Every EMS organization is a business regardless of size or structure. Controversial? Maybe. True? Definitely.  

Municipal fire departments, hospital-based services, investor owned and yes, the thousands of small to mid-sized volunteer or hybrid agencies…all businesses. Unfortunately, too many do not operate as though they understand this fact. 

Stick with me for a couple of minutes while we go through 10 basics of what makes a business a business: 

1. You have staff, clients or customers (patients).

2. You get funds for your services through fees, subsidies, donations or grants 

3. You have to buy supplies and equipment

4. You need state and /or local permits/licenses to operate 

5. You complete tax/accounting paperwork, tax returns, budgets and non-profit 990 forms 

6. You promote yourself to clients, to recruit staff or do damage control when something bad happens 

7. You must make a profit of some kind to stay in business…yes even non-profits have to stay within budget and have enough left over to operate 

8. You maintain insurance and abide by wage and labor laws 

9. You plan for continuity during crisis and disaster situations 

10. You need strong effective leaders to attract quality people to your organization and keep them 

Every single one of these 10 points apply to EVERY EMS agency just as much as they apply to the local hardware store, law practice or auto dealer…we are in business. And what's true about businesses? They will fail due to lack of money, lack of trained staff, poor legal issue management or simply lousy leadership. 

Many EMS agencies still believe they can rest on their laurels, and the communities they serve will let them slide by on some of these issues. You can't. They won't. And you will lose support, funding, staff and, eventually, your ability to operate. 

Our EMS agency360^sm program is designed to review each of these and several other areas to make sure that you've got all of your bases covered.   

Let's connect and discuss what's happening in your service and community. 

This EMS Week, The Holdsworth Group team extends our gratitude and recognition to the EMS providers who show up every day – putting service above self and making a difference for patients in every community across the country. 

EMS Week also offers us a moment to reflect on the state of the industry and what's to come. This year's theme, Improving Outcomes, Together, underscores that high-performing EMS systems – and high-quality patient care – are built through intentional effort, and rarely happen in a vacuum.  

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Improving Outcomes 

Improving outcomes starts and ends with data. A clear picture of your systems' current operational, clinical, and financial performance is more than just data, it's a decision-making tool. 

Knowing your numbers helps you take stock of what's working and what's not, identify solutions, make smart use of your agency's resources, and, of course, measure outcomes.

Better data leads to better decisions, better decisions lead to better care, and better care leads to better outcomes. Rinse and repeat. 

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Together  

Outcomes don't improve in isolation. "Together" means working in collaboration with the people beyond the walls of the station who shape the environment in which your agency operates: municipal leaders, partner agencies, and the community itself.  

This takes communicating clearly about your agency, building trust, strengthening relationships, and securing the support your agency needs to succeed before the tones drop. 

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Improving Outcomes, Together becomes real when agencies commit to understanding their systems and engaging the partners who can help them thrive. We can help you think through what's ahead and we welcome you to get in touch. 

When you think about promoting your agency, you probably picture flyers, recruitment posts on social media, or community outreach events. But your agency’s reputation is shaped long before someone encounters your crew at an event, online, or in your annual fundraising letter.

Your Reputation is Built Every Day

Your reputation is built through every interaction your team has with the public. Yes, even that team member. Yes, even at 2 a.m.

And this reputation matters across the many publics you serve: patients and community members, hospital staff, partner agencies, municipal leaders, and even your own employees and prospective recruits. Your agency’s reputation directly influences your ability to secure funding, renew service contracts, and attract and retain top talent – and it’s being shaped constantly by how you show up.

That’s why your agency’s reputation can’t be built through letters, social media or community events alone.  These “traditional” tools are still vitally important, but they only work when they’re backed by a culture of promotion – an organizational ethos centered around doing good work and making sure it shows.

Building a Culture of Promotion

Building a culture may start at the top, but it can’t stay there. To have real impact, the entire agency needs to ‘buy in’ to the program: EMTs and paramedics, paid staff and volunteers, administrators and frontline crews. This doesn’t happen overnight, and it doesn’t happen by accident. Here are five guiding principles to help you get started:

1. Start with a shared vision.

Define a clear “why.” It may be about building community support to sustain operations, strengthening trust with partner agencies, attracting new team members, or – for most agencies – all of the above. Whatever the reason, articulate it clearly to your team.

2. Train your team.

Teach your team how to talk about your agency. Equip your staff and volunteers with the basic information and resources they need to introduce the agency, explain what you do, and answer common questions. Make sure they know who to direct media inquiries or more detailed questions to.

