.2% of adverse events resulting in permanent disability or death were attributed to the nature of the disease. Interventions to improve reporting were largely unsuccessful. CONCLUSIONS: We have developed a user-friendly Web-based system to track complications and identify patterns of adverse events. Underreporting of adverse events and attributing the complication to the nature of the disease represent a problem in reporting culture among surgeons at our institution. Similar systems should be used by surgery departments, particularly those affiliated with teaching hospitals, to identify quality improvement opportunities.