Workforce Pulse: Our Annual Salary Survey

While most outpatient surgery leaders are satisfied with their compensation, many are buckling under the weight of more responsibilities than ever.

As the nation enters a year of significant change, outpatient surgery leaders continue to expertly move their facilities forward into an uncertain future. As their responses to our annual Salary Survey reveal, their jobs have never been more difficult, time-consuming and challenging. While budgets and margins tighten, staffing difficulties continue and reimbursements remain static or in decline, many find themselves working the jobs of what used to be two or more people.

The people behind the numbers

Only about a quarter of our respondents feel they earn more than their peers nationwide, while about another quarter feel they receive average pay. However, about one-half of respondents believe they earn less than their peers. A slight majority, however, report they are satisfied with their compensation. (For these statistical results and more survey data and opinions not shown in this print article, see our digital exclusive article.

We also asked readers how they feel about prospects for growth in their personal income in 2025. Among both ASC and HOPD respondents, roughly a quarter are highly confident they will increase their income in 2025, a larger number are somewhat confident, and about a third are unconfident about receiving a raise this year.

Some expect cost of living increases and merit-based increases, while others cite tightened budgets due to rising supply and anesthesia costs, decreased patient volume, ownership changes and lower reimbursements as factors they believe will likely result in smaller increases, or in some cases no increases, in pay this year.

On the optimistic side are leaders like Julie Maiden, center director at Surgical Eye Center in Greensboro, N.C. “Our organization values the hard work and dedication of our staff. We receive increases each year,” she says. Gina Hartman, MAOL, RN, CASC, director of operations at Rockford (Ill.) Ambulatory Surgery Center, says, “I have been made aware that I will be receiving a salary increase by our new owners.”

Rebecca Wallace, RN, BSN, clinical director at Arkansas Valley Surgery Center in Cañon City, Colo., received a small salary increase last fall when she was promoted to clinical director of an additional center. “I believe that over the next year if I can accomplish the goals the company has set for my center as well as my own goals, I will have shown that my hard work is worth a little more compensation in addition to any cost-of-living increase that may be awarded to staff at that time,” she says.

The majority, however, are not too sure about pay raises this year.

Ashlee Daniel, RN, nurse administrator at Southern Surgical Center in Albany, Ga., reports she’s had the same salary for three years running but is somewhat confident she will see a pay raise in 2025. Ila Doty, administrator at Covina (Calif.) Surgery Center, is not at all confident she will receive a raise this year. “Productivity is down so I’m not expecting a raise,” she says.

Tiffany Courington, AS, nurse manager at Cataract and Laser Surgery of South Georgia in Valdosta, is also not so confident she will see a pay increase. “Because I work for a large corporation and Medicare reimbursement continues to go down, I got a 0.5% raise this year,” she says.

Cathy McCue, MSN, BSN, RN, administrator at UroPartners Surgery Center in Des Plaines, Ill., is also not very confident. “We were bought by a private equity company,” she says. “All they want to do is cut, cut, cut!”

Pay raises on the horizon?

Respondents who requested anonymity cite negative indicators such as staff cuts, anesthesia cost increases, poor market performance, lower patient volume, new management and tight budgets as reasons they are not optimistic about receiving pay increases this year. Says one, “Post-pandemic estimates used to set the goals for 2024 have been unattainable across the board by all the surgery centers in the part of the country in which we are located. Despite being the highest producer for our region, our bonus structure is based on the group as a whole so I anticipate the same 2% increase I have received for the last four years with nothing additional and about 50% of my bonus from last year (if I am lucky).”

Another respondent who is not confident about a raise this year reports, “Reimbursements are down overall with payors. Implants are not being reimbursed for our orthopedic procedures and we have lost some contracts.”

As more ASCs become part of larger health systems, some physician-owned centers are struggling and pay raises are part of the fallout. “I work for an independent surgeon-owned surgery center and revenue has taken a hit,” says one respondent. A leader at another independent ASC says, “The board has not demonstrated prioritizing staff raises and bonuses in the past.”

One anonymous respondent says, “Insurance problems are limiting the amount of patients we see. No money coming in equals no raises for staff.”

Everyday challenges

We asked respondents about the most challenging aspect of their job, and their answers largely broke down among these categories:

• Managing people. The most frequent responses involved navigating staff, surgeons and their unique and sometimes conflicting or difficult personalities. For example, Suzanne Green, RN, OR manager/director of nurses at The Eye Center of Fort Wayne (Ind.), describes her biggest challenge as “the interpersonal issues within the team. I am a manager, not a therapist.” Lisa York, RN, MSN, CASC, CAIP, executive director of Hunterdon Center for Surgery in Flemington, N.J., says her biggest challenge is “getting staff motivated to do a good job every day.”

