Just about everyone in EMS understands the importance of recruiting and retaining paramedics and EMTs. Employees move on or retire, volunteers come and go, and there’s a never-ending need to have a supply of workers to fill those spots.
But some are beginning to think about workforce issues in broader terms, beyond just meeting immediate needs and instead about what characteristics—from education and training to attitude and aptitude—EMS professionals need to meet and adapt to the changing needs of communities and the larger health care system.
“It’s the pipeline issue that’s most important,” says Michael Greene, a senior associate at the consulting firm Fitch & Associates. “Workforce planning looks at how we are preparing for the future. Are we attracting the right candidates into the profession and training them correctly? Are we recruiting for the profession as a whole?”
In October 2011, the National Highway Traffic Safety Administration released the “EMS Workforce Agenda for the Future,” a comprehensive document that explores the issue of ensuring a properly trained and prepared EMS workforce, including the areas of health and safety, education and certification. It also addresses the need to collect workforce data for research.
“We need to be anticipating needs five to 10 years down the road,” says Gregg Margolis, a member of the steering committee that authored the report and director of the division of health systems and health care policy at the Office of the Assistant Secretary for Preparedness and Response in the U.S. Department of Health and Human Services. “We also must look beyond the numbers of providers and make sure that our workforce has the knowledge, skills and attitudes for success in a dynamic environment.”
The Agenda proposes a National EMS Workforce Technical Assistance Center to help coordinate efforts to collect and disseminate EMS workforce best practices. EMS experts agree that’s a good idea. But in the meantime, the question is: How much workforce planning is currently being done? And if there are problem areas, what can be done now to change them?
Expanding EMS education to meet changing needs
Whether there’s an actual shortage of workers depends on where you are and whom you ask. According to the 2011 JEMS salary & workplace survey published in October, some areas are reporting having difficulty filling vacancies, while others aren’t.
Beyond just numbers, a bigger issue is what types of people are needed to do the job, and what jobs they’ll be doing moving forward, says Doug Key, senior vice president of operations for Transcare. Key, who oversees Transcare’s operations in and around New York City, says between the recession and several recent hospital closures in New York City, plenty of EMTs and paramedics are looking for work.
However, he adds, the days in which EMS can rely on all of its income from transporting patients are numbered. What’s needed is a workforce that’s trained to assume other roles, such as partnering with hospitals to prevent unnecessary readmissions by checking on patients in their homes.
“The traditional practice in EMS education has been to spend our time on life-threatening emergencies,” Key says. “Today, we’re talking about community-based medicine, wellness and health education … it’s really going to be up to employers to give their people some extended training and expanding their scope of practice and working with our partners to make sure they have the skill set our partners are desiring.”
What sorts of additional training might that be? Margolis has some ideas.
“We do a pretty good job of preparing EMTs and paramedics for 911 response and transportation to the emergency department,” he says. “Some organizations, either consciously or unconsciously, have decided that they are going to focus on these traditional EMS services. For them, our educational systems should continue to make incremental changes. However, organizations that want to take advantage of the opportunities for expanded roles for EMS will need a workforce trained in traditional EMS and with a much broader health care and medical background.
“The new EMS workforce will need a much more comprehensive education with a stronger foundation in basic clinical sciences, pharmacology, pathophysiology, health systems, ethics, decision-making and prevention, just to name a few,” he adds.
Another area of education that needs work: training paramedics and EMTs in the business and management of EMS to prepare them to become the leaders of tomorrow. That includes requiring paramedics to have at least an associate’s degree, if not a bachelor’s, says Greene, who is a co-author of the salary survey. “Today in the United States, you grant yourself or achieve mobility if you have a college degree,” he says. “Not all general managers at the large ground ambulance services are paramedics, but 90-plus percent have college degrees.”
Pay an ongoing concern
Yet the concept of requiring additional training or expanding scope of practice can’t be discussed without addressing the issue of pay, experts agree. According to the JEMS salary survey, pay varies significantly by region. Nationally, average pay for an EMT is just under $38,000; for a paramedic, it’s about $50,000.
“EMS has been said to be ‘passion with a paycheck.’ People don’t look at EMS and say, ‘Wow, I want to do that because I’ll make lots of money. They say, ‘I want to help people. It looks cool,’” Greene says. “The paycheck becomes an issue when they get married and have a family.”
