OR leaders at work

Although many OR leaders still view their job favorably, satisfaction was slightly lower this year. The 64% favorability rating is much lower than the prepandemic figure of 70% in 2019. However, the unfavorable rating remained low this year, although up from 2022 (11% vs 7%).

Satisfaction also decreased in two other areas—total compensation and benefits. Less than half (42%) of respondents gave a favorable rating for compensation, down from 51% last year, and the favorable rating for benefits dropped from 64% in 2022 to 56% this year. In addition, satisfaction with top leadership and support provided by the respondent’s boss were both slightly lower than last year.

One area with a significant increase was patient satisfaction with OR services. As in past surveys, this received the highest satisfaction rating (84%, up from 76% in 2022).

Nearly half of respondents (42%) do not plan to leave their current employer in the next year. The top three reasons for leaving (respondents could choose more than one answer) were dissatisfaction with: current work culture (24% vs 18% in 2022), compensation and/or benefits (21% vs 16% in 2022), and management (20% vs 13% in 2022).

Benefits can play a key role in retention, so we asked respondents to select from a list the benefits they would like to receive if they did not currently have them. Consistent with past survey results, money-related benefits were the top three (respondents could choose more than one option). A bonus topped the list, increasing from 35% last year to 45% this year. Profit sharing took the number two slot (26% this year and last), followed by a pension plan (29%, up from 22% in 2022). Respondents suggested other benefits not on our list, such as a sabbatical, free parking, loan debt forgiveness, and health insurance after retirement.

Compensation is trending slightly higher for ambulatory surgery center (ASC) leaders, according to the 2023 OR Manager Salary/Career Survey, with 68% of respondents reporting a total annual compensation of $120,000 or more, up from 50% in 2022 and 40% in 2021.

However, higher wages are unlikely to sufficiently offset the stressors ASC leaders are experiencing. For example, those who responded they are planning to leave their current employer within the next year most commonly cite burnout (22%) as the reason, which is comparable to the 25% who cited this factor in 2022.

In addition, ASC leaders are seeing their responsibilities continue to grow. For example, they now supervise an average of 40 employees, compared to 36 in 2022 and up from 32 in 2019, the last survey before the COVID-19 pandemic. Despite the challenges of the current environment, satisfaction levels are generally on par with prepandemic levels. For instance, 73% view their current job or position favorably, compared to 74% in 2019.

Other highlights from the survey include:

• More respondents received a raise in the past 12 months compared to 2022 (74% vs 66%). The average raise was 5.1% (4.8% when the single 30% response is omitted), higher than last year’s 4.24%, but still lower than the 2022 consumer price index of 6.5%.
• More than half (54%) of respondents plan to retire in 2024 or later, with 10% planning to head for the work exit by the end of 2025.
• Half of respondents plan to stay with their current employer 5 years or more (vs 55% in 2022), but 28% (vs 24% in 2022) plan to stay 2 years or less; 22% plan on staying 3 to 5 years.

This article takes a closer look at findings related to ASC leaders. (Percentages may not add up to 100% due to rounding.)

Satisfaction outlook

Changes in satisfaction compared to 2022 mostly trended slightly downward. Drops in satisfaction were seen in total compensation (52% vs 55%), top leadership of the organization (58% vs 62%), support provided by the respondent’s boss (63% vs 70%), and physician engagement level (64% vs 71%).

On the other hand, satisfaction with staff engagement rose from 69% to 73%. As in previous years, respondents were most pleased with patient satisfaction with OR services (92% vs 88% in 2022).

Comparing these results to prepandemic (2019) satisfaction levels reveal some interesting patterns. For the most part, levels are relatively similar. For instance, job satisfaction was 74% in 2019, compared to 70% this year, and satisfaction with support provided by respondent’s boss was 62%, comparable to this year’s 63%. However, satisfaction with the organization’s top leadership was 63% in 2019, several percentage points higher than this year’s 58%. Patient satisfaction with OR services has risen from 72% in 2019 to 92% this year.

Nearly two-thirds (62% vs 58% in 2022) do not plan to leave their employer within the next year. Burnout and dissatisfaction with compensation and/or benefits topped the list of reasons for those who were planning to leave (22% and 21%, respectively; respondents could choose more than one option). Other common reasons were dissatisfaction with management (14%) or with the current work culture (13%).

