• Sustained Value of Implementation of a Flexibility-Based Compensation Structure for Nurse Anesthetists in a Large Multihospital Healthcare System

    Nurse anesthetists can use their creative problem-solving abilities to benefit both their employers and themselves. In an era when healthcare dollars are in short supply and patients who require anesthesia care are living longer (and requiring more procedures with anesthesia), innovative strategies are needed to achieve value and access to anesthesiology services. Leveraging the professional interests of Certified Registered Nurse Anesthetists (CRNAs), the implementation of a flexibility-based compensation structure can optimize overall staffing requirements to meet patient care demands, particularly in the face of recruitment challenges. This unique program, proposed and implemented by CRNAs, is presented as an exemplar that accomplishes multiple professional and financial goals.

    Keywords: Anesthesia staffing, innovation, practice management, recruitment, retention.


    Traditionally, anesthesia staffing at the hospital or facility level is determined by peak expected demand by hour of day. Shortfalls of staffing due to vacancies, high vacation burden, and family medical leaves of absence are often covered with overtime of employed staff or through the use of agency (locum tenens) personnel or a dedicated group of staff who are employed yet able to provide services at multiple locations. Rapid departmental growth combined with recruitment and retention of staff are challenges that employers face from time to time. Creative management of solutions, though, are often harder to come by.

    A large multihospital system comprising 16 disparate locations (at the time of implementation), faced this very situation and was tasked to meet an ever-growing demand for Certified Registered Nurse Anesthetist (CRNA) professional services.


    An enterprisewide review of daily demand compared with staffing revealed that peak demands rarely overlapped across hospitals. Through modeling based on actual demand, a more efficient approach to enterprise coverage became apparent. Using a CRNA leadership-driven initiative, the health system was able to meet operational needs by the contributions of the CRNA team. In return, the CRNAs had the ability to share in the cost savings by earning additional compensation, based on each individual’s desire to offer flexibility to the integrated health system.

    The United States appears to be experiencing a rapid demand for CRNA services across many regions, although predictive labor data are somewhat contradictory. Whereas the US Health Resources and Services Administration (HRSA) produced workforce projections in 2016 suggesting a surplus of 10,070 CRNAs by 2025,1 RAND Health projects a shortage of 1,282 CRNAs by 2020, with 60% of states reporting a current shortage of CRNAs.2 Schubert et al3 described the continued increase of case mix index, a measure of case complexity, among Medicare recipients. This trend of living sicker and longer intensifies the resources needed in the practice of anesthesiology as patients, particularly the elderly, present for surgical and procedural interventions. Innovative solutions, such as the approach described here, are needed.



    Through guided discussion at CRNA leadership meetings, current staffing challenges were analyzed at a multihospital system. The needs of both the employee professionals and the health system delivery were considered to arrive at a solution that best satisfied all interested parties. In an attempt to improve employee relations, promote recruitment and retention, and initiate a culture change toward an integrated complex healthcare delivery system, a new adjunct to compensation was initiated. Table 1 describes the high-level goals of the flexibility-based compensation structure (“tier” program).

    The health system had clear aims that required active participation by the CRNA staff. The CRNA leadership team felt strongly that active participation in assisting to navigate toward the goals would be beneficial for years to come. Additionally, it had the potential to position the CRNAs to be viewed as positive change agents by a progressive hospital leadership team. The health system desired an enhancement in CRNAs’ flexibility to achieve the dynamic changes in operating room (OR) caseload at multiple campuses on a daily basis. An inherent benefit to this flexibility was the reduction of fiscal unpredictability from overtime and agency costs that were being incurred because of the typical and expected volume fluctuations in a complex medical center. The medical center’s willingness to negotiate an innovative approach to CRNA compensation was fueled though an objective way to develop a method to accommodate rapid expansion and volume fluctuations at a reasonable cost.

    For the CRNA staff, the ability to be self-directed in clinical versatility was paramount. This encompassed the ability to pursue (or refrain from) subspecialty cases such as obstetrics, pediatrics, trauma, transplantation, and others. Feedback from the staff was an important guiding force to ensure professional satisfaction. Some staff members made elections based on geographic consideration (ie, a proximal commute to a different facility). In addition, the ability to respect the practitioners whose choice it was not to enter the program was an important measure of success. Finally, the ability to earn additional income for the sacrifice of providing care at a “less familiar” location was a key element to the program’s acceptance and success.

    A menu of options for program participation was presented to all the CRNAs in the health system through staff meetings that CRNA directors led at each hospital location. A description of the program (Table 2) was distributed at the time of discussion so that each individual could garner a clear understanding. Staff concerns were addressed as the program was rolled out. The ability to enhance personal income and diversify clinical expertise were among the major drivers that CRNAs identified as motivators to enter the program.