Margolis agrees that low pay is a major issue facing the profession. “Too many of our good people leave for other careers due to lack of opportunity and for financial reasons. And too many people who would love to go into EMS don’t even enter partly due to status or compensation issues,” he says. “EMS is a great career that provides incredible opportunities to serve your community and make a real difference in people’s lives. But for long-term success, we need a system that enables quality people to be continually challenged with opportunities to do new things, the status and professional recognition befitting such an honorable profession, and sufficient compensation to maintain a lifestyle that EMS professionals, and their families, deserve.”
When paramedics and EMTs start thinking about leaving the profession, they often have multiple options. EMS agencies pilfer from one another, offering signing bonuses that draw providers from nearby agencies, only to have the agency that lost staff turn around and offer some other incentive, sending people back and forth, Greene says.
Other health care professions, including nursing and other allied health professions, actively recruit EMTs and paramedics. Colleges such as Creighton University in Omaha and several others offer accelerated paramedic-to-R.N. “bridge” programs that can be done online or on nights and weekends.
“Hospitals recognize there is a trained workforce they can bridge from the field into the hospital, rather than hiring a graduate who has never been around somebody who is sick,” Greene says.
And of course there are the fire departments, which are often happy to bring someone on who already has experience in the field.
The fire service, at least at large metropolitan departments with generous pay and benefits packages, faces different workforce issues, says Bruce Evans, who recently retired as assistant fire chief in the city of North Las Vegas and is now deputy chief at Upper Pine River Fire Protection District in Colorado.
“A lot of people come to the door specifically for benefits, stability, wages and schedule, instead of with the idea they are going to serve the community,” he says. “The day they’re off probation, they suddenly become unmotivated and don’t want to do the work. They want to be a firefighter instead of an ‘all hazards public servant,’ which is the new buzzword. That may mean going to someone’s house and putting them back to bed, or dealing with a wildfire, or dealing with a bee swarm.”
And while EMS constantly deals with turnover and finding replacements for staff who have left, the fire service often has the opposite issue—people often stay for life, which is good in some cases, but not when the employee is subpar. “You ‘own’ that person for the next 20 years, and it becomes a boat anchor on the organization,” Evans says.
EMS should learn from other industries
Short of boosting pay and offering expensive benefits packages, what can EMS agencies do to attract, and keep, the right people?
“I’m not sure we have an answer,” Greene says. “But some of the more progressive EMS systems are looking more like the fire service in their ranking, so they have a structure for folks to climb the ladder.”
One issue in EMS is its structure, which offers little opportunity for promotion. In EMS, a paramedic can become a supervisor, but after that step, there’s often nowhere to go other than becoming a director or general manager—and there aren’t many of those spots available. In addition, those top administrative positions aren’t always held by former paramedics, but by MBAs, Greene says.
Contrast that to the fire department, or even fire-based EMS, where there is a career ladder that includes becoming a lieutenant, captain, battalion chief and so on. That’s not only good for keeping the workforce motivated, but it’s a good way to train new leaders, who almost always come from within the fire service, Greene says.
Some of the things that have been shown to improve retention in other industries are applicable to EMS, such as recognizing employees for doing a good job and offering opportunities for growth and learning. “You need to create a workplace that gives people an opportunity to do what they do best,” he says. “Give them somebody within the organization who cares about them. Do they have a friend at work? The most successful organizations say, ‘Yes, I have a supervisor who cares about me.’ Employees have to be involved and acknowledged as a participant in their system.”
Make sure they have the right tools for the job, Greene adds. “That means ambulances that are in good working order, that don’t break down, and are low on mileage,” he says. “EMS is very much about appearances. You really have to create that appearance of a uniform workforce that looks sharp and professional.”
Key believes that continuing to rely on transports alone for income is going to mean continued downward pressure on wages—and therefore, on the ability to attract and retain the right people. Alongside dealing with reimbursement issues, EMS needs to do more to figure out how to participate in some of the new models being developed to contain health care costs, such as accountable care organizations.
“You will not be able to keep an organization viable on ambulance transports alone,” Key says. “You’ve got to look for other revenue sources. And there is a perfect opportunity with the health care changes under way.”
To view the entire EMS Workforce Agenda for the Future, visit ems.gov/pdf/2011/EMS_Workforce_Agenda_052011.pdf.