Benefits can be a powerful retention tool, so we asked respondents to select from a list the benefits they would like to receive if they did not currently have them. Consistent with past years’ surveys, money-related benefits topped the list: profit sharing (35%), bonus (35%), tuition/education reimbursement (30%), and pension plan (26%). These are the same as the top four in 2022. Sixteen respondents provided other suggested benefits, including flexibility in work schedule, 4-day work week, remote workdays for administrative work, and health insurance for dependents.

For most perioperative leaders, discussions about productivity do not top the list of enjoyable parts of the job. For many, productivity is not even a topic area where they have much experience.

Yet perioperative leaders must frequently answer questions from those in senior leadership positions who consistently look to boost productivity as a means for achieving financial goals. Too often, the answers these leaders provide are not well received by senior leadership.

Brian Dawson, MSN, RN-BC, CNOR, CSSM, points to one main reason for the disconnect: “Perioperative services is not like any other nursing location, so there are no national benchmarks for productivity in OR areas.” Dawson, who is system vice president for perioperative services at CommonSpirit Health in Chicago, adds that given this gap, senior leadership frequently turn to consultants for advice on benchmarks, but that advice might not be valid. In many cases, consultants do not have evidence-based data to back up recommendations, yet organizations often accept them as fact.

In response to a question in the 2023 OR Manager Salary/Career Survey that asked about productivity measurement, many leaders agreed with Dawson about the uniqueness of the perioperative setting, noting that productivity tools and performance indicators often do not reflect the setting’s complexity.

So how can perioperative leaders make productivity measurement work for them? This two-part series is designed to help perioperative leaders measure productivity effectively, analyze results, and communicate with the C-suite so that productivity can be a tool and not a burden. This article focuses on the value of measuring, challenges, and making decisions about what should be assessed, as well as on the analysis of productivity data, the role of technology, and communicating results to key stakeholders, such as staff and top leadership..

Analyzing productivity data

Questions to consider when analyzing productivity data include: What level of productivity should perioperative leaders target? What are the comparison data?

To answer the first question, Casteel, uses benchmarking reports from Vizient, which notes that scores below the 40th percentile correlates with effective productivity. “You want to be sure you’re in that sweet spot for productivity,” she says.

The ideal productivity level is 100% to 108% but the percentage will fluctuate. For instance, Casteel says that on Tuesdays, the number of cases are lower, but they are longer and more complex, which results in lower postanesthesia care unit (PACU) productivity. However, Wednesdays bring higher PACU productivity because there are more shorter cases, such as GI and urology. Therefore, Casteel recommends that in addition to reviewing daily data, leaders should review trends over six pay periods. She recommends leaders avoid dipping below 95%. On the other hand, “If you’re consistently above 120%, you need to ask why,” Casteel says. Productivity may be higher because someone was on family leave or out sick, which reduces the number of staff. While a 120% productivity report might seem like good news, if sustained for too long, staff will feel overworked and could leave the organization. For that reason, Casteel says consistently high productivity percentages could indicate an inappropriate staffing model.

Benchmarking with national data can be helpful in answering the second question related to comparison data. For example, Gilliam says the hospital reports data to the Children’s Hospital Association (a collaborative of more than 220 children’s hospitals that seeks to improve child health) and receives quarterly reports in return. “We look at the reports to see how we measure up to other children’s hospitals,” she says.

In general, however, national comparison data for the perioperative setting are lacking, according to Dawson. Instead, healthcare systems may choose to compare hospitals within the system. The goal of data analysis is to use the results to improve care (sidebar, Success stories: Operationalizing productivity results).

Technology’s role

Technology can provide information related to factors such as capacity and patient flow that can be used to facilitate productivity measurement and foster better business decisions. “The newest technology gives leaders real time and predictive information so they can better plan and identify windows of time, which are opportunities for more cases,” says Shawn Sefton, MBA, BSN, RN, a perioperative consultant. “It can help us understand our business much better.” Sefton was chief nursing officer and vice president for clinical solutions at Hospital IQ, which was acquired by LeanTaaS in January 2023.

That understanding helps OR leaders ensure they have the right resources at the right time. For example, when OR leaders can predict the types of cases coming up, they can staff rooms with employees who have the competencies needed for those cases. Leaders also can adjust block schedules to optimize utilization. Sefton says these types of features help leaders present a business case for purchasing a system. If, for instance, utilization is below target, being able to predict where additional cases can be scheduled and how to use staff most efficiently will increase revenue. In essence, the technology can help optimize OR management, which will improve margins and gain the attention of those in the C-suite.

