Nontechnical skills have been widely acknowledged as an important aspect of high-stress and high-stakes fields such as aviation, nuclear power and surgery.1 Effective and safe conduct of a cardiac surgical operation requires competency in both technical-clinical ability as well as in nontechnical skills such as communication, team management, and decision-making. Adverse surgical events and patient harm are sometimes more frequently associated with nontechnical failures than technical errors.2, 3, 4

Despite widespread recognition of the importance of nontechnical skills, they are infrequently formally taught in postgraduate surgical training. Currently the Accreditation Council for Graduate Medical Education (ACGME) requires assessment of just 2 nontechnical skills for trainees: interpersonal communication skills and professionalism.5 Within the surgical specialties, there has been debate over the optimal development of expanded nontechnical skills in trainees. Some argue these skills develop experientially, while others posit that they must be actively taught.6, 7, 8 To address the lack of formal structured training in nontechnical skills, several subspecialties including pediatric surgery, ophthalmology, and general surgery have utilized the nontechnical skills for surgeons (NOTSS) system to assess and teach intraoperative nontechnical skills. NOTSS, which is derived from behavioral assessment systems used in high-stakes occupations such as aviation, has been validated as an objective and reliable method to evaluate and train surgeons in nontechnical competencies.9, 10, 11, 12, 13, 14, 15

Of the many skills cardiothoracic (CT) surgeons must master, the conduct and management of cardiopulmonary bypass (CPB) is one that relies relatively heavily on nontechnical prowess. Although several high-fidelity simulation options, such as TSDA Boot Camp, exist for CPB training, no standardized assessment of CPB-related nontechnical skills exists.16, 17, 18 In this study, we aimed to investigate the use of the NOTSS system as a framework for assessing and teaching nontechnical skills associated with CPB management in CT surgery residents and to compare such skills between Junior and Senior trainees.