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The National Registry’s Board recently reversed a longstanding policy that candidates testing for paramedic certification must come from a program with a CAAHEP accreditation or CoAEMSP’s letter of review (LoR) in the accreditation process.

This reversal begins a new and dark age in EMS.

For anyone who was around when the NREMT announced the policy requiring accredited programs, it was earthshattering—and gutsy. The NREMT made a bold step to standardize and professionalize the paramedic. The number of accredited programs skyrocketed and increasingly moved toward college-based programs and degrees.

This move was not without cost. It became more challenging to hold a paramedic course or start a program. Smaller and independent programs couldn’t stay in the game.

Things changed. Mainly for the better. For students, for programs, and the profession. Many forget that this was simply the culmination of a 5-step process outlined in the 1990s EMS Agenda for the Future and EMS Education Agenda. We asked for this. We saw it as our future.

Over the years, voices have asserted that accreditation was too onerous and burdensome. The consistency and structure required in self-studies, site visits, and the recordkeeping work each year strained against our “patch it with duct tape and shoestring to make it work” upbringing in EMS. It taxed our excitement-driven, short attention span, street-based mindset. It taxed tradition.

But we needed that.

We agree that accreditation is a lot of work. We believe it could be made easier. But we also think it is necessary to have standards, define and level the playing field, and provide reassurance when a program earns and maintains accreditation.

All other allied health professions demand this. Frankly, EMS does not have the best record of policing ourselves.

Source: EMS Education Agenda for the Future (NHTSA)

If those who believe that the NREMT and CoAEMSP are the reasons for their failing students and personnel shortages put as much effort into improving their EMS education as they are complaining things are too difficult or unfair, they wouldn’t have an issue.

For those who believe the NREMT is the issue, it is time to look in the mirror.

The anti-NREMT and anti-accreditation drums have been beating louder recently. States that choose to lower the standard and create their own examinations, part of the reason we believe the NREMT adopted this policy, will return to a “teach to the test, everyone knows what is on it anyway” mentality. Let those states go. They’ll be back. If the NREMT eliminates the accreditation requirement for paramedic, it will never come back. The genie will be out of the bottle.

If those who believe that the NREMT and CoAEMSP are the reasons for their failing students and personnel shortages put as much effort into improving their EMS education as they are complaining things are too difficult or unfair, they wouldn’t have an issue.

We wish the NREMT would take a different approach. One of strategy, education, and continued commitment to quality. The blood is in the water now. Sharks are circling. The NREMT flinched first. What will we lose next?

If we do away with the concept of EMS being part of the healthcare system, the most significant risk of the slippery slope created here; we will have to live with the costs. We predict the only actual paying jobs will be with the fire service. Privates will continue to suffer. Our protocols will become less autonomous over time and more restrictive. We will be considered more of a technician than a clinician in the eyes of people who could have been our healthcare colleagues. We will move steps closer to the “ambulance driver” persona we fight so hard to get away from.

How would you feel if your physician, nurse, respiratory therapist, or ultrasound technician came from a program that chose not to be accredited? Do you think there could be a difference in the quality of the practitioner? Would the school realize they could do more with less and cut corners? Maybe staffing shortages encourage programs to reduce the number of hours and skills to graduate, and hey, let’s not take the national exam. Let’s make our own exam. We will get more people out there more quickly.

More quickly, not better. Not by a long shot. We don’t want that in our healthcare professionals. We don’t want that in our paramedics.

EMS just took a giant step backward. The NREMT is making the wrong decision. We can only hope that individuals, schools, and states do the right thing: choose CAAHEP accredited programs and maintain program accreditation.

Join the discussion 30 Comments

  • Terrie Godde says:

    I could not agree more. The comments here are spot on.

  • Mark Podgwaite says:

    Dan

    I agree with you 100%. A huge step backwards.

    Mark Podgwaite
    Executive Director
    Waterbury Ambulance
    Waterbury Center, VT

  • Drummond Figg says:

    Well said Dan!

    • John F. says:

      I think this is a huge step backwards. However, CoAEMSP needs to be consistent. I agree that EMS has not historically done a great job in policing themselves. We need to have a standard. I’m on the fence with this one, as I see it both ways.