Jennifer Shaarda, ADN, BSN, nurse manager at Cleveland Clinic in Avon, Ohio, characterizes “the management of people” as her primary difficulty. “So many personalities, generations, expectations and a lack of caring about my needs, but I better care for theirs,” she says.

LoAnn Vande Leest, RN, MBA-H, CNOR(E), CASC, executive director at The Orthopaedic Surgery Center at Orthopaedic Associates of Wisconsin in Pewaukee, must devote time to “helping those on my team who don’t take responsibility for their own actions or results.”

Tracy Hoeft-Hoffman, MBA, MSN, RN, CASC, administrator at Heartland Surgery Center in Kearney, Neb., references “entitled staff members and their expectations.”

Rebecca Bentley, RN, perioperative services director with Perham (Minn.) Health, grapples with “younger staff members’ work ethic.” Jodie Sproul, RN, CNOR, MBA, OR manager at TriStar Southern Hills Medical Center in Nashville, Tenn., struggles with “trying to run a surgery schedule with multiple people who are only worried about themselves and how it will affect them.”

Other comments involved “toxic staff,” “getting others to complete and submit required reporting,” “nurse expectations of roles,” “lack of accountability from staff,” “staff discipline,” “having to do my job and others’ as well,” “maintaining a positive culture,” “concepts of teamwork and accountability,” “managing people with different work ethics,” “conflict between staff members,” “managing generational issues,” “divas and drama” and “people who don’t want to work.”

Some leaders describe issues with surgeons as their biggest challenge. One reports “dealing with the physician-owner who believes that since he owns the place, he can do whatever he wants to do with no hospital or higher administrative oversight.” Another cites “communicating with the surgeon-owners to be cost-conscious when requesting new or specialty items.” One respondent mentions the lack of engagement from their Board of Directors.

• Staffing. Finding and retaining experienced and qualified people is another frequently cited issue among outpatient surgery leaders. “A big challenge as an administrator is ensuring you have enough staff to cover all areas and dealing with staff call outs,” says Lauren Phillips, BSN, administrator at The Cardiac and Vascular Institute Ambulatory Surgery Center in Gainesville, Fla. Surveyed leaders lament not being able to pay experienced staff members comparable rates and provide similar benefits to what hospitals offer, or sharing staff with other entities in their systems such as clinics. Many feel hamstrung in their desire to build teams with people they can trust who care about their jobs and want to stay with their organization long-term.

The anesthesia staffing and payment crisis is particularly top-of-mind for many respondents. (We’ll take a deeper dive into that aspect of the survey in our March issue.)

• Workload. Due to staffing and budget crunches, many leaders cite time management and feeling overwhelmed by the ever-growing volume and scope of the tasks they are being charged with handling themselves. Typical comments include “too many duties and not enough time,” “too much work to complete in a regular shift,” “so many tasks that some are not addressed because there is simply not enough assistance,” “finding time to complete my tasks for my role” and “getting everything done.”

Several leaders say their work-life balance is out of alignment due to being overloaded with various roles that should be someone else’s full-time job. Says one, “I am infection control/risk manager/laser safety officer/OSHA manager... it’s too much!”

Ms. Wallace says her biggest challenge is “how to manage my time for daily items, finding my flow without struggling to get things done in a non-rushed, last-minute way. It seems like I get pulled away to put out small fires often and it can be distracting. Allowing time for continued training when needed is a struggle for myself.”

Others describe the challenges of “being intentional about my day and accomplishing my to-do list due to the number of interruptions” and “the balance of having to attend meetings with the amount of desk work that needs to get done. There are never enough hours to do everything.” One leader says, “I feel responsible for keeping all the departments under my purview functional, which often has me working 14+ hour days to ensure everything gets done when we have staff quit with little or no notice.”

Other primary challenges cited include staying on top of reimbursement and payors, dealing with finances, meeting the demands of both surgeons and patients, compliance, supply management, regulatory and reporting requirements, “trying to do more with less” and, as one respondent describes it, “constant recruitment.”

Business health check

A large number of leaders (67% of ASC respondents, 49% of HOPD respondents) report their facilities are in good or great shape. Still, the “but…” embedded in many answers generated concerning responses even among those with optimistic sentiments.

Respondents are concerned about numerous issues that directly impact their bottom line, including anesthesia costs and staffing, shrinking reimbursements, aging facilities that require costly updates, regulatory requirements and reporting, outstanding debt from the pandemic, rising costs of supplies and employee benefits, surgeon and staff attrition, and decreased volume and revenue.