Many organizations pull productivity measures, such as first-case start times and turnover times, from electronic health records (EHRs). Software that provides operational data is usually focused on inpatient units, but a few commercial products can be helpful in the perioperative setting. One option is iQueue for Operating Rooms (LeanTaaS), which CommonSpirit has purchased. The product helps the organization establish realistic productivity standards and staffing for various hospitals. For the SPD, Nemours Children’s Hospital uses SPM Surgical Asset Tracking Software (Steris), which includes a dashboard that measures productivity. Technology tools may be subscription based (factoring in the number of ORs), and some offer different modules, which organizations can add as needed to gain full integration of the patient flow.

Dawson says it pays to invest in commercial products that provide data that can be used to assess and manage productivity. For example, contracts with instrument tracking companies have helped CommonSpirit optimize staffing and save money. “[These products] cost thousands of dollars, but the ROI [return on investment] is there,” he notes, adding that it is usually cheaper for organizations to purchase a product rather than build one internally.

Sefton says another strategy for making the business case for software that provides information that helps a leader manage productivity is to share how much the OR is spending on FedEx because lack of planning led to urgent needs for instruments and other supplies for cases. The costs can run thousands of dollars; reducing or eliminating those costs can help off-set the cost of a system.

As with any new product, it is important to carefully review the software’s capabilities and usability to ensure it meets the organization’s needs. “Consider what problem you are trying to solve and whether the software will help solve that problem,” Sefton says. For example, OR leaders often want to improve prime time or block utilization. She adds that culture plays a role as well. “Those in the organization have to be ready to make the changes that are needed for the technology to be successful,” she says. For example, modifications of the scheduling process might be needed. “You want people to lean in and take advantage of what’s being offered” (sidebar, Culture and productivity).

“You want the system to be adaptable to your facility,” adds Dusty Clegg, MS, RN, operations officer for the Canyons and Desert Regions of Intermountain Health (based in Utah), which also uses iQueue for Operating Rooms. For example, reporting and scheduling functions should be intuitive to use and flexible so they can be tailored to the nuances in various facilities. “You also want transparency at the provider level,” Clegg says. Surgeons can see their block utilization on their phone and when an OR has opened up block time.

Sefton recommends leaders ask for a full demonstration of the product and select one being used by many facilities, as opposed to one in development or early release. Talking with those who are using the technology is valuable, and leaders should ask about customer support and how software updates are handled. Some companies make updates on an ongoing basis, which can help ensure the organization is getting the most benefit from the system. “You want to have a company that will partner with your organization,” Sefton says.

“You want to be a good financial steward and be sure you are getting a good ROI on the product,” Clegg says. “Ask what you are going to get out of it.” The value might come from greater efficiency, increased case volume, or decreased premium pay. Of course, the most important goal is to improve patient care. “Us

ing technology to help leaders plan their resources better brings us back to delivering exceptional patient care,” Sefton says.

Connecting with the
C-suite

“Most CEOs and CFOs don’t understand the OR because they don’t go behind the red line,” says Dawson. “Because they do not understand, they reach out to a third party to tell them what their productivity should be.” Unfortunately, Dawson says, those third parties too often provide information not backed up by evidence.

Perioperative leaders need to educate senior leadership, but they also need patience because it can take time to see results. Yet the effort is worthwhile. For example, Dawson was able to make the business case and demonstrate the ROI to CommonSpirit leadership to purchase iQueue for Operating Rooms 4 years ago. He also was able to do the same for SPD; the organization uses the CenisTrac Instrument Tracking System (Censis) to track workload and productivity data.

Pairing education with building partnerships will help perioperative leaders be more effective in productivity discussions. A good starting point is understanding senior leaders’ jobs and perspectives. “I have a very good rapport with our C-suite because I’ve made it a priority to get to know them and to understand what they are responsible for,” says Casteel at Wellstar Paulding. She reports to the CNO but works closely with the COO and CFO. On their part, senior leadership routinely make rounds in the perioperative setting. “They put on scrubs and see how we work,” she says. Casteel credits the organization’s servant style of leadership that embraces lean management for the effective partnership. “Leaders know that they have to observe so they understand the nuances of what we do,” she says.

