Safer Surgery part 8 docx

Safer Surgery 44 system itself is located on a secure site at: <www.elogbook.org>. As well as giving considerable benets by automating tedious aspects of recording PBA, the online version offers the opportunity to gather information in real time and capture it so that trainees will submit a realistic record of their progression rather than simply retaining those PBAs they deem ‘their best’ – which is counter to the core values of the system. Naturally, electronic data permit one to contrast and compare data from different training programmes and differing contexts of training so that, hopefully, an evaluation may be made of learning in surgical training. International Compatibility Considerable interest from overseas in the orthopaedic curriculum and in particular with the PBA tools has led to a number of proposed international pilot projects. International compatibility of surgical training systems is a key issue in relation to making it possible for trainees to complete part of their training overseas but, at a wider level, may have considerable consequences for the mobility of surgical labour. The PBA tool may offer a way of ensuring that widely differing training systems are producing compatible surgical skill sets. NOTSS It is hoped that we will, in the near future have the opportunity to combine the progress made in both the Non-Technical Skills for Surgeons (NOTSS) project (see Chapter 2 in this volume) and in PBAs by either producing a new assessment tool based on the PBA or to integrate behavioural markers from NOTSS into the existing PBA. PowerPoint Guidance For PBA, as for all elements of the orthopaedic curriculum, we have produced PowerPoint guides available through the website. The use of this technology, in preference to a user manual, enables a trainer and trainee to sit together and review the guidance and also for a programme director to present the guide in a group setting. These guides have been developed for all PBA applications to date and will be added to as work continues. Conclusion PBAs have been an attempt to maintain and improve the high quality of surgical training in the UK. Their development is still in its early stages compared to other, more established and practiced assessment methods. We will have to monitor their progress for some time before we will be able to see whether, in the midst of many other changes, they have been successful. Competence Evaluation in Orthopaedics 45 References Boardman, D., Pitts, D. and Edge, J. (2008) The Orthopaedic Curriculum and Assessment Project: A National Survey of SpR Views Two years after Introduction. Poster presented at the British Orthopaedic Association Annual Congress, Liverpool, September 2008. Department of Health (1993) Hospital Doctors: Training for the Future. The report of the Working Group on Specialist Medical Training (the Calman Report). London: Department of Health. Department of Health (2007) Trust, Assurance and Safety – The Regulation of Health Professionals in the 21 st Century. CM 7013. London: Department of Health. Donaldson, L. (2002) Unnished Business – Proposals for Reform of the Senior House Ofcer Grade. A Paper for Consultation. London: Department of Health Eraut, M. (1994) Developing Professional Knowledge and Competence. London: Falmer Press. ISCP (2008) Intercollegiate Surgical Curriculum Programme: Available at: <http://www.iscp.ac.uk> [accessed June 2008]. Kennedy, I. (2001) Bristol Royal Inrmary Inquiry. Retrieved from <http:/www. bristol-inquiry.org.uk/nal_report/index.htm> [last accessed October 2008]. Langrish, J., Gibbons, M., Evans, W.G. and Jevons, F.R. 1(972) Linear models of innovation, in J. Langrish (ed.) Wealth from Knowledge: Studies of Innovation in Industry. London: Macmillan Machiavelli, N. (1515) The Prince, trans. 1908 by W.K. Marriott. Available at: <http://www.constitution.org/mac/prince.txt> [last accessed October 2008]. OCAP Online (2008) Orthopaedic curriculum. Available at: <http://www.ocap. org.uk/orthocurriculum/Content/01_Intro_160707.pdf> Oliver, C.W., Ross, E.R.S., Hollis, S. and Pitts, D. (1997) Impact of distance learning material on trauma surgeons, Injury 28(3), 245–245(1). Pitts, D. and Rowley, D.I. (2005) Establishing consensus on PBA; Workshops for SAC chairs. Unpublished internal report for OCAP steering group. Pitts, D., Rowley, D.I. and Sher, J.L. (2005) Assessment of performance in orthopaedic training. Journal of Bone and Joint Surgery (British) 87–B(9), 1187–91. Pitts, D. and Ross, E.R.S. (2002) A competence assessment tool for the Dynamic Hip Screw. In D.I. Rowley, D. Pitts and C. Galasko Competence Working Party report to the JCHST. London: Joint Committee on Higher Surgical Training. Pitts, D., Rowley, D.I., Marx, C., Sher, L, Banks, A.J. and Murray, A. (2007). Specialist Training in Trauma and Orthopaedics – A Competency Based Curriculum 2007. Available at: <http//:www.ocap.org.uk/curriculum> [last accessed October 2008]. Safer Surgery 46 Richards, R. (1997) Clinical academic careers: Report of an independent task force chaired by Sir Rex Richards. Available at: <http://www.rcgp.org.uk/docs/ISS_ SUMM97_14.DOC> [accessed November 2008]. Rowley, D, Pitts, D. and