3. Set expectations (and enforce them).

Control how you show up. Unkempt uniforms, poorly maintained vehicles, unprofessional conduct, or substandard clinical care will damage your reputation far faster than you can repair it. Publish clear appearance, conduct, and clinical standards – and reinforce them through regular coaching and accountability.

4. Actively invite participation.

Create simple ways for your team to contribute to your promotional efforts. A shared drive, email alias, or submission form where staff can drop photos, anecdotes, and success stories makes it easier to capture the moments that define your agency.

5. Be consistent.

Trust is earned through repetition. Showing up, doing good work, telling your agency’s story – and fostering organizational dynamics that make this a team sport – will create a positive feedback loop and strengthen trust and support in your community.

Need Help Getting Started?

For today’s EMS agencies, a reputation that builds community support, strengthens partnerships, and helps stabilize your staffing roster isn’t a luxury — it’s a survival mechanism. Want to learn more about how we can help your agency build a culture of promotion? Click here.

 

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“Several minutes had passed and the Ambulance for the suspect was still not on-scene. I requested CAD, via channel 1, several times for an update on when the Ambulance would arrive. My first request was at approximately 1804 hours. CAD advised they would conduct a call back. I then requested an update, via channel 1, at approximately 1806 hours and was advised that they were on hold with [the ambulance company]. At this time, it was decided that we transport the suspect in a marked patrol vehicle.”

Connecticut’s EMS system is in crisis. The signs are all around us, hiding in plain sight. That quote is from a local police officer, from the state Inspector General’s report on the factors contributing to the death of a suspect that had been shot by an officer. The incident is national news and you’ve probably heard about it. You probably didn’t hear that whatever other kind of story it is, just under the surface, it’s an EMS story.

There are many questions being asked about the actions of the police officers involved that night, but the question no one is asking is “Why was a second ambulance unavailable to respond to an officer-involved shooting in the early evening in one of the state’s biggest cities?”. Also left unasked: “How often are the police transporting injured patients to the ER in the back of their patrol vehicles because an ambulance is unavailable?”. In this case, the officers did not end up transporting the patient in their vehicle. The ambulance did eventually arrive.

The ambulance issues under the surface of this tragic story aren’t unique to our cities, and they aren’t unique to Connecticut. But here, they are symptoms of a statewide EMS system on life support, kept alive by a strained mutual aid network, and covered for by police officers who have been forced to improvise ambulance substitutes on the fly. Stories like the one above can be found in the news every day. Scratch the surface and it’s not hard to see the impact of understaffed ambulance agencies and growing response times.

 

The Mutual Aid Mask

In Connecticut, when a town’s ambulance is busy, a neighboring ambulance is called to respond. This might seem like neighborly cooperation, but it’s also a shell game that hides the lack of available EMS resources. If that neighboring ambulance is also already on a call, a third agency is called.

The mutual aid system keeps the wheels turning, but it also makes the problem invisible. Because the system technically “works” (someone eventually shows up), the public doesn’t see the strain. They don’t see the firefighters sitting on scene for 25 minutes stabilizing a patient while waiting for a transport unit to arrive from three towns over, or the police officers trying to decide if they should just throw the patient into their cruiser and rush to the hospital.

 

Our Data Doesn’t Tell the Whole Story

One reason this crisis remains hidden is that our data is both lagging and incomplete. Statewide EMS response data is published two years behind. Worse, the way we track ambulance response time is fundamentally flawed.

As I recently discussed with the Hartford Courant, the Department of Public Health only sees part of the data (“CT Lawmakers Seek More Transparency in EMS Response Times”, March 23, 2026). Those response times are recorded from the moment an ambulance is assigned to a call. What isn’t counted—and what the shooting story highlights—is the “wait time” before an ambulance is available to be assigned. If dispatch is “on hold” with a provider for six minutes before a unit is even found, those six minutes aren’t recorded in the state’s official EMS response time data.

 

Making the Invisible Visible

We can’t fix problems that we can’t see. This is why the EMS response time dashboard proposed by the Legislature’s Public Health Committee in SB-238 is so vital. By requiring DPH to maintain a public-facing, real-time dashboard broken down by town and call type, we can finally shine a light on the system and see where the gaps actually exist.

This kind of transparency is the first step toward understanding the extent of the problem, a step that’s necessary before we can advocate for the supplemental funding the state’s ambulance agencies need to survive. We have towns in rural Connecticut where response times are regularly exceeding 20 minutes. In a cardiac arrest or a shooting, the difference between a 3-minute and a 10-minute response is the difference between life and death.

