Editor’s note: The most recent What Paramedics Want Report from EMS1 and Fitch & Associates highlighted many of the same concerns EMS leaders have been wrestling with for years, including burnout, recruitment, retention and leadership development.
Throughout this series, we have made the case that burnout, high turnover and low morale are not simply problems to solve. They are symptoms and results of the systems in place.
- Part 1 focused on the foundation of leadership, your communication system.
- Part 2 looked at your leadership system and the practices that shape how people experience the organization.
Those first two parts matter because organizational change does not begin with a new policy, staffing model or strategic plan. It begins with how leaders see the situation, how they communicate and how they lead the people around them.
Without the foundation covered in Part 1 and Part 2 of this series, even good ideas could be implemented through the same assumptions and habits that helped create the current results — and they will not be as effective.
Part 3 brings the series to the organizational change level.
Now we can ask a larger question: What kind of organization do we actually want to create?
Rather than beginning with the limitations or constraints of the current system, this final article asks us to imagine what EMS could look like if we designed our organizations around the results we want to produce.
That means examining the systems that shape staffing, schedules, culture, finances, development and the overall employee experience.
The goal is not to ignore today’s challenges. It is to stop assuming that the way EMS works today is the only way it can work.
In Part 3, we will focus on how leaders can begin designing organizational systems that produce different results.
| DOWNLOAD: What Paramedics Want in 2026
In this article, we will focus on designing organizational systems that produce the results paramedics really want — not just survive, but to thrive, to be the best they can be, to do good work and to be cared for while doing it.
The EMS system we have today was born as a response to a specific problem in the United States in the 1950s: people involved in high-speed car crashes on America’s new highway system needed to be transported as fast as possible for medical care. The system was designed to address that need, not necessarily to support the long-term sustainability of the workforce and organizations it would eventually serve.
As the demands on EMS changed, the system continued to expand to include the new roles and responsibilities, but without redesigning how it worked. It is amazing how much EMS has accomplished given the limitations of the design.
To be clear, there’s nothing inherently wrong with the current system; it simply isn’t producing the results we want now. Similar to how CPR and resuscitation science evolved, our understanding of what works can evolve. The system we inherited was aligned with what was needed at the time, but that doesn’t mean we should stop asking how it can work better.
One of the challenges to adopting a new approach is that EMS professionals have become experts at cobbling it together or making do with the resources available. This type of resourcefulness has been essential to survive in the EMS system you inherited, but it can make it harder to imagine a different way of operating. It doesn’t have to be that way. It’s time to question the assumptions from the original system and imagine what we could create if we were not constrained by the way things have always been done.
For example, many of us remember a time when cassette tapes dominated the market. They were everywhere: home stereos, boom boxes, Walkmans and car stereos. The world was designed for the use of cassettes. Yet, even at the height of their popularity, there were limitations to deal with. For example, you had to flip the cassette over in the middle of listening to a symphony and the tape could get tangled in the player. Rather than trying to fix the problem, innovators pursued a different technology.
Out of this exploration, compact discs (CDs) were invented. A whole new system had to be created. The inventors did not go out and destroy cassettes and their players. They designed something so extraordinary that even diehard cassette owners converted to CDs once they heard the difference in the quality of the sound.
This example demonstrates that even though something is pervasive, it doesn’t mean it is permanent. When you come from a systems perspective and you intentionally design your system for the outcomes you want, you open up possibilities the existing system may never produce.
While you may not be in a position to transform the entire industry, you can intentionally redesign your organization (or team) to achieve a different outcome.
The City of Pittsburgh Bureau of EMS: A model for transformation
The transformation of the City of Pittsburgh Bureau of EMS under the leadership of Chief Amera Gilchrist offers a compelling example. When she became chief, the department was experiencing a lot of staffing issues, and these problems tanked morale because people did not have a good work-life balance.
Having come up through the ranks, Chief Gilchrist was very familiar with the challenges her people were facing. Rather than solely trying to fix the “problem” she asked different questions:
- What do we want to create?
- How do we want it to be?
- What results are we committed to and what system can we create to produce those results?
