August 16, 2019
FROM: Bryon E. “BJ” Coleman Jr. CEO, North Tampa Behavioral Hospital
TO: Neil Beedi, Investigative Reporter, Tampa Bay Times
Subject: North Tampa Behavioral Hospital Response to August 8th Email & Questions
Dear Neil,
Thank you for reaching out with questions regarding your planned story and affording North
Tampa Behavioral Hospital (NTBH) the opportunity to respond to your inquiries with
important facts and context about our facility, the patients we are honored to treat and the
overall realities, complexities and challenges of behavioral health care delivery and hospital
regulatory compliance processes in Florida and across the U.S.
As I mentioned at the outset of our email correspondence, state and federal patient privacy
laws and our own internal Code of Ethics significantly impedes our ability to offer detailed
comment on any specific patient encounter, clinical treatment decision or alleged incident
that could risk disclosing confidential and protected patient information. While journalists
and the patients themselves are not held to this same standard, please understand that in
many instances we are nonetheless prohibited from responding even in cases where the
information or allegations are factually untrue, misleading or incomplete.
Based on your limited number of questions and somewhat cryptic allegations (many
inaccurate) it appears your planned story angle and reporting style of highlighting and
extrapolating a very small number of non-representative incidents occurring over many
years has the potential to provide an incomplete and distorted portrayal of inpatient
psychiatric treatment in general and NTBH in particular. It is our hope that the below
information will provide an important perspective that will be objectively incorporated into
your story.
About NTBH: History, Leadership, Clinical Quality & Strong Patient Satisfaction:
Established in 2013, NTBH provides specialized, compassionate and evidence-based
inpatient and intensive outpatient behavioral health and substance use treatment services
to patients living with serious and complex conditions including major depression, anxiety,
bipolar, Post-Traumatic Stress Disorder (PTSD), suicidal ideation, schizophrenia, psychosis,
chemical dependency/addiction and other, often co-existing conditions requiring a
comprehensive individualized approach to care. Since our founding, NTBH and its dedicated
clinicians and support staff have provided high-quality care (both BH and substance use) to
nearly 17,000 patients encompassing 125,000+ total treatment days, and over 20,000 visits
to our various outpatient treatment programs.
Many of our patients arrive at NTBH experiencing some of the most profoundly challenging
periods of their lives, including being transferred (and in some cases turned away) from
other hospitals that are unable or unwilling to provide the specialized services offered at our
hospital. NTBH diverse patient population includes individuals from many socioeconomic
backgrounds and stages of life (e.g. young adult, adult, geriatric) with specialized programs
for specific patient groups such as military members and veterans.
1

 At all times since its founding, NTBH has been fully licensed and certified as a provider in
good standing with all state and federal regulatory and licensing authorities, including the
FL Agency For Health Care Administration (AHCA), FL Department of Children and Families
(DCF), U.S Department of Health and Human Services’ Center for Medicare and Medicaid
Services (CMS) and TriCare (DoD’s insurer). NTBH is accredited by The Joint Commission
(TJC), an independent non-profit organization with a 60-year record of conducting robust
accreditation and inspection services on behalf of the federal government.
Notwithstanding the large number of severe acuity (severity) patients treated over the past
6.5 years, NTBH’s rate of serious and severe level incidents is very low, comprising just
0.000597% of total patient treatment days. Nevertheless, all NTBH clinicians, support staff
and administrators understand that we have a solemn duty and moral responsibility to our
patients and their loved ones to provide the highest-level care possible while constantly
endeavoring to improve and innovate across all aspects of our operations.
To this end, we view patient satisfaction surveys as an important indicator and benchmark
of quality. Over the past 13 months based on the anonymous survey responses of over 600
patients, nearly 74% rated their overall satisfaction as Very Good or Good. Attached as part
of the materials is a summary report from our survey vendor PressGaney detailed these and
similarly positive findings.
NTBH endeavors to recruit and employ dedicated, experienced and compassionate
physicians, nurses, and clinical support staff specifically trained to work with our specialized
and complex patient population. For example, our Chief Nursing Officer has nearly 20 yearsexperience encompassing direct nursing, clinical administration, quality assurance,
compliance and patient experience roles at many respected behavioral, acute/medical
surgical hospitals and BH focused home health organizations in the greater Tampa area. She
has overseen large scale patient safety best practices initiatives, coordinated crisis
intervention trainings for local law enforcement officers and authored hospital wide
employee training materials. She holds three degrees including Bachelors in both Nursing
and Psychology and MBA. She is also a licensed Healthcare Risk Manager. Similarly, our Chief
Medical Officer has practiced medicine in both the U.S. and abroad for over 15 years, the last
8 as an American Board of Psychiatry and Neurology certified Psychiatrist at multiple
inpatient and intensive outpatient treatment settings in Florida, Indiana and Mississippi. He
received an Outstanding Resident Award from the Jackson, MS VA Medical Center in 2009.
I’d also wish to address your inquiries regarding my educational and professional experience
within the context of the overall healthcare sector and my current role as NTBH CEO. As you
are likely aware, the ranks of healthcare and hospital administrators include individuals with
very diverse educational and professional experiences, perspectives and skill sets. While
some healthcare facility leaders transition from clinical roles, many others (including
myself) bring expertise and transferrable skills from previous experiences in management
and team leadership, accounting and budgeting, operations and logistics, marketing and
business development, law and other relevant vocations and proficiencies which comprise
essential elements of a successful hospital CEO.

