A Medical Qual i ty Assurance Publ icat ion January - March 2022 QUARTERLY Florida Department of Health PERFORMANCE REPORT QPR • THREE
Q3 • Quarterly Performance Report 2021-22 2 MISSION To protect, promote, and improve the health of all people in Florida through integrated state, county, and community efforts. VISION: BE THE HEALTHIEST STATE IN THE NATION www.FLHEALTHSOURCE.GOV HOW WE WORK Medical Quality Assurance regulates health care practitioners and facilities through professional licensure, facility permitting, and administrative enforcement in order to preserve the health, safety, and welfare of the public. 4052 BALD CYPRESS WAY BIN C-00 TALLAHASSEE, FLORIDA 32399-3250 VALUES Innovation We search for creative solutions and manage resources wisely Collaboration We use teamwork to achieve common goals and solve problems Accountability We perform with integrity and respect Responsiveness We achieve our mission by serving our customers Excellence We promote quality outcomes through learning and continuous performance improvement
Q3 • Quarterly Performance Report 2021-22 3 4 Letter from the Director 4 Executive Summary 5 Performance Statistics 5 Initial Application 6 License Renewal 7 MODE Inspections 8 Pharmacy Inspections 9 Enforcement Data 11 Unlicensed Activity 12 Financial Summary 13 Glossary 14 Contact Us
Q3 • Quarterly Performance Report 2021-22 4 It is with great pleasure that I present to you the Quarterly Performance Report for the third quarter of the fiscal year 2021-2022. This report includes information on key performance measures for the Division of Medical Quality Assurance (MQA) and highlights recent improvement initiatives and available consumer information. As the economy continues to grow, Florida has become the privileged home to an increased health care workforce. To help sustain this growth, MQA strives to uphold Florida’s public health legacy by pursuing excellence and leading quality health care regulation. We pride ourselves on delivering customercentered services that expedite licenses and inspections so health care practitioners can get to work. This quarter, MQA demonstrated our commitment to applicants, consumers, and health care practitioners through various improvement initiatives ranging from leveraging cutting-edge technology to optimizing our contract management strategy. Through initiatives like those outlined below, MQA strives to become the leader in health care quality regulation and make Florida the healthiest state in the nation. Within the pages of this publication, readers will catch a glimpse of the key processes and additional initiatives completed by staff who embody our core values each day to deliver accessible, timely, and accurate services and information to health care practitioners, licensure applicants, and consumers. Sincerely Jennifer L. Wenhold, MSW, CPM • In February, MQA modeled a new way of doing business by expanding the Artificial Intelligence solution, ELI. Our Enforcement, Licensure, and Information chatbot, ELI, is the best way to learn about licensure requirements, initial application status, renewal requirements, fees, address updates, background screening processes, and public record requests. As a result of this expansion, customers can now interact with ELI by phone or web to receive information specific to them, including their application status. • In March, the Board of Nursing led the charge to speed up the initial licensure process by hosting their first-ever odd month conference call virtually between regularly scheduled in-person Board meetings. As a result, the review and approval of 50 credential files were expedited, meaning that 50 nurses could enter the Florida workforce one month sooner than previously subjected. • The Bureau of Operations secured a three-year contract in March to continue audio and visual (A/V) services at regulatory board meetings, per Section 456.004(7), Florida Statutes. This opportunity saves the Meeting Planning Team time and money, rather than soliciting A/V services for regulatory board meetings every few months. Letter From the Director Executive Summary MQA contributes to the mission of the Department by licensing health care practitioners who meet statutory standards, enforcing laws and rules governing health care practitioners, and providing information to assist the public in making informed health care decisions. The Quarterly Performance Report, required by Section 456.025(9), Florida Statutes, serves as a road map for accomplishing the mission and includes information on revenue and expenditures and performance measures. Additionally, Section 456.065(3), Florida Statutes, requires the inclusion of all financial and statistical data resulting from unlicensed activity enforcement.
