The good news from the 2022 OR Manager Salary/Career Survey is that in the wake of lessening disruption from COVID-19 throughout the country, surgical procedure volume has returned to many ORs, with nearly half of respondents (48%) reporting increased volume over the past year, double last year’s findings (26%).

The good news is overshadowed by OR leaders struggling to find staff to meet the higher demand for surgery. Although the number of respondents who hired more direct care staff during the past year more than doubled, from 14% in 2021 to 32% this year, more than half report that the percentages of open full-time equivalent (FTE) positions for RNs and surgical technologists (STs) have increased in the past 12 months (58% and 56%, respectively).

Part of the staffing problem is turnover—more than half of respondents reported increased turnover in the past 12 months for both RNs (56%) and STs (51%). The staffing situation has led nearly half (47%) of OR leaders to increase agency and travel staff, compared to 35% last year. Although the pandemic’s impact on surgical volume may be easing, its grip on staffing remains strong: More than half (51%) of OR leaders lost staff because of the pandemic, up from 46% last year.

Other key findings from the survey include:

• The percentage of OR leaders who are finding it more difficult to recruit experienced RNs over the past year is 75%, unchanged from 2021, and the “difficult recruitment” percentages have increased for both STs and new or inexperienced OR RNs.
• Surgical volume has not increased for everyone: 16% reported decreased volume over the past year, indicating ongoing challenges. Over a third (36%) noted that volume had stayed the same.

This article outlines the survey’s findings related to staffing. (Percentages may not add up to 100% due to rounding.) Read about results related to OR leaders’ compensation, scope of responsibility, and job satisfaction in the October issue of OR Manager.

Nearly half (48%) of respondents work in a physician-owned ASC, 29% in a joint-venture ASC, 14% in a hospital-owned ASC, and 5% in a corporate or LLC ASC.

Most respondents (60%) start their day in a multispecialty rather than single-specialty ASC. As in 2021, ophthalmology was the most common single specialty, cited by 42% of ASC leaders, followed by orthopedics (17%) and general surgery (11%). No other specialty received more than 10%.

When ASC leaders who work in multispecialty ASCs were asked to choose the specialties their facility offers, most included general orthopedics (71%, compared to 81% in 2021). Specialties receiving more than 50% responses were pain management (58%), general surgery (58%), cosmetic/plastic surgery (51%), and otolaryngology (51%). For respondents working in either single specialty or multispecialty ASCs, podiatry was the most commonly cited specialty that was not on the list of options they could choose from.

Only 10% reported the volume of surgical procedures had decreased in the past 12 months (much lower than the 43% from 2021), with 34% (vs 26% in 2021) saying it had not changed. Interestingly, although volume had increased for most respondents, the average annual volume of surgical procedures (including endoscopies) was 4,242, slightly lower than last year’s 4,801. This may be because of the wide range in volumes reported (6 to 30,000).

This year saw a return to greater job satisfaction, with the 72% favorable rating aligning with prepandemic levels (70% in 2019). One in five (20%) were completely satisfied with their current job, up slightly from last year’s 18%. Only 7% rated their satisfaction as unfavorable.

More respondents had a favorable view of their total compensation compared to 2021 (51% vs 45%), but satisfaction was still lower than 2020 (60%). OR leaders felt more positive about their benefits, with nearly two-thirds (64%) giving this a favorable rating.

Continuing a trend in recent years, satisfaction with support provided by the respondent’s boss remained relatively high, with a favorable rating of 66% (vs 70% in 2021). Although satisfaction with the top leadership of the organization was unchanged from last year (57%), the percentage of those who were unsatisfied declined from 24% to 18%.

Another continuing trend was the high favorability rating for the criterion of patient satisfaction with OR services—76% vs 81% in 2021. Only 5% gave this an unfavorable rating.

