“We’re here to serve others, and they’re important. But they’re not more important than we are.”1 Retired EMT and iconic author Thom Dick shared this consideration in his aptly titled book, People Care. Thom went on to explain how valuable each of us are as caregivers and that most importantly, “first things first: take care of yourself.1 To some, this mindset may seem quite self-centered and in total contrast to what many of us have come to live our careers by: that we are here to serve others and the patient always comes first.

Healthcare systems that have modernized how they deliver services have moved away from systems-centric processes to patient-centric models. Many EMS agencies, for example, are transforming the linear way in which we have historically provided service—wait for someone to call 9-1-1, answer the phone, send an ambulance and transport to a hospital—to the model of mobile integrated health (MIH), which offers proactive options and alternate healthcare pathways that are much more than just conveyance to a hospital by an ambulance.

As these new models are developed, the adoption of the Institute for Healthcare Improvement (IHI) Triple Aim as the framework for performance optimization has been a common point of reference. The three dimensions of the Triple Aim include:

  1. Improving the patient experience of care (including quality and satisfaction);
  2. Improving the health of populations; and
  3. Reducing the per capita cost of healthcare.2

Although the IHI introduced the Triple Aim just over 11 years ago, it’s interesting to recall the way high-performance EMS (HPEMS) was described over 30 years ago by Jack Stout, the father of HPEMS. Stout defined “high performance” in our industry as the ability to simultaneously deliver clinical sophistication, response time reliability and economic efficiency.3 Many of our systems were built upon this premise, but what has been missing in these pursuits, whether it be HPEMS or the IHI Triple Aim, is the people who make or break an organizations ability to succeed.

Enter the Quadruple Aim

The “quadruple aim” includes the concept of adding a fourth dimension for success in systems performance optimization: caring for the caregiver.4 Although this fourth element has been generally characterized as having joy and meaning in our work, it’s in many ways more specific than this.

Figure 1: The quadruple aim

It’s been widely recognized that staff burnout has a direct negative effect on the experience and safety for the patient. The ability for an organization to achieve a high level of staff engagement and best patient outcomes is directly dependent on the caregivers themselves feeling supported, empowered and respected.5

With the framework of the quadruple aim in mind, it begs the question, “How do we ensure our EMS organizations are successful in caring for the caregiver, and what are the characteristics of programs that provide the necessary supports?”

At the 2018 Pinnacle conference, a group of EMS leaders gathered to examine this very issue and the topic was further expanded during an Academy of International Mobile Health Integration (AIMHI) webinar in March of this year.6 Three components were highlighted as they relate to the success of building our organizations for caregiver wellness: 1) service design; 2) structured approach to psychological wellness; and 3) practical application of support programs.

A New Vision of our Future

In a galaxy long ago, EMS systems were developed using the best information available, primarily the White Paper written in 1966 and of course the social media influencers of the time, Johnny and Roy from the TV show Emergency! What was created was a system to support public expectations of “you call, we haul,” and further reinforced through reimbursement models based on quantity and not quality.

The people within these systems were provided the basic tools to meet these basic outputs. Although emotional stability was certainly not foreign to our early pioneer EMTs, paramedics and dispatchers, there was also a culture and system capacity to care for each other. There was an opportunity for a lot of bumper-therapy. We were also expected to “suck it up.” It’s understandable how deep the root is in the characterization of mental illness that plagues us today, as we try to shed the stigma associated with stepping forward to say, “I need help.”

Today, many of our systems are experiencing unprecedented levels in the increase in EMS service utilization. This is primarily driven by calls specific to the influence of social determinates of health and the changing expectations of emerging generations of instant information, instant communication, and above all, instant gratification. It’s creating an environment of increased demands on our systems, but even more troubling is the mental toll this is taking on the caregivers.

To mitigate against these system pressures in how and why EMS resources are utilized, services are adopting patient-centric delivery models to provide smarter, more appropriate response options to meet the needs of our communities. EMS Agenda 2050: A people-centered vision for the future of EMS was created to provide the best possible outcomes for patients and communities into the future.7 To achieve this, six guiding principles were designed:

  1. Inherently safe and effective;
  2. Integrated and seamless;
  3. Socially equitable;
  4. Adaptable & innovative;
  5. Sustainable and efficient; and
  6. Reliable and prepared.

These doctrines are foundational in the construct of our future systems modeling, and without it being explicit, it’s evident that there are many ways in which provider wellness needs to be woven into all six of these principles as a critical element to success.  