Galasko, C. (2002) Competence Working Party report to the JCHST. London: Joint Committee on Higher Surgical Training. Smith, J. (2005) The Shipman Inquiry. Availably at: <http://www.the-shipman- inquiry.org.uk> [accessed June 2008]. Thornton, M., Donlon, M. and Beard, J.D. (2003) The operative skills of higher surgical trainees: Measuring competence achieved rather than experience undertaken. Royal College of Surgeons of England (bulletin), 85, 190–3. Chapter 4 Implementing the Assessment of Surgical Skills and Non-Technical Behaviours in the Operating Room Joy Marriott, Helen Purdie, Jim Crossley and Jonathan Beard Introduction to the Study The Shefeld Surgical Skills Study is currently evaluating the validity, reliability, feasibility and acceptability of three different workplace-based assessment tools for rating surgeons’ technical and non-technical skills in the operating room. This chapter describes the design, methodology and implementation of the study. It focuses on the problem-solving approach taken by the research team to address the practical issues of implementing this broad study of behaviours, drawing upon some of the successes and barriers we encountered, to illustrate this. It is intended to provide valuable lessons for researchers in the eld of surgical skills assessment, and for those involved in implementing workplace based assessment into surgical training. Background to Surgical Skills Assessment Traditionally, surgical training in the UK has been based upon an apprenticeship and examination model without formal assessment of technical or non-technical skills. Trainees undertook a set number of years of training and passed the Intercollegiate Examination of the Royal Colleges of Surgeons (FRCS) to achieve their Certicate of Completion of Specialist Training (CCST) for consultant practice. Progress in surgical competence was historically achieved through many years and long hours spent in the operating room. Although log books formed a useful record of surgical experience (Galasko and Mackay 1997), they did not provide evidence of competence (Thornton et al. 2003). However, opportunities to gain experience in the operating room have decreased due to shorter training time following the Calman Report (Calman 1999) and the changes in working practices following the European Directive on Hours of Work (Department of Health 2003). This has resulted in trainees having reduced access to surgical experience before their CCST (Katory et al. 2001). Safer Surgery 48 Over the last 15 years there has been a move to competency-based surgical curricula in the UK, driven by the introduction of regulations for training by the Postgraduate Medical Education Board (PMETB). The transitions in surgical training have been described previously by Pitts and Rowley in Chapter 3 of this book. Background to Surgical Skill Assessment Tools The surgical skill assessment methods developed by the GMC Performance Procedures (Beard et al. 2005b) and by the medical royal colleges and specialty associations responsible for postgraduate surgical training, are based upon the demonstration of surgical competencies and standards of competence. The need for robust methods of assessment for technical and non-technical surgical skills is axiomatic, as they underpin the competency based assessment strategy and curricula for all UK surgical specialties. Procedure Based Assessment (PBA) and Objective Structured Assessment of Technical Skill (OSATS) are two of the tools being considered in this study. They are the current workplace-based assessment tools being used by UK royal colleges and specialty associations for assessing the surgical competence of trainees and for informing objective feedback. The overall assessment strategies and individual assessment tools they have adopted conform to the assessment principles laid down by the Postgraduate Medical Education and Training Board (PMETB 2008), and the assessment tools are also designed to measure all the domains of Good Medical Practice (General Medical Council 1998). PBAs are embedded within the Orthopaedic Curriculum and Assessment Project (OCAP – <www.ocap.org.uk>) and the Intercollegiate Surgical Curriculum Programme (ISCP – <www.iscp.ac.uk>). The development of the PBA with examples of the assessment tool is covered by Pitts and Rowley in Chapter 3. PBAs have been used by OCAP since 2005, and were introduced into the surgical specialty curricula by ISCP in August 2007. Therefore, this study is taking place alongside the implementation of PBAs for trainees who are required to register onto the ISCP curriculum. Objective Structured Assessment of Technical Skill (OSATS) was introduced by the Royal College of Obstetricians and Gynaecologists (RCOG – <www.rcog. org.uk>) as a requirement of their New Training and Education Programme, launched in parallel with ISCP in August 2007. The OSATS tool was developed by Reznick’s group in Toronto (Winckel et al. 1994, Martin et al. 1997). Ensuring that our assessment methods are valid, reliable and feasible are the principal considerations of a well designed and evaluated assessment system (Van der Vleuten 1996). Evidence of validity and