Enhancing Surgical Performance: A Primer in Non-technical Skills, 1st Edition (Paperback) book cover

Enhancing Surgical Performance

A Primer in Non-technical Skills, 1st Edition

Edited by Rhona Flin, George G. Youngson, Steven Yule

CRC Press

223 pages | 24 B/W Illus.

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pub: 2015-07-28
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Enhancing Surgical Performance: A Primer in Non-Technical Skills explains why non-technical skills are vital for safe and effective performance in the operating theatre. The book provides a full account, with supporting empirical evidence, of the Non-Technical Skills for Surgeons (NOTSS) system and behavioural rating framework, which helps identify the key elements involved in successful operative surgery.

The editors spent the last twelve years as part of the team developing and testing the NOTSS system and delivering presentations and workshops across the world. Readers will benefit by having, in one accessible handbook, a description of the NOTSS system and how it can be used for training, assessment, self-reflection and event analysis.

The book also examines human error, performance limitations, and global safety initiatives in surgery. Because it encourages surgeons to reflect on their own performance and behaviour, it is suitable for surgeons in all specialties and at all levels.


"Describes very well the process of thought, judgement, analysis and evaluation of risk by surgeons. It emphasises the role of the surgeon as a leader and setting up and maintenance of standards… This book explores a new dimension in the operating theatre environment. It is therefore a unique book."

—(BMA Council Chair's Choice, chosen by Dr Mark Porter, BMA Medical Book Awards 2016)

"I am in awe of the knowledge and deep understanding possessed [by the] … contributors of this very important complementary set of skills that not only should but must be embraced by all surgical teams …"

—Bruce Barraclough, Former President, Royal Australasian College of Surgeons

"It defines the types of decision making that surgeons make on a daily basis without necessarily being aware of how they reached those decisions. I believe having this insight will help improve performance."

—Professor Sir Norman S. Williams, Past President, Royal College of Surgeons of England

Table of Contents


Intraoperative Performance, Non‑Technical Skills and Surgical Safety


Surgical Skills

Non-Technical Skills

What Non-Technical Skills Are Not

Factors Influencing Surgical Performance

Surgical Error

About this Book

Human Factors: The Science Behind Non‑Technical Skills


Human Factors Science

Evolution of Non-Technical Skills

Non-Technical Skills for Pilots

NOTECHS: Non-Technical Skills for Pilots

Non-Technical Skills in Other Industries

Non-Technical Skills in Health Care


Non-Technical Skills for Surgeons: The NOTSS Behaviour Marker System


NOTSS System


Underpinning Theory of Non-Technical Skills

Non-Technical Skills at Work in the Operating Room

New Developments with NOTSS Since the Taxonomy Was Published

Importance of NOTSS for Surgeons and Patients



Situation Awareness


Human Memory System

Model of Situation Awareness

Influencing Factors

Training Situation Awareness

Assessing Situation Awareness


Decision Making


Model of Intra-Operative Decision Making

Decision-Making Methods: What Shall I Do?

Factors Influencing Intra-Operative Decision Making

Training Surgeons’ Intra-Operative Decision Making

Assessing Surgeons’ Intra-Operative Decision-Making Skills


Teamwork and Communication


Exchanging Information

Establishing a Shared Understanding

Co-Ordinating Team Activities

Interventions to Improve Teamworking and Communication




Leadership in NOTSS

Setting and Maintaining Standards

Supporting Others

Coping with Pressure

Surgeons’ Leadership Inventory


Performance-Shaping Factors


Stress in Surgery




Training Methods For Non-Technical Skills


Training Design and Development for Non-Technical Skills


Integrating Non-Technical Skills Training into Surgical Training

Training Modalities

Practical Matters and Future Possibilities

Assessing Non-Technical Skills in the Operating Room


Emergence of Non-Technical Skills Assessment

Principles of Assessment

Behavioural Marker Systems

Practical Issues and Problems with Behavioural Marker Systems

Current Methods for Assessing Surgeons


What Next? Development of Non‑Technical Skills

Acquisition: Education in Patient Safety and Non-Technical Skills

Using, Developing and Enhancing Non-Technical Skills

Coaching and Debriefing Using Non-Technical Skills for Surgeons

Non-Technical Skills and Quality Improvement

Safety Management Systems

Safety Culture and Non-Technical Skills

Liability, Indemnity and Non-Technical Skills

Adverse Event Analysis and Non-Technical Skills

Demonstrating and Retaining Competence in Non-Technical Skills

Limits and Boundaries


About the Editors

Edited by

Rhona Flin, BSc, PhD,FRSE, FBPsS,holds the chair of Applied Psychology and is the director of the Industrial Psychology Research Centre at the University of Aberdeen in Scotland. She was involved in the NOTECHS project to develop a non-technical skills rating tool for pilots, and supervised the ANTS, NOTSS, SPLINTS and ANTS-AP projects. She was awarded the Roger Green Medal for Human Factors in Aerospace (Royal Aeronautical Society) and the John Bruce Medal for Behavioural Science in Surgery (Royal College of Surgeons Edinburgh). Her current research is on non-technical skills, surgeons’ intra-operative decision making and senior managers’ safety leadership.

George G. Youngson, CBE, MBChB, PhD, FRCPEdin, FRCSEd is an emeritus professor of paediatric surgery at the Royal Aberdeen Children’s Hospital and University of Aberdeen in Scotland. He is a past vice president of the Royal College of Surgeons of Edinburgh and is the founder of its Patient Safety Board. His interests and contributions have included re-configuration of children’s surgical services in Scotland, surgical education, and clinical human factors as they affect surgical performance. He has been involved in the delivery of the NOTSS masterclass in various continents, including Asia, Europe, Africa and North America.

Steven Yule, MA, MSc, PhD,is an assistant professor of surgery at Harvard Medical School in Boston, Massachusetts. Dr Yule is an Organizational Psychologist and Human Factors scientist. He has been involved in the development of a number of assessment tools including NOTSS, SPLINTS and the Surgical Leadership Inventory (SLI). He has led the development of curricula in non-technical skills for surgical trainees and practising surgeons in the United Kingdom and United States. Dr. Yule is the director of education & research at the STRATUS Center for Medical Simulation, Brigham and Women’s Hospital in Boston, where the current research focus is on demonstrating the impact of surgeons’ non-technical skills on process and outcomes, and implementing scalable interventions to enhance patient safety. He is the vice chair of the American College of Surgeons (ACS) committee on non-technical skills and also on faculty at both the Center for Surgery and Public Health and Ariadne Labs for Health System Innovation, at Brigham & Women’s Hospital/ Harvard School of Public Health.

Subject Categories

BISAC Subject Codes/Headings:
MEDICAL / General
MEDICAL / Allied Health Services / General
MEDICAL / Surgery / General
TECHNOLOGY & ENGINEERING / Industrial Health & Safety