ANNUAL REPORT
FISCAL YEAR 2016

Vision & Mission Statements
The Arizona State Hospital (ASH) is part of the Arizona Department of Health Services (ADHS).
The Department of Health Services has the following Vision and Mission Statements:
•
•

Vision: Health and Wellness for all Arizonans
Mission: To promote, protect, and improve the health and wellness of individuals and
communities in Arizona.

The Arizona State Hospital has the following Vision and Mission Statements:
•
•

Vision: Quality, Compassion, and Excellence in the Provision of Psychiatric Care
Mission: Provide evidence-based, recovery-oriented, and trauma-informed care to the
individuals receiving care at Arizona State Hospital in order to facilitate their successful
transition to the least restrictive alternative possible.

Description of the Arizona State Hospital (ASH)
The Arizona State Hospital (ASH) is located on a 93 acre campus at 24th Street and Van Buren, in
Phoenix, Arizona. ASH provides long-term inpatient psychiatric care to Arizonans with mental
illnesses who are under court order for treatment. The hospital operates programs within a
260-bed funded facility, is accredited by The Joint Commission, and the Civil Hospital is certified
to receive reimbursement from the Centers for Medicare and Medicaid Services (CMS). Also
located on the campus is the Arizona Community Protection and Treatment Center (ACPTC).
The ACPTC is a 100-bed funded facility that provides care, supervision and treatment for those
persons court-ordered into the program as sexually violent persons.
Pursuant to A.R.S. § 36-201 through 36-217, ASH provides inpatient care and treatment to
patients with mental disorders, personality disorders or emotional conditions. ASH protects the
rights and privileges of each patient, including the patients’ rights to confidentiality and privacy.
Treatment at ASH is considered “the highest and most restrictive” level of care in the state.
Patients are admitted as a result of an inability to be treated in a community facility or due to
their legal status. Hospital personnel provide state-of-the-art inpatient psychiatric care and are
committed to treating patients and personnel with dignity and respect. Interdisciplinary care is
delivered in collaboration with the patient, family, legal representatives and community
providers with a focus on recovery and community reintegration.

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Leadership
Leadership is the key to developing and maintaining a culture of change. New ideas and
perspectives are important in creating an environment for change. Overall governance for ASH
is provided by the ASH Governing Body. The Director of ADHS chairs the Governing Body
committee. The Governing Body consists of the Director of ADHS, a representative from the
ADHS Central Budget Office, an ASH Physician, Community Representatives (including family
members and consumer representatives), the ASH Chief Executive Officer (“Superintendent”),
the ASH Chief Medical Officer, a Consumer Advocate (Legal System), and a Mental Health
Provider (Psychiatrist or Psychologist).
ASH receives overall direction from the Chief Executive Officer, who reports to the Director of
ADHS. The CEO directs the various leaders of ASH, who comprise the Executive Management
Team (EMT). The Executive Management Team oversees hospital operations, establishes
administrative policies and procedures and directs ASH planning activities. Starting in August
2016, the ADHS Director designated the ADHS Chief Financial Officer (CFO) as an interim CFO at
ASH, until filling the CFO position on a permanent basis. The addition of the CFO position at the
Hospital allows ASH the opportunity to closely monitor and manage its budget to meet the
Hospital’s specific operational needs. The members of EMT are:
•
•
•
•
•
•
•
•
•
•

Aaron Bowen, Psy.D., Chief Executive Officer
Steven Dingle, M.S, M.D., Chief Medical Officer
Ryan Hoffmeyer, M.B.A, Chief Operating Officer
Debra Taylor, M.S.N., R.N., Chief Nursing Officer
Lisa Wynn, B.S., Chief Quality Officer
Margaret McLaughlin, M.S., Chief Compliance Officer
Shanda Payne, L.M.S.W, ACPTC Director
Levada Coker, C.P.M., Human Resources Assistant Chief
William Bugbee, Chief Security Officer
Justin Lepley, C.P.M., M.B.A., Chief Financial Officer

