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Turnover: We have measured it, but can we manage it?

The AAA/Newton 360 turnover survey measures the cost of replacing EMTs and paramedics


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The cost of replacing a medic, both financially and in time invested, is steep. Finding and hiring promising candidates is only one piece of the staffing puzzle. In an EMS1 Special Coverage Series, “Year One: Creating a career path for new EMTs,” learn how to onboard team members to set them up for long-term success, through the first 90 days, the first 6 months and beyond.

As a former military officer, I am constantly reminded of the adage from British General, Rupert Smith, who said “there is one certain outcome of any operation and that is casualties.” We’ve passed the 18-month point of the public health emergency, and one prediction I made early is that the real casualty of the pandemic could well be EMS itself.

Our hard-pressed EMS workforce has risen to the challenge despite the workforce shortages and has consistently stepped up by offering solutions, including establishing testing, tracing and vaccinations operations, as well as augmenting hospitals and care facilities around the country. While we have turned out to everything, we have also turned over, with organizations losing a fifth of their workforce in the past year; many, probably to higher-paying, better terms and conditions opportunities or simply throwing in the towel on EMS altogether.

One of our deepest battle scars is that of recruiting and retention, and this was recently examined in the third annual American Ambulance Association (AAA)/Newton 360 Ambulance Industry Employee Turnover Study. Employee turnover and conversely, employee retention, have been identified by AAA members as two of the most critical human resource issues facing ambulance service providers.

Measuring attrition

The AAA surveyors corresponded with 19,688 employees working at 258 EMS organizations. The occupations included were full-time EMTs, part-time EMTs, full-time paramedics, part-time paramedics, supervisors and dispatch employees. The survey revealed that despite the impact of COVID-19 on the economy, turnover rates were similar, or even slightly improved, compared to 2019. That said, voluntary and overall turnover remained in the 20-30% range for EMTs and paramedics. As many EMS organizations calculate their workforce needs on unit hours required to meet peak demand, even “normal” turnover places every agency on the back foot.

This is borne out in the now frequent news reports of crew shortages, missed response times (and that’s not including hours lost on the hospital wall) and well-publicized episodes of the dreaded, “No units available.”

The cost of replacing an EMT or paramedic

The survey also collected data on the cost to replace an employee, defined in terms of the cost to attract, screen, select, onboard and train a new EMT, averaging about $6,780. Larger organizations reported higher costs, $8,811, compared to smaller organizations ($5,149.58) to replace an employee. To replace a full-time paramedic, the total estimated cost was $9,113.

An interesting and important data point identified was that 32% of employees who are going to leave depart in the first year. If we take a moment to calculate the cost of turnover in an organization with 100 employees who lose 25 staff members a year (a median rate of $6,780 x 25), the annual cost of maintaining an operational status quo is in the region of $170,000. Of that total, $56,000 would be expended on staff that has only recently been recruited, inducted, precepted and cut loose on the streets in the previous 365 days. While we must invest considerable amounts of cash in recruiting, one must ask, how much is in the budget line marked retention? It may well be an invest to save opportunity.

Reasons for departure

While it can take just one day or a couple weeks to lose an employee (depending on the voluntary or involuntary nature of the departure), it can take more than three months to replace them, while at the same time relying on or mandating staff to work overtime to fill the gaps. This creates a law of diminishing returns as those who remain, in turn, consider departure. The AAA survey identifies that primary exit reasons are for career or occupation change, followed by dissatisfaction with pay and/or benefits. Poor performance was listed most frequently as the reason for involuntary turnover.

Retention recommendations

Recommendations included in the survey focus on implementing organizational interventions associated with a psychologically healthy workplace:

  • Increased attention to employee health and safety
  • Programs to allow for career growth and development outside of traditional career ladders
  • Scheduling to allow for increased work-life balance
  • Increased employee involvement
  • Performance management programs

Collected and collated data on this vital HR area of our operation is sparse and the development of effective strategies for the managing turnover requires the availability of reliable and valid data on turnover frequency. While we are enduring the effects of the pandemic, poor reimbursement, political pressure to do more with less and the heightened stress that operating in 2021 has brought us, if we don’t measure this essential HR metric, we have little chance to manage it. The AAA survey recommends that organizations systematically collect data on their workforce, including the reasons for turnover.

In the final analysis, I, and possibly the AAA, probably didn’t tell you anything that you didn’t already know about our retention issues. But as the sign that has adorned the wall or whiteboard of every office I’ve ever occupied says, “If we do what we always did, we will get what we always got.” The AAA/Newton360 is to be applauded for conducting this survey and highlighting the size and scope of the issue and its commitment to understand the underlying causes of turnover in the ambulance industry and to develop strategies to address employee retention issues. The report can be read in full here.

EMS One-Stop With Rob Lawrence

In this episode of EMS One-Stop With Rob Lawrence, Rob welcomes guest Scott Moore of Moore EMS Consulting and HR consultant to the American Ambulance Association. Rob and Scott discuss the results of the third annual American Ambulance Association (AAA)/Newton 360 Ambulance Industry Employee Turnover Study.

Rob and Scott discuss:

  • How to retain staff throughout the first year
  • The cost of recruitment versus the budget for retention
  • The value of an exit interview, versus a retention interview for those who are not leaving

This article was originally posted July 22, 2021. It has been updated.

Rob Lawrence has been a leader in civilian and military EMS for over a quarter of a century. He is currently the director of strategic implementation for PRO EMS and its educational arm, Prodigy EMS, in Cambridge, Massachusetts, and part-time executive director of the California Ambulance Association.

He previously served as the chief operating officer of the Richmond Ambulance Authority (Virginia), which won both state and national EMS Agency of the Year awards during his 10-year tenure. Additionally, he served as COO for Paramedics Plus in Alameda County, California.

Prior to emigrating to the U.S. in 2008, Rob served as the COO for the East of England Ambulance Service in Suffolk County, England, and as the executive director of operations and service development for the East Anglian Ambulance NHS Trust. Rob is a former Army officer and graduate of the UK’s Royal Military Academy Sandhurst and served worldwide in a 20-year military career encompassing many prehospital and evacuation leadership roles.

Rob is a board member of the Academy of International Mobile Healthcare Integration (AIMHI) as well as chair of the American Ambulance Association’s State Association Forum. He writes and podcasts for EMS1 and is a member of the EMS1 Editorial Advisory Board. Connect with him on Twitter.