Importance of non-technical skills: SACRED in advanced endoscopy

Introduction

Therapeutic gastrointestinal endoscopy is increasingly diverse and complex. The concept of non-technical skills (NTS) is familiar to most and directly linked to performance, quality and safety outcomes in healthcare. In the realm of advanced endoscopy, NTS are more relevant than ever. Highly effective advanced endoscopy teams require key attributes, including the principles of selection, acceptance, complication, reconnaissance, envelopment and documentation (SACRED)—the sacred ‘art’ of high-performance endoscopy. This is particularly the case when considering the coordination required to lead a team in performing an intricate practical procedure associated with a higher risk for adverse events. Knowledge from surgical subspecialties and the aviation industry applies to advanced endoscopy, and suggests there is merit in enhancing the skills of the whole team rather than investing in the endoscopist alone. Additionally, the advanced endoscopy service should not be defined by, or limited to, the procedure within the endoscopy theatre. Instead, it should be considered as an overarching process that embraces the entire patient journey, starting from the moment of referral and encompassing postprocedural care.

NTS in Endoscopy

Much of the literature regarding the impact of NTS comes from the surgical sphere, where insufficient NTS have been shown to increase error and the risk of harm to patients. NTS in gastrointestinal endoscopy were not fully appreciated until the landmark 2004 National Confidential Enquiry into Patient Outcome and Death report highlighted their deficiencies as a contributory factor to 30-day mortality following therapeutic procedures.¹ The landscape of endoscopy changed, and the development of quality assurance and training programmes began. The Endoscopic NTS (ENTS) framework soon followed. This comprises the core NTS relevant to endoscopists: communication and teamworking, situational awareness, judgement and decision-making, and leadership.² ENTS is now embedded into the routine training and assessment of trainee endoscopists. In advanced endoscopy, effective ENTS are key as therapeutic procedures are technically challenging and associated with a higher risk of adverse events. For example, if a complication occurs, the endoscopist’s cognitive load increases, which, in turn, can impact their performance. As such, ENTS should be considered equally important as technical skills in delivering patient care.³

ENTS Training

Early insights into NTS within healthcare were derived from aviation, particularly the concept of crew resource management or ‘CRM’. CRM training aims to improve individuals’ understanding of the behaviours important in promoting safety and reducing error. NTS training in healthcare classically follows principles of CRM, often using simulation-based education (SBE). The use of virtual reality simulation in endoscopy has been shown to improve technical skills acquisition in novice endoscopists. It can be used to deliver integrated, high-fidelity scenarios either in a simulation lab or as in situ simulation, where scenarios are delivered in the place of work.⁴ Such research forms the foundation for emerging NTS training in endoscopy. This is certainly now on national agendas. There is currently a pilot programme in the UK to deliver a dedicated ENTS curriculum supported by tools such as e-learning and SBE.

To date, there are no published studies investigating the impact of ENTS training on patient care. Most of the research has focused on individual performance and demonstrated that ENTS training supports and enhances technical skills. A randomised controlled trial of a dedicated NTS training curriculum for novice endoscopists, incorporating the novel Non-Technical Skills for Endoscopy checklist, demonstrated significantly improved NTS scores and overall colonoscopy performance (assessed using four domains: assessment, consent and communication, safety and sedation, endoscopic skills, and diagnostic and therapeutic utility).⁵ This is supported by national training data in the UK, which shows that ENTS scores improve over time during training and correlate well with other key performance indicators or markers of competency.⁶

Team-ENTS

In recognising the crucial role of understanding ENTS in the performance of an endoscopist, there is now an increasing shift towards developing the endoscopy team as a whole. An example might be an expert endoscopist working in a team to perform a complex endoscopic submucosal dissection. No matter how good the communication of the endoscopist is, if the team is distracted or disengaged, the outcome may not be as optimal as with a fully prepped and vigilant team. Therefore, effective teamworking should incorporate other safety-critical processes including safety huddles, briefings, debriefings and a ‘time out’ to conduct the endoscopy safety checklist. Team empowerment is also crucial and a sense of inclusion for all team members should be fostered during huddles and briefings, particularly with new or temporary staff or those who may be unfamiliar with procedures. Recent work has gone further to draw out the core NTS relevant to team functioning across all forms of endoscopy. The ‘Teamwork in Endoscopy Assessment Module for Endoscopic Non-Technical Skills’ framework outlines five key NTS domains for endoscopy teams: communication, decision-making, planning and problem-solving, leadership and coordination, situation awareness and, teamwork, cooperation and support.⁷ This framework provides a template for team training and assessment in endoscopy, which addresses the non-technical and behavioural skills that are vital to team performance.