2

 Prior to joining NTBH, I served as the Vice President of Sales at large regional transportation
logistics company, overseeing business development programs and client retention
initiatives for portfolios totaling $32+million in annual review. I also served as an Employee
Benefit Consultant (including for complex health insurance products) at a major national
bank where I was responsible for cultivating and growing relationships with customers
though proactive community outreach and engagement while also serving as the
primary liaison and account manager for many large and complex client portfolios. These
experiences required a consistent focus on relationship building and customer satisfaction,
strategic planning, logistics, budgeting and financial forecasting which are all core elements
of my role at NTBH. As it relates to my prior career as a professional (NFL, CFL and Arena
League) football quarterback, I would similarly maintain that that there are many valuable,
transferrable skills and attributes including team leadership, situational analysis and sound
decision-making under extreme time pressure, compliance with detailed and evolving rules
multi-tasking and ability to course correct without sacrificing quality.
For your reference, as part of the overall written materials, I have included a digest
summarizing hospital CEO role expectations and governing body standards from CMS, The
Joint Commission and AHCA. As you will see, the core competencies are primarily focused on
team management, budgeting, operational and compliance matters, with the Chief Medical
Officer and Chief Nursing Officer leading clinical functions.
Clinical Admission Criteria, FL “Baker Act” Protocols & Length of Stay Determinations:
Three main criteria are assessed for any admission to a psychiatric facility such as NTBH
satisfaction of one or more which will justify admission, whether voluntary or involuntary.
The first is suicidality – if someone is suicidal, or at significant risk of harm to themselves.
The second is whether there is a significant risk that the patient may harm someone else,
which is often referred to as homicidality. The third is whether the individual is gravely
disabled and/or unable to care for themselves to the extent that their present psychiatric
symptoms and diagnosis significantly interferes with their ability to undertake essential
daily activities. These admission criteria are uniform across all acute psychiatric facilities
including NTBH and the clinical determination on whether to admit any patient is made by
the attending psychiatrist in consultation with other members of the clinical support team
and is based on the patient’s unique symptoms and current functioning.
Similarly, each state proscribes specific legal protocols for involuntarily committing an
individual into inpatient care if he or she is determined (based on the opinion of one or more
applicable experts) to constitute a legitimate risk to themselves or the overall community.
The Florida Mental Health Act of 1971 (FL Statute 394.451-394.47891 (2009 rev.),
commonly known as the “Baker Act,” permits the involuntary examination and temporary
commitment of individuals who meet certain established clinical and legal criteria. NTBH is
one of the few local facilities designated as a Baker Act receiving facility given our unique
clinical expertise in providing high quality care to some of the most complex and challenging
BH patients and conditions. It is important to note that the initial determinations and
attestations that a particular patient requires involuntary care is typically not made by NTBH
or any of its clinicians, but rather by the initial treating facility (typically acute/medical
emergency) or by other authorized parties such as law enforcement or EMS who transport
the patient to our facility.
3

 Nevertheless, all patients (including those initially admitted with Baker Act/involuntary
status) patients are provided a full evaluation by the attending psychiatrist regarding
suitability for both admission and involuntary status designation including where deemed
clinically appropriate and safe for the patient; the option to re-classify as a voluntary patient.
In situations where the psychiatrist and other clinical staff determine that a patient for their
own safety and the safety of the community requires ongoing involuntary treatment, NTBH
clinicians (like all “Baker Act” credentialed facilities) are required to outline such concerns
within a formal petition that must signed off by two psychiatrists and approved by an
impartial judge. A facility itself cannot commit or “Baker Act” a patient on its own; only
qualified clinical personnel can do so, through established legal and clinical protocols.
Importantly, NTBH does not actively advertise or market its status as a credentialed Baker
Act receiving facility. The fact that we treat a significant number of such patients is instead
related to increased community demand and relatively few facilities that are qualified to
provide the specialized care as well as the reputation of our clinicians among referring
hospitals and community partners such as law enforcement. Over the past 6 years, patients
admitted under initial involuntary status have on average comprised approximately 65% of
NTBH’s total census at the time of admission. Many of these patients eventually are
transitioned to voluntary status based on determinations in accordance with the statute and
clinical best practices.
Regarding your questions and inferences about purported patient allegations relating to
length of stay (LOS) and potential financial impacts in comparison to other hospital facilities,
some important corrections, clarifications and context are necessary to set the record
straight. Regardless of a patient’s voluntary or involuntary status, all decisions regarding
admission, treatment and discharge including LOS are clinical determinations made by the
attending psychiatrist in full consultation with other members of the treatment team based
on that patient’s unique condition acuity. Key factors include the patient’s acuity (illness
severity and functioning), treatment progression, feasibility of post discharge treatment
options and similar considerations. Every patient care decision is made with the goal of
furthering the best interests of our patients; this includes decisions regarding the amount of
time a patient spends in treatment.
You also erroneously imply that NTBH personnel could keep a patient (including involuntary
patients) hospitalized solely for financial considerations, that NTBH’s average length of stay
(ALOS) and its profit margins are demonstrably higher than that of its peers. These
inferences are highly inaccurate, misleading and unsupported by publicly available data,
including AHCA’s aggregate hospital financial and ALOS data. First, as stated above, all
decisions regarding patient length of stay are made independently by the attending
physician with input of the clinical treatment team based on patient progress toward
treatment goals. Second, in most states including Florida, initial and continuing stay clinical
decisions are often made in consultation with state and private insurance utilization
management representatives, outside case managers, and in the case of involuntary patients,
independent judges, who review extensive clinical materials and speak often with treatment
providers before rendering pre-authorization decisions. NTBH therefore rejects any
accusation that patients not meeting clinical criteria are intentionally held for purely
financial reasons and no regulatory or accreditation survey has ever alleged or revealed any
such conduct.
4