  • Scott Francis McConnell says:

    Dan,
    I 100% agree, this is a step backwards, along with allowing all recorded education for re-testers and recertifications, I have personally reported to CAPCE several services that allow you to FF through the education and test, sure some will say hey they pass the test right? Sure but did you learn anything? The other issue with just recorded content, as our medicine changes so should educational delivery, great example almost over night LSB became a thing to almost never use, yet If I spend thousands on trauma educational content that feature LSB I will need to recoup those monies through sales so the content will always be years behind actual practice.
    Thank you,
    Scott McConnell

  • Sarah Slader-Waldorf, MSEd, MSN, FNP says:

    Nursing schools are also in the process of dumbing down healthcare. The patient is the loser. I wouldn’t trade my paramedic experience for anything. We need to raise the bar all around not lower it.

  • Eric Slazenik says:

    I agree with you Dan a major step back.

  • Toni Wyse says:

    This is so sad! We’ve tried so hard to build our profession, to be included and accepted as excellent partners in the healthcare field, to be acknowledged for our worth, and appreciated for the importance of our role in providing excellent patient care in the prehospital setting. I hope our future patients don’t suffer.

  • Dena Smith says:

    Well said! As educators, we all need to advocate for moving forward, not stepping back. Thank you for articulating so well.

  • John Miller IV says:

    Okay I guess I will be the bad guy here and disagree atleast in part. I do not now or ever have in my many years of education ever believed that having CoAEMSP or CAAHEP ment anything but headaches, paperwork, and stress for educators and especially administrators. The same goes with requiring the paramedic programs to be affiliated with a college or university. In theory yes the alphabet soup and higher education requirements should have made everything great, but that has not been the answer in many cases. First off in most cases every level below medic can be taught by a local or regional EMS training center without any of the above requirements. This is where the basics, the fundamentals, and the ground work for new EMS providers are started. So why not make the same requirements start at the very basic if your logic is to make “professionals”. Are EMTS and Advanced EMTs not professionals? The other issue is the states can hold greater oversight of EMS training programs at all levels better than the alphabets who are so backed up on site visits they may review a school once every 5-6 years, i know some that other than emailing some documents havnt been reviewed in over 10 years. So they could be a dumpster fire with horrible programs and noone would know. The other issue i have is in my part of the stare of PA the nearest Paramedic programs are an hour and a half away. There used to be some top level programs here but under the alphabet rule they disappeared. So this is why i do not agree with the need. A local program can be just as good or better than any big school program. It comes down to quality of the instructors and the integrity of the programs. Reputation is everything. And the state can easily watch every classes pass rating and take immediate action. To me this is the best system and the way to help the rural EMS.

    • Thomas Kamplain says:

      I agree with John 100%!!! CoAEMSP & CAAHEP has not been the answer!

      The biggest issue I have with CAAHEP is that they do not want to have ANY small local schools teaching paramedic courses. In addition, they have multiple standards that allow larger State, Government, and corporate-sponsored schools a much easier path to becoming accredited. All schools should follow the same path with no exceptions. If a fire department wants to have an accredited paramedic program then they should have to go through the exact same process as the small private school. Make it one standard and I would be closer to 100% agreeance.

      As far as standards go CAAHEP does not ensure anything. Our local technical college went over a year without a medical director! Our medical director lent their hand at the end of a paramedic class to help out. Let me ask you something. Did that program lose its accreditation? Was there any discipline? Nope, just crickets and swept under the rug. The program should have been shut down or someone should have lost their license but nothing happened at all. And guess what!! They are still accredited.

      So, right now I agree with the NREMT’s decision.

      But, what I would like to happen is this.

      One accreditation standard for ALL schools, no exception.

      An end to the requirement that schools must have a board that will require that board to have a competitor on it.

      The establishment of a competitive accreditation body that will give schools different choices. This would end the monopoly that CAAHEP has.

      I want to see the profession move forward, however, we do not need to put people out of their jobs in doing so or limit access to quality education. We can do this with accreditation standards that represent everyone as a whole.

  • Richard Cluff says:

    Very, very well said. I could not agree more and I will contact the NREMT as well.

  • Jon Politis says:

    Spot On…..

