In January of 2024, the San Francisco Fire Department and San Jose State University convened a groundbreaking EMS Data Equity Conference bringing together EMS stakeholders, including frontline clinicians, agency analysts, local EMS authorities, and EMS data and equity experts.
The conference, funded by the CARESTAR Foundation and the National Science Foundation, launched a yearlong learning community that met monthly to explore inequities in emergency medical care and develop strategies to address them. The learning community鈥檚 curriculum was structured around three modules:
- See it
- Understand it
- Address it
We seek to share the findings from this learning community in this series with the hope that others will replicate and build on this work.
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The first two installments in this series recapped the lessons learned in Modules 1 and 2, which focused on recognizing and understanding inequities, respectively.
In this final article of the series, we detail Module 3: Address it, a practical exploration of how EMS agencies can take action to reduce inequities in prehospital care, workforce diversity and community outreach. Over four sessions, participants identified specific strategies, resources and frameworks for bringing about meaningful, data-driven change in EMS.
Module 3: Address it 鈥� How do we reduce inequities in EMS care delivery and patient outcomes?
The core objective of the Address it module is to move from insight to action. Armed with a deeper understanding of how inequities emerge (from Module 2), participants in Module 3 were tasked with turning ideas into concrete steps 鈥� whether those steps involve securing leadership commitment, launching training programs, changing hiring practices or developing targeted community outreach campaigns.
Participants examined three major areas with substantial gaps in equity:
- Inequities in treatment
- Workforce diversity
- Community outreach and partnerships
During the final culminating session, the learning community explored how improvement science, specifically the , can drive and sustain positive change. Below, we recap each of these sessions and highlight the tools, techniques and best practices that emerged in hopes that others replicate and build off of this work.
Module 3, Session 1: Addressing treatment inequities
In the first session of the Address It module, participants turned their attention to tackling specific disparities in treatment. They began by walking through a five-step process for designing and implementing interventions:
- Obtain organizational commitment. Meaningful, system-wide change needs clear direction from leadership. Participants stressed the importance of presenting data on inequities in a compelling way and using real-world stories and examples to highlight the urgency of addressing disparities. Organizational commitment goes beyond a simple endorsement 鈥� it requires leaders to actively champion equity initiatives and allocate adequate resources, while also removing barriers.
- Animate and empower your team. While leadership support is vital, lasting progress often emerges from grassroots level initiatives. This principle involves engaging EMS clinicians, dispatchers and other frontline staff in data collection, analysis and solution design. These groups not only bring unique insights into patient care processes, but also help champion changes that affect their day-to-day work.
- Determine your organization鈥檚 starting place. Every EMS agency differs in its policies, patient populations and resources. When designing equity interventions, it鈥檚 crucial to map out your agency鈥檚 current position. Some agencies may already have robust data collection methods or relationships with community groups; others might be starting nearly from scratch. Understanding your baseline will prevent you from trying to replicate someone else鈥檚 鈥渕iddle鈥� when your organization is still at its own 鈥渂eginning.鈥�
- Recognize the cultural shift. Cultural transformation is inevitably more challenging than technical adjustments. A new policy or checklist can be implemented quickly on paper, but getting clinicians and administrators to internalize and sustain changes often demands a shift in mindsets and attitudes. This is especially important in addressing implicit biases or entrenched assumptions about certain communities.
- Adopt a structured approach. Participants were encouraged to emulate the structure of the learning community itself:
- See it: Ensure visibility of data and evidence regarding inequities
- Understand it: Analyze root causes using tools like driver diagrams and focus groups
- Address it: Identify, pilot and refine interventions
Intervention ideas
A variety of potential strategies emerged for each phase (See it, Understand it, Address it):
- See it
- Conduct a thorough audit of your current data environment
- Improve race and ethnicity data collection in patient care reports
- Stratify continuous quality improvement (CQI) reports by race and ethnicity to reveal systemic patterns to be examined and addressed
- Understand it
- Administer culture and climate surveys among EMS providers to detect attitudes or biases
- Gather community feedback through town halls or listening sessions
- Conduct EMS clinician focus groups to hear frontline perspectives
- Address it
- Provide comprehensive resources and training on working with patients with limited english proficiency (LEP)
- Develop checklists and compliance protocols to standardize best practices, especially on calls where cognitive resources might be stretched thin
- Publish race charting rates and treatment-equity performance reports by team or provider
- Offer training on the fallacy of biological race to combat potential misconceptions
- Post agency-wide metrics on racial treatment equity to encourage accountability and signal leadership support
By adopting these measures, EMS agencies can begin to close the gap in treatment outcomes across racial and ethnic groups, creating more equitable care for every patient.