reliability are essential characteristics of fair and defensible assessments, particularly in identifying under-performing surgeons who could compromise patient safety (Schuwirth et al. 2002). The observation of real-time surgical performance in the workplace is essential in the authentic assessment of competence. Direct observation of skills and behaviours in Surgical Skills and Non-Technical Behaviours in the Operating Room 49 the operating theatre has good authenticity for assessing surgical competence, since this method approximates to the ‘real world’ as closely as possible. In addition, the feasibility and acceptability of such assessments will inuence the successful implementation of competency-based assessment, which is a key consideration for stakeholders with a responsibility for postgraduate surgical training. Preliminary validation studies on PBA have been performed by Rowley and Pitts (see Chapter 3). Our study seeks to further examine the validity and evaluate the reliability of the PBA tool. OSATS has demonstrated inter-rater reliability and construct validity in assessing general surgeons performing common operations (Winckel et al. 1994). However, there have not been validity and reliability studies performed for the ten OSATS of obstetrics and gynaecology procedures used by the RCOG. The third tool considered in this study is the Non-Technical Skills for Surgeons (NOTSS) tool (Yule et al. 2008) described in Chapter 2. This tool is not currently used in a formal way for training in the UK. However, there is increasing recognition of the need for training and assessment in non-technical skills because of the importance of these skills for patient safety. Purpose of the Surgical Skills Study The aim is to evaluate the validity, reliability, feasibility and acceptability of three different methods of rating the technical and non-technical skills of trainee surgeons in the operating room across a range of different procedures and surgical specialties. The three tools under evaluation in the study are: PBA: Procedure-Based Assessment; OSATS: Objective Structured Assessment of Technical Skill; NOTSS: Non-Technical Skills for Surgeons. The PBA forms for index procedures used by each UK surgical specialty can be downloaded from the ISCP (<www.iscp.ac.uk>) and OCAP websites (<www. ocap.og.uk>). The OSATS forms used by the RCOG can be downloaded from: <www.rcog.org.uk/resources/public/pdf/section6_at.pdf>. The NOTSS rating form and booklet are available from <www.abdn.ac.uk/iprc/notss>. Design and Methodology Timescale The study commenced in April 2007 at a large UK teaching hospital NHS foundation trust and is due to be completed in June 2009. • • • Safer Surgery 50 Sample Size Our intention is to perform between 400 and 500 assessments of surgical procedures. The rst case was assessed in June 2007. To date we have completed 240 cases. Reliability estimates become more dependable as the evaluation includes more cases, assessors and trainees. However, there is no accepted equivalent of a power calculation to guide sample sizes. Participants We are assessing trainee surgeons using the tools for those cases which have the informed consent of the patient. The assessments on individual trainees are performed with as little delay as possible to avoid the confounding effect of training. Procedures We are assessing a total of 15 index procedures within six surgical specialties (see Table 4.1). Each case is judged for complexity by the supervising consultant. Observation and Assessment Within each specialty, the aim is to assess each trainee performing at least two cases of each relevant index procedure. Assessments of their technical and non-technical Specialty Index procedures Upper Gastrointestinal Laparoscopic cholecystectomy Open hernia repair Orthopaedics Primary hip replacement Primary knee replacement Obstetrics & Gynaecology E lective Caesarean section Urgent Caesarean section Diagnostic laparoscopy Surgical evacuation of uterus Vascular Saphenofemoral ligation C arotid endarterectomy Abdominal aortic aneurysm repair C olorectal Open right hemicolectomy Open anterior resection C ardiac Coronary artery bypass grafting A ortic valve replacement Table 4.1 Index procedures within the surgical specialties Surgical Skills and Non-Technical Behaviours in the Operating Room 51 skills are undertaken across the cases by as many supervising consultants (one for each case) and independent assessors (up to three in one case) as is practicable. Methods of Observation Direct observation by assessors in the operating room. Video observation. We are currently lming approximately 20 per cent of the cases using a picture in picture technique which records the operating eld and the operating room. Filming is performed by medical illustration technicians with audio provided by microphones tted to the trainee surgeon and supervising consultant. During the consent process, patients have the option to decline videoing, with consent only for the direct observation of their operation. We will be able to compare the delity and reliability of video observation with direct observation. The videos will also provide rich data on the non-technical