Early endeavours at team training in endoscopy did demonstrate an improved understanding of ENTS and safety attitudes among endoscopy teams.⁸ Although, initiatives to expand training have stalled recently, there is increasing acknowledgement of the need for dedicated endoscopy team training, incorporating a combination of didactic and simulation training.

The next steps: SACRED

As we have seen, NTS are both crucial to team performance and patient outcomes. For advanced endoscopy teams to perform well, they need to work well together. NTS are part of a wider set of principles that should be considered to ensure effective care at every point of the patient journey through endoscopy, not just the procedure. We require a more holistic view of teamworking, particularly in advanced therapeutic endoscopy, and that is, where we introduce the concept of SACRED (table 1). The six key principles of SACRED attempts to address the non-technical demands of advanced endoscopy teams and services.⁹ By following these principles, advanced endoscopy teams can improve their performance and ensure effective delivery of high-quality care throughout the patient’s journey.

Table 1.

The SACRED approach to advanced endoscopy

SACRED principles	Process	Examples
Selection	Selecting appropriate patients for advanced intervention is crucial. The preassessment of patients should be meticulous, which could be effectively facilitated by a multidisciplinary team (MDT) meeting.	Using local experience and resources to define which interventions require MDT discussion. Discussing endoscopic interventions in existing meetings such as cancer MDTs. Networked MDTs for complex therapy to facilitate training and access to appropriate Endoscopy team
Acceptance	Acknowledging the higher risk for adverse events associated with regular advanced interventions and the inevitability of complications with high caseload volume.	Adopting a no-blame culture when encountering adverse events. Providing a safe uninterrupted space to prepare team members through preprocedural team briefs. Postprocedural debriefing particularly following a significant adverse event.
Complication	Dealing with adverse events immediately following preplanned management protocol.	Ensuring access to interventional radiology in case of post-therapy bleeding if endoscopic haemostasis is not achieved, and to surgery in case of perforation. Regular morbidity and mortality meetings to identify common complications associated with individual procedures.
Reconnaissance	Employing verbal conscious competence to prime the team immediately before the crucial act of intervention, allowing the endoscopist to focus on the technical intricacies of the intervention at hand.	Rehearsing ‘closed-loop communication’ between the endoscopist and the team by describing how the intervention will be performed and checking that all team members understand and acknowledge their assigned role in the intervention.
Envelopment	Taking ownership of the entire patient care pathway from the point of referral.	A priori agreement between referring and interventional team on how and where each potential adverse event is managed, and an exit strategy should the index procedure fail. Clear instructions regarding the management of postprocedural adverse events, including recognition of signs and symptoms, who to contact and contact details.
Documentation	Encompassing the entire patient’s journey through comprehensive documentation.	Record all treatment options given to the patient and the patient’s final informed decision. Documenting the periprocedure management of medications such as anticoagulants and antiplatelets. Periprocedural checklists to ensure the appropriate equipment and expertise are available.

Conclusion

Amidst the rapidly growing popularity of therapeutic endoscopy, there is a natural attraction for endoscopists to primarily concentrate on their technical skills. However, members of an advanced endoscopy team cannot function with a silo mentality. The literature on team NTS is in its infancy but studies on endoscopists, surgeons and the aviation industry will attest to the importance of team NTS in higher-risk vocations. The principles of SACRED are applicable to the lexicon of available advanced interventions. We hope to encourage our readers to broaden their horizons and shift their attention from the endoscopist to the team, from technical skills to NTS and from inside the endoscopy theatre to the entire advanced endoscopy care pathway.

Ethics statements

Patient consent for publication

Not applicable.