Module 3, Session 2: Addressing workforce diversity
Building a diverse workforce is a critical component of achieving equity in EMS. During earlier sessions, participants examined data indicating a widespread lack of diversity in EMS agencies nationwide. In Session 2 of Address it, they studied successful programs designed to boost EMS workforce representation, including:
- Black Fire Brigade (Chicago)
- EMS Pathways Academy (Minneapolis)
- Freedom House 2.0 (Pittsburgh)
- A youth outreach program in Wake County, North Carolina
These models provide insight into how targeted recruitment, mentorship and community engagement can make EMS careers more accessible to underrepresented individuals. In small-group discussions, participants tackled two overarching questions:
1. Identifying barriers to workforce diversity
Groups brainstormed barriers that prevent applicants from underrepresented backgrounds from joining and thriving in EMS:
- Unfamiliar career pathway: Many communities are unaware that EMS is a viable, stable and rewarding career option.
- Lack of role clarity: Uniformed services can be daunting for those who have had minimal interaction or feel they 鈥渄on鈥檛 belong.鈥�
- Lack of career mentorship and support: At the point of entry, applicants might drop out of programs or fall short on exams due to lack structured follow-up or re-entry pathways. Others may leave the workforce due to lack of mentoring and promotion opportunity.
- Funding challenges: Training and certification costs can create financial barriers, especially for low-income communities.
- Perception of 鈥渄iversity hires鈥�: Applicants sometimes fear being tokenized or undervalued.
- Workplace culture: Women and racial minority EMS providers are more likely to leave the profession, potentially reflecting unwelcoming work cultures.
2. Assessing leadership diversity
When asked to examine the diversity among their own leadership ranks, most participants acknowledged that their management teams lacked significant representation. This can perpetuate a cycle in which new applicants from underrepresented groups have trouble envisioning themselves in leadership roles.
3. Creating three action steps
Each small group then outlined three concrete steps their agencies could take to enhance workforce representativeness:
- Encourage and mentor: Actively identify potential applicants and early-career professionals and guide them through the application, training and retention process.
- Annual demographic audits: Conduct yearly reviews of the demographic composition of leadership, frontline personnel and applicants to identify trends and gaps.
- Cross-training and internships: Partner with local schools or organizations to provide hands-on experiences that demystify EMS careers.
Participants also revisited the finding actionable strategies to adapt to their own agencies 鈥� such as establishing mentorship networks, revising recruitment procedures and ensuring fair testing protocols.
Module 3, Session 3: Addressing inequities in community outreach
Next, the group considered how to build more equitable community partnerships. Ryan McClinton of Public Health Advocates facilitated a discussion on community engagement and co-production, which emphasize shared power and mutual respect between EMS agencies and the communities they serve.
Community engagement and co-production
Community engagement goes well beyond periodic public education campaigns or open-house events at fire stations. Co-production involves a deep, collaborative relationship in which community members help shape programs, policies and services from the ground up. This approach not only improves effectiveness, but also fosters trust and sustainability. Key principles include:
- Shared power and decision-making: Community members have a meaningful voice in determining priorities and solutions.
- Mutual respect and value: A recognition that community expertise is on par with clinical and operational expertise.
- Collaboration and capacity building: Working with local organizations to build collective knowledge and resource networks.
- Transparent communication: Maintaining an open dialogue about data, outcomes and challenges.
Innovative engagement strategies
Participants explored innovative strategies that EMS agencies can employ:
- Community action research: For example, mapping neighborhoods with low AED distribution or usage rates to collaborate on targeted outreach.