The Chief Medical Officer (CMO) is responsible for the clinical administration of the hospital
pursuant to A.R.S. § 36-205, and directly manages psychiatric providers; contracted medical
providers, laboratory services, and pharmacy services; psychology, social work, and
rehabilitation services, such as occupational therapy, recreational therapy and psychosocial
rehabilitation.
The Chief Operating Officer (COO) is responsible for managing financial and administrative
support services, facilities management, dietary services, managing the environment of care,
promoting the wellness and safety of the patients and staff and management of environmental
and housekeeping services.
The Chief Nursing Officer (CNO) oversees and assures the provision of quality psychiatric and
medical nursing services for patients and coordination of nursing care based on individual
patient needs. In addition, the CNO oversees the Hospital’s Training and Education Department
and the Specialty Clinic, which includes infection control, employee health, contracted dental
services, patient transportation services, and contracted podiatry services.
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The Chief Quality Officer (CQO) is responsible for maintaining the hospital-wide quality
management program including: quality assurance and performance improvement activities,
data analytics, and incident reporting.
The Chief Compliance Officer (CCO) is responsible for monitoring hospital-wide compliance
with the Centers for Medicaid and Medicare (CMS) Services regulations, Arizona State Rules
and The Joint Commission accreditation standards; development of policies and procedures;
managing patient complaints, grievances and appeals; and overseeing the ASH health records
department.
The Director of ACPTC is responsible for managing the day-to-day clinical and administrative
operations for the Sexually Violent Persons Program.
The Human Resources Assistant Chief is responsible for compensation and benefits, employee
relations, recruitment and retention, and employee-related special investigations.
The Chief Security Officer (CSO) is responsible for overall monitoring and safety duties of the
hospital.
The Chief Financial Officer (CFO) is responsible for tracking the Hospital’s budget and
coordinating with program areas to monitor and manage the budget within those respective
areas.

Personnel
Leadership at ASH and ACPTC continue to closely monitor the established agency head count,
recruitment efforts for approved positions, and staff turnover. Data on Full-Time Employees
(FTEs) for fiscal year 2016 is presented below. This information was taken from the last payroll
record of each month for the entire fiscal year. Employee turnover per month is also provided
below.

Full-Time Employee Count
680
660
640
620
600
580

645

652

673

675

672

672

669

666

661

644

635

611

560

Page | 3

Staff Turnover
30
25
20
15
25
10

17

16

5

10
5

7

10

16

18

20

19

9

0

Hospital Program Overview
ASH has three (3) separately licensed facilities: The Civil Hospital, Forensic Hospital and the
ACPTC. Civil adult patients are involuntarily court ordered to ASH if they have not responded to
a minimum of 25 days in a community hospital setting. Forensic patients are court-ordered for
pre- or post-trial treatment as a result of involvement with the criminal justice system due to a
mental health issue. ASH has three Population-Based Programs. Patients are housed separately
in accordance with legal, treatment and/or security issues.
The Civil Adult Rehabilitation Program (116 beds) consists of six (6) treatment units specializing
in providing services to adults who are civilly committed as a danger to self, danger to others,
gravely disabled and/or persistently and acutely disabled, who have completed a mandatory 25
days of treatment in a community inpatient setting prior to admission. Medical beds are also
available.
The Forensic Adult Program (143 beds) consists of court-ordered commitments through a
criminal process for either:
•

Pre-Trial Restoration to Competence Program (“RTC”): These patients are currently
housed on one unit providing pre-trial evaluation, treatment, and restoration to
competency to stand trial.

•

Post-Trial Forensic Program: These patients are adjudicated as Guilty Except Insane
(“GEI”) serving determinate sentences under the jurisdiction of the Psychiatric Security
Review Board (PSRB), or for those adjudicated prior to 1994 as Not Guilty by Reason of
Insanity (“NGRI”). These patients are currently housed on six separate units.
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Arizona Community Protection and Treatment Center (ACPTC) (100 beds)
The Arizona Community Protection and Treatment Center (ACPTC) is located on the same
grounds as ASH. The ACPTC is a statutorily mandated program (ARS §36-3701 - §36-3717). It is
a separately licensed facility under Arizona Administrative Code (A.A.C.) Title 9, Chapter 10,
Article 13, Behavioral Health Specialized Transitional Facility, and the ASH CEO is responsible for
the oversight and management of the facility. ACPTC provides care, supervision and treatment
for those persons court-ordered into the program while protecting the community from
sexually violent offenders. There are several types of residents at ACPTC:
•

Pre-Trial Detainee Residents: Pre-trial residents are awaiting a court decision to
determine their sexually violent person (SVP) status.

