 Hello, thank you for inviting me to speak to you today. I have no disclosures. Last year, I spoke to you about the critical triangle of trust, a collaboration among the surgeon, anesthesiologist, and perfusionist in the cardiac operating room, and how these three communicate and work together for the good of the patient. I was inspired to write this editorial by my experience working with excellent surgeons, perfusionists, and anesthesiologists, and really doing our best work together as a team. I have continued to think about teams and what allows them to perform at the highest level, how we can build them and nurture them intentionally, and also how we can troubleshoot suboptimal team functioning. I hope that you find this talk engaging and that you come away from the presentation with some ideas about how to look at your own teams and how you want to practice your craft. I'm going to talk about and reference a surgeon, anesthesiologist, and perfusionist for this talk. But I do want to say that every single person in the operating room is part of the team, and each person is incredibly important to the process. Here are some examples of high-performing teams, aviation, military, nuclear power plan operation, and surgical. What do these teams have in common? Well, they are groups of humans doing complex tasks for which errors in execution or suboptimal responses to non-routine events can have catastrophic consequences. They are also teams that operate at the sharp end, meaning that they have their hands on the controls and on the patient. So specifically, what do you need to build a high-performing cardiac surgical team? Are these the elements? A surgeon that does the most awesome operation or perfusionist who manages bypass perfectly and an anesthesiologist who delivers the most amazing anesthetic and provides the most amazing hemodynamics? These are all important elements that they are not all you need. I would like to suggest to you that the essential elements for optimal performance are alignment, technical skills, and non-technical skills. And we're going to spend the next little while diving deeper into these elements. First, alignment. Alignment embodies a number of things, a common mission, a culture of excellence, commitment to the patient, commitment to the team, a strong work ethic. Great teams speak of the culture and the mission. And this is very important when building a team or a program to find people who believe in and gravitate toward the culture and the mission. Second is technical skills. This is what we just talked about. Yes, we want a surgeon who does the most awesome operation, a perfusionist who manages bypass perfectly and an anesthesiologist who delivers the most amazing anesthetic and provides the most amazing hemodynamics. The honing of technical skills in every area takes study, practice, more practice, experience, and reflection. 10,000 hours and then some. The third element is something that I want to explore more, non-technical skills. I think that this area is really important, but these skills are not often taught in our training programs. They are so-called soft skills. Non-technical skills are the social, personal, and cognitive abilities that complement technical skills, and they are essential to optimal team performance. Let's start by talking about some big disasters and other high-reliability industries. On March 28, 1979, around four in the morning, the Unit 2 reactor at Three Mile Island Nuclear Power Plant in Pennsylvania experienced a technical failure. The Unit 2 operators, the people at the sharp end, misread the situation and shut off the emergency water pumps that had come on to cool the radioactive core. This resulted in a near meltdown situation. Some plant workers were exposed to radiation, and fortunately the community was unharmed. There were many investigations into the accident, and there were some technical failures, but there were also non-technical failures in areas such as problem-solving, teamwork, situation awareness, personal limitations, and decision-making. Recommendations were made to improve the safety of nuclear power plants. These included technical improvements, but also operator training and staffing that focused on situation awareness, decision-making, and simulation. Aviation is another high-reliability industry that was having multiple safety incidents in the 1970s. One important and often recounted disaster was at Tenerife, in a canary island off of Morocco on March 27, 1977. Two large planes were taking off at a foggy, unfamiliar airport that was not part of the original flight plan of either aircraft. These planes collided, killing almost everyone on board, 583 people. The cockpit voice recorders were analyzed as part of the investigation, and the investigation uncovered failures in leadership, poor team coordination, communication breakdowns, lack of assertiveness, inattention, and adequate decision-making and personal limitations relating to stress and fatigue. As a result of this plane crash and others, pilots and crew are now explicitly trained in non-technical skills. Training and crew resource management is now mandatory. Investigations of serious safety events in healthcare have led to the awareness of non-technical skills in this industry. In the 1990s, crew resource management started to be applied to anesthesiology. It is reported that human factors play a role in greater than 80% of anesthesia-related complications, so the applicability is there. The trend has continued with anesthesiology and surgery and some other specialties. Frameworks for teaching and evaluating non-technical skills have been developed. I would like to add two other non-technical areas that I think are vitally important, emotional intelligence and cognitive task analysis. NOTS is the acronym for Non-Technical Skills for Surgeons and includes the areas of situation awareness, decision-making, communication and teamwork and leadership. ANTS is the acronym for Anesthetists, Non-Technical Skills. This framework from the UK is very similar and is broken down into task management, teamworking, situation awareness and decision-making. I would like to say that these non-technical skills are also applicable to the perfusion team. Situation awareness is a combination of knowing what is going on around you, monitoring the environment continuously, interpreting the information and anticipating future conditions and events. For example, when a patient is coming into the cardiac operating room for a heart transplant with poor function, tenuous physiology and hemodynamics, the OR team should be cognizant of the situation, the risk, what could happen with induction