5 Tips to Reduce Turnover in an EMS Agency


Working in the EMS field is unquestionably difficult. The hours can be long, the environment unpredictable, and the work emotionally challenging. According to the American Ambulance Association/Avesta 2019 Ambulance Industry Employee Turnover Study, the national EMS turnover rate is 25%, costing an EMS employer with 100 employees nearly $200,000 annually. The high turnover rate, coupled with the projected increase in workforce demand for EMS personnel at a rate greater than other professions, necessitates that EMS leaders take definitive action to attract and retain employees.

This article acknowledges that compensation and benefits are a significant driver in the recruitment and retention of any workforce. Historically EMS pay scales have been on the lower end due to numerous factors, such as, reimbursement from both governmental and commercial payors. Given that EMS leaders have a limited ability to impact reimbursement rates, this article will focus on the strategies that are in reach of every EMS leader.

1. Identify and Live Your Organizational Culture

Culture has become a bit of a buzzword in every leadership program. Culture is one of those concepts that we all generally understand but most cannot meaningfully define. In their whitepaper, Gallup’s Approach to Culture – Building a Culture that Drives Performance, Gallup defines culture as “how we do things around here”. More broadly, it means what an organization stands for and what the team’s organizational purpose is. Every organization has a culture, and each is unique, much in the way individuals have personalities.

Frequently, when I ask leaders what their organizational culture is, they will recite the company’s mission statement. A mission statement is a statement of an organization’s aspirational purpose, which is an element of culture, but not the only component. Culture encapsulates more than just purpose. Culture is what differentiates your organization from your competitor. All EMS organizations have ambulances, equipment, and patients. My guess is, most EMS company mission statements look relatively similar. However, your employees will tell you that the cultures vary from one EMS organization to another. 

To identify your company’s culture, start by asking your team. My recommendation is to start with your senior leadership and work your way down. Many suggest asking your frontline employees. Frontline employees are the ones who witness and live your organization’s culture every day. However, many will not give candid and honest answers when speaking to their boss.

When meeting with your team, ask them the following questions:

  • What is our company’s personality? Ask them to describe the organization as if it were a person. Ask for personality traits. Examples may be, reliable, smart, honest, caring, good communicator, etc. For the most part, an organization can be described the same way we describe an individual. Both are living beings interacting with individuals and the world around it.
  • What is our communication style? Ask them how your organization communicates on a day-to-day basis versus when trying to convey critical messages. Do we seek a dialogue or more of a monologue? Communication is a two-way process, both sending and receiving. Is our communication style one that suggests that we are truly approachable?
  • Why should someone work for us? Be honest. Expect the following answers. We have great equipment, good contracts, 911 work, etc. However, do not stop there. Those are the easy answers. Dig deeper, for the real answers. What can an employee expect when they come to work for us? What will we promise to give them in exchange for their valuable commitment? The answer to these questions will help to develop the framework of your organizational culture.
  • Once you have identified and framed your organizational culture, it needs to serve as the compass to every decision the leadership team makes. It should be conveyed in every communication the organization makes with its team, patients, partners, and the community. When implementing any new policy or process, ask if this decision or action is consistent with the organizational culture. Just like with a compass, if you stay true to your culture, you will be heading in the right direction.

The top five factors cited in the AAA/Avesta 2019 Turnover Industry Employee Turnover Study impacting employee turnover in EMS organizations were: 

  1. Pay 
  2. Communications — transparency with supervisors and management.
  3. Fairness exhibited by supervisors and managers. 
  4. Performance management 
  5. Work-life balance and stress

2. Develop a Meaningful Career Ladder

One significant driver of EMS turnover is a lack of an organizational career ladder or professional development plan. A common criticism from EMS leadership is that EMS is a transitional career or a “stepping stone” to a position in the fire service, a police department, or a further career in medicine. My response is that this is largely true. However, much of the blame for this lies with EMS organizations for failing to demonstrate what a career at their organization could look like. Often, we are genuinely surprised when a job candidate suggests that they have no aspirations of progressing into a career with a municipal public safety agency or to become a nurse or a physician.

When I interview most EMS executives about their path to EMS leadership, most state that they had to forge their own path. Watching for a professional lane to open and shifting gears when they spotted the opportunity. In rare situations, I find an individual who had a mentor or a professional guide who assisted them in navigating their professional journey.

When an organization hires an individual it makes a promise. If you give me your efforts, we will provide you with an environment and a culture that will get you where you are looking to go. However, many entering the EMS field have not yet figured out where they want to go. People tend to trust and follow the person with a plan. A clearly defined career ladder with a professional development plan increases the likelihood that an employee chooses to stay with you. It reinforces that promise that you will get them where they are looking to go.

The benefits of having a defined career ladder or development path are competitive differentiation, decreased turnover, higher employee engagement, and retention of key employees. Elements of a career ladder are clearly defined job descriptions, a career map that identifies all positions within the organization and how they relate to each other, education, and professional development courses and opportunities that expose individuals to those roles, and a mentorship or career coach/counselor program for employees. Career coaches/guidance counselors help your team members to understand what opportunities exist and to help them navigate the landscape. The person is not there to critique or rate the employee, more in a supportive role to ascertain the employee’s experience and professional interests.

Be sure to create a public relations and marketing plan for your career ladder program. This is the most important marketing and public relations project at your organization. If you publicize your organization as an employer, your employees will take care of portraying your organization’s medical sophistication and professionalism. The existence of the plan will differentiate your organization from your competitors.