•

Treatment Resident (Full Confinement): Residents in this program have been
adjudicated as SVP pursuant to A.R.S. §36-3701-3717 and have been committed to
treatment. Full confinement residents can only leave the grounds for court-ordered
legal proceedings and medical appointments during this phase of treatment.

•

Less Restrictive Alternative (LRA): "Less restrictive alternative" means court ordered
treatment in a setting that is less restrictive than total confinement and that is
conducted in a setting approved by the CEO of ASH. LRA residents are conditionally
released to begin community reintegration activities. Residents in LRA are monitored
via Global Position System (GPS) satellite.

•

LRA Level 6 Resident: Residents are ready for community living placement. Only the
court can order a resident to Level 6 status. Once the court orders a resident into
Community Based Living (LRA Level 6), the resident is expected to find suitable housing
and employment and begin community reintegration under strict supervision by ACPTC.

Admission, Discharge, & Census Data for Treatment Programs
The table below includes the total admissions and discharges per program for ASH and ACPTC
during fiscal year 2016.
Type
Civil
Forensic (RTC)
Forensic (GEI)
Forensic (GEI-75)
Forensic (NGRI)
ACPTC (Pre-Trial)
ACPTC (Treatment)
ACPTC (LRA)

Admissions and Discharges - FY 2016
Admissions
40
10
13
8
2
10
3
0

Discharges
29
13
17
6
3
3
1
0

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ASH collects census data by population to meet the maximum funded capacity. For fiscal year
2016, the funded capacity and allocation of ASH beds was as follows. The funded capacity of
fiscal year 2015 was the same (260 beds).
Funded Hospital Capacity - FY 2016

Type
Total Hospital Beds
Forensic (Adult)
Civil (Adult)
Civil (Medical bed for Infection Control)

Type
Total ACPTC Beds

Funded ACPTC Capacity - FY 2016

Number
260
143 (58% )
116 (42%)
1

Number
100

The average daily census distribution for ASH and ACPTC for FY 2016 were as follows:
Type
Civil
Forensic (RTC)
Forensic (GEI)
Forensic (GEI-75)
Forensic (NGRI)

Average Daily Hospital Census and Distribution - FY 2016

Average Daily ACPTC Census and Distribution - FY 2016

Type
ACPTC (Pre-Trial)
ACPTC (Treatment – Full Confinement)
ACPTC (Least Restrictive Alternative)

Number
111
4
100
2
12

Number
8
16
75

Hospital-wide Operational & Environmental Improvements
ASH is continuously striving to create a safe and secure environment of care for the patients
and staff alike, as well as providing more technology to assist staff in the delivery of care. The
following are improvements for the past year:
•

ASH has continued to enhance its Electronic Health Record (Electronic Health Record).
Enhancements to the EHR over the past fiscal year have allowed ASH the opportunity to
collect data and run automated reports. Such reports include medication utilization,
which allows for effective monitoring of prescription narcotics. Enhancements to the
EHR also include new assessments for Social Work and Nutrition Services, and
improvements were made to many other screens to improve the user experience and
reporting capabilities across the patient care continuum. In addition, users have logged
the following statistics while using the EHR:
o Unique Patients Served – 390
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o Electronic Medication Administration Record (EMAR) Administrations –
1,500,287
o New Orders Created – 54,082
o Progress Notes Finalized – 167,980
o Total Assessments Finalized – 35,145
o Number of Time Vital Signs Taken – 92,008
o Number of Appointments Scheduled (entered) – 9,768
•

Patient Stand-Alone Computers (no internet access) were upgraded with current
Microsoft products. Hardware for patients was also upgraded and new printers were
provided for patient use.

•

Patient internet was introduced to the forensic patients on the Community
Reintegration Unit, so patients can log on to the internet on patient computers with
controlled internet access.

•

In order to provide redundancy and to ensure uninterrupted patient care, a Desktop PC
was added to each nursing care area for continued documentation capability in the
event of an interruption of the virtual network. Previously, only VDI terminals were in
the nursing areas.

•

Wireless capabilities were expanded to the last area of the ASH campus.

•

The campus power plant received a new heat condenser system that will replace the
existing duel boiler system that had reached their end of life. The project will produce
hot water for ASH and the Department of Corrections heating needs in a more efficient
and cost effective manner.