  • Don Wilson says:

    I disagree with the NREMT’s decision, however, CoAEMSP has brought this on by themselves. Hidden polices, inconsistent expectations, and a focus on statistical numbers as the end result is not how to achieve good outcomes. Heck, you can’t even have legal representation at site visits. Why all the secret squirrel stuff? We don’t need to drop accreditation, we need CoAEMSP to not be so one sided in their expectations. Trying to put everything in pigeon holes Nationally does not work. Take annual report dates as an example. College classes don’t follow a calendar, but CoA forced us to comply with it. They don’t appreciate that it is virtually impossible to keep up with students and who they go to work for. But they make program directors out as bad guys if WE don’t provide them the data. I could go on all day , but CoA does not care about local issues.

  • Gary Whiteaker says:

    This is right on. It’s a step backward. Paramedics are for the most part grossly underpaid and under-estimated as far as ability and truly being accepted as medical professionals. When compared to nurses who have similar education, nurses (which are worth every penny) make a lot more money. A contributing factor to this is the Paramedic’s reluctance to solidify their education and to accomplish standards for education. The age old argument that I would rather have a street smart Paramedic than one with “book learning” loses it’s punch when it is realized that the two are NOT mutually exclusive. You can be both.

  • Sean says:

    I strongly agree with this change, COAEMSP/CAHEEP has done nothing to improve EMS education. They have raised costs of paramedic education more than double and they have changed the focus from the student to what does COAEMSP say about it. We as a program do not have education issues with students, students are very successful. I am not against the NREMT its a hard test, but it is valid and its the best way to certify students initially. COAEMSP is a waste of money, time, and resources. I remember a conversation a long time ago with Dr. Hatch, he told me its COAEMSP’s goal to reduce the number of paramedic programs by half, so that only quality exists. In the meantime only the programs that could afford COAEMSP survived and quality had nothing at all to do with it. I applaud this move and support it 100%

  • Mark Self says:

    I agree with John Miller. I have been in EMS in South Carolina for 47 years now. We were duped by the NREMT many years ago that having NREMT testing would bring professionalism to EMS. What a crock. Programs are good or bad based on the quality of their instruction, period! We ARE technicians AND health care providers. At least here in SC we practice on a more advanced level for EMT than many states who adhere to the NREMT. Remember the NREMT is a money making machine just like COAEMSP and CAAHEP. It has done nothing for the profession except make the costs skyrocket and passing scores drop! Read Bryan Bledsoe’s response to this. If you are operating a high achieving and quality program you don’t have nor need a bunch of outsiders telling you what to do. The NREMT has become the “tail wagging the dog” and this must stop. I havbe no difficulty stacking the skills of SC medics and programs against those in other locations.

  • Janny Jarvis says:

    This is a sad day for the EMS profession and as said, seen more as a clinician than a technician has been shoved backwards and hard.

  • Steven Pengra says:

    Along with my Fire Service career, I have been involved with Paramedic education since 1986. Worked with an Associate Dean to help implement the AAS Degree program for our Community College when Oregon required it. Thirteen years ago, became CAAHEP accredited and have been ever since. Disappointed in the NREMT for moving back. We like many programs have worked to help professionalize Paramedicine. Our student success rate has been excellent. They are getting jobs and starting their long careers in EMS and the Fire Service. I agree with you Dan, this is a step backwards.

  • Jeremy Gassert says:

    You make a very good point by saying things could be easier. Like much of life, this is a not a binary on or off standard. Standards can remain in place while simultaneously being reasonable for an educational institution to adhere. In this case, as many others in recent NREMT history, stakeholders were not given a voice. I think an important question to ask in this situation is, cui bono? From where I stand, it doesn’t look like a step forward.

  • Chris Sanders says:

    I certainly respect and value all opinions in this matter, in my perspective a paramedic needs the clinical experience, the street smarts as some have termed it, but also the clinical education that can only be derived from the texts book, to help her or him answer the of what is going on with the patient and how the the disease process works or what is causing the medical conditions, as was stated in a fine comment both are “NOT” mutually exclusive, the have to be combined, clinical education, data driven, fact based learning with experience that comes with time and street smart education and old fashioned book learning. EMS is heading in the right way but I feel this is a step backwards away from a more education clinician background. There are still many issues that need resolved from a legislative perspective to the Federal, state and local level. EMS has to be recognized as an essential service with salary and benefits in place. I think moving away is a backwards step, but at the same time these organizations have made a paper work and record keeping and that CAAHEP accreditation or CoAEMSP’s letter of review (LoR) have became an administrative night mare for educators and administrators. I also think that NREMT needs to be more defined and the organization as a whole is not popular with many rank and file paramedics and EMT’S. The NREMT regulations and renewal every two years is cumbersome and burdening for many people and facilities. This is why many people if their state allows will get a state license and drop the National Registry. I do not like the fact of an unaccredited course, too me this is like have a college degree from a school that is not properly accredited. I would like to see some all around refinements but I do agree the NREMT should have stood their ground. Only my opinion.

