News / Periop Café

Operations vs. Nursing: Does it Make a Difference Who You Report To?

March 2, 2018


Operations vs. Nursing: Does it Make a Difference Who You Report To?

Two pros discuss the ins and outs of perioperative leaders reporting to COOs or CNOs

Throughout their careers, Directors of Surgical Services may report to any number of leadership roles, with titles from VP of Nursing, to CNO, to CEO, to VP of Operations, to COO, with straight lines, dotted lines, and innumerable other varied structures. These various reporting structures boil down to a simple distinction: whether these directors report to Operations or Nursing.

Over the past decade, Whitman Partners has detected a trend: more Directors of Surgical Services are now reporting to Operations. We wanted to verify this trend, and explore what it means for those who lead surgical departments and their varied components. To find out more about the pros and cons of reporting structures, we spoke to two longtime, respected leaders in the field, both of whom are nurses who have come up through the ranks and gone on to have careers in management over Surgical Services.

Kim Meeker, BSN, MBA, is CNO of Saint Agnes Medical Center in Fresno, California, with 25 years of executive experience. Her previous roles included Senior Operations Administrator at Wiser Women and Infants’ Hospital in Jackson, Mississippi, and VP of Surgical Services for Mercy Health System North in Ohio. Her positions have fallen under both Operations and Nursing, and she has reported to both in the course of her career.

“Surgical directors have historically bounced around back and forth. I think it really depends quite frequently on the organization’s priorities and the skill set within both the CNO and the COO,” she says. “And by that I mean surgery is probably one of the biggest drivers in most organizations in terms of cost and revenue. So there tends to be lots of interest from a COO perspective in making that department as efficient as possible.”

Meeker noted that she’s learned how to be more operationally efficient, and why that should be a focus, by reporting to COOs. “Depending on the CNO and their skill set, you can also have that same experience. But CNOs tend to be less operationally focused and more focused on the nursing care provided. So, having gone from one to the other, I’ve learned a lot on both sides,” she says.

So would the ideal situation for a Director of Surgical Services to report to a CNO with operations experience? Meeker says that would that definitely be the best scenario. “It’s not a typical learning path for a
CNO though, so there’s not a lot of them that necessarily have the experience,” she adds.

Although Meeker has not noticed a trend for Directors of Surgical Services to report to Operations, she finds that it’s a step that makes sense. “It doesn’t surprise me,” she says, “considering what’s going on in healthcare overall and the need to continue to decrease cost and increase revenue. And departments of surgery tend to be the area that you would want to focus on.”

In thinking about implications for bedside nursing for directors of surgical services reporting to COOs, Meeker says that this reporting structure pulls the discussion away from the care at the bedside to more operational throughput focus. “Whether you’re a COO or a CNO, if your focus is on revenue, expense, and throughput, and those are your stated goals and the goals of the departments, and you don’t state the same goals about patient care, patient satisfaction, and evidence-based practice, then people work the way the leader pushes them,” she says.

“Ultimately, if it’s not a balanced approach it definitely could have an impact. But, I also think within a C Suite, within every C Suite, there’s a team approach,” she says. “A COO is not typically working in isolation. Usually, the CNO is very involved in that conversation and helping to balance that.”

When asked what advice she would have for Directors of Surgical Services, Meeker says “My advice would be that there are pros and cons to each strategy: there isn’t a right and wrong on this. So no matter who you’re reporting to, or which role you’re reporting to, you should seek a balance between the two, whether it be a dotted line reporting structure, or just simply a relationship. So if you’re with a COO reporting structure, you should have a very strong
relationship with the Department of Nursing. And you should be involved in all of the committees and structures under nursing purviews so that you can stay very connected to what’s going on there.

“And it’s actually easier to do it that way than the opposite. If you are reporting to the CNO, it’s harder to get into that operational performance improvement structure that the COO tends to try to oversee.”

Larry Creech, BS-HCA, MBA, is Senior VP of Perioperative and Emergency Services at Barnabas Health, in West Orange, New Jersey. His previous positions include Division Director of Perioperative Services at Capital Health in Trenton, New Jersey, and Vice Presidential positions at several hospitals and systems nationwide. He started out in nursing and has also reported to both Operations and Nursing over his 25-year career.

Creech thinks that the reporting structure could work well either to a CNO or COO, depending upon who is the chief nurse and also who is the administrator. “But what I find more when reporting under the nursing structure is that some CNOs pull the resources out from under the clinical department, including educators, to spread to other places that need help, including the ICU and the cath lab. And I’ve heard that from a lot of my peers. It’s not always a financial decision,” he says.

No matter what the structure, maintaining good relations between Nursing and Operations is critical, he says. “Mine is to work together, not against each other, for a collaborative goal. And that’s the way I’ve always done that—I’m a nurse myself so I understand.”

Creech says that he has noticed the trend for Directors of Surgical Services to report to Operations. “Of course, it depends on who the leaders are,” he says. “But we are finding more of a trend of them trying to pull and go back under Operations, even if they’re under nursing now, because they feel a stronger support and feel they’re listened to as the perioperative leaders.

Operations is a logical place to report because we’re one of the four departments that are the moneymakers for the hospital, and we basically cover the expenses for all the other departments.

By reporting to Operations a lot of the teams feel that they truly trust that leadership. Operations is not trying to gain more, as often happens when perioperative leaders report to Nursing.”

“What the future looks like to me is that many more perioperative departments, and other procedural departments are moving to reporting to a non-clinical leader—unless that clinical leader is the COO, CFO, or CEO of the hospital. Cath lab, IR, and other clinical procedural areas are truly going under Operations, usually a vice president of operations or a COO, because so much of it is tied to dollars that cover the whole hospital,” says Creech.

As someone who guides perioperative leaders and teams, currently over seven hospitals and a surgery center, Creech has developed a leadership style that emphasizes a strong connection with the staff—a style that would work well for all those who oversee Directors of Surgical Services and their teams.

“I tell my team, I’m not here to catch anybody into anything. But a fresh set of eyes, that’s not there daily, walking in there every month or every other month, just helps you. I go to the team and say, how can I help you? Here’s some things I’ve seen. What’s your plan? Do you need me to help you? So you have roadblocks, what can we do? We work on a collaborative basis: I don’t say, why haven’t you had this done? I try to spend close to fifty percent of my time
in scrubs in all my areas where I’m actually seeing staff, seeing physicians, interacting, working on projects going, oh wow, I see you’ve been able to work on your turnover times or changed a new clinical practice. Then I go with them, into the emergency room, working with them on a throughput initiatives.

“So I’m there with them seeing what they’re dealing with and what they’re doing,” says Creech. “At times I’ve actually gone to the waiting rooms to watch the process from the front end. And the teams see that I really understand, because I try to walk in their shoes. I came up through the ranks from an orderly at age 16 and became a surgical technologist in the Navy. I became a nurse and just kept on living and working. And that’s why I love my job. I get to
have both.”