“Financially we are so much better than last year, but we need to continue to improve efficiencies to attract more providers,” says Cheryl Stanley, RN, director of surgical services at Franciscan Health in Michigan City, Ind. Surgeon shortages and retention were included in numerous anonymous responses. “Unless administration recruits a new surgeon, we will have lots of open block time and will have to decrease staffing for those days,” says one. “We’re losing a lot of money. Surgical volume is down. We need to hire surgeons but no one is recruiting,” says another. “Retention of staff will be an issue with the planned growth of our competitors,” says a third. “If we lose a surgeon, we will be in poor shape very quickly,” worries a fourth.

External factors have also complicated matters for many centers. Says Tiffany Courington, AS, nurse manager at Cataract and Laser Surgery of South Georgia in Valdosta, “We have had an increase in volume this year, but had two hurricanes, and Medicare cuts have taken some revenue from our practice, just like everyone else.”

Ms. Wallace says case volume is down slightly. “Staffing with competitive pay is a struggle for a small center like ours,” she says. “We recently lost a provider and have had a hard time bringing new ones onboard on a constant basis. We also have a few providers who are at the retirement age, which could change the case volume here drastically if replacement providers are not found to step in.”

Says Ms. Sproul, “We currently have good volumes and a good mix of surgeons but it could change quickly if our surgeons become disgruntled or dissatisfied with our services. We provide the best patient care possible and have tried to develop good relationships with our surgeons to help lower this risk in the future.”

Anonymous responses include, “We are always looking to grow but with limited staffing an increase in volume is not always wanted,” “physicians need to bring more cases to the center,” “we have to work harder and smarter than we already were to maintain financial stability,” “cases are down” and “expenses surpass revenue mostly due to the cost of travelers.”

Insufficient reimbursement remains an existential issue for many centers heading into 2025. “Until Medicare recognizes the value of surgery centers and does better to reimburse at fair rates, the patients are the ones who will suffer the most,” says Ms. Hartman. “Our underpayment directly affects our ability to hire and keep experienced staff.”

Anything else?

We asked surgical leaders if the volume of their work responsibilities increased in 2024. The great majority unsurprisingly answered in the affirmative.

Some say they were busier because their companies opened or acquired new centers, renovated existing ones or added new service lines or surgeons. Some went from managing one facility to managing multiple facilities. Many describe growth in volume at their facilities or among their company’s portfolio of centers that led to increased and sometimes unanticipated responsibilities they were forced to take on because staff hirings that could make their lives easier weren’t or couldn’t be made.

Even at centers where there haven’t been acquisitions, expansions or other growth, some leaders are finding themselves taking on roles for positions that aren’t filled or have been eliminated. As often occurs with high-achieving individuals who possess a strong sense of responsibility, they take on additional tasks as needed… only to find themselves drowning in work. “I wear so many hats, I can’t keep up,” says Kathleen Meccia, RN, BSN, nurse administrator at Lake George Surgery Center in Fremont, Ind.

Kristen Shepard, BSN, RN, clinical manager at 32nd Street Surgery Center in Joplin, Mo., is an example of many leaders who report they are forever balancing clinical and administrative tasks. “I was able to be out and help more on the floor,” she says. “Now I am finding I need to be in the office more working on tasks that are state and federal requirements.”

Kristin Gillard, MSN, RN, clinical director at Advanced Ambulatory Surgery Center in Redland, Calif., laments this juggling act for the opposite reason. “Filling in for missing staff has taken me away from director responsibilities,” she says.

Karen Snyder, ASC administrator at Park Center for Procedures in Fort Myers, Fla., is filling roles that she should be managing. “I also oversee the inventory department and IT,” she says.

Stretched too thin

Anonymous quotes reinforce the “doing more with less” theme:

• “I am responsible for the work of what was previously handled by three people.”
• “Doing my job along with working on the floor due to staffing issues.”
• “If staff members leave, we only replace them with per diems and there is increased case volume. It’s more work with less staff.”
• “My responsibilities have increased because we’ve lost staff and not replaced them correctly.”
• “More staff, procedures, regulations and responsibilities added without additional compensation.”
• “Retirement of key position holders has increased workload.”
• “The ever-changing landscape of HR and constant fighting with insurance companies gets worse each year.”
• “Due to staffing shortages, I’ve taken on many new roles, including staffing sterile processing.”
• “I went from accreditation and surgery start-up consultant to managing the facility. Once accredited, the owner-physician delegated every position to me with no staff support.”
• “Finding good hard workers who care is difficult, which puts more work on management’s plates year after year.”
• “More project management, more staff coverage, meetings tend to be shifted to after hours to allow for management to work during business hours.”
• “I lost my clinical supervisor and cannot hire another. I am doing two jobs.”
• “I used to have a co-director and she was not replaced.”
• “Administrative assistants were eliminated from the budget.”
• “I was given oversight of a second facility without any increase in compensation.”
• “The digitalization has increased the bureaucracy.” OSM