In addition to the environment, Casteel says being able to speak in terms of data enhances her ability to obtain resources and add new service lines more quickly. “I can concisely prove my point using data,” she says. Casteel, who meets weekly with the C-suite, adds that taking an “elevator speech” approach and being prepared are keys for success. “You have to always be thinking about what you need next week, next month, next quarter, and next year,” she says. “When you have the opportunity, drop hints and keep building on that so you tell the story of what you need and keep them informed.”

Jessica Gruendler, DNP, RN-BC, CPHQ, CNOR, senior director of nursing operations and perioperative services at Dignity Health in San Francisco, says perioperative leaders need to be able to communicate the units of service for each of their departments. As noted in Part 1, these units differ by location. “You not only have to understand the complexity behind those units of service, you also have to be able to verbalize all of the other resources (such as nonclinical staff) and all of the other tasks that go into maintaining an OR,” she says. For example, schedulers are needed no matter how many cases or minutes of service there are during a day.

Gruendler also spends time helping the C-suite understand how acuity in the OR differs from patient acuity on a hospital unit. Acuity for postsurgery patients can be measured based on data from the EHR, but in the OR, acuity is based on the type of surgery. For example, a simple mastectomy might require a surgical technologist, a circulator, and two instrument trays, while a total joint might require an additional surgical technologist and 25 instrument trays. In addition, a third person in a robotics or total joint OR to help with setting up the first case and turning over the room can improve efficiency.

As with Wellstar Paulding, rounding is a key component to helping senior leadership at Dignity Health to understand perioperative departments. As part of the “Stronger Together” program, senior leadership (including the C-suite) round every day; rounds include discussing metrics being measured. Rounding assignments change weekly. “The C-suite becomes familiar not only with the complexity of the OR but the terminology,” Gruendler says.

Even with strong partnerships, it can be difficult for perioperative leaders with underperforming metrics to face questions from senior leadership. Gruendler recommends sharing efforts to address the problem. “If I can get them to understand how I am working to keep down my costs, avoid waste, and be efficient, it helps a lot,” she says.

Perioperative leaders also need to ensure they understand productivity so they can communicate effectively with upper management. “Many OR directors don’t have a good understanding of the financial and operational part of the OR because they’re so focused on the clinical,” Gruendler says. “That’s a huge knowledge gap that OR directors need to fill with education.”

The effort to build understanding can provide significant benefits (sidebar, Success story: Productivity and positive change). A year ago, Gilliam says Nemours retooled the OR education program and built pipelines with area colleges, which resulted in nearly erasing a deficit of 15 open positions. Now, however, those new nurses are completing orientation and require mentoring as they continue to learn their craft.

“I need to give them the ability to learn while also maintaining an appropriate staff mix to keep patients safe,” Gilliam says. She feels the work she has done with leadership has positioned her well to advocate to the C-suite to “overhire” slightly so veteran nurses are available to help new nurses, who will not be fully comfortable in their role for 1.5 to 2 years. The strategy also will help avoid staffing crises related to unexpected resignations or family medical leave and make it easier to reallocate staff to other locations during staffing shortages.

To encourage buy-in for the strategy, Gilliam had the vice president who gave approval visit the perioperative setting so he could see the entire process, starting with the preoperative area and through PACU. “I think he was a little overwhelmed,” she says. However, learning what new nurses would deal with gave him valuable insight into the request. “He understood that this would help to build specialty teams for highly complex patients, keep ORs open, and maintain safety parameters as we navigate a significant number of new graduate nurses in the OR,” Gilliam says.

Future directions

What is the future of productivity measurement? In this era of value-based healthcare, many surgical procedures are navigating from the more costly hospital setting to the less costly outpatient setting. And in the future, Clegg says, some of the procedures currently performed in ambulatory surgery centers will migrate to physician offices. All this is part of the larger focus on population health. “As we shift from fee for service to a population health approach, we need to look at things very differently,” Clegg says.

Under population health and value-based care, the goal is to keep patients healthy, particularly because providers receive a set amount of money, rather than being paid for services provided. Therefore, perioperative leaders must consider the procedures the hospital is doing, how they are being done, and whether the hospital is the best venue for the patient. “In the future, the goal will be to keep patients out of the OR because it’s costly,” Clegg says. “We will still look at productivity because time in the OR is very expensive, so you want to be as efficient as possible.” However, leaders also must take a wider view. “It’s not just productivity, it’s the cost of what we are doing and what value we are bringing to the patient,” Clegg says. “We have to be good stewards of the dollars we are responsible for.”