 Third, mental health facilities and the patients we treat are unique, complex and often unlike
traditional acute care hospitals or patients. In light of the serious nature of their conditions,
many patients (including many admitted under “Baker Act” protocols) are often unable to
make similar types of objective judgements regarding the necessity of clinical care and
suitability of admission and discharge that they ordinarily would when undergoing other
non-psychiatric treatment. These situation can invariably lead to confrontations and
disagreements where a particular patient believes they don’t need care when the totality of
the clinical evidence confirms the necessity of such care. There are also scenarios where
evaluation, discharge planning and document and recording may be slightly delayed due to
scheduling, documentation sign-off and other factors that have nothing to do with financial
considerations and are typically resolved within a very short period. Fourth, a subjective
examination of both publicly available audited hospital financial statements and NTBH’s
own financial and patient stay records do not support your contention that our aggregate
profit margins or ALOS are appreciably higher than other Florida psychiatric facilities.
Attached to this email is a spreadsheet detailing NTBH’s aggregate operational and
financial data from 2013 – 2019 YTD, including information we previously submitted
to the state in accordance with our reporting obligations. We have also included
aggregate annual published data from AHCA’s online Financial Dashboard data which
includes information from our founding though 2017. As you can clearly see, while ALOS
and profit margin vary over the years based on a variety of factors, NTBH’s average annual
figures for both the 2013-2017 (i.e. based on currently published data) and 2013 - YTD 2019
are slightly lower than the multi-year averages of other Florida psychiatric hospitals.
Finally, the contention that involuntary patients comprise an unusually “lucrative” segment
is also inaccurate. In general, involuntarily committed patients include a higher percentage
of indigent and charity care situations compared to voluntary patients with either
commercial insurance (which generally reimburses at higher rate than Medicaid) or those
who elect to self-pay. Since its founding, NTBH has provided millions of dollars of
uncompensated and charity care to patients, including those arriving at our facility under a
Baker Act petitions.
Isolated Regulatory Compliance & Adverse Incident Allegations in Context:
You make reference to certain regulatory compliance, law enforcement and other isolated
matters occurring over many years. These characterizations provide a highly incomplete and
distorted depiction of the overall realities of BH care, the comprehensive regulatory
oversight system governing it and NTBH’s aggregate positive record of compliance, low
serious incident rates, clinical quality assurance and risk management programs.
As stated above, NTBH is fully licensed, certified and in good standing with all relevant state
and federal government regulatory agencies and insurance providers (Medicare, Medicaid,
TriCare and commercial providers). NTBH has never been suspended or terminated by any
government or commercial insurer nor has it ever been subjected to fines or licensure
actions (including revocations) or restrictions of any kind. NTBH is also fully accredited by
The Joint Commission (TJC), a non-profit organization with a 60-year record of conducting
comprehensive accreditation services on behalf of the federal government. TJC performs
intrusive onsite triennial onsite accreditation inspections as well as unannounced visits.
5

