Administration and Leadership, Exclusives, Operations

Show Me the Money: The Business Case for Safety and Wellness in EMS

Bryan Fass (Facebook photo)

Editor’s note: The author, Bryan Fass, suddenly passed away on September 16, 2019, at the age of 46. This is the last submission he sent to JEMS.

As a whole, the EMS industry takes better care of their trucks and IT infrastructure then they do their employees. Departments hire and train specialists in billing, logistics, compliance, vehicle maintenance and clinical excellence. What makes your business run are the employees that you have hired to run the calls, but who is responsible for them and their wellness?

As you are all aware, there is a shortage of EMTs and medics nationally and the employees that are interested are often not well qualified or not fit for duty. Historically, EMS has had one of the highest occupational injury rates nationally.1 Plus, injury rates are significantly higher during the first one-to-four-years of employment.2,3 This is a training and cultural safety issue!

All of that coupled with the stress of shift work and high call volumes has many employees limping for the door. I may be going out on a limb here but could some of the historically high rates of stress-related disorders and suicide be correlated to EMS poor history of investing in their future?4

It may be safe to say that the industry is at a tipping point. When EMS is unable to sustain its historical business model, it’s only a matter of time until the business fails or it can no longer meet its charter.

In full disclosure, I am a safety and wellness consultant. This means that for over a decade I have gone into, assessed and trained every make, model and type of EMS and fire-EMS organization. There is an underlying theme that constantly rings true in all of this.

‘This is the way we have always done it here’

Leadership in EMS can be challenging as there are always pressing issues to deal with and problems to solve If we step back and step out of the box for a moment it begs the question: Are all the problems and issues your fault?

A common theme that I see in the majority of the systems I work with is some basic and outdated safety training done in the classroom. The rest is left to the field training process, and this is where it almost always goes off the rails. Not all, but a significant portion of field training staff, teach via opinion versus a system. “This is how we do it on my truck,” is not a safety training system. It’s a hand me down attitude that has EMS mired in the past.

Let’s say that instead of a haphazard hiring, onboarding and training process that rushes to get your new employees into the field, you put all your potential employees through an EMS specific personality and psychological assessment. Then, when they pass that assessment, they have to go through a nationally validated EMS task-specific physical abilities test. If they can pass both of those tests, then they must take and pass an EMS specific safety, wellness, patient handling and resiliency course.

After all that, they are trained in the classroom and then rigorously assessed in the field by a dedicated and highly trained field preceptor.

When EMS leaders understand that the job is inherently risky with high demands for physical and mental resiliency, then we might be able to finally put in place some standards that will reduce the operational exposure to loss and the employee’s exposure to stressors that are currently spiraling out of control.

Step 1 is to put in place a dedicated risk and safety officer. This individual’s job is to ensure the safety, training, wellness and resiliency culture is firmly in place. Their job is as much a coach as it is compliance, daily interaction with the crews, establishing an open and ‘just’ reporting system free from retribution are all critical components of their job.

Step 2 includes building the framework for your safety and wellness culture.

A. All pre-hire employment candidates must take and pass a nationally validated EMS specific physical abilities test. We need to establish a fitness standard as it lays the groundwork for your wellness culture/

B. Pre-hire candidates need to take an EMS specific psychological evaluation to ensure that that can function in your safety culture and have the key resiliency characteristics needed to survive the job.

C. A critical component is to train and educate all your employees on the critical components of the job. This includes, but is not limited to, job-specific mobility/flexibility, how to eat when on duty, the effects of and how to mitigate the fatigue and hormone cycle disruption from shift work, and of course how to not get hurt. Finally, we need to teach them how to defend themselves from violent encounters.

D. Just like we train everything else in EMS, so must we train and retrain on what we just discussed. The PAT must be annual, the mobility and flexibility should be daily, the safety and wellness training should be ongoing and tested annually. On top of that, all your employees should have open access and trust with your local counselor and your peer support team.

So now for the counter argument. “It costs too much money;” “It takes too much time;” “We are short staffed and need butts in the seats;” and “We have always done it this way.” If we reframe the problem and look at it from a purely financial perspective, we can make the following cases:

1. The cost of turnover is not sustainable for many EMS systems. Look at it this way: While we can’t capture every single expense, or even some of the big intangible costs like impact on employee morale, we can get a good sense by analyzing four major buckets:

Cost of hiring

Cost of onboarding and training

Cost of learning and development

Cost of time with the unfilled role

We can now describe your overall annual cost of turnover to be: Hiring + Onboarding + Development + Unfilled time/OT X [number of employees X annual turnover] = Annual cost of turnover

As an example, if you are a 150 person department with 11% annual turnover, and you spend $25,000 on per person on hiring, $10,000 on each of turnover and development, and lose $50,000 of productivity opportunity cost on average when refilling a role, then your annual cost of turnover would be about $1.57 million.

Reducing this by just 20%, for example, would immediately yield over $300,000 in value. And that says nothing of the emotional headache and cultural drain felt from losing great people.5

2. The cost of Insurance. Insurance can be complicated as you need liability, workers comp and any excess coverage plus specialty coverages.

If we examine only the worker’s compensation side of the equation, where we can also gauge the effects of lost work time injuries, we can make the following correlations: If your system averages 30 lost work time injuries annually (OSHA recordable lost workdays), plus the cost of overtime to cover the shift, medical expenses and the effect on morale, we can infer — based on our 150-person department — that your annual costs would be roughly $121,800.

When we can reduce the exposures and lost work time injuries by 50% the incurred cost is roughly $14,200. While difficult to extrapolate a hard number in this example the huge drop in cost is due to both rate and severity of injury on top of the reduced number of claims. More severe injuries cost more due to the severity of the injury and probable surgical interventions. When the severity of the injury drops, the incurred cost also drops, saving the employer money and the employee pain plus lost wages. 

What is Your Why?

What matters most to you? Is it leaving the department better then you found it? Is it creating a stable business model that is sustainable for future growth? Is it being a good person and stopping the vicious cycle of pain, disability and suicide? When you figure out your why, write it down. Make it your mission statement. When you fix just one of the issues discussed in this article, all the others slowly fall into place. So, get out front, lead from the apex and leave your department or company better then you found it.


1. Studnek JR, Crawford JM, Wilkins JR, 3rd , Pennell ML. Back problems among emergency medical services professionals: the LEADS health and wellness follow-up study. Am J Ind Med. 2010;53(1):12-22.

2. Reichard AA, Marsh SM, Tonozzi TR, Konda S, Gormley MA. Occupational Injuries and Exposures among Emergency Medical Services Workers. Prehosp Emerg Care. 2017;21(4):420-31.

3. Widman SA, LeVasseur MT, Tabb LP, Taylor JA. The benefits of data linkage for firefighter injury surveillance. Inj Prev. 2018;24(1):19-28.

4. Vigil NH, Grant AR, Perez O, Blust RN, Chikani V, Vadeboncoeur TF, et al. Death by Suicide-The EMS Profession Compared to the General Public. Prehosp Emerg Care. 2019;23(3):340-5.

5. Atlman J. How much does employee turnover really cost? 2017 [cited 2019 December 30]. Available from: