How to address your biggest staffing problems

By Stephen W. Earnhart, MS
President and CEO
Earnhart & Associates
Austin, TX

Last month, I received a number of e-mails about issues related to staffing — both with hospital departments and ambulatory surgery centers (ASCs). The questions and, I hope, the answers might benefit others.

Issue: Staffing levels related to net revenue.

Question: Is there any percentage of staffing levels that is remotely tied to net collected revenue for our ASC? I hear people talk about how it should tie to our reimbursement, but I cannot find anyone who has that information.

Answer: While there always are exceptions, as a general rule, you can look for your staffing budget to be approximately 30% of net revenue. Net revenue is your gross income minus your contractual allowance from the various payers (typically, but not always, between 38% and 55%). If your percentage is above or below this, there are many factors that can explain that. Typically, a new center that has not optimized its caseload will be higher; while an established facility with appropriate staff incentives might be lower.

Issue: All RN staff vs. scrub techs.

Question: Our hospital is fighting two new ASCs in town that are trying to recruit our surgeons. One way our surgical department executive committee thought we could prevent this is to have an all-RN staff in the operating suites and not use techs. Does this make sense?

Answer: Whether it makes sense depends on many factors; the most important is: "What do the surgeons think?" While having an all-RN staff in the operating room might make sense from a cross-training standpoint, it can be expensive. There are great surgical techs out there that most ORs fight to keep. I think the answer might not be in sacrificing loyal staff members but in finding out what the surgeons say will keep them with your hospital. For that decision (eliminating techs) to be made in a vacuum (without input from the surgeons) is indicative of a far greater problem for the hospital.

Issue: ASC cherry picking of hospital staff.

Question: The new ASC in town is recruiting our staff. They are offering about the same rate of pay as the hospital but fewer benefits. However, they are offering profit sharing that our hospital cannot provide. How can we legitimately hang on to our staff?

Answer: You might not be able to. The lure of relatively healthy patients, no call, no weekends, and a piece of the action is tough to counter. Some areas that you might want to look at are more flexible hours, tuition reimbursement, a better retirement plan, comp time vs. overtime, pay for child day care, retention bonus (pay staff $1,000 bonus for signing a six-month agreement — by then the ASC should be staffed), and an open meeting to ask the staff their intentions and what would it take to keep them.

Issue: Certified registered nurse anesthetist (CRNA) employees of the surgery center.

Question: We are considering hiring our own CRNAs to be employees of the ASC to supplement the outside anesthesia department that provides services to the center. How can we recoup their salaries? The CRNAs want $120,000 plus benefits, and they will only work about 30 hours per week. I wish I could get that kind of money for those hours.

Answer: You can bill the professional fee for the CRNAs (make sure the anesthesia group is not before you do — big issues there), but it is very unlikely you will recoup their salary levels in fee for service. It is always a trade-off: cost vs. need. There are some situations in which you have no choice but to enter into the arrangement you have made. As far as the CRNAs’ pay rate — it should not be tied to the number of hours they are putting in, but to the responsibility they are assuming. If you want that kind of salary — go to anesthesia school like they did. They earn every penny of it.

[Editor’s note: Earnhart & Associates is an ambulatory surgery consulting firm specializing in all aspects of surgery center development and management. Do you have additional questions? Contact Earnhart at 3112 Windsor Road, Suite A-242, Austin, TX. 78703. E-mail: Web:]