Q3 • Quarterly Performance Report 2021-22 5 1. Initial Applications In partnership with 22 regulatory boards and four councils, MQA regulates over 40 health care professions, more than 200 license types, and 10 unique health care facility types through timely professional licensure to support the growth of Florida’s workforce. Licensure regulation also protects practitioners and the public by defining a quality standard of practice including prerequisite knowledge and experience needed of the practitioner to perform the role. While the scope of practice and licensure requirements vary by profession and evolve over time, MQA maintains a goal of one day to process an initial application. Whereas an approved applicant may still be required to pass an examination or satisfy additional requirements prior to licensure, a qualified applicant is one who has met all licensure requirements. MQA continues to measure the average number of days to issue a license for a qualified applicant as one way to assess the efficiency of its licensure process (Figure 1.1). Performance Statistics To maintain an average target goal of one business day to issue a license, MQA streamlined the licensure verification process. Applicants were previously required to send license verifications through the mail from licensing agencies to the Florida board office. Most states charge a fee for this service and because some applicants have to verify their licenses in multiple states, this often resulted in increased fees for the applicant. Concurrently, the application processing times were subject to the delays caused by mail delivery of license verifications. Since most states provide the same information used to verify licensure over the web, staff transitioned to searching for a license verification online prior to requesting one from the applicant. As a result of obtaining license verifications online, MQA was able to reduce the amount of time it took to issue a license to a qualified applicant at no additional cost. Examples in Action Figure 1.1: Average Days to Process an Initial Application Data source: MQA Licensing and Enforcement Information Database System (LEIDS). FY 2016-17 FY 2017-18 FY 2018-19 FY 2019-20 FY 2021-22 Average Days FY 2020-21 0.0 1.0 2.0 3.0 0.5 1.5 2.5 2.1 1.3 1.8 1.4 1.9 1.6 1.9 2.5 2.8 1.9 1.0 1.4 1.6 1.2 0.9 1.2 1.5 1.0 1.2 1.3 0.9 GOAL = One Day 1.0 1.1 Quarter One Quarter Two Quarter Three Quarter Four Indicates Average Time to Process
Q3 • Quarterly Performance Report 2021-22 6 Practitioners are responsible for maintaining their licenses by renewing according to the various regulatory requirements of their profession, such as continuing education requirements. Through partnerships with licensing vendors and continuing education providers and by leveraging advanced technology to implement self-service channels, MQA creates both reliable avenues for health care practitioners to enter the workforce and consistent license renewal experiences to retain them. MQA has measured the average number of days to process a renewal application for a qualified applicant (Figure 2.1) since 2012 when a quality improvement initiative reduced the average time to process a renewal from three days to one day. While applications may still be processed through the U.S. mail delivery system, over 95% of renewals continue to be processed online. Regardless of whether a renewal application is processed online or by mail, the time to renew is always contingent upon receiving a completed application, as shown in Figure 2.1. What constitutes a completed application varies by profession, as some professions have more or fewer requirements than others. However, MQA strives to process each renewal application within one day, as shown below (Figure 2.2). 2. License Renewals Figure 2.2: Average Days to Process a Renewal Application FY 2016-17 FY 2017-18 FY 2018-19 FY 2019-20 FY 2021-22 FY 2020-21 Data source: MQA Licensing and Enforcement Information Database System (LEIDS). GOAL= One Day 0.0 0.3 0.6 0.9 0.3 0.2 0.5 0.5 0.5 0.2 0.2 0.2 0.3 0.5 0.4 0.4 0.1 0.3 0.2 0.3 0.2 0.2 0.7 0.5 0.6 0.2 Average Days 0.1 Quarter One Quarter Two Quarter Three Quarter Four Indicates Average Time to Process Figure 2.1: Average Time to Renew Explained