 Like all U.S. healthcare facilities, NTBH is routinely subject to unannounced visits and
detailed inspections (“surveys”) by federal and state licensing agencies and regulators (in FL
AHCA, DCF) as well as independent accreditation organizations such as The Joint
Commission with authorized deeming authority from CMS. Regulators and accreditors
conduct thousands of inspections annually at hospital facilities nationwide. Incident and
deficiency reports, corresponding Plans of Correction (POC), occasional notices of potential
termination of CMS certification or similar state enforcement actions represent routine
aspects of the comprehensive regulatory process governing all hospital facilities. The
surveys, depending on the circumstances, can be triggered the regulator itself, or in other
instances from complaints (whether substantiated or not) from patients, staff and family
members as well as the facility self-reporting incidents requiring an onsite survey inspection.
These site visits include but are not limited to, reviewing current and historic performance
data, medical records reviews, facility inspections, patient interviews, employee interviews,
staffing sufficiency, and a host of other clinical and environment of care concerns. Regulators
and accreditors can and do make unannounced visits with or without cause at any time of
their choosing. The central goal of the regulatory process is to ensure that all facilities are
compliant with CMS and state licensing regulations and accreditation standards while
providing appropriate, therapeutic care to patients. Thousands of facilities nationwide
encounter instances of alleged non-compliance in clinical and operational areas sometimes
necessitating follow up surveys, CMS termination threats and other more serious remedial
and punitive enforcement measures.
If a facility is suspected to be non-compliant in a specific area, CMS and many state regulatory
authorities and accreditation organizations utilizes multi-tier system to indicate the alleged
severity of the non-compliance. Standard-level findings constitute issues a facility must
address but which do not jeopardize its participation in federal healthcare programs, usually
minor administrative, maintenance or record keeping matters. Conditional-level deficiencies
are more serious allegations that require a facility to submit a formal POC to the applicable
regulator. subcategory of the conditional level is the immediate jeopardy designation. These
scenarios stem from findings deemed serious enough that regulators can suspend
admissions, impose fines, freeze reimbursements and, in rare instances, terminate a facility
as a provider and force it to temporarily or permanently close and transfer patients. Alleged
patient safety-related or other citations do not necessarily equate to a definitive conclusion
that any actual patient harm occurred or will occur. Rather, it constitutes a subjective
allegation or finding from a particular surveyor(s) that there is potential for harm.
The vast majority of survey and accreditation inspections (including CMS, AHCA/licensure,
DCF, and The Joint Commission) conducted at NTBH over the past 6.5 years resulted in
determinations that our hospital was in substantial compliance with all CMS Conditions of
Participation (COP), TJC accreditation and FL licensure requirements with several surveys
100% deficiency free, which is our consistent goal. NTBH has never been subjected to any
immediate jeopardy designations, fines, admission freezes, payment suspensions or
facility closure orders by any regulator or accreditor.
Notwithstanding, NTBH takes all feedback received from regulators and accreditors
seriously and views these important processes as key opportunities to consistently explore
ways we can improve on the already high quality the services we provide. Similar to nearly
6

 every hospital (whether or acute or BH), a number of surveys conducted by regulators and
accreditation organizations since NTBH’s founding included alleged citations. Many related
to standard and administrative matters not directly impacting patient care or safety and
which were quickly resolved without the need for a formal POC. Other (mostly AHCA
surveys) included more serious alleged shortcomings requiring submission and approval of
a POC. In each of these relatively rare cases, NTBH full addressed and remediated all
concerns to the full satisfaction of AHCA. The preparation and submission of POCs (even in
cases when we may disagree with the merits of the allegation) are designed to reduce the
possibility of the potential or actual harm from occurring or re-occurring, the goals of which
NTBH strongly and consistently supports.
You also briefly reference in somewhat vague terms alleged incidents (purportedly
extrapolated from police reports and surveys), claiming that NTBH “has allowed patients to
hurt themselves or others.” This representation is also incorrect and misleading as we would
never knowingly or willfully “allow” or permit any patient to hurt themselves or others. The
safety of all of our patients and staff members is of tantamount importance and a
responsibility we take very seriously, particularly in light of the high acuity patient
population that can occasionally exhibit aggressive and unpredictable behaviors. As stated
earlier, severe and grave incidents (e.g. assaults, disturbances, patient and/or staff injuries,
elopements, etc.) are highly uncommon occurrences at NTBH, with such matters comprising
0.000597% of all patient treatment days since 2013.
Similarly, law enforcement dispatch to NTBH (particularly for 9-11 calls) is not a common
practice or occurrence. This is in large part due to our staff’s specialized training (including
in advanced de-escalation and therapeutic restraint techniques) which better equips them
to deal with the unique medical needs of psychiatric patients as opposed to police who are
primarily trained in legal enforcement and public safety issues. However, like nearly all
hospitals (particularly ones treating patients whose illnesses can manifest in aggressive and
assaultive episodes), we do sporadically experience situations necessitating law
enforcement support. Furthermore, state and federal law and regulations actually require
notification and referral to law enforcement for particular types of matters including alleged
abuse, serious property damage, theft and to serve outstanding warrants. Given that NTBH
is a credentialed Baker Act receiving facility, police often transport needy patients to our
hospital. Overall, NTBH values its long-standing collaborative relationship with all local law
enforcement agencies and greatly appreciates their service to the community.
Notwithstanding our very low serious incident rates, NTBH constantly evaluates our policies
(e.g. though ongoing staff training in advance de-escalation techniques), treatment protocols
and capital improvement plans (including in safety/security technologies) in an effort to
reduce negative incidents with the aspirational goal of zero negative incidents, including
assaults and injuries to patients and staff. As part of this effort, NTBH maintains and adheres
to strict policies requiring that all applicable adverse incidents be reported to AHCA and/or
DCF in full accordance with FL statute 395.0197. Our staff are trained to identify events
meeting criteria for reporting and our consistent goal and expectation is 100% compliance.
It is also important to clarify that not all incidents (including ones that could reasonably be
deemed undesirable) necessarily meet the formal legal criteria for classification as adverse
based on the FL guidelines. It is NTBH policy to err on the side of disclosure of such incidents,
both internally for evaluation and performance improvement purposes and to meet our state
7