•

Phase III of the fire safety project was initiated, and efforts continue on improvements
to the the hospital-wide fire and smoke detection and suppression system.

•

An upgrade of the Quality Management System (QMS) was implemented to enhance
and streamline the electronic reporting of incident reports. These enhancements create
efficiencies for staff who are documenting incidents and the Executive Risk
Management Team, who review the reports daily for quality improvement
opportunities.

•

Efforts to increase patient enrollments for Medicare eligible patients in Medicare Part D
were initiated (the hospital is currently billing Medicare Part D for 24 patients, but
working on enrollment for total of 80 patients).

Hospital-wide Condition of Existing Equipment
ASH continued to monitor the power plant equipment for performance and efficiency and
outlined the needs in the capital equipment needs in the 2018 Capital Improvement Plan
report. This report focuses on the equipment that is coming closer to end of life and will need
attention in the near future:
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•

Power Plant Controls and pumps – the Central Power Plant continuously provides the
hospital buildings with hydronic heating and cooling capabilities.

•

Chiller replacements – the power plant is also in need of two replacement chillers to
provide a reliable source of cooling capacity that will adequately meet demands during
the summer months.

•

Cooling Towers – the addition of two new cooling towers will assist the power plant and
the cooling system in a more energy efficient process that will also provide ASH with
additional cooling capacity in warmer temperatures.

•

Repair/replace and calibrate all Direct Digital Control (DDC) controllers in the Civil
Hospital. This is needed to capture true energy savings after central plant upgrade
(many of these controllers are not supported by Control Engineering anymore).

•

Upgrade external lighting system in parking lots, mall and yard areas.

•

Upgrade or replace the HVAC system or control system at General Services. The current
system is unable to control the space zone temperatures in the building that houses
pharmacy and medical records.

Initiatives
In conjunction with other state agencies, ASH has been implementing the Arizona Management
System (AMS) in accordance with the direction and guidance of the Governor’s Office. ASH and
ADHS leadership have identified key issues with measurable goals for the Hospital, so ASH can
effectively evaluate and provide a visual depiction of progress in meeting those goals. ASH has
the following metrics that are reported on the ADHS scorecard:
ASH Metric

Corresponding ADHS Strategic Initiative

Performance Metric Title

Promote and Support Public
Health and Safety: Implement
Strategies to Promote
Nonviolent Behavior

Rate of Assaults per 1000
patient days
Percent of Staff with
Nonviolent Crisis
Intervention (NVCI)
Training
Percent of Items in
Compliance During
Performance Audits

Maximize Agency
Effectiveness: Support State
Hospital in Achieving
Outcomes






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In addition to the ADHS scorecard, ASH has a separate scorecard to track the following metrics:
ASH Metric

Corresponding ADHS Strategic Initiative

Performance
Metric Title

Promote and
Support Public
Health and
Safety:
Implement
Strategies to
Promote
Nonviolent
Behavior

Rate of Assaults
per 1000 Patient
Days
Percent of Items
in Compliance
During
Performance
Audits
Rate of Seclusion
& Restraint
Events per 1000
patient days on
the Civil Campus
Percent of Staff
with NVCI
Training
Number of
Employees
Leaving Job
Within the First 6
Months of
Employment
Medication
Variances that
result in an
adverse outcome
to the patient
Staffing that
meets the Acuity
Needs of the
Patients
Percent of Staff
with CPR Training

Maximize
Agency
Effectiveness:
Support State
Hospital in
Achieving
Outcomes

Make Focused
Improvements in
Public Health
Infrastructure:
Enhance
Workforce
Development

Maximize
Agency
Effectiveness:
Implement
Performance
Measures

















Page | 10

ASH Metric

Corresponding ADHS Strategic Initiative

Performance
Metric Title

Promote and
Support Public
Health and
Safety:
Implement
Strategies to
Promote
Nonviolent
Behavior

Number of
Patient
Complaints
Number of
Clinical Service
Hours
# of Agency FTE
Count
% of Arizona
Management
System Adoption
(metric is
pending)
# of Regrettable
Attrition
# of
Breakthroughs
Achieved

Maximize
Agency
Effectiveness:
Support State
Hospital in
Achieving
Outcomes

Make Focused
Improvements in
Public Health
Infrastructure:
Enhance
Workforce
Development

Maximize
Agency
Effectiveness:
Implement
Performance
Measures











ASH is continuing to implement AMS and anticipates enhancements to already developed
metrics through FY2017.

