Category Grades
16C+ 24C-
Access to Emergency Care:
22C 44F
Quality/Patient Safety:
39D+ 16B-
Medical Liability:
16C+ 30D+
Public Health/ Injury Prevention:
5A- 2A
Disaster Preparedness:
24C+ 41F

Hawaii boasts a strong commitment to Public Health and Injury Prevention, for which it ranks second in the nation, as well as a top-notch emergency medical services (EMS) system focused on patient safety and quality of care. However, a severe gap in hospital capacity impedes the state's ability to respond to both everyday emergency care needs and potential disasters or mass casualty events.

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Hawaii continues to stand out in Public Health and Injury Prevention. The state has both low rates of chronic disease and low rates of fatal injuries in almost all measured categories. These stellar numbers are supported by the state's fiscal commitment to injury prevention, with high per capita injury prevention funding ($961.64 for every 1,000 people) and funding sources specifically set aside for prevention of occupational injuries, childhood injuries, and injuries among older adults. Hawaii also has some of the lowest rates of adult and child obesity in the nation.

Hawaii has greatly improved its Quality and Patient Safety Environment since the last Report Card. The state has adopted a uniform system for providing pre-arrival instructions and has implemented a statewide trauma registry. Hawaii is ninth in the nation in terms of hospitals with computerized practitioner order entry (87.0%). It provides funding for quality improvement within the EMS system and has a funded state EMS medical director, demonstrating a strong commitment to quality improvement and system oversight.

Although Hawaii has numerous challenges related to Access to Emergency Care, the state ranks among the five best states for the proportion of adults (91.0%) and children (95.9%) with health insurance. Rates of underinsurance for both adults and children are also well below the national average.

Challenges.Hawaii's poor grade in Access to Emergency Care is primarily due to a lack of adequate hospital capacity, which can lead to dire outcomes. The closure of two hospitals in 2011 could be a contributing factor to a sharp need for beds and treatment centers, and Hawaii's isolated geography keeps its people from taking advantage of facilities in other states. Hawaii has one of the highest per capita rates of emergency physicians but few emergency departments (ED; 9.3 per 1 million people). Its hospitals are nearly at capacity, with the second highest hospital occupancy rate in the nation (77.1 per 100 staffed beds) and low numbers of staffed inpatient beds overall (231.9 per 1 million people), which contributes to long waits in the ED (330 minutes from ED arrival to departure). Other contributing factors to Hawaii's poor grade include low Medicaid reimbursement rates and shortages in some specialties, such as neurosurgeons and ear, nose, and throat specialists.

Hawaii's infrastructure problem is echoed by challenges in Disaster Preparedness. The state has no verified burn centers and low numbers of burn unit beds (2.2 per 1 million people), the lowest per capita rate of intensive care unit (ICU) beds in the nation (117.8 per 1 million), and the second lowest bed surge capacity (229.8 beds per 1 million). These infrastructure issues will greatly hamper Hawaii's ability to respond to a large-scale disaster or mass casualty event.

Hawaii's subpar grade for its Medical Liability Environment is aided by relatively low numbers of malpractice award payments (1.5 per 100,000 people) and average medical liability insurance premiums for primary care physicians ($10,432) and specialists ($44,860). Offsetting these relative advantages are few protections for the state's health care workforce and the highest average malpractice award payments in the nation ($681,839).


Hawaii has high rates of insurance and plenty of doctors overall, but gaps in hospital and treatment facility capacity are highly problematic and lead to overcrowding, long waits in the ED, and poor overall Access to Emergency Care. Increasing the availability of medical facilities, ICU beds, burn beds, EDs, and inpatient beds would go a long way toward improving the state's access to emergency medical care and increase its ability to respond to large-scale disasters.

Hawaii should consider adopting medical liability reforms such as reducing the medical liability cap on non-economic damages to $250,000, requiring awards to be offset by collateral sources, and requiring periodic payments of malpractice awards. These reforms can reduce the incidence of defensive medicine and encourage more specialists to provide on-call services to emergency patients. Additionally, Hawaii should implement expert witness rules requiring case certification; ensure that expert witnesses are of the same specialty as the defendant; and institute liability protections for care mandated by the Emergency Medical Treatment and Labor Act, which requires emergency care providers to perform life-saving procedures without a pre-existing patient relationship and little to no knowledge of a patient's medical history.