 reporting responsibilities. For the FL statute adverse incident requirements, NTBH’s
incident rate is 0.000199% of total patient treatment days between 2013 – 2019 YTD.
NTBH constantly strives for excellence in all aspects of our operations and because we hold
ourselves to the highest clinical and ethical standards, we believe that even one negative
incident or outcome is one too many. Nevertheless, we are mindful that over the course of
treating thousands of patients annually, regrettable and unpredictable events will invariably
occur including deviations from our hospital’s own internal policies, procedures and high
standards. We also forthrightly acknowledge that such events can result in negative and
traumatic impacts to the individuals involved and to their loved ones. In these rare
situations, we do our best to provide support and compassion to all those affected. It is also
never our intention to diminish or trivialize the seriousness of these matters as they
represent important opportunities for reflection, evaluation and improvement.
When these uncommon situations arise, we do our best to identify lessons learned and
where applicable, make changes to our protocols while holding all individuals fully
accountable for any actions which violate our policies and high expectations (including in
the case of employees; mandatory retraining, suspensions and in serious cases, termination
and potential referral to external regulators and law enforcement). We consistently strive to
reduce and eliminate negative occurrences to all patients entrusted to our care as well as our
valued staff members. We also strongly emphasize the crucial importance of placing such
atypical events in the appropriate context i.e. as regrettable but wholly non-representative,
temporary departures from the overall high level of quality clinical care experienced by the
overwhelmingly majority of NTBH patients as opposed to evidence of any systemic problem.
Conclusion:
On behalf of the entire NTBH team, we sincerely hope this information will assist in your
efforts to produce a balanced, fact-based portrayal of FL’s mental health treatment system,
our hospital’s role in providing care to our valued patients and the dedicated efforts of our
clinicians and support staff that I have the sincere privilege to lead.
Doing anything less would be unfortunate, just not for NTBH and similar providers but more
importantly, in light of the ongoing and serious need to proactively confront the historical
stigmas, shame and societal misconceptions that too often surround mental health disorders
and patients. I’d therefore respectfully encourage you be sensitive and objective in how you
portray these complex matters to lessen the possibility of the reportage being unwittingly
misconstrued and sensationalized, perpetuating fear inducing stereotypes that could
dissuade needy individuals from seeking life-saving care for themselves or their loved ones.
NTBH will continue to focus on our core mission of providing critically needed, high quality,
compassionate and specialized care to our valued patients and their families across our
beloved Tampa Bay community.
Sincerely,
Byron “BJ” Coleman Jr.
CEO, North Tampa Behavioral Health
8

 North Tampa Behavioral Health
Data Collection Request - Tampa Bay Times Inquiry
2013
Admissions
Discharges
Patient Days
Self Pay %
OP Visits
Involuntary Admissions
% Involuntary

Average Length of Stay (ALOS)
Audited Financial Statements (Submitted to AHCA)
Net Revenue
Net Income

Operating Margin

158
171
1,041
35.0%

N/A
N/A

701
35%

6.6

6.5

208,074.00
(1,677,100.00)

8,207,067.00
(1,282,176.00)

-806.0%

-15.6%
StatewidePyschiatric
Hospitals

7%
7%

10%
9%

SOURCE:
AHCA Financial Data Dashboard Available at:
https://www.floridahealthfinder.gov/researchers/studiesreports.aspx (Florida Hospital Financial Data)
https://bi.ahca.myflorida.com
Average Operating Margin per AHCA
For Profit
Not For Profit

2014
2,010
2,027
13,083
3.7%
2,321

Statewide Psychiatric
Hospitals
Average Length of Stay (ALOS)
NTBH Charity Care 2017 - Present
NTBH Bad Debt 2017 - Present
% of Net Revenue

8.70

8.00

 2015
2,878
2,883
19,856
4.8%
5,894

2016
3,197
3,220
25,406
4.0%
3,871

2017
3,010
3,074
26,297
5.1%
3,274

2018
3,457
3,522
25,515
6.9%
3,469

2019-July YTD
2,047
2,074
14,258
8.1%
1,449

1996
69%

2307
72%

2142
71%

2383
69%

1485
73%

6.9

7.9

8.7

7.4

7.0

13,670,333.00
1,645,292.00

17,455,021.00
2,642,409.00

18,271,320.00
2,546,698.00

17,349,207.00
954,192.00

8,996,355.00
(411,910.00)

12.0%

15.1%

13.9%

5.5%

-4.6%

10%
11%

9%
10%

9% Not yet reported
9% Not yet reported

Not Yet Reported
Not Yet Reported

7.70

7.60

7.00 Not yet reported

Not Yet Reported

$ 1,268,682.25 $ 765,352.00 $ 244,572.20
$ 1,107,649.23 $ 1,630,880.00 $ 1,434,376.00
6.9%
4.4%
2.7%

 TOTALS & AVERAGES
16,757
16,971
125,456
9.7%
20,278
11,014
65%

7.3

4.4%

9%
9%

7.80

*2013 excluded from average due to small
patient census and first year operating loss
status

 North Tampa Behavioral Health

infoEDGE

INPATIENT BEHAV. HEALTH REPORT
Filter Definition
Filter
Discharge Date

Choice(s)
From 07/01/2018 To 08/15/2019

08/15/2019 16:37:15 EST

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1

 North Tampa Behavioral Health

infoEDGE

INPATIENT BEHAV. HEALTH REPORT
Question Analysis
Overall
Section
Question
Overall
Admission

