For its fifth annual salary survey, Outpatient Surgery Magazine invited ASC and hospital outpatient administrators to describe the state of their industry in terms of what they're earning, what their employees are worth to them and how they feel about salary issues. More than 250 readers responded to our online survey between October and December 2007. Here are some of the insights our readers contributed.

Work and worth
A hot-button issue among the survey's respondents was how an administrator's work is never done — and how that tends to devalue their salaries.

"I am dissatisfied with my own salary," writes the clinical director of a New Jersey ASC, "because when you look at the amount of hours I put in — at least 11 per day — and divide it out to an hourly rate, I'm barely making more than my OR and PACU nurse managers who receive an hourly wage."

A Cleveland hospital's supervisor agrees. "My annual income is exceeded by my staff's income, since they are eligible for overtime pay," she writes. "As a salaried employee, it is expected that my ????-??contribution to the cause' is overtime. My usual workweek is 55 to 60 hours per week. The gap between my salary and my staff's pay is quickly shrinking."

"With the 60 hours a week that I am currently working to get the work done, I would make more money going back to being a staff RN, with fewer headaches and less heartburn," says an Ohio hospital's director of surgical services.

If it's not possible to change over to an hourly pay scale, as one Arizona administrator wished, a re-examination would be ideal. A Philadelphia pre-op and PACU manager notes, "My position encompasses duties and responsibilities that have substantially increased over the past four years, to the point where it would warrant a re-evaluation in the job description, and to be compensated appropriately."

Require to hire
One factor that puts salary into particularly sharp focus for administrators is the amount that the latest hires start at in comparison to longtime staff nurses. There's an uncomfortable feeling, as one administrator explains, that administrators are forced to pay for more than what they're getting.

"We are paying more for less," he writes. "The quality and dedication has drastically gone down over the years and I am worried. We have to hire in new staff at almost the same amount as tenured employees due to the market."

"The latest-hired nurses have a starting hourly wage that's more than nurses that have been here for two-plus years," says a St. Louis surgery center administrator. "I'm addressing this when the nurses with seniority have their annual review by a market increase (if that's approved by shareholders)."

"I dislike having to offer new staff more than those who've been here get," says the administrator of a Nashville urology center. "They aren't necessarily any better qualified, but times are more desperate."

Salary shocks
Across the nation, the cost of retaining the nursing staff you already have on board — whether through hourly wage or salary — is rising.

Some report relatively minor increases. "They are higher, obviously, but not by much," says Donald Cook, MBA, the president and CEO of San Gabriel Ambulatory Surgery Center in San Gabriel, Calif. "It is just harder to find qualified nurses at the price that is economic for our operation."

For others, the increases are astronomical. "Paying ridiculous amounts of money now for a 40-hour workweek!" fumes a suburban Boston ASC's administrator. "We are combating that by offering strong benefits, great working conditions, bonuses, parties and overall job satisfaction."

Some administrators, on the other hand, would like to pay their nurses more and make sure they're fairly compensated, but can't. "We pay more, but are leaner staffed," says a Georgia orthopedic ASC's administrator. "Still, I have some employees who are really topped out salarywise. How do you handle that? What can you offer to keep them happy?"

The New Jersey clinical director reports that her board's ASC aims to similarly cap salaries, offering bonuses instead of raises as compensation for those who reach the ceiling. A Texas surgery center's administrator also suggests larger bonuses, or perhaps more paid time off.

In the final analysis, some concede that painfully high salaries are an unavoidable cost of maintaining a quality team. "My nursing salaries are higher than I would like them to be," says a New Orleans surgery center administrator, "but for experienced nurses that will stay with you, it is necessary."

In short supply?
"As the nursing shortage becomes more critical," writes Sharon Bowen, vice president of operations for Ambulatory Surgery Centers of America, the Hanover, Mass.-based management firm, "it will become more and more difficult to hire and retain nurses. Many nurses will leave for higher wages, but those for whom job satisfaction is key will remain."

Throughout the survey responses, many hospital and ASC administrators reported having no trouble staffing their facilities. Some ASCs even reported having waiting lists for nurse hiring. But for those who've seen a nurse-staffing drought, the situation is dire, particularly when it comes to recruiting specialty nurses to staff ORs and PACU wards. "The nursing shortage is a national emergency and should be addressed so," says the Dallas administrator.

In a pinch to staff these areas, some administrators make do by hiring nurses with fewer years of experience or specialty skills than those they'd hired previously — sometimes even hiring new graduates — and expanding their training and orientation programs, despite the cost.

Writes a Lincoln, Neb., surgery center administrator, "I have found that in some instances it has been to our benefit to train new nurses in ambulatory care, easier even than retraining nurses with years of experience in the inpatient arena."