Promoting Quality Care
In concert with the implementation of the Arizona Management System (AMS), ASH continues
to focus on quality care for patients and residents of ACPTC. Activities include the continuous
review and evaluation of performance indicators, key metrics on the ADHS and ASH scorecards,
and presenting data/information to staff at ASH and ACPTC. ASH and ACPTC continue to refine
major processes with a focus on Recovery based treatment:
•

Further revising the roles and responsibilities of security staff at ASH and ACTPTC.
“Campus Support and Safety” has been renamed “Hospital Security” to focus on
ensuring a safe environment for staff, patients and visitors alike. Hospital security
provides additional support to unit staff by conducting rounds through the units and
being present on the units when staff are addressing escalating situations that could
lead to a behavioral crisis.
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•

Continuing to Improve the Patient and Family Experience by continuing to support
processes that include patient voice, choice and self-advocacy, and promoting healing
and trusting relationships. Family members provide feedback on services and are
provided with education on specific topics related to mental health. Patients are
members of certain ASH committees including the Human Rights Committee (HRC).
Patient forums are also held at the Forensic Hospital, Civil Hospital and ACPTC on a
quarterly basis. The forums are utilized to hear patient concerns, address progress in
addressing patient concerns, and to provide a venue for direct dialogue between
patients and hospital administration/leadership.

•

Addressing assaultive behavior by reviewing incidents, evaluating data trends, and
involving staff at all levels in creating solutions to identified issues. A number of
activities have been implemented as part of these efforts, such as the following:
o Clinical Intervention: The treatment team meets daily to review behavioral,
environmental, and pharmalogical interventions, including behavior plans,
medication adjustments, rehabilitation events, staffing assignments, and other
clinical wrap around services. The goal is to decrease the patient's symptoms and
increase their positive affect.
o Behavioral Plan: For individuals that exhibit repetitive self-harming and
assaultive behaviors, an individual behavioral plan may be implemented by the
clinical team to decrease the patient's maladaptive behaviors and to increase
adaptive behaviors.
o Nursing Care Plan (NCP): The NCP format gives prompts for inclusion of triggers,
comfort measures, de-escalation measures and prevention measures. Psychiatric
Nurse Unit Manager's and the Mental Health Program Specialist staff have
addressed the care plan process, implementation of the process, and control of
the milieu resulting in a mutual respect for all team members and their
skill/knowledge related to the individual patient and the group dynamics.
o Refined NVCI Training: Training and Education has revised the NVCI training with
more emphasis on prevention techniques. Staff have refined the 8 hour training
to emphasize prevention and safety first and physical intervention last. Annual
training hours were reduced.
o Review of Standard Work: Incident report reviews are completed by the
Performance Improvement team for all events involving a code gray, a seclusion
or restraint, or an assault. These reviews occur on the day of event, or the next
business day post event. During these reviews, the following items are
examined: root cause analysis of the situation, method of de-escalation,
outcome of the situation, and whether staff followed their standard work (NonViolent Crisis Intervention Policy). Information from the reviews are provided to
the clinical team to use during clinical case conferences. If the review finds that
the employee did not follow their standard work, the employee is provided
additional training, and as necessary, referred to HR.
o Increased staffing for acuity: An assaultive individual may be put on one to one
supervision (COS) to ensure safety. The Nursing Care Plan ensures that nursing
interventions are readily accessible and easily understood. All patients on COS
Page | 12

o
o
o

o

or who have tendencies to be assaultive to others should have specific
interventions addressed on the Nursing Care Plan. Interventions and patient's
response are documented.
Increasing staff for security: Security staffing's goal is to fill all 85 approved FTEs.
Policy and procedure review: The administration will continue to look at policies
and procedures to see if revisions are necessary.
Supportive Milieu Interventions: The Department of Psychology has been
tasked with the responsibility to complete surveys of the individual milieus in
which the outlying patients reside to determine what social factors could be
contributing to the assaultive behaviors of these patients. As findings arise, the
Psychology team is working with unit based teams to create interventions to
decrease or mitigate the precipitating factor.
Adjustments to Action Plan: The Executive Management Team (EMT) discusses
individual cases and aggregate data each week during the EMT meeting in order
to discuss any changes to the plan that need to be implemented.