of anesthesia and how the team would proceed. Decision-making involves defining the problem, identifying options, looking at the risks and benefits of each option, communicating and implementing the decision and then re-evaluating. Teamwork is a broad category. It includes having a shared understanding of expectations and norms. It includes ample communication and exchange of information, knowledge of team members and their strengths, weaknesses and capabilities. And it includes support of the team and team members. Task management includes proper planning and preparation, prioritization, assessment of time constraints and resource utilization. This can also include assessment of fatigue and other human conditions. Communication, as we talked about in the Triangle of Trust is clear, unambiguous and closed loop. The operating room environment should be quiet to facilitate a communication. Here's an example of non-technical skills in action. We have a patient presenting for a right ventricle to pulmonary artery conduit. We go on bypass and start to open the old conduit. It's unbelievably calcified down to the body of the right ventricle and it's recognized that the placement of a conventional conduit is impossible, but we need to do something. So with the support of the entire team, problem-solving behaviors are optimized. We call the interventional cardiologist, that's resource utilization, and come up with a solution together. The surgical and interventional cardiology team construct a working valve conduit. We come off bypass, close the chest, wake the patient up, extubate and head to the CVICU. One important point to make is that this major change in operative plan did not derail the whole case. The non-routine event was managed and we pressed on per usual. Emotional intelligence has some overlap into most of the categories. This term has been around since the 1960s, but it became popularized in 1995 when Daniel Goldman, a psychologist and science writer, published a book by that name. The five elements are self-awareness, self-regulation, motivation, empathy and social skills. When leaders focus on themselves and generate self-awareness, focus on others, build relationships and develop cognitive and emotional empathy toward others. The emotional intelligence of a team is high. High EI is associated with a culture that includes information sharing, trust, learning and healthy risk-taking behaviors. In our world, EI enhances the ability to work through complex cases to navigate physiologic crises and to meet the needs of the entire team. This leads to the optimization of patient care and outcome. The next topic I'd like to talk about is cognitive task analysis. A team working in a complex socio-technical system like surgery, aviation or nuclear power, it's exposed to increased cognitive demands. That is each member of the team has cognitive tasks associated with their area of expertise and collectively there is a team cognitive demand. The cognitive or mental workload fluctuates throughout the case. This group in Boston that's very interested in cognitive task analysis found that the highest cognitive demand for perfusionists during a bypass case was during the period from the initiation of bypass to the application of the aortic cross-clamp. This was based on both reported and physiologic data. Another study by the same group in Boston looked at individual and team cognitive demand from self-report through various periods of a cabbage operation. It's interesting to see how the cognitive demand differs at different times among the team members. Looking at something like this helps one to understand and empathize cue emotional intelligence with other team members. You can also look at the team cognitive state. There is a heightened team cognitive state and high synchronicity among team members at critical parts of the case and when dealing with unexpected events or expectedly difficult periods during the case. These are also times when the teams perform exceptionally well with excellent communication and team behaviors. There is no doubt that this operating room is a complex socio-technical system. There are multiple team members doing complex tasks collaboratively and concurrently. Cognitive engineering focuses on how humans can cope and master the complexity of processes in technical environments. It tries to augment human capabilities rather than trying to automate them. Cognitive engineering may involve altering the environment by placing physiologic monitors and headcam displays so that each member of the team can access the same vital information. One can also minimize redundancies by studying optimal ratios of people to tasks and minimizing flow disruptions or intentionally planning them to reduce distraction. For example, having a plan for staff relief at an optimal time. We can also work to identify periods of increased cognitive load and soften them. For example, reducing room noise and conversation during induction of anesthesia and line placement. Increasing perfusion support during critical periods like cannulation and initiation of bypass and augmenting surgical support for difficult repairs. I think that this work is really fascinating and it all starts with examination and self-awareness. I believe that all three of these elements are essential for optimal performance, especially when doing complex tasks. So how do you do it? Well, that could be another whole presentation in itself. But first, alignment. Develop a shared set of values and make them part of the culture. Speak about them, teach them. Lead by example. Technical skills. They take hard work, education, practice, experience, evaluation, and support of the technical growth of the team. And non-technical skills. Learn more about them. Examine and recognize their importance for every member of the team. Have a non-technical skill retreat. Take part in simulation. Critically evaluate team performance. Since this is something we don't explicitly learn, it takes intention. So why do it? Well, I think that patients do better and that's why we're here. I think it leads to higher team engagement and engagement in clinical success are associated with professional satisfaction. And finally, you're creating something special, a legacy of excellence. This is the operating room team that came together for one of our first transplants. Every single person on this team contributed to the success of the operation. I hope that you have learned something about non-technical skills today and are curious enough to examine your own team dynamics and to see how these skills can be applied to optimize your performance. I do thank you for your attention.