Access to Emergency Care

Title 2009
Report Card
Report Card
Board-certified emergency physicians per 100,000 pop 13.9 15.7
Emergency physicians per 100,000 pop 15.3 16.7
Neurosurgeons per 100,000 pop 1.5 1.1
Orthopedists and hand surgeon specialists per 100,000 pop 9.5 9.8
Plastic surgeons per 100,000 pop 2.3 1.9
ENT specialists per 100,000 pop 3.2 2.9
Registered nurses per 100,000 pop 752.4 740.9
Percent of children able to see provider 96.2
Level I or II trauma centers per 1M pop 0.8 0.7
Percent of population within 60 minutes of Level I or II trauma center 70.4 61.7
Accredited chest pain centers per 1M pop 0.0 0.0
Percent of population with an unmet need for substance abuse treatment 7.2 9.9
Pediatric specialty centers per 1M pop 1.6 0.7
Medicaid fee levels for office visits as a percent of the national average 97.7 79.4
Percent change in Medicaid fees for office visits (2004-05 to 2007/2007 to 2012) -48 0.0
Percent of adults with no health insurance 9.6 9.0
Percent of adults underinsured 6.3
Percent of children with no health insurance 6.3 4.1
Percent of children underinsured 13.3
Percent of adults with Medicaid 7.0 12.5
Hospital closures in 2006/2011 0 2
Staffed inpatient beds per 100,000 pop 290.2 231.9
Hospital occupancy rate per 100 staffed beds 79.7 77.1
Psychiatric care beds per 100,000 pop 31.7 24.6
Median time from ED arrival to ED departure for admitted ED patients 330
State collects data on diversion YES YES

Disaster Preparedness

Title 2009
Report Card
Report Card
Per capita federal disaster preparedness funds $16.47 $9.38
State budget line item health care surge NO
ESF-8 plan is shared with all EMS and essential hospital personnel NR STATE DOES NOT HAVE ESF-8 PLAN
Emergency physician input into the state planning process YES, YES YES
Public health and emergency physician input during an ESF-8 response YES
Drills, exercises conducted involving hospital personnel, equipment, or facilities per hospital
Accredited by the Emergency Management Accreditation Program (EMAP) NO NO
Special needs patients included in medical response plan NO NO
Patients dependent on medication for chronic conditions in medical response plan NO NO
Medical response plan for supplying dialysis NO NO
Mental health patients included in medical response plan NO
Medical response plan for supplying psychotropic medications NO
Mutual aid agreements in place with behavioral health providers STATE LEVEL
State requires long-term care and nursing home facilities to have a written disaster plan YES
State able to report number of exercises involving long-term care facilities or nursing YES
Just-in-time training systems in place STATEWIDE STATEWIDE
Statewide medical communication system with one layer of redundancy YES YES
Statewide patient tracking system YES YES
Statewide real-time or near real-time syndromic surveillance system YES YES
Real-time surveillance system in place for common ED presentations YES NO
Bed surge capacity per 1M pop 272.7 229.8
ICU beds per 1M pop 188.5 117.8
Burn unit beds per 1M pop 2.3 2.2
Verified burn centers per 1M pop 0.0 0.0
Physicians registered in ESAR-VHP per 1M pop 46.8 25.1
Nurses registered in ESAR-VHP per 1M pop 163.6 185.3
Behavioral health professionals registered in ESAR-VHP per 1M pop 14.4
Strike teams or medical assistance teams YES YES
Disaster training required for essential hospital/EMS personnel YES, YES NO
Percent of RNs that received emergency training 40.2 41.1