- Culturally specific outreach events: Tailoring activities that recognize cultural norms, language preferences and community-specific health beliefs.
- Local partnerships: Engaging faith-based groups, community centers or advocacy organizations to identify and address health barriers collaboratively.
A powerful example emerged from a group鈥檚 discussion of disparities in calling 911 during cardiac emergencies. Instead of speculating about why half of patients drive themselves to the hospital, participants advocated for analyzing data by zip code, focusing on specific communities where EMS usage rates are disproportionately low. They emphasized conducting listening tours, town halls or small tests of change within these areas, then refining interventions based on direct feedback from residents.
Module 3, Session 4: Defining a quality improvement aim
The final session served as a capstone, inviting participants to consolidate the year鈥檚 worth of insights into specific, data-driven quality improvement projects. Using the IHI Model for Improvement, participants worked to translate broad goals into actionable steps.
IHI Model for Improvement
The IHI Model revolves around three core questions, followed by iterative Plan-Do-Study-Act (PDSA) cycles:
- What are we trying to accomplish?
- Formulate a clear aim statement. For instance, an agency might aim to reduce disparities in pain management between English-speaking and non-English-speaking patients by 50% over the next year.
- How will we know a change is an improvement?
- Identify metrics tied directly to the aim. By disaggregating data by race, ethnicity, and language, agencies can see whether disparities are narrowing and adjust interventions accordingly. Participants were encouraged to consider NEMSQA national measures and resources from the CARESTAR research library when identifying possible metrics.
- What changes can we make that will result in improvement?
- Brainstorm interventions using tools like driver diagrams to link potential solutions to underlying causes. Ideas might include additional language services, standardized pain assessment protocols or improved LEP resources on ambulances.
Testing changes with PDSA cycles
Rather than implementing a new policy agency-wide, the model emphasizes small tests of change. By starting with a single station, shift, or unit, leaders can evaluate whether the intervention works in practice before scaling up.
For instance, an EMS agency might pilot a newly created language-line phone app in one response unit. If that reduces on-scene communication barriers, the next step would be to refine the process and expand to additional units or stations. This measured, data-driven approach ensures that each iteration incorporates real-world feedback and that buy-in grows organically as successes accumulate.
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Psychology of change
The session concluded with a reminder that technical solutions alone 鈥� such as new checklists 鈥� are insufficient without addressing human factors and organizational culture. Seeking genuine commitment from clinicians, dispatchers, and community stakeholders is crucial. This requires:
- Involving key stakeholders early: Let staff and community representatives co-create projects and help define success metrics.
- Creating project charters: Document goals, roles, timelines and resources to foster accountability.
- Providing ongoing support: Encourage transparency about what is working and what isn鈥檛, and celebrate small victories along the way.
Putting it all together: Achieving lasting change
The Address it module underscores that transforming EMS systems to be more equitable requires sustained, intentional effort. EMS leaders and frontline providers must remain committed to:
- Improving data collection: Accurate, stratified data can reveal the scope of inequities and track improvement over time.
- Enhancing workforce diversity: A more representative workforce can better understand and serve diverse communities.
- Engaging communities: Deep partnerships driven by shared power and co-production lead to more effective, culturally attuned solutions.
- Implementing quality improvement frameworks: Tools like the IHI Model for Improvement guide agencies through iterative, evidence-based changes.
Perhaps most importantly, participants have learned that the technical fixes (e.g., new data systems, checklists) must be accompanied by cultural transformation. Agencies willing to confront biases, learn from community members, and support staff through the sometimes difficult process of changing norms are more likely to see real, sustained progress.
What鈥檚 next in providing equitable care?
As the year-long learning community concludes, agencies are encouraged to carry these lessons forward. The combination of robust data analytics, thoughtful engagement and continuous quality improvement methods sets the stage for a new era in EMS 鈥� one in which every patient, regardless of background, has access to high-quality, respectful and equitable care.
By weaving these strategies into everyday operations and adopting a mindset of continuous improvement, EMS leaders can help ensure that no one falls through the cracks. The call to action is clear: gather your data, involve your communities, and transform your practices so that high-quality care is accessible to all.