    Outcomes from the program implementation were apparent nearly immediately. Locum tenens CRNAs were slowly able to be released from their contracts with the medical center as employed CRNAs assumed more flexible assignments throughout the enterprise locations. Within 2 years, the elimination of expenses for locum tenens reduced approximately $2 million to payroll expenses (Figures 1 and 2). Concurrent to this, recruitment efforts were enhanced through the hiring of new CRNAs who were eager to practice across campus locations while enjoying the ability to earn additional income. This phenomenon allowed staffing across the health system to be adjusted to 94% (instead of 100%) of total demand since capacity, in terms of closed anesthetizing locations, could be met more efficiently through the flexible contributions of CRNAs. Because the medical center was in a growth phase, the demand adjustment from 100% to 94% did not result in any workforce reduction; rather, it reduced the recruitment demand in a modest fashion. This alone allowed for a budget savings of $3.9 million. As the pace of anesthesia demand continued to grow, nearly 175 additional full-time equivalent CRNAs were added to the enterprise over 4 years. In the same period, overtime expenses were reduced by 28%. The program, which has been in place for 10 years, allows a continued cost avoidance to the health system of approximately $2.5 million annually.

    Figure 3 demonstrates the general CRNA participation in the “tier” program after implementation. Approximately 22% of the CRNA staff initially elected to enter the program. This statistic remained relatively constant over time, even as staff members chose to enter, exit, or change their commitment level in the program. Figure 3 also demonstrates 2 other job classifications titled “trauma/transplant” and “staffing network.” The trauma/transplant designation had been in place before the implementation of the tier program, and it was incorporated into the new scheme. Trauma/transplant CRNAs were designated as those who had received additional orientation and training to care for medically complex patients receiving solid organ transplants (ie, kidney, pancreas, heart, lung, and liver) as well as trauma patients. This designation was placed at the urban, level 3 hierarchy (see Table 2). The staffing network category had also been in place before the tier program, but it was enhanced along with implementation of the tier program. Approximately 12 CRNAs were on the staffing network team and were oriented and trained to travel to all facilities in the health system to care for all case types.

    Unexpected positive outcomes were also achieved. From a professional socialization standpoint, CRNAs were able to network with both new colleagues and old. Best practices became more readily shared and emulated, and a standardized workstation was agreed on and developed at all campus locations. This allowed the benefit of anesthesia supplies being readily available in an expected location in each OR suite, which enhanced provider comfort in what may have been a foreign facility. In addition to enhancing the familiarity of the supply location for CRNAs, anesthesiology trainees (student registered nurse anesthetists and anesthesiology residents) also enjoyed the same benefit. These trainee groups gave feedback indicating that their ability to focus on care delivery and educational goals was enhanced when the distraction of attempting to locate supplies was eliminated.



    The ability to leverage professional talent and service delivery is paramount in today’s healthcare environment. Whenever possible, the ability to avoid “local only” planning for staffing utilization will create a more cost-efficient system. Such costs are compounded in a multihospital coverage model. The creation of a flexible workforce that allows appropriate distribution of resources according to a moving actual demand for anesthesia services can maximize service delivery and optimize costs. This principle plays out regularly through large anesthesia management companies that have realized the same economies of scale of this type of provider flexibility.

    One of the less favorable outcomes of providers’ movement through health systems (or facilities) is the obvious fact that they are less “known” to the surgical staff. This can cause some adjustment at the beginning of the day and is a bidirectional stressor to the anesthesia professional as well since the CRNA may not be familiar with the surgeon or nursing staff nuances. Some providers identified this stressor as a reason not to participate in the program. In such cases, those providers felt most comfortable in an environment where they were acutely familiar with their surgical colleagues.



    Healthcare costs continue to rise at an unsustainable rate. Although many healthcare professionals often struggle with a way to individually contribute to cost efficiency, opportunities through a team effort can be one way to have an impact on the bottom line. Innovative ideas that enhance the quality of care and reduce cost are the precise definition of value. This effort represents the ability of nurse anesthetists to create, implement, and enjoy direct benefit from a program that directly contributed to a large health system’s ability to deliver anesthesiology services to patients. This program designed by CRNAs has been in place for 10 years with only minor modifications, and it continues to deliver the same results.



    1. US Health Resources and Services Administration. Health workforce projections: Certified Nurse Anesthetists. Published December 2016. Accessed November 29, 2019.
    2. Daugherty L, Fonseca R, Kumar KB, Michaud P-C. An analysis of the labor markets for anesthesiology. Rand Health Q. 2011;1(3):18.
    3. Schubert A, Eckhout GV, Ngo AL, Tremper KK, Peterson MD. Status of the anesthesia workforce in 2011: evolution during the last decade and future outlook. Anesth Analg. 2012;115(2):407-427. doi:10.1213/ANE.0b013e3182575b4e



    Brent A. Dunworth, DNP, MBA, CRNA, NEA-BC, is an assistant professor of clinical anesthesiology and assistant professor of nursing at Vanderbilt University, Nashville, Tennessee. He is also the director of advanced practice and division chief of nurse anesthesia in the Department of Anesthesiology at Vanderbilt University Medical Center in Nashville, Tennessee.



    The author has declared no financial relationships with any commercial entity related to the content of this article. The author did not discuss off-label use within the article. Disclosure statements are available for viewing upon request.



    Special thanks to my CRNA leadership colleagues at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, for their diligent work to innovate and lead when it was needed most.

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