The pandemic prompted many to re-think their careers, and half of respondents seem to be open to leaving their employers within the next year. The most common reason cited for leaving was to pursue a new career (19%, up from 14% in 2021); it is unknown whether this means in a different field or a new career within nursing. Other common reasons for leaving included dissatisfaction with the current work culture (18%), dissatisfaction with compensation and/or benefits (16%), and burnout (15%). Two reasons for leaving that had significant percentages changes were too much work, which increased from 9% last year to 14% and dissatisfaction with the organization’s response to the pandemic, which increased from 3% to 9%.

Benefits may help lessen the likelihood of OR leaders leaving, so we asked respondents to select from a list of benefits they would like to receive if they did not currently have them. Unsurprisingly, money-related benefits took the top four spots: bonus (35%, down from 48% in 2021), profit sharing (26%), pension plan (22%), and tuition/education reimbursement (17%). Significant increases occurred in childcare, which jumped from 8% to 17%, and disability. Both short- and long-term disability benefits were cited by 11% of respondents, versus 3% for short-term and 5% for long-term in 2021.

Compensation has remained relatively flat for leaders in ambulatory surgery centers (ASCs), according to the 2022 OR Manager Salary/Career Survey, even as leaders face ongoing stressors. This is reflected in the 40% of respondents who reported a total current annual compensation of $120,000 or more—unchanged from 2021. Ongoing stress is reflected in the reasons given by respondents who plan to leave their employers within the next year—one-fourth cited burnout, nearly double last year’s 14%, and 17% cited too much work, up from 12% in 2021.

Other key findings include:

• Two-thirds of respondents had received a raise in the past 12 months. The average raise was 4.24%, significantly lower than the 2021 consumer price index of 7%.
• The percentage of respondents who view their current job/position as favorable dropped slightly, from 78% in 2021 to 73% this year, although the percentage of those with a favorable view of the support provided by their boss rose from 64% to 70%.
• Nearly three-fourths (71%) plan to retire in 2030 or later, up from 59% in 2021.
• More than half (55%) of respondents’ plan to stay with their current employer 5 years or more, but 24% plan on staying 2 years or less.

Here is a closer look at other findings. (Percentages may not add up to 100% due to rounding.) For results related to staffing, see “Survey: ASC leaders experience persistent staffing challenges in face of rising volume” (OR Manager, September 2022, pp 24–26).

Clinician satisfaction with the EHR has been linked to how the system was implemented. The 2022 KLAS study found that satisfaction varied from one organization to another, even when the same type of EHR was in use. The reason for the difference? How the system was implemented. “In one case, the clinical staff drove the change process, and in the other, they were victims of the process,” Glaser says. “In one case, there was really good training and they were able to personalize the systems to reflect their practice, and in the other they were pushed into a mold or cookie cutter.” Taking care—and time—to implement a system in a positive way will pay off with satisfied staff.

Education is part of implementing a new system, and most organizations integrate the EHR into orientation. However, ongoing education is important, too. Updates not only keep staff informed of changes, but also can be used to foster good documentation habits. For example, although staff may be tempted to fill in parts of the EHR before a case to save time, Robison at UCLA says, “I tell staff and students not to pre-document, but to document in real time.” Pre-documentation can lead to errors when staff fail to correct previously entered information to reflect a change, such as not using an implant that had been entered into the system.

Iuppa at Cleveland Clinic also advocates for real-time documentation. “The more time people batch or wait until the end of the case, the harder it becomes because things back up and distractions, changes in the patient condition, and interruptions to the flow of the day frequently happen,” she says.

Education also should include being transparent about the trade-offs of an EHR. Glaser cites a prescription as an example. When paper was used, it took only a few seconds to write a prescription, but when the clinician has to log in, identify the patient, and go through other steps, it takes longer. “It’s safer and more accurate, but there is a price to be paid,” he says. Organizations should say, “We’re going to ask you to do a little extra work for the greater good—quality and safety.”

OR staff and leaders also need to develop basic competency in technology. “You can’t rely on IT to fully understand your world and translate that into an effective EHR,” Iuppa says.

“Sometimes nurses are a little intimidated by technology, but that can be overcome,” Kelley adds. Although OR leaders do not need to understand in detail how an EHR is built, they can take time to envision what is needed to support clinicians in achieving goals, such as great quality. “Your ideas will matter because you will help other people see what’s needed; it’s a team approach,” Kelley says.

