North Dakota

Category Grades
10C+ 8C+
Access to Emergency Care:
6B- 8C
Quality/Patient Safety:
31C- 36D+
Medical Liability:
14C+ 8B+
Public Health/ Injury Prevention:
30D+ 38D-
Disaster Preparedness:
5A 2A

North Dakota continues its solid performance, ranking eighth in the nation overall, improving with regard to Disaster Preparedness and its Medical Liability Environment. However, problems have worsened in Public Health and Injury Prevention, requiring that effective actions be taken to improve public health and safety.

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North Dakota continued to excel in Disaster Preparedness. The state has a budget line item for Disaster Preparedness funding specific to health care surge (one of 11 states to do so), as well as a patient-tracking system and a statewide medical communication system with one layer of redundancy. The state also has systems in place to address behavioral health concerns during a disaster, having incorporated mental health patients and patients dependent on psychotropic medications in its medical response plan and instituting mutual aid agreements with behavioral health providers to provide services during an event. The state also has the fifth highest number of behavioral health professionals registered in the Emergency System for Advance Registration for Volunteer Health Professionals (52.9 per 1 million people).

North Dakota's Medical Liability Environment has improved since 2009, primarily due to decreases in medical liability insurance premiums and an increase in the number of insurers writing policies. The average medical liability premiums for specialists is $25,510 (the fifth lowest in the nation) compared to $35,922 in the 2009 Report Card. North Dakota has maintained its medical liability cap on non-economic damages and has abolished joint and several liability.

North Dakota's grade in Access to Emergency Care reflects a mixture of positive and negative results. The state ranks among the top 10 with regard to health insurance for adults and children and has the lowest proportion of underinsured adults (4.6%). It has the fourth highest proportion of underinsured children, however, with 21.7% of parents of children with insurance reporting that their out-of-pocket costs were not reasonable. The state fares excellently regarding hospital capacity, with 514.3 staffed inpatient beds per 100,000 people and 37.2 emergency departments (ED) per 1 million people. ED wait times are third best in the nation, averaging 189 minutes from ED arrival to ED departure for admitted patients.


A few factors contributed to North Dakota's poor grade in regard to the Quality and Patient Safety Environment. The state lacks funding for both an emergency medical services (EMS) medical director and quality improvement of the EMS system. Additionally, North Dakota's hospitals are among the least likely to collect data on patients' race and ethnicity and primary language (28%), or have a diversity strategy or plan (18%).

North Dakota continues to falter with regard to Public Health and Injury Prevention. While the state has one of the lowest combined rates of homicides and suicides, it has the third highest rate of fatal occupational injuries (94.0 per 1 million workers) and 10th highest rate of fall-related deaths (12.3 per 100,000 people) in the nation. In addition, the state has only secondary enforcement of adult seatbelt laws applying to front seat occupants, despite having the fourth lowest proportion of front-seat occupants using seatbelts (76.7%). Nearly a quarter of adults in North Dakota binge-drink (23.8%), for which they rank third worst in the nation, and 45% of traffic fatalities are alcohol-related (rank: 47th).


North Dakota should take action to improve the public health and safety of its people. One way to do so would be to consider legislation aimed at reducing traffic fatalities, which are much higher than the national average (14.2 versus 9.0 per 100,000 people), including requiring helmets for all motorcycle riders, strengthening adult seatbelt laws through primary enforcement and requiring that seatbelts be used in all seats, and instituting an intermediate driver's license stage with nighttime driving restrictions and supervised practice driving hours. Additional health promotion efforts should be aimed at reducing cigarette smoking and binge drinking, the latter of which may contribute to the state's high rate of traffic fatalities that are alcohol-related.

North Dakota could also help to improve its Quality and Patient Safety Environment by funding an EMS medical director and encouraging hospitals to collect data on patients' race and ethnicity and primary language. This may be a first step in helping to address the relatively high cardiovascular disease and infant mortality disparity ratios in the state.

Access to Emergency Care

Title 2009
Report Card
Report Card
Board-certified emergency physicians per 100,000 pop 6.1 7.3
Emergency physicians per 100,000 pop 6.9 9.4
Neurosurgeons per 100,000 pop 1.9 2.1
Orthopedists and hand surgeon specialists per 100,000 pop 8.3 9
Plastic surgeons per 100,000 pop 1.9 2.4
ENT specialists per 100,000 pop 3 2.9
Registered nurses per 100,000 pop 1,098.1 1,308.5
Percent of children able to see provider 97.9
Level I or II trauma centers per 1M pop 9.4 8.6
Percent of population within 60 minutes of Level I or II trauma center 56.1 60.2
Accredited chest pain centers per 1M pop 0 0
Percent of population with an unmet need for substance abuse treatment 9.7 9.8
Pediatric specialty centers per 1M pop 11 10
Medicaid fee levels for office visits as a percent of the national average 120.1 193.6
Percent change in Medicaid fees for office visits (2004-05 to 2007/2007 to 2012) 3 98.2
Percent of adults with no health insurance 12.8 10.4
Percent of adults underinsured 4.6
Percent of children with no health insurance 10.3 4.7
Percent of children underinsured 21.7
Percent of adults with Medicaid 4.8 5
Hospital closures in 2006/2011 0 0
Staffed inpatient beds per 100,000 pop 618.5 514.3
Hospital occupancy rate per 100 staffed beds 61.3 62
Psychiatric care beds per 100,000 pop 48.5 23.3
Median time from ED arrival to ED departure for admitted ED patients 189
State collects data on diversion NO NO