Improving Psychological Health in EMS

The Mental Health Commission of Canada reports that mental illness is the leading cause of disability in Canada, accounting for nearly 30% of disability claims and 70% of the total costs.8 Of the $51 billion economic cost each year attributed to mental illness in Canada, $20 billion stems from workplace losses. By improving the management of mental health in the workplace, productivity losses can be decreased by as much as 30%. For emergency service agencies, we know that the impact of mental illness related to our profession is much higher than most other industries and to this point, a greater emphasis that EMS organizations need to ensure a comprehensive, structured approach to ensuring the psychological wellness of providers.

Guarding Minds at Work identified 13 workplace factors that impact psychological health. (See Figure 2.)9

Figure 2: Workplace factors the impact psychological health9

Organizations committed to supporting the psychological wellness of staff might reference this list to ensure all aspects of their business considers these factors in the development and delivery of the various programs and services—keeping in mind that these are focused inwards, towards the people within the service and not the external customers. Practical examples of these factors can be seen through the adoption of organizational culture philosophies such as STAR CARE, anti-stigma campaigns, formal initiatives such as peer support, chaplain and therapy dog programs, as well as those that include family and alumni.

One such example of caring for the caregiver in action is the MedStar’s Hope Squad. The Hope Squad model first originated in the Provo, Utah, school district in 2005 to address youth suicide. Student groups were trained to identify warning signs in their peers and alert adults to those signs. MedStar took the Hope Squad model and created the first-of-its-kind corporate and first responder Hope Squad.

Evidence often shows that peers are considered to be the most effective at identifying mental health warning signs. Members of MedStar’s Hope Squad were nominated by their peers as being trustworthy, and were then selected to be on the team and represent the communications, field operations, administration, billing, support services, human resources and mobile integrated healthcare departments on both days and nights. Through evidence-based training modules (both initial and ongoing), Hope Squad members are empowered to identify and navigate their peers to mental health and wellness resources, and they also agree to uphold commitment and confidentiality requirements.

MedStar employees have identified the Hope Squad as being a source of comfort and trust. Since the implementation of the program, the squad has navigated employees to multidisciplinary mental health resources that include: individual and group therapy, employee assistance programs, inpatient and outpatient programs, educational programs and holistic therapies. The Hope Squad aims to enhance the health and safety within the organization by cultivating a culture that allows employees to say “I’m not OK, but that’s OK.”

Who Matters Most?

“We’re here to serve others, and they’re important. But they’re not more important than we are.” If EMS organizations are truly committed to achieving performance optimization as described through the IHI Triple Aim, HPEMS or EMS Agenda 2050, success will only be found through the well-being of those who matter the most: our caregivers.


1. Dick T: People Care, 2nd edition. Cygnus Business Media: Ft. Atkinson, Wis., 2012.

2. Institute for Healthcare Improvement. (n.d.) The triple aim. Retrieved April 17, 2019, from www.ihi.org/Engage/Initiatives/TripleAim/pages/default.aspx.

3. Stout J. The public utility model—Part I: Measuring your system. JEMS. 1980;5(3):22–25.

4. Bodenheimer T, Sinsky C. From triple to quadruple aim: Care of the patient requires care of the provider. Ann Fam Med. 2014;12(6):573–576. doi: 10.1370/afm.1713.

5. Freely D. (Nov. 28, 2017.) The triple aim or the quadruple aim? Four points to help set your strategy. Institute for Healthcare Improvement. Retrieved April 17, 2019, from www.ihi.org/communities/blogs/the-triple-aim-or-the-quadruple-aim-four-points-to-help-set-your-strategy.

6. Smith K, Dow D, Traub M, et al. (March 6, 2019.) On-Demand Webinar: Caring for the Caregiver. Academy of International Mobile Healthcare Integration. Retrieved April 17, 2019, from http://aimhi.mobi/ondemand/7202099.

7. EMS Agenda 2050 (January 2019.) EMS.gov. Retrieved April 17, 2019, from www.ems.gov/projects/ems-agenda-2050.html.

8. Mental Health Commission of Canada. (2017.) Case study research project findings. Retrieved April 17, 2019, from www.mentalhealthcommission.ca/sites/default/files/2017-03/case_study_research_project_findings_2017_eng.pdf.

9. Guarding Minds at Work. (2018.) A workplace guide to psychological health and safety. Centre for Applied Research in Mental Health and Addiction. Retrieved April 17, 2019, from www.guardingmindsatwork.ca.