"We take experienced nurses and provide training for them as required, such as ACLS or PALS," says Patricia Wade, RN, BS, administrator and director of nursing for the Hoffman Estates Surgery Center in Hoffman Estates, Ill. "We will train nurses for GI and the OR."

Says Linda Pavlak, BS, clinical director of the Trinity Surgery Center in New Port Richey, Fla., "We will hire RNs who do not have PACU experience, but who have worked ER or critical care."

Even then, there are no guarantees. "Training unskilled perioperative nurses is time-consuming," says Vickie Arnold, AAS, clinical director of the Roanoke Valley Center for Sight in Salem, Va. Denise Adams, RN, BSN, the ambulatory surgery coordinator at the Baltimore-Washington Eye Center in Glen Burnie, Md., adds that "it is frustrating to invest time and energy training someone who leaves in a year or two."

However, Margo Mynderse-Isola, BSN, MBA, the CEO of the Surgicenter of Palo Alto in California, has found a positive in training. "We have accepted some RNs who are ????-??refreshing' their OR or PACU skills," she says. "This is something we would never have done in the past. It has proven to be a great way to bring new nurses in as per diems, then work them up to part-time and even some into full-time positions."

Attractive offers
Outpatient surgery facilities nationwide overwhelmingly rely on word-of-mouth referrals to recruit new staff, especially when their staff, surgeons or anesthesia providers routinely operate at neighboring facilities. ASCs still depend on their no-evenings, no-weekends, no-call program to attract experienced staff, says Monica Ziegler, MSN, CASC, administrator of the Physicians Surgical Center in Lebanon, Pa. "The lifestyle of the ASC is a seller all by itself," she writes.

The director of a Cincinnati eye surgery center counters that prize candidates now sometimes want more. "We have pretty much given the hourly wage they ask for to get them to come work here," she writes. It used to be that having weekends off and not having to work holidays was enough to get them here, but this is not true anymore."

Some, but by no means a majority, of facilities employ signing bonuses or other perks for the recruited, and hospitals often have the resources to offer more extensive packages. But, as the perioperative services manager of a Montana hospital warns, "There needs to be more incentive for retention, instead of recruitment getting all the rewards."

Causes of competition
Among those respondents reporting difficulty in recruiting qualified personnel, the thorniest staffing issues are driven by competition. ASCs and hospitals compete against each other, as well as against themselves, for the best talent.

"The ambulatory surgery industry is always in a state of flux," says a Colorado surgery center's clinical director. "Nurses are in high demand and can secure a better benefit package and annual income in other settings. We have a difficult time recruiting qualified clinical staff."

"The nursing shortage has forced area hospitals to compete with each other at levels never seen before," says Mario Garza Jr., MSN, director of surgical services at McAllen Medical Center in McAllen, Texas. "The nurses are able to demand more of the hospitals, and if one institution does not meet their needs, there will always be another one who will."

"I have had to increase my nursing salaries to compete with the local hospital and other surgery centers," says Maureen Lamson, RN, nurse administrator at the Annapolis ENT Surgery Center in Maryland. "The increase of new ambulatory surgery centers has increased the demand and competition for experienced nurses who can function independently."

Experienced nurses know their value, says the administrator of a Nashville urology center, and the advantages of ASC nursing may not be enough if their salaries don't compete. "We try to promote the facility, benefits, physician owners and great staff, but sometimes the almighty dollar speaks louder," she writes.

Trickling down
Another factor that's putting the squeeze on salaries and staffing is the economic climate that outpatient facilities face, both outside and inside their operations. It's impossible to understate the impact that the Center for Medicare and Medicaid Services' ASC payment system revisions will have on 2008 budgets. "It is becoming increasingly more difficult to keep the cost per case lower than the Medicare reimbursement," says the director of a New Hampshire surgery center. "By [2008], Medicare will not cover the cost per case, so we may need to make some staffing cuts."

"Nursing shortages are not the current problem," writes Carol Mitchell, RN, clinical director of the Dekalb Endoscopy Center in Decatur, Ga. "The current problem is the Medicare cuts for ASCs in GI. We are currently unable to afford the hiring of more nursing staff. We are working so short-staffed that the nurses ????- ? feel they are being taken advantage of, and I agree." She says she fears the rate cuts may take many GI centers out of the market.

Other administrators argue that the real pressure on salaries and benefits comes from inside. "In an ASC, the battle is constantly over finances and maintaining the bottom line," says the New Jersey clinical director. "My board of directors is always pushing me to offer the absolute least I can to any new employee as a cost-saving measure. As a nurse, I find that objectionable."

A Colorado surgery center's clinical director bemoans the downgrading of employee benefits due to their increasing burden on the bottom line. "I know we are in an arm of healthcare which is supposed to be profitable," she says, "but not at the expense of staff."