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Assessment of non-technical skills: why aren’t we there yet?

Knowledge and application of non-technical skills (NTS) may represent the greatest challenge facing medical education today. For centuries, medical education focused on developing individual clinical knowledge and technical skills. But, the modern complexities of healthcare delivery and rapid expansion of medical knowledge necessitate a high-functioning team approach, which requires human factors engineering and NTS to operate effectively.

Other complex high-risk industries—like aviation, oil drilling, nuclear power and the military—have aligned their educational systems to match.1–3 While certain healthcare disciplines have developed frameworks to ensure the acquisition and maintenance of clinical and technical skills, no standard framework for NTS exists. With the increasing computational support for clinical and technical skills—decision aids, predictive algorithms, robotic surgery and image interpretation—the true added value of human clinicians may lie with their mastery of NTS.

Failure of NTS has been linked to poor quality and safety of care.2 A prospective observational study of 28 laparoscopic cholecystectomies found a strong correlation between surgical team situational awareness and fewer technical errors.4 In Japan, a 3-year retrospective review of fatal medical accidents submitted to a third-party safety organisation found roughly half to be due to failures of NTS, most often related to situational awareness, teamwork and decision-making.5 A review of malpractice claims identified >1 personnel involved in 83% of errors, but only 24% directly attributable to communication breakdown, which was the only NTS specifically studied.6 A review of trauma and orthopaedic-related adverse events from the National Reporting and Learning System found many to be related to NTS—situational awareness (52%), communication/teamwork (21%), leadership (16%) and decision-making (12%).7 Prospective direct observation of 293 surgical procedures found a strong association between less effective teamwork behaviours—as measured by the Behavioural Marker Risk …