Commitment to Quality Care
Quality care must be sustained on an ongoing basis. Quality requires analyzing what works and
what could be done better on a daily basis. It also requires identifying areas for improvement.
The Quality Management department presents data to committees and leadership for
discussion of findings and program improvement.
ASH collects data on a monthly basis for seclusion, restraint, “Code Gray,” assaults, self-harm
and falls. The data is used to measure progress and identify quality improvement activities.
ASH also compares its data with other Western Psychiatric State Hospitals (WPSHA). Below is
the fiscal year 2016 summary data for the Civil and Forensic hospitals:
Civil Summary - FY16
Mon

Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Total

Seclusion

Mechanical Restraint

Physical Holds

Code Gray

Patient on Patient Assault

Patient on Staff Assault

Patient Self-Harm

Falls Unwitnessed

4
11
10
7
4
4
9
6
8
16
12
3
94

28
29
43
25
26
21
21
13
16
25
9
9
265

41
80
63
65
22
38
47
28
44
47
37
27
539

41
80
63
65
22
38
46
44
46
51
58
47
601

12
19
14
14
4
12
14
9
25
19
29
19
190

16
24
16
26
7
11
15
11
22
28
33
16
225

23
51
36
53
17
19
24
15
43
45
28
33
387

3
6
1
3
1
4
4
2
6
3
9
1
43

Page | 13

Forensic Summary - FY16
Mon

Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Total

Seclusion

Mechanical Restraint

Physical Holds

Code Gray

Patient on Patient Assault

Patient on Staff Assault

Patient Self-Harm

Falls Unwitnessed

0
2
1
1
3
4
1
1
7
1
0
0
21

1
0
5
1
0
0
0
0
3
1
0
0
11

2
2
5
6
1
6
1
0
4
1
0
0
28

2
7
8
7
1
4
1
4
10
3
4
5
56

1
2
0
2
2
2
0
3
2
2
0
3
19

1
4
3
7
2
1
2
3
3
3
0
1
30

1
3
5
4
2
2
1
0
0
1
0
3
22

2
3
1
3
1
3
2
1
3
4
3
0
26

Seclusion:
• There were a total of 115 seclusion episodes with a total of 178 hours and 41 minutes.
• For the Civil Hospital, there were 25 unique patients with a seclusion episode equating
to 21.7% of the patients secluded.
• For the Forensic Hospital, there were 7 unique patients with a seclusion episode
equating to 6.0% of the patients secluded.
Restraint:
• There were a total of 827 restraint episodes, 551 physical holds and 276 mechanical
restraints. This resulted in a total of 900 hours and 48 minutes for ASH; 879 hours and
51 minutes for Civil and 20 hours and 57 minutes for Forensic.
• For the Civil Hospital, there were 83 unique patients with a restraint episode.
o Physical Hold Restraint: 52 unique patients, 62.7%
o Mechanical Restraint: 31 unique patients, 37.3%
Physical and Mechanical Restraints combined had a total of 83 unique patients, which
means that each unique patient accounted for under the Mechanical Restraints was also
accounted for under the Physical Restraints.
• For the Forensic Hospital, there were 10 unique patients with a restraint episode .
o Physical Hold Restraint: 7 unique patients, 70%
o Mechanical Restraint 3 unique patients, 30%
• Physical Hold and Mechanical Restraints combined had a total of 10 unique patients,
which means that each unique patient accounted for under the Mechanical Restraints
was also accounted for under the Physical Hold Restraint analysis.
Regarding comparison to the WPSHA partners, ASH’s seclusion rate fared as follows:
Per 1000 patient days, ASH has the 3rd lowest rate of the WPSHA hospitals with 24 hospitals
participating. Regarding comparison to the WPSHA partners, ASH’s restraint rate fared as
follows: Per 1000 patient days, ASH has the 11th lowest rate of the WPSHA hospitals with 24
hospitals participating.