Q3 • Quarterly Performance Report 2021-22 7 Inspection teams across the state routinely examine health care practitioners and facilities to ensure compliance with applicable Florida Statutes, administrative codes, and applicable federal regulations in a manner that protects the health and safety of the public (Figure 3.1). Inspections may be conducted prior to beginning practice at an establishment, after a change in location or ownership has occurred, and/or on an annual or biennial basis. Inspections for massage, optical, dental lab, and electrolysis establishments, also referred to as M.O.D.E. inspections, are prioritized to ensure the health and safety of the public. Inspectors routinely collaborate with unit managers to identify, monitor, and execute the tasks involved in the inspection process with intermediate goals and timelines. For example, Inspectors are tasked with contacting the applicant within two days of receiving the request for inspection. These processes are documented, standardized, and evaluated regularly through the use of process guides, checklists, and performance reports. As a result, MQA consistently performs below the 10-day target goal to complete a M.O.D.E. inspection, including all initial inspections where the applicant did not formally request a delay, as shown in Figure 3.2. 3. Massage, Optical, Dental Lab, and Electrolysis Establishment Inspections Figure 3.1: Investigative Services Area Map Figure 3.2: Average Days to Complete a M.O.D.E. Inspection Data source: MQA Licensing and Enforcement Information Database System (LEIDS). 8.0 6.0 4.0 2.0 0.0 GOAL= 10 Days 10.0 12.0 Average Days FY 2016-17 FY 2017-18 FY 2018-19 FY 2019-20 FY 2021-22 FY 2020-21 4.8 5.4 4.2 5.4 4.3 4.4 4.5 5.4 7.6 5.6 5.1 5.9 5.2 4.8 4.3 4.6 4.8 9.0 5.0 4.2 5.3 4.9 4.7 Quarter One Quarter Two Quarter Three Quarter Four Headquarters Pensacola Tallahassee Alachua Jacksonville St. Petersburg Tampa Orlando Fort Myers Jupiter Fort Lauderdale Miami
Pharmacies are included among the facilities inspected across the state; Both Section 456.069, Florida Statutes, and Section 465.17, Florida Statutes, provide inspectors in MQA with the legal authority to inspect pharmacies. During an inspection, components such as proper record-keeping, inventory maintenance, and security of controlled substances are evaluated to ensure that facilities meet minimum standards of operation and practice. While pharmaceutical compliance is complex and can differ depending on the type of pharmacy at issue, pharmacies are generally subjected to inspection prior to permitting and licensing, after receipt of an application for a change in location or change of ownership, and routinely to ensure compliance. Like is required of M.O.D.E. facilities, pharmacy inspections are statutorily required to be completed within 30 days – a benchmark that MQA consistently outperforms. In fact, over the last five years, MQA continues to complete each pharmacy inspection within 14 days, including all initial inspections where the applicant did not formally request a delay (Figure 4.1). Q3 • Quarterly Performance Report 2021-22 8 4. Pharmacy Inspections Figure 4.1: Average Days to Complete a Pharmacy Inspection Data source: MQA Licensing and Enforcement Information Database System (LEIDS). 8.0 6.0 4.0 2.0 0.0 GOAL= 14 Days 10.0 12.0 14.0 Days FY 2016-17 FY 2017-18 FY 2018-19 FY 2019-20 FY 2021-22 FY 2020-21 8.8 6.7 8.8 9.1 10.0 6.5 7.8 7.4 9.4 9.1 8.5 8.2 8.2 8.6 9.6 11.5 10.9 7.0 8.2 11.5 10.9 13.8 16.0 8.5 Quarter One Quarter Two Quarter Three Quarter Four
Q3 • Quarterly Performance Report 2021-22 9 64% of the 77 Emergency Orders issued during the fourth quarter were Emergency Suspension Orders, whereas 36% were Emergency Restriction Orders. After final orders are imposed, CMU works with licensees to ensure compliance with applicable terms and penalties. During the fourth quarter, 224 final orders were imposed and, of the $409,139.54 fines and costs imposed by final orders, 98% or $401,179.82 were collected. The majority of active cases that remain are located in CSU at 9,219 active cases, followed by CMU at 5,393, PSU at 4,217, and ISU at 685. Enforcement Data The Consumer Services Unit (CSU), Investigative Services Unit (ISU), and Compliance Management Unit (CMU) investigate complaints involving regulated health care practitioners. Together, these units comprise the Bureau of Enforcement, which collaborates with the Prosecution Services Unit (PSU) to enforce appropriate Florida Statutes, rules, and laws. CSU investigators and analysts identify, analyze, monitor, and centralize all complaints. During the fourth quarter, CSU received 12,500 complaints alleging the improper practice of a health care profession or the operation of establishments without an appropriate license. Of those complaints, 1,441 were deemed legally sufficient. PSU attorneys litigate disciplinary cases on behalf of the health care regulatory boards and councils by reviewing investigations, drafting Emergency Orders, and providing boards and councils with disciplinary recommendations. Emergency action is imposed for violations that pose an immediate and severe threat to the public, per Section 456.074, Florida Statutes. Figure 5.1: Enforcement Process Explained Complaints Received Analysis Legally Non-Sufficient Investigation Disputed Citation Issued Attorney Review Election of Rights Final Order Imposing Discipline Filed Probable Cause Review Non-Disputed Final Order Referral Complaint Closed Informal Board Hearing (No Dispute) Appeal Procedures Compliance Monitoring Board Hearing Waived (No Dispute) DOAH Hearing Settlement for Board Approval Dismissal (No Probable Cause) Probable Cause Prosecution Administrative Complaint Filed Full Board Action and Deposition Emergency Action Mediation