    Chris Sanders, MS, NRP

  • Donald Speicher says:

    I would agree with John Miller as well, particularly the last part of his statement.
    “A local program can be just as good or better than any big school program. It comes down to quality of the instructors and the integrity of the programs. Reputation is everything. And the state can easily watch every classes pass rating and take immediate action. To me this is the best system and the way to help the rural EMS”
    Rural EMS, those of us out here with 30 minute, 60 minute, 120 minute or more, transports to a hospital are really the services that need providers with advanced skills. The states, even though their records can be and are spotty and inconsistent, should be better able to make that possible. If you work in the city and can be at a hospital in 10 minutes, the requirement for advanced skills takes on a different perspective. And lets face it; who would you rather have treating you after a devastating MVC; a newly minted and highly certified paramedic or one with fewer letters after the name but with 10, 15, or 30 years experience. We really learn this profession on the job. To me credentiallng comes in second to experience, particularly in rural America.
    .

  • George Gray BS NRP says:

    Well stated! Here is an article from that was shared with me on Facebook last week. https://www.firerescue1.com/career-1/articles/why-so-many-firefighters-dont-become-paramedics-VKO8qSI6qA7pkEwI/. Seems very coincidental considering the news out of NREMT this week. My response to the person who shared the article was this: EMS both public and private have done this to themselves. When you have an industry with a long track record of paying and treating employees poorly, this is what you get. I think the education component is being used as a scapegoat for a systemic problem in EMS that has been going on for decades. Covid and full employment have given many in EMS life changing opportunities and they have moved on. Now the leaders who have ignored the problems are in a panic over staffing and are trying to pick up the pieces by any means possible.

  • John Todaro says:

    Well said and solidly true!

  • Kenny Raynor says:

    I agree and can understand most sides of the argument. However, those saying accreditation created paperwork or is the reason for your program’s failure need to look in a mirror. Any accreditation should hold you to a standard and ensure you do what you say you are doing. You and your instructors are responsible for the product you produce not the NREMT or any accreditation company. As part of only 2 federal government programs that are accredited we have the same or more hurdles that state and local agencies have. We produce over 350 paramedics per year, and we stand behind every student produced from our program. In my personal opinion the removal of this requirement allows lazy program to be lazy. I will be contacting NREMT with my thoughts. God Bless and Stay Safe,
    Kenny

  • Randall Benner says:

    Get a cup of coffee….what started out as a few sentences turned into a small novel…….

    When I went shopping for a paramedic program back in the late 80’s – how was I supposed to know how to seek out a quality education? I, like many of my EMT friends at the time only looked only at 2 variables when selecting a paramedic program. What is the cost and how long is it? (and I bet the students of today ask the same question). I had the option of going to a hospital based (state accredited) program or a college based (nationally accredited) program. I’ll give you one guess what I did (although I know you guessed right), I went to the shorter and cheaper hospital based program. And my choice had nothing to do with accreditation because as a student, how was I to know to even ask about it? I didn’t ask about first time pass rates, I didn’t ask about attrition, I didn’t care if the educational curriculum was good or not. All I cared about was they said they would turn me into a paramedic in the shortest time with the least amount of pain, suffering, and money. Well, I completed my hospital based program and got my medic certification after taking the state test. After working the streets for about a year or two, I realized I was going to make EMS a career, so I decided to get an AAS degree in paramedicine at the local college (the same college I skipped over initially). Since I didn’t have college credit though, I wound up retaking all the paramedic classes there, even though I was a medic (I did get a break on the clinical hours though). Essentially I took another paramedic class. What I realized was this, the nationally accredited program was better organized, better administered, the education was immensely better, the exams were harder, the skills days more challenging. But everything was fair. I was AMAZED at what I didn’t know. I am sure I learned probably 50-60% more about prehospital medicine than I knew walking in…not that I learned the same stuff better, but I learned NEW stuff that a medic needs to know. I was AMAZED (and scared to death) that I was caring for patients without some of the knowledge I learned at the university.

