Attracting and retaining a high-quality staff is important to every ASC, but perhaps most important to a new surgical facility. In the fast-paced world of ambulatory surgery, patients spend the majority of their time with your nurses and techs, and often, just minutes with the surgeon. Nothing will build your reputation like a great staff'and nothing will sink it so fast as patient care that seems lackluster, rushed or careless.

In 14 years of operation, our surgical center has learned a few things about building a great staff and retaining the high performers. Here are five tips that might help tame the challenge of staffing a new ASC.

1. Hire the right administrator
One of the most important hires any new surgery center will make is the ASC Administrator or Executive Director. This is the person who will be in charge of the overall operations of the surgery center on a day-to-day basis. He or she will be interfacing with you and other surgeons, managing the profit and loss statement, working to attract more surgeons to the center if that is a goal, and negotiating insurance and supply contracts. If hired early enough in the process, this person should play an active role in the development of your ASC. In most new centers, this person may also function as the nurse manager, or ASC Director, as we call this position, overseeing clinical matters in the center. In our more mature center, two individuals split these tasks.

Before beginning your search for this person, check with your state department of health to see whether there are credentialing requirements for the job. In the two states where we have surgery centers, the administrator must be a registered nurse with at least a bachelor's degree. Ideally, the person should also have a master's degree in nursing or possibly in management, but people with this kind of training may not be readily available in some parts of the country.

Among the qualities this person needs to be successful:

• A commitment to always putting the patient first;
• At least three to five years of management experience, either in a hospital or in a physician's office. During this time, ideal candidates should have been integrally involved in project development-for example, directing the addition of a cardiac catheterization lab to a hospital, supervising the buildout, buying the equipment, hiring the staff and attracting the surgeons. Ideal candidates have managed and been accountable for a profit and loss statement. They have negotiated vendor contracts and perhaps even insurance contracts. They have been involved with billing and collections. They possess a reasonable understanding of employment law. They have had to get physicians to buy in to new policies and procedures;
• Excellent written and verbal communications skills;
• Excellent negotiating skills. This person will need to lead the center's stakeholders to compromises, over and over again; and
• A thick skin.

Determining who is the best candidate can be challenging. We find it most helpful to use a behavioral interviewing style, asking questions such as "Tell me about a time when you needed to discuss an issue with a physician and convince him or her to see things your way," or "Tell me a time when you had to take a project from inception to completion. What were the steps you took to get from point A to point B?" or "Tell me about a time you had difficulty with a staff member? How did you handle it?"

2. Build a flexible staff
Your next step will be hiring the staff to actually do the work of caring for patients.

The key to filling out a staff at a surgery center without breaking the budget is to build in flexibility. Set up your staff and your hours so that you can always have just the right amount of people on hand-not too many, and not too few.

One way to help is by hiring full-time people who are able to be cross-trained to do more than one thing. There are two reasons for this. First, it gives management precious added flexibility with scheduling. Second, it gives you the opportunity to vary employees' work-weeks and keep them fresh.

At our center, we tend to hire mostly RNs for full-time work. The reason is that RNs are utility people; they can be trained and cross-trained for virtually any task in the surgery center, so they can do virtually any job in the surgery center; they can circulate, do pre- and post-op assessments, run the equipment, and so on.

RNs generally are more costly; according to the 2001 Federated Ambulatory Surgery Association salary survey, they make about 25 percent more than Licensed Practical Nurses, and in our experience, earn 30 to 40 percent more than a scrub technician. So it's reasonable and smart to use LPNs and scrub techs where you can.

A second key is to build a part-time and what we call a "PRN," or "as-needed" staff for heavier days. Doing this offers two major advantages. It broadens your talent pool, since some nurses want to work but don't want to work full time. It also offers cost savings over hiring full time staff. As long as the person works less than 30 hours, you are not required to extend employee benefits.

At our center we employ 12 full-time people, two part-time people (each works two 10-hour days per week) and four "PRN" people.

Incidentally, although we were concerned that it might be difficult to find qualified people for these PRN positions, we found them very easy to fill. One RN has relocated to the area and was not interested in a full-time position, another one works three 12- hour shifts at a local hospital and is happy to pick up extra hours at our ASC, and the two techs are mothers with young children at home.

The final piece is to employ creative scheduling to maximize the use of your staff.

All our full-time staff members work four 10-hour days. This offers two benefits. First, our employees really like having three days free per week. Second, it allows us to "overlap" staff during heavy days.

