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The EMS workforce: Critical condition!

Why right-sizing EMS response is crucial to increasing pay and improving work-life balance


“As the respondents to the [NAEMT survey] clearly state, this is not purely a pay issue – it’s a combination of hard work-life balance, economics, leadership and culture,” write the authors.

Photo/Amanda McCoy via MCT

By Matt Zavadsky and Robert Luckritz

The National Association of Emergency Medical Technicians’ 2022 EMS Worker Engagement Survey should be a Klaxon for EMS and community leaders across the country. This report is a treasure trove of insights that, on the one hand, may not be terribly surprising to most EMS leaders; but on the other hand, may dispel some myths and urban legends about what EMS leaders think their practitioners want.

Here are the top 5 things we feel are most revealing about the report.

5. We stink at communicating effectively with our workforce

Only 32% of the survey respondents agreed with the statement “Management provides clear and consistent information to personnel.” We get it, EMS systems often scatter personnel across geography and the clock, but we have to find a way to communicate, really communicate with our workforce.

Email is easy, but ineffective and impersonal. Perhaps the first step to improving effective communication is to ask what methods of communication your employees would prefer, and then do that.

At MedStar, we have an employee-only social media platform that helps foster interesting communication processes. We also conduct monthly virtual Town Hall meetings that are video recorded and distributed to all employees.

At Austin-Travis County, we conduct biweekly Chat with the Chief podcasts to relay the latest department information. Employees are encouraged to submit topics and questions that the Chief answers, regardless of how delicate or controversial. It’s critical to be willing to discuss difficult topics.

Implementing structured rounding tools to track leadership interactions with front-line employees eliminates unconscious bias and ensures all employees are getting a chance to interact with leadership. The most time-consuming, but most effective thing EMS leaders should do is go visit the employees, in their offices. That may be a station, it may be the cab of an ambulance at a post location, whatever! Go to them, sit in the dayroom, stand in the parking lot of the post location, and listen to what they share with you. What do they enjoy about their job? What drives them crazy? What can you and the agency do better? They will rarely come to you with that information, but when you’re in their environment, you’d be surprised how open they tend to be.

4. We stink at providing feedback to our employees about their performance (and their patients)

When asked to rank “Management provides regular constructive feedback on my overall performance as an employee” and “My agency provides easily accessible patient outcome information to its EMS practitioners,” 48% of the survey respondents disagreed, while only 28% agreed.

Today’s workforce needs lots of feedback. A recent study cited in an article by Inc. found that 66% of Gen Z say they need feedback from their supervisor at least every few weeks to stay at their job. Similarly, EMS practitioners want to know how their patients did after they cared for them. This is due to the deeply rooted desire to make a difference with their actions. EMS leaders need to find a way to deliver feedback at least monthly to their employees – this could be through specific metrics that the employee can access or a push notification about some aspect of their performance (patient experience scores, clinical bundle compliance, anything!).

One high-performance EMS agency positions a supervisor in their deployment center to literally touch base with every crew member before they go out for their 12-hour shift, just to say “hi,” address them by name, smile and ask if they need anything for their truck, did they get water, etc.

Medical oversight departments should automate processes that link EMS patient charts to hospital data so crews can log in to a prior EMS chart and review the outcome fields (e.g., admitted, discharged, deceased, etc.). This will not only improve employee satisfaction, but also allow crewmembers to do some self-analysis, and help them feel more like they are a part of the patient care team for that patient.

3. We don’t pay our people enough

Not surprisingly, the lowest score from the respondents to the engagement survey related to pay and compensation. Sixty-three percent of respondents indicated they disagreed with the statement, “My pay and benefits are adequate and appropriate for the work I perform.” The economic model for EMS is challenging. Revenue is derived from two sources, user fees and public funding. For EMS agencies to be able to increase pay rates, those two funding sources must support the expense. Fee for service reimbursement has been static, if not decreasing, at a time when expenses for personnel, equipment and supplies are skyrocketing.