Top Box
43.7

n
617

34.5

612

Speed of the admission process

16.4

608

Courtesy of staff during admission

44.8

603

Information about Patient's Rights

42.5

600

Unit

33.5

609

Comfort of the unit

26.4

606

Noise level of the unit

23.8

596

Overall condition of the unit

32.7

597

43.8

603

40.9

594

Cleanliness of your room
Cleanliness of the unit

†

†

Meals

37.4

607

Quality of the food

27.9

603

Quantity of the food

38.4

602

Temperature of the food

38.8

598

44.6

594

42.2

606

Friendliness/courtesy of the nurses

50.5

600

Nurses' intro to unit/program

38.6

594

Nurses' prompt response to requests

40.2

592

Nurses' info re treatment program

35.4

593

Nurses' info re medication

42.1

592

Helpfulness of the nurses

46.2

595

Cleanliness of the dining area

†

Nursing

Psychiatrist

37.4

600

Courtesy of psychiatrist

42.7

599

Helpfulness of time w/psychiatrist

34.7

594

Psychiatrist's info re medication

37.3

584

Psychiatrist's info re condition

34.9

591

54.0

598

Overall rating of social worker

50.9

574

Overall rating of case manager

52.2

579

Overall rating of rec therapist

57.3

576

Overall rating of psychiatric techs

55.5

586

Treatment Team

Program Activities

41.7

598

Helpfulness of contact with staff

41.5

593

Time in therapeutic activities

37.2

591

Helpfulness group therapy

43.7

590

Helpfulness social/rec activities

44.3

589

46.4

428

Staff's courtesy toward visitors

49.5

410

Adequacy of visiting hours

37.7

414

Visitors & Family

Continued...
08/15/2019 16:37:15 EST
† Non-standard question
For a list of filter and benchmark definitions, click here.

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2

 North Tampa Behavioral Health

infoEDGE

INPATIENT BEHAV. HEALTH REPORT
Question Analysis
Overall
Section
Question
Confidentiality re visitors

Top Box
49.9

n
405

48.8

402

55.9

599

Felt prepared for discharge

57.1

597

Understand disch med instructions

55.7

576

Info re care after discharge

55.8

579

Discharge instructions if need help

54.9

577

Space to meet with family/friends
Discharge

Personal Issues

47.1

578

Staff concern for privacy

48.1

574

Staff asked about physical pain

45.0

571

Physical pain taken care of

44.4

522

Safety felt on unit

48.7

569

Sensitive to lang/cultural needs

52.3

547

Sensitive to emotional needs

48.9

568

Sensitive to spiritual needs

47.4

542

Included in decisions re care

41.3

567

Staff concern to treat with respect

†

51.7

572

Response to concerns/complaints

†

42.7

562

46.3

578

Overall impression of the hospital

36.2

574

Feel condition has improved

48.6

570

Staff worked together care for you

47.2

574

Overall rating of care given

43.5

573

43.0

563

46.4

571

52.2

571

53.6

569

44.3

560

44.3

560

Overall Assessment

Likelihood of recommending
Overall cleanliness of hospital
Kindness of staff

†

†

Hopefulness as result of care

†

Medical Doctor
Overall rating of medical doctor

†

08/15/2019 16:37:15 EST
† Non-standard question
For a list of filter and benchmark definitions, click here.

1-800-232-8032

3

 North Tampa Behavioral Health

infoEDGE

INPATIENT BEHAV. HEALTH REPORT
Frequency Analysis
Overall
Section
n
Question
32,495 Overall
1,811