This deep-dive has covered the nuts and bolts of productivity measurement. But it is important not to lose sight of the ultimate goal of everyone working in healthcare—patient safety. “Productivity metrics are important to analyze your staffing, but my goal is determining what’s safest for my patients and what’s safest for my staff,” Gruendler says. “I have to put my patients and my staff first at all costs.”

—Cynthia Saver, MS, RN, is president of CLS Development, Columbia, Maryland, which provides editorial services to healthcare publications.

Productivity is a foundational concept for leaders of ambulatory surgery centers (ASCs). “Measuring productivity is essential to be successful,” says Beverly Kirchner, BSN, RN, CNOR, CASC, chief compliance officer for SurgeryDirect, LLC, Salt Lake City, Utah. “When you’re measuring productivity, you’re looking at efficiency, which affects the types and numbers of cases you can do.”

Time invested in productivity measurement yields dividends for ASC leaders. “It helps leaders be more effective in managing staff and working with surgeons,” says Becky Ziegler-Otis, MHA, CASC, RHIA, CPHQ, CHC, an ASC healthcare consultant in Plover, Wisconsin, and a member of the board of directors for the Ambulatory Surgery Center Association (ASCA). Ziegler-Otis also is assistant executive director for the ASC Quality Collaboration, which partners with outcome measure developers and payers on measure development projects impacting the ASC industry. “Productivity measures can help you assess processes that impact center operations and help pinpoint and focus efforts on what needs attention.” For example, a leader who identifies under-utilized block time might learn that the problem is not lack of volume from the surgeon, but rather that the surgeon’s office staff finds it cumbersome to schedule cases with the ASC. Smoothing the process could increase volume.

But productivity measurement is not without its challenges, as indicated by results from the 2023 OR Manager Salary/Career Survey. In response to an open-ended question, respondents cited issues such as difficulty in obtaining data and lack of time. (For more information, return to the survey results also included in this digital booklet) To overcome these challenges, ASC leaders need to establish a measurement process that is both effective and efficient, and they need to closely analyze and communicate results.

Productivity process

A recurring productivity theme from ASC leaders is to “keep it simple.” Start by looking at the big picture, then drill down as needed. “The more complex you make the information gathering, the more likely an error is going to creep into it,” says John Goehle, MBA, CASC, CPA, chief operating officer for Ambulatory Healthcare Strategies, Inc, in Rochester, New York, and host of The ASC Podcast. Kirchner agrees, adding, “If you ask staff to track every time they pick up the phone to make a preop call to a patient and the end time, you’ll never get accurate numbers.”

Ziegler-Otis says ASC leaders should realize that they do not have to be looking at multiple metrics all the time. “If you’ve been tracking a lot of metrics, it’s easy to get data analysis paralysis,” she says. She recommends focusing efforts and working on improving a few key measures at a time. Ziegler-Otis says this approach aligns productivity metrics with continuous quality improvement principles.

Kirchner adds that productivity goals, quality goals, and patient satisfaction are all linked. “When we look at productivity, we want to make sure we don’t cut staffing so short that we’re not delivering quality care, or that the patient feels they didn’t receive individualized care that met their needs,” she says.

What to measure

“The most important productivity measure for ASCs is nurse staffing,” Goehle says. “How do we staff efficiently?” To answer that question, he recommends ASC leaders use a simple measure: clinical hours per case. “It is one of the most useful tools and one of the easiest to calculate, but it can be very powerful,” he says (sidebar, Calculating hours per case).

This simple calculation has several advantages. First, it does not require obtaining information from an electronic health record (EHR), which many ASCs still lack. Second, it avoids more complicated calculations that ASCs may not have the resources to perform. And third, ASC leaders can use historical data to make the calculation and establish trends. “Every surgical center in the country can use clinical hours per case,” Goehle says.

Kirchner also uses hours per case as the primary productivity measure, but she includes nonclinical staff in the calculation. She tracks productivity daily but primarily focuses on monthly results. “If we keep our staff hours per case at 12 or less, we are profitable that month, our patients don’t complain, and our staff have gotten their hours,” she says. The data are kept in an Excel sheet for easy reference, and an iris recognition time clock helps ensure accuracy of staff hours.

