Improving Civility in the OR

Client: Cardinal Health

Team: Jessie Andrade, Autumn Dang, Andrea Obradors·Puerto and Erika Rittenhouse

Date:  Fall 2019



“Uncivil actions and unintentional non actions can result in life-threatening mistakes, preventable complications and even the death of a patient”


-AORN Journal: Civility in the OR: An Ethical Imperative, 2016

Key Findings

  • Hospitals tend to hire for skill, not culture and they often don’t consider the dynamics of the individuals of the team when scheduling shifts

  • Success in hospitals is measured by the amounts of surgeries finished on time without considering how these occur

  • OR members don’t see themselves as a team because they don’t constantly work with the same people and most of their interactions occur only during surgery

  • OR members only assume responsibility for their assigned role, not the performance or outcome of the surgery

  • OR jobs are already stressful and incivility incidents add to it, affecting the team’s mental and physical state during surgery 

2nd Design Sprint


In our next sprint we wanted to learn more about how OR interactions occur, the moments when and how they happen, what the possible causes may be and if these are currently being addressed at all. We asked participants to tell us about stories where they had witnessed/heard in the OR. After hearing their stories we split into groups and asked them to play out the scenarios and where they saw the problems/tensions laid and propose ideas on how these could have been prevented or alleviated. Additionally, in an effort to get deeper insight around the interactions and possible solutions we worked w/ ex-clinicians and had them use open-ended tools. 


Takeaways from the sprint were the following:


  • Every individual brings personal baggage to the surgery (we’re humans!)

  • Hierarchy- the surgeon sets the tone, and the rest of team doesn’t have authority

  • Personal biases ("Suzy is lazy")

  • Lack of communication before and after

  • It’s not only important what happens in the actual surgery, but also before and after

Based on our findings, we came up with a concept focused on the idea that someone needed to be managing civility in an OR setting. 

3rd Design Sprint

In our final sprint we wanted to know if this person managing civility was someone in the team that could be responsible for it, or someone external to the team. We created an activity that would allow participants to perform different scenarios provided and test their reactions. We prepared a mini OR setting and used puppets for the performances.


We provided different scenarios in which we had one specific situation that of uncivil behavior. Each person was assigned to play a different role, and one of the roles marked as responsible for managing the civility in the situation, but the rest of the participants couldn’t tell who had this role. We also provided an “oh shit button” that any member of the team could press to summon external help in the case they felt the situation was out of control. What we quickly learned is that in every single scenario external help was requested.


Our conclusions from the sprint were the following:

  • Behavior and reactions depend on the individuals in the room and their personalities

  • People don’t like confrontation and won’t step in to de-escalate or mediate uncivil situations when they witness them 

  • It would be more effective for an external party to manage civility in the OR

Solution and Value 


We came up with CounselOR, a new service by CAH that sets an industry standard of excellence for hospitals by promoting and rewarding civility in the OR. Or findings show that incivility needs to be addressed at an individual as well as at an institutional level. This service would set the bar of civility for hospitals to follow and be accountable for.


We envision this service as having 3 main components

  1. Prevention: Achieved by equipping hospitals with the tools and resources to cultivate civility at an organization level

  2. A call-to-action mechanism enabling OR team members to identify uncivil behaviors and patterns and allowing them to report these as they occur

  3. Incentivizing hospitals by creating a new certification of excellence that could be used to making civility a measurement of their success and prestige.


The service would start by deploying a hospital-wide assessment survey to measure where the personnel would rate the civility level in the organization. Employees would have access to an app for accessing continuous education materials, tracking their progress and getting rewarded for it, and sending appreciation to other team members.

To provide a holistic approach, the service would include embedding a counselOR team advisor in hospitals to support with things like scheduling shifts based on personalities, coaching on communication skills, touching base w/ teams to motivate them during huddles, and counseling 1-1 with them. This person would be someone with a degree in psychology specializing in team dynamics. The advisor would be that extra member of the team that supports team members in their journeys.

CouselOR can position Cardinal Health as an innovative thought leader in the healthcare industry by promoting a service that doesn’t currently exist in the marketplace.

The service would include a call-to-action mechanism that each individual in the OR could use to report uncivil situations as they occur, alerting the Team Advisor to up with the team. This would have to be something subtle and discreet, either built in the team’s scrubs or the equipment. The purpose is that whoever is reporting wouldn’t have to worry about feeling like a whistleblower. This reporting mechanism becomes your measure of success for the service, the less reports, the more civility... being the goal of the service to have zero reports!


The idea is to make civility a measurement of staff wellbeing and patient safety that everyone cares about. The CAH Certification of Excellence would be in an untapped space by linking patient safety to healthy work environments. Achieving a healthy work environment where civility and communication are valued contributes to overall staff wellbeing.