Very Poor
%
4.3%

Fair
%
16.6%

Good
%
30.1%

Very Good
%
43.7%

8.3%

9.9%

21.3%

26.1%

34.5%

608

Speed of the admission process

16.8%

16.4%

29.6%

20.7%

16.4%

603

Courtesy of staff during admission

2.7%

7.0%

15.9%

29.7%

44.8%

600

Information about Patient's Rights

5.3%

6.2%

18.2%

27.8%

42.5%

2,996

Admission

Poor
%
5.3%

3.6%

6.9%

22.3%

33.6%

33.5%

606

Unit
Comfort of the unit

5.3%

9.2%

25.1%

34.0%

26.4%

596

Noise level of the unit

5.4%

10.6%

30.4%

29.9%

23.8%

597

Overall condition of the unit

2.5%

4.9%

24.0%

36.0%

32.7%

2.5%

5.1%

15.6%

33.0%

43.8%

2.5%

4.7%

16.7%

35.2%

40.9%

603

Cleanliness of your room

594

Cleanliness of the unit

2,397

†

†

3.8%

4.3%

19.6%

34.9%

37.4%

603

Quality of the food

6.8%

6.6%

26.4%

32.3%

27.9%

602

Quantity of the food

2.7%

4.8%

20.6%

33.6%

38.4%

598

Temperature of the food

3.5%

2.8%

16.9%

38.0%

38.8%

2.0%

3.0%

14.6%

35.7%

44.6%

4.2%

7.1%

16.1%

30.4%

42.2%

594
3,566

Meals

Cleanliness of the dining area

†

Nursing

600

Friendliness/courtesy of the nurses

1.3%

3.2%

12.7%

32.3%

50.5%

594

Nurses' intro to unit/program

4.2%

8.9%

16.0%

32.3%

38.6%

592

Nurses' prompt response to requests

5.4%

7.1%

18.6%

28.7%

40.2%

593

Nurses' info re treatment program

7.3%

10.1%

20.1%

27.2%

35.4%

592

Nurses' info re medication

4.4%

7.9%

14.4%

31.3%

42.1%

595

Helpfulness of the nurses

2.7%

5.4%

15.1%

30.6%

46.2%

2,368

7.6%

7.4%

18.6%

29.0%

37.4%

599

Courtesy of psychiatrist

5.5%

4.5%

16.5%

30.7%

42.7%

594

Helpfulness of time w/psychiatrist

7.7%

8.6%

21.7%

27.3%

34.7%

584

Psychiatrist's info re medication

8.0%

6.7%

17.1%

30.8%

37.3%

Psychiatrist's info re condition

9.1%

9.8%

19.0%

27.2%

34.9%

2.4%

3.1%

12.9%

27.7%

54.0%

591
2,315

Psychiatrist

Treatment Team

574

Overall rating of social worker

2.6%

2.8%

13.8%

30.0%

50.9%

579

Overall rating of case manager

2.9%

3.6%

13.6%

27.6%

52.2%

576

Overall rating of rec therapist

2.3%

2.8%

12.5%

25.2%

57.3%

586

Overall rating of psychiatric techs

1.9%

3.1%

11.6%

28.0%

55.5%

2,363

3.1%

5.5%

17.1%

32.6%

41.7%

593

Helpfulness of contact with staff

2.9%

4.7%

16.2%

34.7%

41.5%

591

Time in therapeutic activities

3.2%

7.4%

19.3%

32.8%

37.2%

590

Helpfulness group therapy

3.2%

4.7%

17.3%

31.0%

43.7%

Helpfulness social/rec activities

3.2%

5.1%

15.6%

31.7%

44.3%

4.1%

5.0%

16.7%

27.7%

46.4%

589
1,631

Program Activities

Visitors & Family

410

Staff's courtesy toward visitors

2.4%

2.9%

15.6%

29.5%

49.5%

414

Adequacy of visiting hours

8.2%

9.7%

19.6%

24.9%

37.7%

Distribution

Continued...
08/15/2019 16:37:15 EST
† Non-standard question
For a list of filter and benchmark definitions, click here.

1-800-232-8032

4

 North Tampa Behavioral Health

infoEDGE

INPATIENT BEHAV. HEALTH REPORT
Frequency Analysis
Overall
Section
n
Question
405
Confidentiality re visitors
402
2,329

Space to meet with family/friends
Discharge

Very Poor
%
2.5%

Poor
%
3.5%

Fair
%
17.3%

Good
%
26.9%

Very Good
%
49.9%

3.2%

4.0%

14.4%

29.6%

48.8%

3.2%

3.1%

9.7%

28.1%

55.9%

597

Felt prepared for discharge

3.5%

3.9%

9.2%

26.3%

57.1%

576

Understand disch med instructions

2.6%

2.3%

10.2%

29.2%

55.7%

579

Info re care after discharge

3.1%

2.9%

9.7%

28.5%

55.8%

577

Discharge instructions if need help

3.6%

3.3%

9.5%

28.6%

54.9%

5,594

4.1%

3.9%

15.0%

29.9%

47.1%

574

Staff concern for privacy

2.6%

3.5%

14.3%

31.5%

48.1%

571

Staff asked about physical pain

5.1%

3.9%

13.5%

32.6%

45.0%

522

Physical pain taken care of

6.5%

5.9%

15.1%

28.0%

44.4%

569

Safety felt on unit

2.3%

3.3%

14.8%

30.9%

48.7%

547

Sensitive to lang/cultural needs

1.8%

1.8%

13.5%

30.5%

52.3%

568

Sensitive to emotional needs

3.5%

3.0%

14.8%

29.8%

48.9%

542

Sensitive to spiritual needs

3.7%

3.9%

15.9%

29.2%

47.4%

567

Included in decisions re care

6.0%

5.8%

16.0%

30.9%

41.3%

572

Staff concern to treat with respect

†

3.7%

2.8%

14.3%

27.4%

51.7%

Response to concerns/complaints

†

5.9%

5.3%

17.6%

28.5%

42.7%

4.0%

4.7%

15.5%

29.4%

46.3%

562
4,565

Personal Issues

Overall Assessment

574

Overall impression of the hospital

4.7%

6.6%

19.2%

33.3%

36.2%

570

Feel condition has improved

2.5%

3.3%

13.5%

32.1%

48.6%

574

Staff worked together care for you

3.1%

3.5%

15.3%

30.8%

47.2%

573

Overall rating of care given

4.2%

4.7%

17.3%

30.4%

43.5%

563

Likelihood of recommending

10.5%

7.1%

15.5%

24.0%

43.0%

571

Overall cleanliness of hospital

3.2%

4.9%

16.3%

29.2%

46.4%

1.8%

3.7%

14.2%

28.2%

52.2%

2.5%

3.7%

12.8%

27.4%

53.6%

6.3%

4.8%

17.3%

27.3%

44.3%

6.3%

4.8%

17.3%

27.3%

44.3%

†

571

Kindness of staff

569

Hopefulness as result of care

560
560

†

†

Medical Doctor
Overall rating of medical doctor

†

Distribution

08/15/2019 16:37:15 EST
† Non-standard question
For a list of filter and benchmark definitions, click here.