skills of trainee surgeons in the operating room for collaborative work with the NOTSS team. Process of Study Implementation and Assessments The implementation of the study within a surgical specialty is illustrated by the owchart in Figure 4.1. Progress to Date The original proposal for recruitment was 400–500 surgical cases from three teaching hospitals but it soon became clear that this would be logistically impossible without dedicated research staff at each hospital trust. We have therefore recruited from a single teaching hospital’s NHS trust, including two hospital sites with an independent assessor based at each hospital. At the time of writing (June 2008), we have completed 240 cases in 5 surgical specialties, with a further 11 months of study time for recruitment. Provided recruitment continues at the same pace, we will be on target to complete 400 to 500 assessments. Relating the Study Design to the Research Aim The study aim encompasses several research questions. We have outlined the main questions below, showing how they have driven the overall study design, and provided examples of how we have addressed them within the study. Our research questions take into account the assessment characteristics proposed by Van der Vleuten (1996) in his model of assessment utility. 1. 2. Safer Surgery 52 Are the Tools Valid? Validity can be described in a number of ways depending on the context of the assessment. For us, it refers to evidence presented to support or refute the interpretation of assessment scores, i.e., the degree to which the scores of the assessment reect the intention of the assessment. In the case of the assessment Figure 4.1 Flowchart of the study implementation Surgical Skills and Non-Technical Behaviours in the Operating Room 53 tools included in this study, the intention is for the assessment scores to reect the technical and non-technical surgical competence of the trainee being assessed. Validity requires multiple sources of evidence to allow a meaningful interpretation of assessment scores (Downing 2003). Our study design provides many sources of validity evidence and these will all be used to support or refute the validity of the three assessment tools. As one example, if the assessment tools are valid for the assessment of surgical competence, we would expect scores to increase with the trainee’s level of training and experience. We have ensured that the study includes all grades of trainees and that our demographic questionnaires include questions addressing years of surgical experience and the number of index procedures previously performed by the trainee. Are the Tools Reliable? Reliability refers to the reproducibility of assessment scores. Indicators of test score precision (e.g., Standard Error of Measurement) and indicators of reliability (e.g., G co-efcient) are both based upon estimates of measurement error. Reliability within this study is a measure of how well an assessor’s score of the surgical competence for a particular trainee would reect any assessor’s score when the trainee carried out the operation on any patient. To be able to generalize the construct of ‘surgical competence’ to all of its possible measurements requires that all sources of error (termed ‘variability’) are quantied. Therefore, its calculation depends on comparing the effect of assessor-to-assessor variability and case-to- case variability in scores with overall trainee-to-trainee variability in scores. The use of generalizability theory for the analysis of assessment scores within the study is fundamental in providing the most elegant estimates of assessor variability and case variability, which represent the greatest threats to the reliability of real time assessments in the workplace (Downing 2004). Within each surgical specialty, we have aimed to assess each trainee performing two cases of each relevant index procedure, providing four to eight assessments overall for each trainee. Assessing a particular trainee performing several index procedures of varying complexity with different assessors provides a broad sample of observations for assessing surgical skill. Assessment scores from observations on a number of occasions by different assessors provides the most dependable reliability data (Crossley et al. 2002). Are the Assessment Tools Feasible in Practice? Feasibility governs the likelihood of implementing an assessment method. There are a number of strands to consider within the scope of assessment feasibility, including the time and resources required for implementation as well as cost effectiveness of the assessment strategy. . Joint Surgery (British) 87 –B(9), 1 187 –91. Pitts, D. and Ross, E.R.S. (2002) A competence assessment tool for the Dynamic Hip Screw. In D.I. Rowley, D. Pitts and C. Galasko Competence Working Party. Hours of Work (Department of Health 2003). This has resulted in trainees having reduced access to surgical experience before their CCST (Katory et al. 2001). Safer Surgery 48 Over the last 15. September 20 08. Department of Health (1993) Hospital Doctors: Training for the Future. The report of the Working Group on Specialist Medical Training (the Calman Report). London: Department of