Medical Liability Environment

Title 2009
Report Card
Report Card
Lawyers per 10,000 pop 16.6 12.2
Lawyers per physician 0.5 0.4
Lawyers per emergency physician 10.8 7.3
ATRA judicial hellholes (2009 range 0 to -7/2014 range 2 to -6) 0 0
Malpractice award payments per 100,000 pop 3.1 1.5
Average malpractice award payments $246,221 $681,839
National Practitioner Databank reports per 1,000 physicians 10.0 12.0
Apology laws: Apology is inadmissible as evidence in a court of law YES
State has implemented a patient compensation fund NO NO
Number of insurers writing medical liability policies per 1,000 physicians 9.8 13.4
Average medical liability insurance premiums for primary care physicians $10,284 $10,432
Average medical liability insurance premiums for specialists $49,348 $44,860
Presence of pretrial screening panels MANDATORY MANDATORY
Pretrial screening panel's findings admissible as evidence NO NO
Periodic payments are: required, granted upon request, at court's discretion NO NO
Medical liability cap on non-economic damages $350,001-500,000 $350,001-500,000
Additional liability protection for EMTALA-mandated emergency care NO NO
Joint and several liability abolished YES PARTIALLY
Collateral Source Rule/Provides for Awards to be Offset NO
State provides for case certification NO NO
Expert witness required to be of the same specialty as the defendant NO NO
Expert witness must be licensed to practice medicine in the state NO NO

Public Health & Injury Prevention

Title 2009
Report Card
Report Card
Bicyclist fatalities per 100,000 cyclists 2.5
Pedestrian fatalities per 100,000 pedestrians 3.5
Percent of traffic fatalities alcohol-related 52.0 50.0
Percent of front occupants using restraints 97.6 96.0
Child safety seat/seat belt legislation - score out of a possible 10 points 7 8
Helmet use required for all motorcylce riders NO NO
Distracted driving legislation score - out of a possible 4 points 4
Graduated drivers' licenses legislation score -out of a possible 5 points 0
Percentage of children aged 19-35 months who are immunized 80.1 80.7
Percentage of adults aged 65+ who rec’d an influenza vaccine in the last 12 mos 75.7 64.7
Percentage of adults aged 65+ who ever rec’d pneumococcal vaccine 68.8 67.7
Fatal occupational injuries per 1M workers 36.3 35.5
Homicides and suicides (non-motor vehicle)(per 100,000) 10.4 14.6
Unintentional fall-related fatal injuries (per 100,000) 7.8 7.1
Fire/burn related fatal injuries (per 100,000) 0.3 NR
Rate of unintentional firearm-related fatal injuries (per 100,000) 0.1 NR
Rate of unintentional poisoning-related deaths (per 100,000) 7.6
Total injury prevention funds per 1,000 persons $717.41 $961.64
Dedicated child injury prevention funding YES
Dedicate elderly injury prevention funding YES
Dedicated occupational injury prevention funding YES
Anti-smoking legislation score - score out of a possible 3 points 3
Infant mortality rate per 1,000 live births 6.5 6.2
Percentage of adults who binge drink 17.9 21.5
Percentage of adults who currently smoke 17.5 16.8
Percentage of adult population who are obese (BMI > 30.0) 20.6 21.9
Percentage of children who are obese 11.5
Cardiovascular disease disparity ratio 1.5
HIV diagnosis disparity ratio NR
Infant mortality disparity ratio 1.3

Quality & Patient Safety

Title 2009
Report Card
Report Card
Funding for quality improvement within the EMS system YES YES
Funded state EMS medical director YES YES
Emergency medicine residents per 1M pop 0.0 0.0
Adverse event reporting required NO NO
% of counties with Enhanced 911 capability 100.0 100.0
State has a uniform system for providing pre-arrival instructions NO YES
State uses CDC guidelines for state field triage protocols YES (2011)
State has or is working on a stroke system of care YES YES
State has triage and destination policy in place for stroke patients NO
State has or is working on a PCI network or a STEMI system of care YES YES
State has triage and destination policy in place for STEMI patients YES
State maintains statewide trauma registry NO YES
State has triage and destination policy in place for trauma patients YES
Prescription drug monitoring program score (range 0-4) 3
% of hospitals with computerized practitioner order entry 20.0 87.0
% of hospitals with electronic medical records 36.0 91.3
% of patients with AMI given PCI within 90 minutes of arrival 51 88
Median time to transfer to another facility for acute coronary intervention 219
% of patients with AMI who received aspirin within 24 hours 99
% of hospitals collecting data on race/ethnicity and primary language 50.0
% of hospitals with or planning to develop a diversity strategy or plan 42.9

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