About 70 percent of the time, we run two rooms. On these days, we tend to have nine staff on duty: Five or six RN's, one LPN and two to three techs. One RN or LPN is in pre-op checking in patients and taking health histories, another RN is in holding assisting the CRNAs. In each of the two ORs, is a circulator and a scrub nurse or tech, and a float who moves between the two suites to assist with room turnover. One RN assists in recovery and another RN provides post-op instructions for the patients and their families. On exceptionally busy two-OR days, we may add one more float person to the mix.

On the days we run four ORs (usually on Thursday and an occasional additional day) we require almost twice as much staff-17 people as opposed to nine. To accomplish this, we schedule all 12 of our full-timers, both part-timers, and at least three of our four "PRN" staff to work on Thursday. In this way we can "staff up" without having to increase our commitment to full-time positions.

3. Look in the right places
Finding good full-time staff in today's market for nurses takes some creativity. Although we advertise openings in our city paper, we've had greater success with some other proactive measures.

The first of these was holding a job fair. We advertised this in the Kansas City Star two to three weeks in advance specifically for nurses and techs with surgical experience. We offered tours from 1 to 7 p.m., conducted on-site job interviews, and served refreshments. Fifteen to 20 candidates applied that night, and two very good employees were hired from that group.

We've also had success with ads placed in the Kansas City Nursing News, a weekly newsletter for nurses, and by advertising on the Internet through www.hotjobs.com. Current staff has referred good candidates to us, as well, and they are rewarded by an Employee Referral Bonus. The referring employee receives a $200 bonus after the new employee has completed six months on the job, and another $300 at the new employee's 12-month anniversary.

Community relationships are another good source for candidates. We receive RN students on rotation from the local community college, and we also have a program with a high school for their Health Career Students. This is a good investment in candidates for future staff.

4. Seal the deal
In this job market, you're always walking a fine line between moving too quickly and moving too slowly. When you seek candidates for your staff you need to be ready with:

• A competitive salary. You don't have to offer the highest salary in the area, but it has to be competitive. You can find out what local health care facilities are offering just by looking at the "Help Wanted" ads, talking to the HR people at the local hospital, and talking with officers of the local nurses' association.
• Good benefits. One big benefit most ASCs offer is day shift with no weekends or call. Of course, you should be offering health insurance, vacation and sick pay comparable to the local hospital. Try your best to develop a work schedule that accommodates individual needs, such as later starting times for parents with kids in school, or a four-day work week (the entire permanent Hunkeler staff has this, and they love it).
• A positive environment. We called staff members aside and asked what really matters to them. They told us they want to feel they are offering high-quality care, being recognized for their efforts, and are part of a really good team. In response to this, we improved our CE reimbursement and in-service offerings, created some performance recognition programs, and developed team-building activities.

When interviewing candidates, think about how each person will fit into the total team. A surgery team has been described as a cake batter-if you put in one wrong ingredient, it just won't turn out well. You're looking for team players who will complement and support each other.

Once you have identified this person, don't wait too long to make an offer. We've lost a few good candidates because of hesitation. Now, for someone who appears to be a perfect fit, we make an offer that same day or the next day. The offer is always made pending full reference and background checks.

5. Don't lose 'em
Staff retention is key to productive operation of an ASC. If you've hired well, you have just the right number of high performers. Losing just one will mean an added burden to the remaining staff, as well as a time-consuming search for a replacement. We've found that maintaining the positive environment goes a long way toward retaining people. Here's a quick list of things that were found to work.

• Surgeons who say, "Thanks." Our surgeons frequently thank the staff at the end of the day, and they often ask the staff for suggestions on improving patient flow and care.
• Employee Recognition. OR recognition day is celebrated yearly and birthdays are celebrated each month. This year we celebrated the holidays with a homemade breakfast provided by management, and will have a Christmas Party at a local restaurant. Years of service will be recognized at this party.
• Movie passes. After a particularly busy day or week, we give movie passes to the staff as a thank-you. You could offer other small gifts, such as flowers or a gift certificate.
• Team-building sessions. In order to share information and improve communication, we held a staff session with a "Jeopardy" game show format. Facts about doctors, procedures, lasers, equipment and staff were compiled for the game. Of course, there were refreshments and prizes.

In general, it's not important what you do to keep staff happy, just that you do it. Employees need to know you care, or they will look for an employer who does. In today's job market, they won't have to look far.