From left: Egide Abahuje and Robert Riviello stop for a photo in Butaro, Rwanda, after teaching courses in Kigali.

Scalpels and forceps aren’t the only vital instruments in the operating room. Situation awareness, communication and teamwork, decision-making and leadership skills are equally indispensable tools for safe, successful surgeries — a principle that Brigham experts are helping advance here and abroad.

Those four concepts are the pillars of a behavior-rating system known as non-technical skills for surgeons (NOTSS). Inspired by safety and training programs used in other fields, including the aviation and offshore-drilling industries, NOTSS trains operating room teams on a suite of social and cognitive skills designed to improve patient safety and surgical outcomes.

Most recently, two Brigham surgeons were part of a team that traveled to Rwanda last month to expand access to NOTSS training there. Egide Abahuje, MD, a Simulation Education fellow in the Neil and Elise Wallace STRATUS Center for Medical Simulation, and Robert Riviello, MD, MPH, director of Global Surgery Programs in the Center for Surgery and Public Health (CSPH), along with University of Rwanda faculty, taught a series of NOTSS courses in the country’s capital, Kigali. The team also included Rachel Koch, MD, a fellow in the Program of Global Surgery and Social Change at Harvard Medical School.

“Research shows that at least 50 percent of adverse events in the operating room come from a deficiency in non-technical skills, stemming from misperceptions of a situation, lack of communication or incomplete communication,” said Riviello, also an associate surgeon in the Division of Trauma, Burns and Surgical Critical Care.

Cultivating Sustainability

The journey to implementing NOTSS training started in 2013, when Georges Ntakiyiruta, MD, former chief of Surgery at University of Rwanda, took part in a simulation course in Scotland.

After completing the course, what impressed him most was not the cutting-edge technology but the concept of non-technical skills and their potential to improve intraoperative behavior and patient outcomes. Ntakiyiruta turned to partners at CSPH to help adapt NOTSS to the Rwandan setting. Using a curriculum based on feedback from dozens of Rwandan surgeons, anesthetists and perioperative nurses, the course has been offered annually at the University of Rwanda the past three years — reaching an ever-expanding and engaged audience.

When the Rwanda NOTSS course first launched in 2016, participants consisted solely of surgical residents. On the team’s second trip in 2018, university faculty opened the course to anesthesiologists, general practitioners, gynecologists, nurses and obstetricians — a move directly inspired by feedback from attendees about which other types of providers are most commonly involved in surgical care in Rwandan hospitals.

The initiative is just one of many collaborative efforts the Brigham has pursued in Rwanda, partnering with Rwanda’s efforts to rebuild and innovate in the health care sector as part of its remarkable recovery from a devastating civil war.

The most recent two-week trip marked a new milestone for the NOTSS training program. Organizers debuted their first course for 16 local instructors, with the goal of creating a multiplier effect as these instructors disseminate their new skills across Rwanda’s 44 district and provincial hospitals (akin to community hospitals in the U.S.), an initiative driven by Rwanda Surgical Society leadership.

“We thought training instructors would help the NOTSS course scale up and become more sustainable — putting it in the hands of local people, rather than having instructors fly in from the U.S. or Europe,” said Abahuje, who was introduced to the course as a resident in Rwanda three years ago before joining the Brigham.

Egide Abahuje leads NOTSS training at the University of Rwanda.

After undergoing their own training, the new instructor cohort led NOTSS courses for perioperative nurses, non-physician anesthetists and residents in the University of Rwanda’s surgical, anesthesiology, and obstetrics and gynecology programs.

“It was great for me to see people from different professional backgrounds taking the course,” Abahuje said. “They said that during their medical training they had never been exposed to the concepts in this course, yet they found it just as important as learning technical skills.”

Riviello said it’s been exciting to see the program grow these past few years. Based on the team’s initial successes, they are working with the College of Surgery of East, Central, and Southern Africa — the region’s independent body for postgraduate surgical education and training — to implement NOTSS training across Africa.

“Sustainability comes with sustained effort, and training more instructors is essential,” Riviello said. “We want to create more in-country expertise and enthusiasm around non-technical skills for surgery, and part of that is identifying champions and leaders, such as Egide, who will continue to promote this effort.”

Incorporating Feedback

Customizing some components of the course based on input from Rwandan participants has been essential to its success, he added.

For instance, the U.S. version of the course is mostly taught through videos of simulated operating room scenarios filmed at the STRATUS Center. During the curriculum development phase, Riviello and his team heard from Rwandan surgical providers that the scenes didn’t feel relevant to what they see most days; even though the NOTSS course doesn’t teach technical surgical skills, depictions of unfamiliar settings and uncommon procedures inadvertently became a distraction.

The team used this feedback to improve the curriculum, working with a local film school and Rwandan faculty, medical trainees and operating room personnel to refilm the videos in a more authentic setting. In addition, they also selected different simulations to depict and redesigned them to reflect a resource-variable setting.

One of the original videos, for example, showed a minimally invasive operation to treat acid reflux, but participants said they had trouble relating because they rarely perform minimally invasive surgeries and the country has a low incidence of acid reflux; the condition is more common in the U.S. due to the prevalence of obesity, Riviello explained.

“The content of what we teach is the same, but the context is different,” he said. “You need something that feels familiar to pull people toward the desired outcome: engagement with the videos, course facilitators and the small-group discussions.”