Chief Gilchrist challenged the status quo by rethinking how the department hires, develops and retains its workforce. She reduced the time to hire a new employee and established the Freedom House EMT Academy, a paid training program that removes financial barriers for aspiring EMS professionals, and developed an advanced training academy for existing employees. She and her leadership team also conducted employee interviews, listened to concerns, and took action to address the challenges identified.
The results were significant. In less than two years, the department quadrupled its hiring rate and went from understaffed to fully staffed for the first time in 40 years. With an interview pool of more than 100 candidates and a waiting list, the department began attracting people who previously saw a career in EMS as financially out of reach. Some applicants shared that they had always wanted a career in EMS but never could afford to go to school.
During an interview featured at the EMS Leadership Summit, Chief Gilchrist shared how these changes were made possible by listening to employees, investing in professional development, and challenging long-standing systems. Her experience offers an important lesson for EMS leaders: recruitment and retention challenges are not simply problems to solve. They are opportunities to examine and reinvent systems that drive culture and shape the employee experience.
This is not rocket science or pure academic theory. It’s design and it’s a practical approach you can use today for your biggest organizational challenges. As we have said throughout this article series, every result is an outcome of the design of the underlying system.
Work backwards to identify pathways to your goals
A good place to start is to imagine your organization as a blank canvas. Set aside, temporarily, the constraints you usually focus on: limited resources, resistance to change, existing processes and procedures, any assumptions about what is or isn’t realistic. Give yourself permission to imagine what you might create without worrying about how it is today.
Give yourself some time to imagine it the way you truly want it to be without compromise. Allowing yourself this space will enable you to engage your creativity without getting sideswiped by your opinions and assessments about how it is.
You don’t need to redesign your entire organization from scratch to transform your results. But imagining it from scratch can help you get clear on what you truly want to create. Stepping back from your interpretation of the situation will allow space for creativity. When you give your mind the opportunity to slow down and reflect on a situation, solutions become apparent.
Once you have clarity on what you truly want, for example a fully staffed, highly engaged team of quality professionals, work backward from that outcome to build the system by identifying various strategies, actions and milestones. Working backward will help you to use your imagination rather than analyzing the current problems which isn’t as helpful at this stage. This process can reveal possibilities and pathways to your goals that you might have missed using a more traditional approach.
You can apply this process to every area of your organization including finance, communication, facilities, community engagement, equipment and vehicle maintenance, to name a few. We recommend starting with culture because it influences how the rest of the organization functions.
When people can see a future they want to be a part of, and have a voice in creating it, they are more likely to contribute to making it happen.
Of course, designing the new system doesn’t mean you can ignore the challenges created by the old one. Those issues will still need to be addressed while you are building the system for the future you want. But by starting with the end in mind, you and your team will be building something together with a shared vision to guide your decisions. The issues don’t instantly disappear, but they can be viewed as opportunities to learn and used to strengthen the system you are building.
The future of EMS doesn’t have to be a continuation of the past. When we understand the power of systems and intentionally design our organizations for the results we want, new possibilities emerge.
The question is no longer: how do we fix burnout, turnover and low morale. It’s what kind of organization do we want to create, and then what system can we create to make that possible?
EMS professionals do meaningful work and deserve to be valued for their contributions, and flourish in organizations designed to bring out their best.
We have the opportunity to move beyond improving the existing system and instead begin creating something different: thriving, magnetic organizations.
ABOUT THE EMS LEADERSHIP ACADEMY
Co-founded by Robbie MacCue and Lisa Giruzzi, the EMS Leadership Academy focuses on helping leaders navigate organizational change, culture transformation and leadership development within the emergency medical services industry. Having trained thousands of leaders, published essential resources for emerging leaders and hosted the annual EMS Leadership Summit featuring global experts, the Academy empowers agencies to build high-trust, learning organizations and eliminate operational burnout. Evaluate your leadership skills and pinpoint critical gaps in your agency by taking our free Leadership Self-Assessment. If you are ready to drive deeper systemic change, sign up for our Keeping The Best training program designed to support leaders in coaching and mentoring the next generation of leaders within an organization.