3. Hire the Right People

Often, because EMS organizations have been struggling with low levels of staffing, there has been a tendency to hire the “good enough” or “good for now” job candidate. While this may solve the short-term staffing need, it ends up being counterproductive and costing the organization more money overall. Hiring the wrong person expends limited resources and the valuable goodwill of your existing workforce. Worse than the wasting of money and resources, it breaks the trust your employees have in your leadership team and organization. If your workforce thinks that your organization will hire “any warm body”, it erodes employees’ self-image and their confidence that you have their best interest in mind.

Design a hiring process that meaningfully identifies the knowledge, skills, and abilities that an individual will need to perform the essential functions of the job. It is critical that human resources personnel perform a thorough background screening and employment reference check on all candidates. Ask the candidate for the contact information for their immediate supervisor. The human resources representative is only going to verify position and dates of employment. There is a greater likelihood that the immediate supervisor will provide you with more detail, even if their company policy is to direct all employee reference requests to HR.

Lastly, make sure that the candidate is a good fit with your organizational culture. Be sure to understand your organizational culture so that you can identify when a candidate is not a good fit. When an organization stretches its culture to fit the wrong candidate, it never seems to return to its original shape when that individual eventually leaves.

4. Develop a Robust Retention Plan

What is a Retention Plan? All too often organizations focus heavily on developing robust recruitment plans. It is true that an organization needs to develop a strategy for identifying and attracting the right people to apply for job openings. However, if you hire 100 people but lose 100 in that same period, you have failed to make any progress. More likely, while your organization was spinning its wheels, your competitor was taking the lead. The revolving door will take its toll on your whole team.

Generally, employees do not just pick up and leave an organization on a whim. It is generally a long process where we lose an individual over time. Newton’s First Law of Motion, an object at rest will stay at rest unless acted upon by an outside force. In other words, your current employees are not looking to leave your organization. It is far easier for an employee to stay at a company than it is to go out and look for a new job. Why, when a seasoned employee leaves the organization, they give up many valuable benefits, such as a seniority, often a great schedule, and working with a group of people with whom they have become friends.

A Retention Plan recognizes that an organization should expend as much energy and resources in retaining an employee as it does in recruiting and onboarding them. Your organization is sending a message to your workforce when it expends enormous amounts of money and resources on recruitment activities, but very little effort and resources are allocated to employee retention. The message to employees, “we will do whatever we have to do to get you here but will leave you on your own afterward.” Retention is not a “set it and forget it” activity.

A Retention Plan starts during the recruitment process and overlaps your recruitment plan. Leaders sometimes fail to recognize that a job candidate is constantly working to identify and assess your organizational culture and what they get if they work for you. We discussed earlier in this document how your culture is the glue that makes the employment relationship sticky. A Retention Plan works actively through all stages of the employee life cycle to keep employees engaged in your organizational culture. This includes how a new employee experiences the onboarding process, orientation, field training, and every other day of their employment following the release from onboarding.

A Retention Plan is more about a shift in organizational thinking rather than a formulaic plan. The leadership team needs to answer these questions at some point in every single management meeting. “What is our team doing to retain employees?” and “Why should an employee stay at our company?” Seriously, these two questions should be standing agenda items for every single meeting. If your team is not clear on the answers to these questions, how do you expect your employees to know?

5. Regular & Ongoing Feedback

Many employers still utilize an annual performance review process despite volumes of research that suggest that most employees prefer regular and ongoing feedback. In an EMS organization, the annual performance review process is particularly difficult because of the distributive nature of the workforce and the rotating schedules of both the supervisors and the field employees. These factors make consistent oversight and performance assessments in EMS nearly impossible.

Many EMS organizations cling to their annual review process, despite the fact that a recent Gallup survey revealed that only 14% of employees felt that the annual performance review process inspired them to improve. In other words, the survey suggested that “if the annual performance review process were a medication, it would not meet the FDA criteria for approval.” Would you continue to take a medication if it were not approved by the FDA and only effective 14% of the time?

Think about all of the annual performance reviews that you have had over the course of your professional career. Have you ever really had one that accurately assessed your performance and drove you to work harder?

Consistently, what drives performance is more frequent and regular performance encounters between frontline leaders and employees. Regular and ongoing feedback models foster and solidify the relationship between employee and their immediate supervisor or manager. The more employees and the supervisors interact and discuss performance, the stronger and more transparent that employment relationship becomes. The byproduct is trust, improved performance, and engagement for both the employee and the supervisor.

If EMS organizations want to improve employee engagement, performance, and turnover of both frontline employees and supervisors, they need to transition to an ongoing performance feedback model. EMS leaders should be assessing how often their supervisors and managers are encountering employees. The more often frontline leadership is encountering employees and providing performance-related support and feedback, the more likely they are to see a corresponding change to the current turnover rates. EMS organizations do not have to completely abandon sitting down with their employee on a yearly basis to discuss their performance. These yearly meetings will take on a new significance as a stronger, more transparent, and trusting relationship will support the feedback provided.

Additionally, seeking regular and ongoing feedback from the employee about how the organization is performing results in an even more trusting and transparent employment relationship. Employees are far more accepting of constructive criticism from leadership if the same energy and weight is put into soliciting feedback about how the leadership team is performing. Trust and accountability will be the most obvious and compelling influence in shaping the organization’s culture.


These are five simple tips for reducing an EMS organization’s turnover rate. This is not an exhaustive list. However, organizations that utilize these tips consistently experience lower turnover rates than their competitors. EMS organizations that focus on fostering an organizational culture of trust and transparency, that provides a roadmap for employee professional development, protects its culture by hiring the right people, takes deliberate steps to retain each team member, and provides and solicits regular and ongoing feedback will outperform it competitors and experience a significantly lower turnover rate.