Thankfully, some states and local communities have recognized the need to increase compensation for EMS providers and have provided supplemental funding to support increased pay rates. EMS leaders need to get serious (and creative) about finding ways to increase compensation for EMS practitioners. You can seek additional funding by either increasing reimbursement (Medicaid rate increases), or convincing local elected officials that additional tax support is needed.

You can also consider EMS delivery re-design, such as tiered (BLS & ALS) deployment, changing response time goals, or alternate response models (e.g., medic only, RN/NP only, medical first response only) for low-acuity calls. This would reduce staffing needs while having minimal impact on revenue. The financial savings can be used to increase wages for EMS practitioners.

2. Work-life balance is a real thing

When asked why they were leaving EMS, 50% of the respondents said, “Better work-life balance.” Yes, EMS is a 24/7 operation, and someone will always have to work nights and weekends, but the problem is more deeply rooted. Due to staffing shortages, many agencies are mandating overtime to achieve optimal coverage, while many EMS practitioners are working two or three jobs to make ends meet due to the low pay. Those extra jobs tip work-life balance to the point people become dissatisfied and leave EMS. It’s almost a self-fulfilling prophecy. Practitioners leave, which means others in the agency must work extra shifts to fill the void. That, in turn, leads to dissatisfaction with work-life balance, causing EMS practitioners to leave, which causes ... well, you know!

EMS leaders should work with practitioners to create schedules that A) meet the agency’s needs and B) allow the employees some work autonomy and balance. MedStar allows select EMTs and paramedics to self-schedule. As long as the employee meets certain eligibility and schedule requirements, they pick their shifts. This helps with retention of folks that may have left for work-life balance.

System redesign isn’t just about economics; it affects work-life balance as well. Shifting to a tiered system changes staff workload and work experience by different levels of providers and can also extend careers by providing a better career ladder for providers. Shifting staff to alternative resources to address high utilizers and provide alternatives to EMS transport relieves the workload on transport providers. We can’t be afraid to reimagine our systems. Systems need to look at staff resources, and if they aren’t necessary at a certain time, be willing to shut them down. Employees don’t want to be mandated in, even on overtime.

At Austin-Travis County EMS, we began electing not to staff some ambulances instead of mandating overtime, and have seen a minimal impact on system performance when done with a strategy in mind. Employees that are working would rather spend time during their shift moving and ensuring coverage than being mandated in.

1. This is a long-term challenge that needs long-term solutions

The EMS staffing crisis was looming for years; the pandemic merely accelerated the inevitable. A perfect storm of changing workforce expectations, with employment needs across healthcare and many other sectors is exacerbating the crisis. As the respondents to the survey clearly state, this is not purely a pay issue – it’s a combination of hard work-life balance, economics, leadership and culture.

It’s up to us to dig ourselves out of the hole we’ve dug. Employees need to be put first, not last or even second. No EMS system can survive, no matter how advanced, without an engaged workforce. EMS delivery needs to be totally transformed away from a “you call, we haul” model to a “you call, we navigate” model. We need to take a hard look at long-held preconceptions about things like ALS staffing, response times and throwing everything, including the kitchen sink, to every EMS call. We need to seriously reduce workloads, and the resulting costs of readiness, based on processes that are not supported by evidence-based research.

Community partnerships with clear, transparent and frank conversations about community expectations and costs of service delivery need to be held with local stakeholders. If we are successful at right-sizing responses, we just might be able to increase the value of EMS delivery with a reduced workload – allowing us to increase funding and reduce costs. Then, we may be able to help EMS practitioners achieve a better work-life balance, and increase pay rates.

About the authors

Robert Luckritz is the chief of Austin-Travis County (Texas) EMS. He has more than 25 years of experience in EMS and healthcare, serving as an EMS provider, EMS leader, attorney and healthcare executive. Rob is also the treasurer for the National Association of Emergency Medical Technicians (NAEMT) and chairs its Workforce Committee.

Matt Zavadsky is the chief transformation officer for MedStar Mobile Healthcare, the Public Utility Model EMS system serving Fort Worth, and 14 other cities in Texas. He has 43 years of experience in EMS. He is an at-large director for NAEMT and chairs its EMS Economics Committee.