That approach depends on a strong manager-IT partnership.

A key task for managers and staff who want to optimize the EHR is creating a partnership with IT. “Developing that partnership helps you when you need to implement something or want to make improvements,” Harrison says. “You have a shared vision, which helps rally the troops.”

Iuppa notes that collaborating with IT promotes “usable systems that are intelligent and that are enjoyable to use.” In a strong partnership, IT shares their priorities and their limitations, which promotes mutual understanding. “You can have more of an intelligent dialogue versus being frustrated that you want something customized and can’t get it because it will cost too much money,” she says.

Building a relationship with IT may start with simply inviting staff to meetings or having a one-on-one meeting, says Kelley. She says OR managers might open the door by saying something like, “I’m trying to better understand how to use the data in the EHR. Can you help me understand how we can work together to do that?”

When working with IT staff, Padden at Texas Health says it is best to describe the problem that needs solving, rather than asking for a specific solution. “You want to let IT use their creative juices to help you solve it,” she says. For example, a manager might request a best practice alert, but further analysis reveals that it is a matter of needing to document data in a different way. A manager might then request a flow sheet, but the IT staff could recommend a smart form instead.

“A smart form is like a flow sheet, but it has a lot more functionality to it,” Padden says. When users answer items in a smart form, it can adapt to the response entered, so the user does not have to go through unnecessary steps. In addition, one-line reminders can be embedded, rather than flashing an alert. “The more best practice alerts you fire, the more staff will ignore them,” Padden says. “You can guide them down the correct path without having to throw alerts at them all the time” (sidebar, Managing alerts). IT staff also can consider how items such as order sets are displayed on the screen to make it easier for staff to complete documentation.

Kelley says that IT staff strive to design a solution to meet the needs of clinicians and their workflow. When someone requests a form be digitized, IT staff first ask questions to understand how the form is being used and completed. For example, staff may fill out part of a paper form, put it in their pocket, and finish it later, something that is harder to do with an EHR. “You can’t fold a computer,” Kelley says. She also points out that asking staff how they complete a form and watching them do it are two different things. “They may not be aware of some of the steps they do,” she says. “It takes time to shadow them, but it’s more effective.” Otherwise, a redesign may be needed after the new form is implemented in the EHR. “You need to break the assumption that you’re just replicating something on paper and expecting it to work as it did before,” Kelley says. “You’re going from a static framework to something that is dynamic.”

IT also can help managers and work groups investigate sources of documentation time. “The vendor usually has a tool you can use to analyze how long someone spends on certain sections,” UCLA’s Harrison says. The team can then focus on sections that take longer to complete, asking questions such as: “What is truly necessary to document and what is not?” and “Can what is documented be streamlined?”

On the OR side, OR leaders need to keep IT informed. “When you come up with new policies or practices, they need to know,” Iuppa says. She recommends regular meetings. “This helps both sides to keep their fingers on the pulse of what’s happening in each other’s world and how to optimize the IT side and the clinical experience side,” she says. These regular touch points help ensure OR leaders are aware of upgrades and changes and that they have a voice in features that are planned to be deployed.

“IT is your friend,” Padden sums up. An optimal EHR can be a positive force in the OR as long as leaders ensure that staff are heard. “If technology is not adapted to their workflow, nurses will feel frustrated which will have implications on care delivery,” Kelley says. “Make sure the focus is on the clinician and what they need, and then build the technology to support that.”

Electronic health records (EHRs) can be a force for good, promoting patient safety, but they also often have multiple pain points. OR leaders can take steps to ease those pain points.

After providing an overview of EHR challenges and how managers can work with staff and their IT departments to overcome those challenges, the focus will turns to interoperability, setting the stage for successful EHR use, and how OR managers can obtain reports from the EHR that support their leadership endeavors. 

How can OR leaders best leverage the data in an EHR? “The fundamental question is, how can the data better inform your decision?” says Kelley. “What do you need to know to make a particular decision?”