The shooting incident was a tragedy, but it must also be a wake-up call. The evidence of our failing EMS system is no longer just in a spreadsheet buried in a two-year-old report; it is written in the police logs of our cities. It’s time we stop letting the hidden nature of this crisis be an excuse for inaction.

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EMS organizations around the country are facing the same pressures. Chronic underfunding, staffing challenges, a lack of community recognition and a lack of leadership training and support.

In several places around the country long-standing EMS contracts have been terminated, others sent out to RFP, and a few organizations have been disbanded or stripped of their service areas which were handed over to neighboring organizations – sometimes without warning.

The two common themes that ran through many of these cases were either politics or, more commonly, the fact that the EMS agency was seen as a commodity and not a valuable community resource and partner. Changing political winds are hard to fight, but when the EMS agency does little to make their everyday actions known they become easy targets.

Your choice, starting today, is either to begin telling your story and showing how valuable and remarkable the work that you’re doing is, or continue to rely on the outdated and dangerous path making you easy to replace which is “we don’t need to promote ourselves, they call 9-1-1 and we come, what’s to tell?”

Being remarkable is not hard. You do good work. You have good response times. Your team is professional and compassionate. NO ONE KNOWS THAT.

You must consistently and clearly tell your story. You have to be seen, not just on responses, but at school events, interacting with kids, seniors, and helping with charity events.

Part of being remarkable is being understood. Tell your community what you do, in terms that they understand. Explaining the services that you provide. Looking for ways to help.

An agency that I had the privilege of running for a few years participated in everything. We had units at church fairs, charity walkathons and school fairs taking blood pressures and handing out vials of life, getting to talk with the people we served. We taught first aid and CPR and always had a CPR station set up in an ambulance. It helped to recruit some people but also showed them how we did our work as they replicated it for their certification.

We collaborated with the community health agency and set up one of our ambulances as a mobile vaccination clinic. We even sent medics into a third-grade class and let the kids get hooked up to the monitor to put a six second strip (picture of their heart) into a valentine’s day card for their mothers. We were remarkable.

Our contracts were renewed, we got funding, we had people wanting to work for us all because we did the work…and told the world about it…consistently.

So again, you have a choice, do you want to be remarkable or replaceable?

No sure how to get started? Get in touch.

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Over the years I've watched EMS leaders ask for, beg, or request funding only to be told either NO outright or watch their request get cut by 50% or more. A recent example was a service chief who told me he was asking for $300k so that he could get the $150k he actually needed. That is a rookie mistake – it perpetuates the problem and it breeds an adversarial relationship between the service and the local government officials. 

The typical result, the EMS agency licks its wounds and continues to operate with the amount provided, thereby 'proving', in the municipality's mind, that they didn't really need the amount requested.  This dance happens year after year until finally the EMS agency reaches a breaking point and their request now becomes an emergency. 

It is time that every EMS agency in this country break out of this cycle and systematically show their actual operating costs, billing revenue and identify any shortfalls so that proper funding of EMS can be addressed before it reaches a critical point of failure. 

This reporting should be done throughout the year, I recommend at least quarterly, so that there are no surprises at budget time. 

Any reports provided to municipal leaders should include at a minimum: 

• Number of EMS requests
• Number of completed transports (great discussion point)
• Response times (average is good, fractile is best) 
• Mutual aid given and received 
• Amounts billed and collected 
• Payer mix, showing the discounts and non-allowables 
• Community events covered 

Quite often I find myself explaining to municipal boards of selectmen, boards of finance, county commissioners or the public the realities of EMS Economics. 

Most have no idea how the finances really work, that almost every completed trip is done at a significant discount, that there is often a high bad debt component to the service and that there is little the EMS agency can do about it. 

When budget time comes and the justified amount of subsidy is put forward there needs to be explanation showing what the community gets for that money.  

More importantly, and this is where EMS fails, is to fully explain what happens to service if the subsidy amount is not provided. 

NOT as a threat but as an operational reality.  By doing it this way the community leaders and the public can decide if they want a cut in service, if they want to have fewer paramedics, if they want continued turnover because wages are under market, making recruitment and retention difficult, or if capital expenditures should be pushed off again potentially resulting in equipment failures and possible litigation from a bad outcome. 

EMS leaders need to hold firm if a decision is made not to fund the justified subsidy amount and actually cut units, explain extended response times and add downtime to the quarterly reports showing the results of their decisions. 

Sounds harsh right?  Spoiler alert, in our experience when the numbers are transparent and the subsidy request is fully explained and justified, we have been able to secure funding for our clients more than 90% of the time.   

