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Diversity in EMS: A Tool to Measure Inclusion

Diversity in EMS is a new bimonthly column in which rotating authors will confront difficult questions of bias and discrimination in the emergency medical services, and how agencies can lead change in their communities.

You’re not a bigot. You would never dream of giving a patient different care because of their race, gender, or some other demographic factor—at least never intentionally. 

Unconscious bias can affect us all, however, and lead to unintended judgments, often subtle and unrecognized, that can color care and follow patients downstream. These may contribute to suboptimal outcomes and even some of the persistent healthcare disparities that plague vulnerable populations. 

You may be familiar with unconscious bias as background assumptions or near-imperceptible prejudices about certain groups held walking in the door: Lots of drug-seekers in this group. These people can be overdramatic. EMS providers, interacting with patients in their homes and natural environments rather than the scrubbed sterility of offices, may also be susceptible to the related error of inferring snap judgments from someone’s circumstances. 

“With unconscious bias, there are assumptions we make in a split second,” says Maria Hernandez, PhD, president and COO of Impact4Health, a California-based organization that works to reduce healthcare disparities. “They’re quick judgments, negative or positive. There’s evidence that in about seven seconds, we make almost 11 different decisions about new people. The obvious ones are about race and gender and age and ability—the outward appearances people tune in to. But when you go down that list, it’s also about things like social status and friendliness—those two right there can be a big factor in how someone reacts to you.” 

Beyond care, how you respond to patients on a visceral level can have impacts beyond the EMS encounter. Hernandez described a physician preparing to see an ill Black child whose mother had been vigorous in advocating for him—or, the chart told him, Mother is hysterical and complaining wildly.

“That’s going to set the physician up to walk in the door with expectations about what’s going to happen and how they’re going to deal with it,” Hernandez says. “So consider how an EMS provider might describe a patient a certain way: ‘Oh, they’re just complaining about pain,’ versus ‘They report a pain level of 8 out of 10.’ It gives a very different impression.” 

At the far end of this equation, abundant data quantify healthcare disparities for susceptible groups that span everything from mortality differences to analgesia administration to hospital destination choices. So what can EMS systems do to interrupt any contribution unconscious bias may be making to that?

Attacking the Roots

Impact4Health offers a free tool to help healthcare organizations identify and mitigate biases that may influence care. Its Inclusion Scorecard for Population Health is a customized online assessment of efforts to reduce health disparities by addressing issues of diversity, inclusion, social determinants of health, and community engagement. It was designed for hospitals but can apply also to EMS. 

“We spent several years looking at best practices across different health systems, and we did a comprehensive literature review of the protocols and programs and policies that hospital systems can apply to address health inequities,” Hernandez explains. “We placed all of those—there are about 75—into an online platform where users can review them and analyze where they are on them: Are they using them? And to what degree are they applying them?”

The scorecard’s best practices are divided into four areas:

1. Monitoring and responding to key inclusion metrics for overall operations, professional development, and disparities in patient outcomes; 

2. Building a culture of inclusion with clear values, principles, and protocols to support staff engagement and promote quality service to unique populations; 

3. Rewarding and reinforcing inclusive leadership and management practices that improve outcomes and reduce disparities; and

4. Strategies for inclusive community engagement in prevention, targeting the social determinants of health, and health promotion and education. 

Sample activities for the first quadrant, for example, may include tracking patient outcomes by demographic group; tracking health inequities among communities served; tracking employee demographics to gauge diversity; and mapping the social determinants of health that influence patient communities. 

Some hospital systems appoint chief equity officers to spearhead these kinds of projects, but it takes across-the-board participation from HR, quality, and medical leaders as well. Impact4Health recommends creating a health equity or diversity and inclusion council of leaders from across the organization. EMS systems can tackle things similarly, and ideally in conjunction—for best results all components of the system should move in concert. 

As not all systems are identical, any council’s first priority is to assess which of the scorecard’s areas are applicable to its system—“It’s difficult to have a one-size-fits-all solution,” notes Hernandez. With those identified, Impact4Health consultants interview key leaders and staff, coordinate focus groups, and otherwise collect information. The results are presented in a secure online platform and via written summary report. 

With that assessment complete, Impact4Health works with system leaders to develop a customized strategy to address disparities through specific activities over 18–24 months. The platform lets leaders review all activities and access resource libraries for each practice. Metrics are provided to measure progress. 

Thus far seven hospital systems are using the scorecard, with additional interest high, Hernandez says, and they’re making some important discoveries. One is that addressing healthcare disparities—as those in EMS well know—is best a collaborative effort. 

“We’re getting them to break down a lot of silos and begin to recognize that we can’t achieve health equity inside the four walls of the hospital,” she says. “You have to do that in partnership with community organizations, public health, and other players that provide care to the communities.”

Learn more at 

Sidebar: How the Scorecard Works

The Inclusion Scorecard for Population Health divides its best practices into four main areas:

  • Monitoring and responding to key inclusion metrics; 
  • Building a culture of inclusion with clear values, principles and protocols; 
  • Rewarding and reinforcing inclusive practices linked to better outcomes; and 
  • Strategies for community engagement in prevention and targeting social determinants of health.

As no two health systems are identical (especially in EMS), Impact4Health advises identifying a subset of its 70-plus best practices most relevant to your system. Its consultants calculate ratings for the activities assessed and provide the results in a written report and online dashboard, then help guide a customized strategy to address them over 18–24 months. A directory of metrics helps measure progress and inform adjustments. For more see 

John Erich is the senior editor of EMS World. 

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