Answering that question requires having a conversation with the nurse informaticist or another IT analyst who listens to what challenges the leader is trying to address, such as staffing or turnover. The two can then determine what data would be helpful in addressing the challenge. IT will know if that data can be obtained from the EHR and presented in a report. “There are thousands of fields, so picking the right field is just as important as knowing what data you want,” Kelley says. If the data are not there, the IT staff can help determine the best way to obtain it. “It’s not just asking for a report,” she adds. “It’s walking through the process and understanding each and every step.”

When considering reports, Texas Health’s Padden advises focusing on a specific topic: “We see people struggle when they try to incorporate too many things into one report.” Managers tire of reviewing lengthy reports and quit using them. “Having shorter, easier reports is better than one long one,” she says.

Managers typically use two types of EHR-related reports: those that have been set up and run automatically and those that managers set up and run as needed, usually to examine longitudinal trends (sidebar, “Types of reports”). For example, a report might pull all patients scheduled for a total knee to ensure that planned implants are available.

Padden notes that reports should match the needs of the person receiving the report. For instance, a charge nurse who is running the OR board may need a real-time report on room status, but the manager of orthopedic services may need to know the number of implants in the past 6 months and trends in which surgeons are using which implants.

Iuppa says that capacity planning is an important use of real-time data. “PACU managers can forecast what kind of care a patient is going to need postoperatively, so they can better align resources,” she says. Knowing factors such as blood loss, medication infusions, and number of wounds can help determine if a patient will be best served in the PACU or in a critical care unit, and how much one-on-one care will be needed.

Padden notes that a key factor in gaining useful reports is to ensure the contract with the EHR vendor specifically states that the organization owns the data. “You have to be able to access the data whenever you want,” she says. Managers should be wary of vendors who agree that an organization owns the data, but then require managers to access it only through reports in the vendors’ systems. “It has to go into your data warehouse so you can do with it what you need to do and not simply have them send you a PDF of a report,” she says. “That doesn’t work.”

Padden adds that many leaders, particularly mid-level ones, may struggle with data analysis because they tend to focus on where something is documented, such as a flow sheet, rather than reviewing a full report. “You have to get really good at looking at reports,” she says. Those include spreadsheets and graphic representations of trends.

“The better managers get at understanding the powerful tools of reports and how to get them, the happier and the more productive they will be as managers,” Padden says.

Many EHR changes can be made at the organizational level, but not all. When asking an EHR vendor to make a system change, Iuppa says it is important to understand that the vendor has limited resources and constraints, just as the organization does. “What we often don’t understand when we’re requesting changes is that sometimes it takes time to design a solution, code it, and evaluate it to make sure it’s compliant with other requirements for the design,” she says.

One tactic for change is for organizations to partner with others using the same EHR to gain greater leverage for a request. User groups are a valuable resource because those in the group will have similar challenges and goals. Multiple organizations can then approach the vendor with the same request. “The more you can show that it’s a problem not just for you but for many people, the more likely they are to hear you and to prioritize your request among the thousands they receive every day,” Iuppa says. “It’s harder to say ‘I want this one-off niche solution for my organization.’” Those types of solutions create a problem for vendors in the case of upgrades that might have to then be adapted for one organization.

Dr Hettinger points out that some changes are more difficult than others because many organizations are now working with systems that have been in place for years. “Some think about the EHR as this tool that gets implemented almost like a smart phone where you go to the store and buy a smart phone and everything is set up for you,” he says. “But the reality is that it’s very much a configuration among the vendors, the healthcare systems that are implementing it, and the staff members who are using it.” Decisions made years ago were made by those with the best of intentions and with the best available information at the time. Now that EHRs have become embedded into systems, organizations—and staff—are finding that the original configuration is not optimal.

Fixing the problem requires a team approach. “You need conversations among OR managers, the healthcare system, frontline staff, and the vendors to understand what can be done at the local institution level and which things are difficult to change because they are hard coded,” Dr Hettinger says. The latter may require waiting for an upgrade, or, in some cases, a need for the organization to change to a different product.