Page | 14

Assault:
• There were a total of 464 assaults, 209 Patient on Patient assaults and 255 Patient on
Staff Assaults.
• For the Civil Hospital, there were 58 unique patients that committed 415 assaults. Of
the 415 assaults, 66 required first aid or medical treatment and 349 resulted in no
injury or required treatment.
o Patient on Patient Assaults: 40 unique patients, 69%
o Patient on Staff Assaults: 18 unique patients, 31%
• For the Forensic Hospital, there were 15 unique patients that committed 49 assaults. Of
the 49 assaults, 12 required first aid or medical treatment and 37 resulted in no injury
or required treatment.
o Patient on Patient Assaults: 11 unique patients, 73%
o Patient on Staff Assaults: 4 unique patients, 27%
Regarding comparison to the WPSHA partners, ASH’s assault rate fared as follows:
Per 1000 patient days, ASH has the 17th lowest rate of the WPSHA hospitals with 24 hospitals
participating.
Self-Harm:
• There were a total of 409 Self-Harm incidents. Of the 409 Self-Harm incidents, 106
required first aid or medical treatment and 303 resulted in no injury or required
treatment.
o Civil Hospital: 387 Patient Self-Harm Incidents, 95%
o Forensic Hospital: 22 Patient Self-Harm Incidents, 5%
ASH is not able to compare rates of self-harm with other participating WPSHA hospitals, as this
data is not collected for all WPSHA hospitals and reported in a similar manner as the other data
categories.
Falls Unwitnessed:
• There were a total of 69 incidents of patient falls. Of the 69 patient fall incidents, 15
required first aid or medical treatment and 54 resulted in no injury or required
treatment.
o Civil Hospital: 43 incidents of patient falls, 62%
o Forensic Hospital: 26 incidents of patient falls, 38%
Regarding comparison to the WPSHA partners, ASH’s falls rate fared as follows:
Per 1000 patient days, ASH has the 10th lowest rate of the WPSHA hospitals with 24 hospitals
participating.

Page | 15

Below is the fiscal year 2016 summary data for ACPTC, including seclusion, restraint, “Code
Gray,” assaults, self-harm and falls:
ACPTC Summary - FY16
Mon

Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Total

Seclusion

Mechanical Restraint

Physical Holds

Code Gray

Patient on Patient Assault

Patient on Staff Assault

Patient Self-Harm

Falls Unwitnessed

0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0

7
3
1
1
7
1
2
2
1
0
5
1
31

14
13
3
4
5
2
4
8
6
5
8
6
78

7
2
2
3
1
2
4
8
7
4
7
4
51

2
0
0
1
3
1
1
4
0
0
1
0
13

2
0
0
0
1
2
0
1
2
2
0
0
10

1
0
0
3
2
3
4
11
3
3
3
1
34

Page | 16

Hospital and ACPTC Budgets – Fiscal Year 2016 Financial Summary
Funding Sources (Appropriated and Non-appropriated)
General Fund
Arizona State Hospital Fund
Arizona State Hospital Land Fund
IGA/ISA Fund
Donations Fund
Total Funding

$59,643,803
$9,575,300
$650,000
$902,248
$170,000
$70,941,351

Expenditures
Personal Services and Related Benefits
Professional and Outside Services
In-State Travel
Out-of-State Travel
Other Operating
Capital Equipment
Non-Capital Equipment
Total Expenditures

$47,930,592
$12,096,891
$96,193
$4,620
$9,563,128
$119,206
$132,851
$69,943,481

Collections
Patient Care Collections to General Fund
Patient Care Collections to the Arizona State Hospital Fund - RTC
Patient Care Collections to the Arizona State Hospital Fund – Title XIX
Patient Care Collections to the Arizona State Hospital Fund–ACPTC
Non-Patient Care Collections to General Fund
Total Collections
Daily Costs by Treatment Program
ASH
Specialty Rehabilitation
Psychosocial Rehabilitation
Forensic – Restoration to Competency
Forensic Rehabilitation
Average

$1,033,844
$906,661
$1,325,991
$3,252,500
$3,499
$6,522,495
$926
$767
$743
$784
$805

Rates became effective 01/01/2016
ACPTC Less Restrictive Alternative (LRA) Levels 1-5
LRA 6
LRA 6 Community
Pre-Trial
Treatment
Medical Unit/Hospitalization

$284
$369
$206
$291
$291
$388

Rates became effective 07/01/2016

Page | 15