If these issues sound like what you're facing, let's discuss your situation and see if we might be able to help.  Click the link to take the first step: https://www.holdsworth.com/contact/ 

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A new report from the New York State Rural Ambulance Task Force exposes a critical reality that EMS leaders across the country are feeling every day:

"Today, EMS is an unanticipated safety-net provider of pre-hospital healthcare, to all patients regardless of their ability to pay for services." 

While the report is focused on rural agencies in New York, its core finding could just as easily be true anywhere in the country: EMS agencies and systems are nearing a breaking point. 

In states like New York, the critical needs of EMS are starting to be noticed, but the real work remains. The report includes 38 proposals as a starting point to help address this crisis, including: 

• Designating EMS as an essential public service, and allowing the creation of special taxing districts to promote sustainable funding 
• Developing countywide/regional EMS systems to foster a more efficient allocation of resources and coverage 
• Improving Medicaid reimbursement, through rate increases and mechanisms for reimbursement of treatment in place/transport to alternate destinations 
• Strengthening data collection and reporting and establishing an accreditation process for EMS agencies to support increased reimbursement, public funding and grant opportunities 
• Supporting workforce development, through a designated minimum wage for EMS providers and a 3-year public affairs campaign to promote volunteerism and EMS as a career

For EMS agencies across the country, this report shines a light on the importance of thoughtful system design, knowing your agency's clinical, operational and financial data, and being prepared to communicate your agency's needs in a clear voice.  

Because the question isn't whether these challenges identified in New York apply to your agency – it's whether you're prepared to meet them head on and build a more sustainable future. 

Click here to read the full report. 

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Every day we read about the staffing shortage in EMS. There are meetings, web-trainings, and gurus with ‘secret techniques’ to recruit and retain staff, yet the situation appears to remain.

I agree that there may be fewer people entering the field, but as leaders, we are using the same old methods to recruit them into our agencies and are not being smart about how we treat the people that we have.

In looking at an agency with high turnover, or with a lack of applicants, it’s almost always a safe bet that the agency’s culture and reputation are a top cause.  The grapevine does a great job of luring your staff to better employment options, and it equally identifies your agency as a toxic place to work if the culture sucks.

Before you begin a recruiting process, there are several things you should do before you ever place an ad or put a listing on Indeed.  You need to make sure the welcome mat is out.

1. Look in the mirror.  Why are people leaving?  Where are they going? What can you do about it?
2. Look at your agency as a prospective team member.  If you were an EMT or medic, would you want to work for you?   If not, why not?   Fix the issues.
3. Who exactly are you looking for? Are schedule formats and staffing patterns optimized?      Can you change staffing or deployment patterns or shift hours to attract a different type of team member?
4. Do you have field training officers (FTOs) or preceptors ready to meet, greet and make new hires feel welcome?
5. Is your orientation program designed for candidate success, or is it a gauntlet set up to fail all but the strongest (the Darwin-istic system where only the strong survive)?

New team members arrive wanting to succeed. If the orientation program or those administering it are set up to crush a newbie’s spirit, they will leave.

When an organization’s culture is strong, your team members feel that they are listened to and are part of something bigger than themselves and that their efforts are appreciated, people want to work there even if the pay and benefits are not the highest in the area.  If the work schedule, culture, and salary are all sub-par, you have no chance of recruiting or retaining quality people.

Before you recruit, take a long, hard and honest look at your organization and make the changes necessary to make the workplace inviting, challenging in a positive way and truly embrace creating a culture of excellence (more on that in my next post).  Prospective team members will notice, and the current ones will become ambassadors for your agency.

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I recently heard a partner tell a patient that they are their "own best advocate." It's true – nobody is better at telling us about our patients' needs or experiences than they are. 

That got me thinking – is the same true for EMS agencies? 

Not quite. In fact, as an industry, we may very well be our own worst advocates. We tell our story infrequently to policymakers, the press and the public – and almost always in the same breath that we're asking for help.  

As a result, EMS has come to be the forgotten safety net in many communities – top-of-mind only for those who need us.  

But we shouldn't accept this as our reality. Consider it a wake-up call. 

In Connecticut, EMS providers recently came together to urge state legislators to include EMS providers in proposed legislation that would provide tuition assistance as a recruitment incentive for first responders. This is a prime example of the voice our industry can have – and an opportunity to make sure we're not left behind once again as an industry – but the real work lies ahead. 

We know better than anyone the work that we do, the challenges we face, and what we need to future-proof our operations. These are the stories that we – and only we – can tell. And, if we want to build sustainable EMS systems, they are the stories we must tell.  

Have questions, or want to discuss further? Get in touch here.