Rena Courtay, MBA, BCN, RN, CASC, CPPM, CNOR(e), does not include nonclinical staff such as schedulers in productivity measures. “Those positions don’t change on a daily basis the way clinical staff do,” says Courtay, who is assistant vice president for perioperative ambulatory surgery at Duke Health and an ASCA board member. Instead, nonclinical staff are considered a fixed cost, so part of the annual budget process is determining the appropriate number for the anticipated volume.

For OR staffing, Courtay uses the formula of 2.5 fulltime equivalent employees (RNs and surgical technologists) for each OR. “That will cover you for nonproductive hours such as meetings and for things like breaks and lunch,” she says.

For the most part, ASCs do not have detailed productivity measurements for the postanesthesia care unit (PACU) or sterile processing department (SPD). “That isn’t information that’s easy to gather and benchmark nationally,” Goehle says. Duke uses number of trays processed for the SPD, but Courtay acknowledges it should not be the sole measure because it fails to account for the complexity of processing some trays. She adds that keeping up with the increasing volume of trays as surgical procedures become more complex is challenging, and that last-minute arrival of loaner trays also is a problem. “We’re needing a lot more people in SPD than we ever did before to keep up with the load,” she says.

Compared to hospitals, the role of technology in obtaining productivity measures is more limited in the ASC because of cost and, in some cases, not having an EHR. Courtay says Duke was able to negotiate a special price for iQueue for Operating Rooms (LeanTaas), which uses predictive analytics and machine learning to provide information used to manage capacity. The detailed information has helped facilitate her discussions about block utilization with surgeons.

Ziegler-Otis says that even ASCs without an EHR usually have a practice management system for scheduling that leaders can leverage to obtain useful productivity data. “Most scheduling software has the ability to run analytics and data reports,” she says. For example, practice management software typically can track surgeon-specific surgical procedure time and calculate an average case time that can be used to schedule future cases, resulting in effective utilization of a surgeon or group block time. As with any system, data entry must be precise to obtain useful data.

Data analysis

Benchmarking can be a challenge for ASC leaders because few national resources exist. One resource is Intellimarker (VMG Health), which has data for multispecialty ASCs, including revenue, expenses, case volume and mix, payor mix, reimbursement, and staffing. Courtay adds that Becker’s sometimes publishes articles with benchmarking data, and that the ASC management company often sets benchmarks. Another resource is ASCA’s Clinical & Operational Benchmarking Survey (sidebar, Benchmarking resource).

In addition to external sources, ASC leaders can benchmark productivity measures, such as clinical hours per case, against their own performance over time to determine operational efficiency levels. Goehle gives the example of an ASC that has been running at 8 hours per case for the past four quarters but slipped to 7 (a number the center has never seen). In this case, more staff are likely needed, unless staff is complaining about their workload, which may indicate that the center was properly staffed before the decline. “The beauty of this is that you can sell it to the doctors,” Goehle says. For instance, the ASC leader could say, “We’ve never been as low as 7 and staff and patients are complaining; it may be time for us to staff up a bit more.”

Clinical hours per case can serve as an early warning sign for other problems. If, for instance, the number of hours increases from 10 to 13 and staff satisfaction has not changed, an ASC leader would want to examine other possible reasons, such as an increase in delays in first case on-time starts as a result of adding a new surgeon.

A key factor to consider when analyzing data is knowing when to dive deeper into the data. “You have to understand the whole picture,” Kirchner says. “When you break processes down too much, you lose focus of what your end goal is.” For example, if the first case is 15 minutes late, but the time is made up by the end of the day, a leader would not want to criticize staff for the late start.

On the other hand, if overall productivity measures are declining, the ASC leader should look at the process in more detail to identify problem areas. Kirchner cites the example of focusing on preoperative patient preparation. “The preop process drives the ASC’s efficiency,” she says. The centers she works with spend time educating patients and families to improve time to discharge and establish parameters for what is needed before each case. For instance, patients who will undergo complex spine procedures must have a full history and physical at least 7 days pre-surgery, or the case gets cancelled.

After making a change, Ziegler-Otis says ASC leaders should continue monitoring to ensure the change had the desired impact. For example, a leader might implement 10-hour shifts as a staff satisfier and to improve productivity, only to discover that staff do not support the change and productivity does not improve; unintended staff turnover could occur as a result. In addition, solutions should be tailored to the ASC’s need. “What works at one center doesn’t necessarily work at another,” she says. “Each ASC is unique, so you might have to tweak things based on your needs.”