    So what is my point?

    If you have been around long enough to remember the Lifepak 5 and the Thomas half-rings, then you know there are EMS programs out there that will cut corners. You know there are programs out there tethered to EMS systems that will churn out medics in 6-10 months only to put butts in ambulance seats in order to meet staffing needs. You know that without proper oversite, quality in some (not all), but many programs will slide. There is no avoiding this. The slide will be subtle, it will be quiet, it will not be obvious, but it will happen. You can pump your chest, you can stomp your feet and say “it won’t happen here”, and you can tout statistics galore about your own program, but you cannot stop the educational slide of other programs. How will we identify those programs that are starting to slide? Oh yea, that’s right, we won’t be able to because there won’t be a national accreditation or standardized test anymore to help keep the field level with this current trajectory. With this trajectory, we are putting everything back in the state’s hand, and remember, the states had their chance at regulating this once and they decided to give it up to national accreditation and national testing entities. Do you really think that each and every state has the bandwidth to provide meaningful accreditation and the capability to provide defensible examinations for licensure? Because if your in the camp of burning down the Registry and sending the CoA packing, then you are placing that load squarely on the shoulders of your state…..do you think they are ready? Do you think they even want it? Do you think they have the budget for it? Do you honestly think they can do a better job, or just a job that your more in agreement with?

    Now, to all those EMS educator colleagues I likely just offended, I apologize. Please know your counter arguments do not fall on deaf ears, it is not lost on me that some EMS programs do not need the rigors of the CoA because they have already imposed high educational standards on their own program. In fact, I would bet my last dollar that those commenting on this blog are individuals from programs that already have high educational standards, and why do I believe that? I believe that because it is a personal quality of solid EMS educators to keep one’s eyes on the EMS horizon. You watch what is going on nationally, you engage, you send up your voice, you go to conferences, you remember putting your money into a hat to help fund a new organization that would ultimately become the NAEMSE, you do the next right thing to make EMS education a little better, you come here to Dan’s site and share your thoughts. Its for the EMS educators that don’t do those things, that do not even know of this webpage because they are not looking up-and-out that I long to reach. Its sad, but in reality, the words I type here are for the EMS educators that will likely never read it.

    I can say though, as a person that attended two different medic programs, as a person that has taught in the same two different medic programs, and as a person who had the wonderful opportunity to serve as a CoA onsite reviewer, that maybe there is something to the CoA standards and/or the accreditation process that could be improved (I’ve done my fair share of CoA accreditation documents, and I agree they are a pain in the buttocks to do). And maybe there is a way to somehow improve on what the NREMT is currently doing to better align themselves within the perceived chasm that exists between new graduates, certification, and the CoA. But the answer is NOT to simply trash them both and go back to the ’80’s as it seems the NREMT may be heading towards…..because history will repeat itself my friends. The slide will start, and we no longer have the stop-gaps in place to prevent it.

    To this end, change is always hard. It is always noisy, it is always nasty, and sometimes we get it wrong – but we also have the ability to fix it. Would it not be better to engage the CoA and NREMT entities with fresh ideas? Do you really think they exist in a dimly lit and poorly ventilated room where they make decisions with zero input? They are not our enemies, and they are not gonna throat-punch us if we ask to have an audience with them. They are not going to act like they don’t know us and hide behind a locked door with the lights turned out. Even if they did…..they are still easy to find, they go to all of our EMS conferences!

    So, in conclusion at 0253 hrs, I am saddened to see the current trajectory of the NREMT and EMS education, because we have been down this road before. EMS education, like medicine, is an art that is still not in a state of perfection. But we know with certainty what will make it worse. Unfortunately there are too many people running towards that end screaming that we would be better off somehow. What they are really running towards is a dumpster fire. They are running towards mediocrity.

    We can’t make things better by doing what we did before – history has already shown us that it failed.

    I’ll be the first to say I don’t have all the answers…..even after 30+ years being and EMS educator. But you know what I do know? None of us is as smart as all of us. Collectively we can fix this, we’ve done it before.

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