By Jamie Kennel, PhD, NRP; Remle P. Crowe, PhD, NREMT; Soma de Bourbon, PhD; Miranda Worthen, PhD; Celeste Calderon; Michael Mason; Daniel Nazzareta; Joseph Graterol, MD
Following a novel EMS Data Equity Summit held in January of 2024, a year-long learning community was launched. Each month, participants gather virtually to discuss a topic related to health equity in EMS. This learning community represents a collaboration between members of the San Francisco Fire Department, researchers from San Jose State University, experts in EMS data and equity, and the CARESTAR Foundation.
The health equity curriculum for the learning community is structured into three modules:
- See it
- Understand it
- Address it
This article is the second in a three-part series that highlights the key lessons in health equity from the learning community, with this installment focusing on Module 2: Understand it.
Attendees of the learning community included representatives from EMS agencies, EMS authorities, public health departments, academic institutions, non-profits and state regulators. Each session included presentations of research, small group conversations and full group discussion.
Module 2: Understand It - Why are inequities happening in EMS care delivery and patient outcomes?
The Understand it module focuses on finding out why some patients receive different prehospital care or have different outcomes. Just like we wouldn’t give a medication without first knowing the patient’s condition and how the drug works, we need to understand what’s causing these differences in care. If we skip straight to implementing solutions without enough information, we might waste resources on ineffective approaches or even inadvertently cause harm to patients and the community.
Over the course of three sessions, participants explored better understanding why these inequities exist and persist so that future work toward interventions are more likely to be effective. Each session delved into a specific aspect of inequity causes, from community engagement to workforce diversity, leveraging practical tools to uncover underlying drivers.
Community engagement and community advisory boards
The first community learning session, led by Ryan McClinton and DeAngelo Mack of Public Health Advocates, tackled the vital role of community engagement in understanding treatment and outcome disparities. Just as we train our EMS students to engage in partnership with their patients in the delivery of their healthcare, we need to also consider how to build community partnerships with communities that are calling upon us for their EMS healthcare. The session began with two guiding questions:
- What does it mean to engage with the community?
- What are we currently doing to foster this engagement?
The broader discussion then shifted to explore community expectations:
- What does the community seek from its relationship with EMS clinicians?
- How do we know what the community needs?
Beyond simply providing CPR and Stop the Bleed training, participants learned about various strategies to deepen community partnerships, such as collaborating with community-based organizations to co-create safe, inclusive spaces. Establishing community advisory or stakeholder boards was highlighted as a formal way to consistently involve community members in shaping EMS policies and practices. If done right, these boards can serve as a critical feedback mechanism, ensuring that the voices of underrepresented populations are heard and valued in the decision-making process.
One valuable tool shared during the session was the SMART (Skills, Metrics, Assessment, Review, Tools) assessment, which allows EMS agencies to systematically examine the drivers of racial and ethnic inequities. By utilizing a matrix that aligns skills and tools with the needs of specific communities, EMS organizations can better understand how to reduce disparities in care delivery.
Understanding the drivers of EMS treatment and outcome inequities
In the second session, participants looked for reasons why some patients receive different care or have worse outcomes. The group used a tool called a driver diagram to help map out root causes and identify ways to make improvements. The discussion focused on how systemic issues, like societal racism, can influence EMS organizations and front-line clinicians, often in ways that are not recognized or consciously endorsed.
Several drivers were identified during the session that likely have an impact on the care provided by front-line clinicians. For example, when EMS clinicians are not able to speak the same language as their patient, the quality of EMS care suffers. Language barriers primarily impact already racially and socioeconomically marginalized patients and despite the predictability of encounters with this patient population, EMS agencies are still struggling with poor field technology support tools as well as limited internal training and quality reporting in this area.
Second, the group explored the fallacy of understanding race as a biological construct, which likely continues to shape assumptions in medical treatment. For example, there remains a common misconception that Black patients have a higher pain tolerance than White patients. This false belief has been widely debunked but still influences medical decision-making. Understanding race is a social determinant or driver of health and healthcare rather than a biologic or genetic marker is critical to dismantling systemic and individual biases.
Third, we discussed how high cognitive loads can bring forward implicit bias and activate stereotypes. When EMS clinicians are managing complex scenes, making quick decisions, and juggling multiple tasks, their cognitive capacity becomes strained. This mental overload increases the likelihood of relying on mental shortcuts, including stereotypes, rather than deliberate decision-making. In these moments, the brain is more likely to default to biases, which can unintentionally contribute to inequities in care.
And finally, we discussed how front-line clinicians are keenly aware and in tune with what their supervisors and managers care about. If their supervisors or medical directors never talk about racially disparate treatment at their agency, it sends a clear signal of where this topic stands.
The driver diagram discussions emphasized the importance of understanding these mechanisms to better design and implement meaningful changes in EMS protocols and practices that can mitigate inequities in EMS care delivery.
|More: Stopping the bias snowball, before it kills your patient
Understanding the drivers of workforce diversity
The final session of the Understand it module focused on the factors that hinder diversity within the EMS workforce. Many EMS agencies struggle to recruit and retain employees from underrepresented backgrounds.
The session explored several barriers to workforce diversity, including:
- Workplace culture and incivility. A lack of inclusivity and instances of microaggressions can create a hostile work environment for minority employees, contributing to high turnover rates.
- Legacy hires and recruitment practices. Historically, EMS hiring practices have favored certain demographic groups, perpetuating a lack of diversity within the field.
- Mentorship and support. Many underrepresented candidates lack access to mentorship programs, which are crucial for career development and long-term retention.
- Financial barriers. The cost of EMS certification programs, coupled with the time commitment required for training, can be prohibitive for candidates from low-income backgrounds.
- Testing and application requirements. Standardized testing and complex application processes can unintentionally disadvantage minority applicants, further perpetuating inequities.
Factors that drive health inequity
The Understand it module of the learning community has illuminated the systemic and structural factors that drive inequities in EMS care delivery and workforce diversity. By using practical tools like driver diagrams and engaging with community stakeholders, EMS agencies can begin to understand these root causes.
Stay tuned for the final installment of this series, where we will explore actionable strategies for addressing and mitigating these inequities in practice.
