During the typical 8-to-5 workday, Emilie Keene, MHA, administrator of Parkridge Surgery Center in Columbia, S.C., spends the bulk of her time attending to what she calls "immediate issues" — conference calls, meetings, employee- and patient-related concerns, and anything else that comes across the threshold of her always-open office door. When the lights go out in the clinical areas and the rest of the staff leaves for the day, Ms. Keene returns to her desk and begins attending to the mounting piles of regulatory paperwork, unread e-mails and financial invoices vying for her attention. When she finally closes up shop and heads home for the day, she knows that whatever dent she's made in the workload will probably be refilled by the time 5 o'clock rolls around tomorrow.

Sound familiar? "Unless you actually work in a position such as this from day to day," says Ms. Keene, "it's impossible to appreciate what administrators really do: The extra hours that are worked, the constant fires that are put out, continuously ensuring new regulations are followed — which happens more now than ever before — and the many, many hats that are expected to be worn at any given time. Although I love my job and I love my profession, I definitely feel underpaid and underappreciated."

She's in good company, according to the results of our 7th annual salary survey, in which 54.5% of respondents (291 [35%] from ambulatory surgery centers and 138 [23%] from hospitals) said they don't feel they're fairly compensated for the work they do and another 8.6% said they're only somewhat satisfied with their compensation. One-third of respondents in both groups said their pre-tax annual income didn't change from 2008 to 2009; 10.5% of ASC administrators and 5% of HOPD administrators actually saw a decrease in pay over that time period. Meanwhile, many indicated that mounting regulatory burdens and the added pressure of keeping business afloat during an economic recession have only made their jobs more difficult.

Putting the job in perspective
Reading the job description of the typical ASC administrator, one gets the mental image of a 1-man band: trumpet in his left hand, guitar in his right, a drum strapped to his back and a harmonica dangling from his neck. Whereas a small business of a comparable size to an ASC might have separate management positions for people in charge of human resources, marketing, legal and regulatory issues, inventory and accounting, surgical administrators are often expected to juggle — or at least oversee — all of these duties simultaneously. In many cases, they're also expected to help out in clinical areas, too.

"As administrator, I probably spend about 50% of my time in clinic doing direct patient care, then I have to do payroll, QA studies and analysis, incident reports and human resources," says a surgical nurse administrator at a small, physician-owned ASC in Minnesota. Even in areas where the duties have been delegated, she still has to maintain an oversight role. "And yet, my salary reflects that of a highly paid staff nurse and doesn't take into account my administrative role."

A Nebraska surgery center's director of nursing says her workload increased significantly when she moved from the hospital to the ASC setting. "I worked at a hospital for about 16 years as the OR director, and we had a lot of outside resources. Here we don't — I wear all those hats," she explains, naming infection control, risk management, quality improvement, credentialing and personnel as just some of her duties that lie outside of the nursing realm. "ASCs are just a lot tighter on staffing, so you can't just delegate everything."

It's become something of a clich?© to say that ASC administrators are expected to wear many hats, but according to our survey responses, this characterization is rather accurate. It's becoming increasingly true of leaders on the hospital side, too. "Not only do I manage 25 FTEs, I also am called upon to perform clinical skills," says Mary R. Peeters, RN, BSN, perioperative services manager for St. Joseph's Area Health Services in Park Rapids, Minn. "I assist, scrub, circulate, recover, admit and discharge patients, so I am out of my office frequently, helping out." Several hospital-based respondents said that by taking on management roles and moving to salaried positions, they lost the opportunity to earn money for the extra hours they spend on call. "I am salaried as supervisor of the outpatient surgery," says Karen Hausteen, RN, of Hi-Desert Medical Center in Joshua Tree, Calif. "I'm also an RNFA and take half the call for that role without extra compensation for the on-call status and the call-backs." Explains another HOPD supervisor: "My staff nurses are paid $6 an hour for call. I am salaried and take call without compensation. At the end of the year, the staff nurses generally take home more than me."

Financials foster frustration
While Ms. Keene has nothing but praise for the physician-owners of her center, she admits that she doesn't think "they realize exactly how much work administrators put into the day-to-day operations" of the typical ASC. "It seems one of the problems is there's not a good definition or description of the roles," agrees the clinical manager of a physician-owned ASC in Philadelphia. "When our former clinical manager resigned," she recalls, "a question from one of the surgeons was, "?Why do you have to replace her?'" She speculates that physicians who aren't heavily involved in the day-to-day operations of a center don't understand the difference between how ASCs operate and how hospitals operate. "We don't have all those ancillary departments" to take care of things like maintenance and risk management.

Meanwhile, administrators are all too familiar with how the workload is distributed — and how the money is, too. "The people I meet at conferences are all pretty much happy in their job," says Greg DeConciliis, PA-C, administrator of Boston Out-patient Surgical Suites. "The big thing is, we have intimate knowledge of the center's profitability and what the owners are making and what some of our staff members are making. That's what drives the frustration." He notes that, particularly in large metropolitan areas, nurses' salaries are on the rise, so it's possible that an ASC could have a nurse on staff who's making $110,000 working 40 hours a week, but if you calculate the administrator's hourly wage, it comes out to a lesser amount despite the greater degree of responsibility that comes with the job.

A tough year all around
Several survey respondents were reluctant to gripe about their compensation packages at a time when many Americans are facing layoffs. "I'm very fortunate to have a job in the current economy and thankful for the salary!" wrote an administrator. Another was less thankful than resigned to reality: "In these economic times, you take what you can get."

But in more than one instance, respondents expressed frustration that they'd endured salary freezes or taken pay cuts, only to have to work twice as hard to keep the business — and staff morale — afloat. "Our center is a very profitable and stable center even in these bad economic times," says the administrator of a surgery center in St. Louis. "I work very hard at every aspect to ensure a profitable and high-quality center," and yet, she says, her salary is 23% below the average for her region. Stuart Katz, MBA, CASC, FACHE, executive director of Tucson Orthopaedic Surgery Center, says he's taken a reduction in pay because of the economic downturn, even as he's "worked harder for an increased financial bottom line."

In addition to taking pay cuts themselves, some administrators note that salary freezes are stoking discontent among staff, which makes managing them that much harder. "It's one of the reasons employees grumble," says an ASC director of nursing in California, who adds that while the owners of his center use the economy as an "excuse" for not giving raises over the past year, he's not completely buying it. "I do tend to see what goes through this place, and considering that, it seems to me they could compensate their employees a little better."

On top of the economic strains, administrators also say they're being squeezed by increasing regulatory burdens, particularly the new Medicare Conditions for Coverage enacted for ASCs last year. "The new infection control regulations that came out for ASCs have been huge. We now have to designate an infection control person, and that person has to have official training," says an ASC nurse manager in Missouri. "The CMS requirements pile up every day, and it's hard to keep up."

The other side of the coin
Not all of you are dissatisfied with the compensation you receive. According to the survey results, 56.5% of ASC administrators saw their salaries increase by at least 1% from 2008 to 2009, and 57% were eligible to or did receive a 2009 bonus. On the hospital side, 61.6% said their salaries went up at least 1% in 2009, although a much smaller percentage — just 29.7% — received or were eligible for a bonus. Plenty of survey respondents enthusiastically praised their employers for being generous with pay and benefits.

• Bonuses should be tied to performance and profit. Administrators appreciate the opportunity to earn bonuses when they perform well and contribute to growing the facility's bottom line, especially in this tough economy. "As an owner, why wouldn't you incentivize that?" asks Mr. DeConciliis. "If you pay them a straight salary, there's no incentive to make the business better or worse, to squeeze every penny out of things."

A quarterly bonus structure awarded across the board for advances in productivity and cost-containment at the Plastic Surgical Center of Rapid City, S.D., keeps both Director Colette Klein, RN, and her staff satisfied. "If there are dispersements made to the physicians, a certain percentage" is allocated for staff bonuses, which are divided evenly among the staff, from the reception desk to the OR to the back office. "It's very important to our physicians to recognize the staff and what they do," says Ms. Klein. When owners share the wealth of the facility, it also helps eliminate the resentment that comes when administrators see physicians lining their own pockets while slashing staff salaries and bonuses.

• Benefits are a big plus. Satisfied survey respondents frequently touted the added perks they receive, like generous health benefits, overtime pay, vacation time and 401(k) plans ("The match is incredible," raved one administrator). While Ms. Hausteen laments not being eligible for extra pay when she takes call at her hospital, she says she's thankful her employers let her take comp time to make up for the extra hours she works. Several dissatisfied respondents, on the other hand, said they weren't adequately compensated for the time they spent filling in for staff when needed, attending conferences and training sessions, and even lobbying lawmakers on behalf of the industry.
• A little appreciation goes a long way. ASC administrators, in particular, cited pleasant working conditions and appreciative physician-owners as some of the reasons they feel satisfied with what they make. "I am respected and complimented on successes," says Diane M. Elmore, RN, administrator of the Metro Surgery Center in Phoenix, Ariz. In contrast, many HOPD respondents said they don't receive enough recognition and appreciation for the extra hours they put in on call or doing administrative tasks.

Not just about the money
Considering the hours spent on the job, the headaches and frustrations that come with it, and the dissatisfaction many of you express with the salary you receive in return, it's clear that very few, if any, surgical administrators are in it purely for the money. Indeed, many of you suggest the job is something of a labor of love — one you wouldn't necessarily trade, even for the higher salary you could get doing comparable work in a different industry. "I love my job. I love the ambulatory surgery industry," admits Ms. Keene. "As soon as I landed the job here, I knew I didn't want to be anywhere else."