Disaster Preparedness

Title 2009
Report Card
Report Card
Per capita federal disaster preparedness funds $21.51 $15.85
State budget line item health care surge YES
ESF-8 plan is shared with all EMS and essential hospital personnel YES YES
Emergency physician input into the state planning process YES, NO 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) YES, ACCREDITED NO
Special needs patients included in medical response plan YES YES
Patients dependent on medication for chronic conditions in medical response plan YES YES
Medical response plan for supplying dialysis NO YES
Mental health patients included in medical response plan YES
Medical response plan for supplying psychotropic medications YES
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 NO YES
Statewide real-time or near real-time syndromic surveillance system YES YES
Real-time surveillance system in place for common ED presentations YES YES, STATEWIDE
Bed surge capacity per 1M pop 789.4 1,223.5
ICU beds per 1M pop 434.5 350.2
Burn unit beds per 1M pop 0 0
Verified burn centers per 1M pop 0 0
Physicians registered in ESAR-VHP per 1M pop 73.5 11.4
Nurses registered in ESAR-VHP per 1M pop 636.2 497.4
Behavioral health professionals registered in ESAR-VHP per 1M pop 52.9
Strike teams or medical assistance teams YES YES
Disaster training required for essential hospital/EMS personnel YES, YES NR
Percent of RNs that received emergency training 44.8 45.7

Medical Liability Environment

Title 2009
Report Card
Report Card
Lawyers per 10,000 pop 9.3 9.9
Lawyers per physician 0.4 0.4
Lawyers per emergency physician 13.4 10.5
ATRA judicial hellholes (2009 range 0 to -7/2014 range 2 to -6) 0 0
Malpractice award payments per 100,000 pop 6.3 1.4
Average malpractice award payments $293,146 $320,688
National Practitioner Databank reports per 1,000 physicians 18.8 31.5
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 26.6 25.8
Average medical liability insurance premiums for primary care physicians $10,621 $7,330
Average medical liability insurance premiums for specialists $35,922 $25,510
Presence of pretrial screening panels NONE NO
Pretrial screening panel's findings admissible as evidence N/A N/A
Periodic payments are: required, granted upon request, at court's discretion AT JUDGE'S OR COURT'S DESCRETION AT COURT'S DESCRETION
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 YES
Collateral Source Rule/Provides for Awards to be Offset YES
State provides for case certification YES YES
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 1.6
Pedestrian fatalities per 100,000 pedestrians 2
Percent of traffic fatalities alcohol-related 45 45
Percent of front occupants using restraints 82.2 76.7
Child safety seat/seat belt legislation - score out of a possible 10 points 3 3
Helmet use required for all motorcylce riders NO NO
Distracted driving legislation score - out of a possible 4 points 2
Graduated drivers' licenses legislation score -out of a possible 5 points 0
Percentage of children aged 19-35 months who are immunized 82.8 84.1
Percentage of adults aged 65+ who rec’d an influenza vaccine in the last 12 mos 71.4 58
Percentage of adults aged 65+ who ever rec’d pneumococcal vaccine 69.4 70.1
Fatal occupational injuries per 1M workers 75.8 94
Homicides and suicides (non-motor vehicle)(per 100,000) 16.2 15.7
Unintentional fall-related fatal injuries (per 100,000) 11.8 12.3
Fire/burn related fatal injuries (per 100,000) 1.3 1
Rate of unintentional firearm-related fatal injuries (per 100,000) 0.2 0.2
Rate of unintentional poisoning-related deaths (per 100,000) 3.9
Total injury prevention funds per 1,000 persons $4,505.60 $3,422.30
Dedicated child injury prevention funding YES
Dedicate elderly injury prevention funding NO
Dedicated occupational injury prevention funding NO
Anti-smoking legislation score - score out of a possible 3 points 1
Infant mortality rate per 1,000 live births 6 6.8
Percentage of adults who binge drink 21.2 23.8
Percentage of adults who currently smoke 19.5 21.9
Percentage of adult population who are obese (BMI > 30.0) 25.4 27.8
Percentage of children who are obese 15.4
Cardiovascular disease disparity ratio 2.6
HIV diagnosis disparity ratio NR
Infant mortality disparity ratio 2.9

Quality & Patient Safety

Title 2009
Report Card
Report Card
Funding for quality improvement within the EMS system YES NO
Funded state EMS medical director NO NO
Emergency medicine residents per 1M pop 0 0
Adverse event reporting required NO NO
% of counties with Enhanced 911 capability 98.1 100
State has a uniform system for providing pre-arrival instructions YES 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 YES
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 YES 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 4.9 80
% of hospitals with electronic medical records 18 91.1
% of patients with AMI given PCI within 90 minutes of arrival 80 93
Median time to transfer to another facility for acute coronary intervention 68
% of patients with AMI who received aspirin within 24 hours 99
% of hospitals collecting data on race/ethnicity and primary language 28
% of hospitals with or planning to develop a diversity strategy or plan 18

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