1-800-232-8032

5

 Joint Commission:
Introduction to Leadership Structure, Standards LD.01.01.01 Through LD.01.05.01
Each hospital, regardless of its complexity, has a structured leadership. The leadership structure may consist of
distinct groups, or leaders may act as a whole. Individual leaders may participate in more than one group and may
have several different roles. A leadership group is composed of individuals in senior positions with clearly defined,
unique responsibilities. These groups might include governance, management, and medical staff and clinical staff.
Not every hospital will have all of these groups, and an individual may be a member of more than one group.
Many leadership responsibilities directly affect the provision of care, treatment, and services, as well as the day-today operations of the hospital. In some cases, these responsibilities will be shared among leadership groups, and in
other cases, a particular leader or leadership group has primary responsibility. Regardless of the hospital’s
structure, it is important that leaders carry out all their responsibilities.
A variety of individuals may work in the hospital, including licensed independent practitioners, staff, volunteers,
students, and independent contractors. These standards describe the overall responsibility of the governing body
for the safety and quality of care, treatment, and services provided by all of these individuals. In hospitals, the
organized medical staff is responsible for overseeing the quality of care provided by individuals with privileges. The
structure of the organized medical staff and its responsibilities are covered in the “Medical Staff” (MS) chapter.
How well leaders work together is key to effective hospital performance, and the standards emphasize this.
Leaders from different groups—governance, senior management, and the organized medical staff—bring different
skills, experiences, and perspectives to the hospital. Working together means that leaders from all groups have the
opportunity to participate in discussions and have their opinions heard. Depending on the topic and the hospital,
individuals from different leadership groups may participate in decision making, and the governing body may
delegate decision making to certain leadership groups. Final decisions, however, are always the ultimate
responsibility of the governing body; this key principle is assumed in any standard that describes how leaders work
together.
The chief executive provides for the following:
- Information and support systems
- Physical and financial assets
The chief executive identifies a nurse leader at the executive level who participates in decision making. (See also
NR.01.01.01, EP 3 for specific nurse leader responsibilities)
CMS:
§482.12(b) Standard: Chief Executive Officer
The governing body must appoint a chief executive officer who is responsible for managing the hospital.
Interpretive Guidelines §482.12(b)
The Governing Body must appoint one chief executive officer who is responsible for managing the entire hospital.

-

Survey Procedures §482.12(b)
Verify that the hospital has only one chief executive officer for the entire hospital.
Verify that the governing body has appointed the chief executive officer.
Verify that the chief executive officer is responsible for managing the entire hospital.
AHCA – FL State Regulations
59A-3.273 Management and Administration.
(1) Each hospital shall be under the direction of a chief executive officer appointed by the governing body,
who is responsible for the operation of the hospital in a manner commensurate with the authority conferred by
the governing body.
(2) The chief executive officer shall take all reasonable steps to provide for:

 (a) Compliance with applicable laws and regulations; and
(b) The review of and prompt action on reports and recommendations of authorized planning, regulatory, and
inspecting agencies.
(3) The chief executive officer shall provide for the following:
(a) Establishment and implementation of organized management and administrative functions, including:
1. Clear lines of responsibility and accountability within and between department heads and administrative
staff;
2. Effective communication mechanisms among departments, medical staff, the administration and the
governing body;
3. Internal controls;
4. Coordination of services with the identified needs of the patient population;
5. A policy on patient rights and responsibilities;
6. A mechanism for receiving and responding to complaints concerning patient care;
7. A policy on withholding resuscitative services;
8. Policies and procedures on identification and referral of organ and tissue donors including notification of
organ and tissue procurement agencies when organs and tissues become available as specified under Rule 59A3.219, F.A.C.;
9. Policies and procedures for meeting the communication needs of multicultural populations and persons
with impaired hearing or speaking skills;
10. Policies and procedures on discharge planning;
11. A policy to assist in accessing educational services for children or adolescents when treatment requires a
significant absence from school;
12. Policies and procedures to assure that the treatment, education and developmental needs of neonates,
children and adolescents transferred from one setting to another are assessed;
13. Dissemination and enforcement of a policy prohibiting the use of smoking materials in hospital buildings
and procedures for exceptions authorized for patients by a physician’s written authorization;
14. A policy regarding the use of restraints and seclusion; and
15. A comprehensive emergency management plan which meets the requirements of paragraph
395.1055(1)(c), F.S., and Rule 59A-3.078, F.A.C.
(b) Personnel policies and practices which address:
1. Non-discriminatory employment practices;
2. Verification of credentials including current licensure and certification;
3. Periodic performance evaluations; and
4. Provision of employee health services.
(c) Financial policies and procedures;
(d) An internal risk management program which meets the requirements of Section 395.0197, F.S., and
Chapter 59A-10, F.S.C., and
(e) Assurance of compliance with educational requirements on human immunodeficiency virus and acquired
immune deficiency syndrome pursuant to Sections 381.0034 and 381.0035, F.S., and Chapter 64D-2, F.A.C.,
September 1994.
Specific Authority 395.1055 FS. Law Implemented 395.0197, 395.1055 FS. History–New 9-4-95, Formerly 59A-3.218.