4 Leadership Strategies for Growing Surgical Volume in Rural ORs

Leading in a rural surgical setting demands a different kind of strength. Staff may be lean, but the need for cutting-edge technology, an exceptional patient experience, and unwavering safety and quality never wavers.

That’s where JohnRich Levine, DNP, DPA, DBA(c), MSN, MHA, MPA, BSChE, ABLit, APRN, NEA-BC, NPDA-BC, CCRN, CNOR, CSSM, comes in. After serving as perioperative director at a major medical center in Houston, he’s now chief nursing officer at Reeves Regional Health in Pecos, Texas, where resourcefulness and adaptability drive success.

Whether he’s fostering ownership among team members or cross-training staff to boost flexibility, Levine says his move from an urban center to a rural OR has required essential shifts in his leadership mindset.

As Levine has driven case volume growth through strategic specialization and efficient resource reuse, he’s also expanded his leadership playbook. Below are four ways he says any leader can grow case volume with small, highly efficient teams.

1. Refine Skill-Mix Flexibility

Levine’s team adopted a tiered coverage model anchored in skill-mix flexibility rather than fixed assignments. Each perioperative RN and surgical technologist is cross-trained in at least two—or often more—service lines, creating what he calls a “float-with-competence” system.

2. Hone Huddles

Levine’s team utilizes real-time readiness boards that track case progression, turnover status, and available staff. Morning huddles set the tone for the day, while midday micro-huddles help the team recalibrate when cases run long or emergencies arise. Communication stays clear and immediate through a secure group text thread managed by the charge RN—giving instant visibility across periop, SPD, and PACU. “This approach converts uncertainty into coordinated adaptability,” Levine said. “Everyone sees the same picture, speaks the same language, and adjusts together.”

3. Inspire Ownership

For Levine, true ownership begins when team members see how their actions protect lives, not just how tasks are performed. During debriefs, his teams connect each safety outcome to a name and story from a patient served that day. “This helps us see how we transform compliance into accountability,” he said.

To reinforce this mindset, Levine’s teams practice several “ownership” habits:

• Harness clarity of purpose for daily reminders that safety and quality are acts of respect for the patient.
• Embrace psychological safety where anyone can speak up, pause a case, or request a timeout without hesitation. (He says this is “very doable,” but teams aren’t always comfortable doing it without practice.)
• Make follow-through visible when staff raise issues and leadership responds quickly and transparently.

“By pairing empathy with evidence, panic gives way to purpose,” Dr. Levine said. “You should see how our team acts with calm precision even under pressure, probably due largely because they trust the system and each other.”

4. Promote Smart Resource Use

With ophthalmology and orthopedic service lines projected to increase case volumes, Reeves Regional Health is preparing now for higher daily demand on instrument sets. The team has standardized instrument trays to reduce weight and reprocessing time, freeing SPD capacity for more cases each day.

They also created a shared pre-op pathway for orthopedic and ophthalmology patients, combining education, clearance, and discharge planning into a single streamlined workflow.

These steps have positioned the facility to grow both programs while maintaining FTEs.

“This work is helping us prove that smart resource stewardship and service-line growth can coexist,” Levine says.

Learn More at AORN Global Surgical Conference & Expo 2026

Want to learn more on developing strategies for smart growth with a streamlined staff? Dr. Levine will be discussing this work during the Leadership Summit April 11–14 in New Orleans at AORN Global Surgical Conference & Expo.