Q3 • Quarterly Performance Report 2021-22 10 FINES AND COST DATA FOR CURRENT LICENSEES $409,139.54 FINES AND COSTS IMPOSED 77 EMERGENCY ORDERS ISSUED 1,394 INVESTIGATIONS COMPLETED CSU CMU PSU ISU 9,219 5,393 4,217 685 NUMBER OF ACTIVE CASES Emergency Suspension $7,959.72 Emergency Restriction $401,179.82 64% 36% EMERGENCY ORDERS ISSUED INVESTIGATIONS COMPLETED No Probable Cause Probable Cause Citations Issued Dismissed ICU PSU CMU CSU Active Cases 9219 5393 4217 685 ICU PSU CMU CSU Emergency Orders Issued 907 Dollar Amount Uncollected 44 302 Dollar Amount Collected 43
From conducting public outreach and complex investigations to issuing cease-and-desist orders, the Unlicensed Activity (ULA) program aims to educate and protect Florida residents and visitors against the potentially serious and dangerous consequences of receiving medical and health care services from an unlicensed person. The ULA program relies on its partnerships with law enforcement agencies and the state attorney’s offices to prosecute those who practice without a license. In many instances, unlicensed activity is a felony-level criminal offense per Section 456.065, Florida Statutes. More importantly, receiving health care from unlicensed people is dangerous and could result in further injury, disease, or even death. MQA continues to track the number of cease-and-desist orders against unlicensed persons to assess the impact of its enforcement processes (Figure 6.1). When practitioners pay their licensing fees, five dollars is designated specifically for the enforcement of unlicensed activity. FIGURE 6.1 ULA - Orders to Cease and Desist Q3 • Quarterly Performance Report 2021-22 11 Unlicensed Activity EXPLAINER: What is Unlicensed Activity? Unlicensed activity is considered the unlicensed practice of a health care profession or the performance or delivery of a medical or health care service to patients without a valid, active license to practice, regardless of the means of the performance or delivery of such services. Consumers are encouraged to verify the license of their health care provider by utilizing the www.FLHealthSource. gov/ula website, or calling 1-877-HALT-ULA, to speak directly with an investigator in the Consumer Services Unit. Tips of suspicious or potential unlicensed activity may be emailed to HALTULA@FLHealth.gov. 80 60 40 20 100 120 160 180 200 140 Number of Orders FY 2016-17 FY 2017-18 FY 2018-19 FY 2019-20 FY 2021-22 118 FY 2020-21 162 102 101 55 35 40 131 125 162 119 156 164 146 120 179 146 118 172 110 138 136 0.0 Data source: MQA Licensing and Enforcement Information Database System (LEIDS). 155 Quarter One Quarter Two Quarter Three Quarter Four
Q3 • Quarterly Performance Report 2021-22 12 MQA is funded by a trust fund, which consists of fees and fines collected throughout the licensing and enforcement processes. These funds are allocated among the regulatory boards and councils to provide administrative support for the licensure and regulation of health care practitioners. Per Section 456.025(9), Florida Statutes, MQA continues to provide a quarterly management report of revenues and expenditures, including the fees that are collected and the expenses paid from the trust fund (Figure 7.1). At the end of each year, MQA calculates the cost to regulate professions and reviews the adequacy of license renewal fees to ensure professions cover their costs of regulations. MQA collaborates with the regulatory boards and councils whenever possible to reduce fees and ensure that the administrative costs of licensure and regulation do not dissuade health care practitioners from practicing their profession in the State of Florida. Financial Data Financial Data MQA licenses qualified applicants in conjunction with the regulatory board that oversees each profession. Title Licensed Unlicensed Total Beginning Cash Balance $32,209,759 $5,405,926 $37,615,685 07/01/2021 Total Revenues $87,733,751 $2,199,103 $89,932,818 3/31/2022 Total Expenditures $60,010,230 $3,374,271 $63,384,501 3/31/2022 Ending Cash Balance2022 $59,953,244 $4,230,758 $64,164,002
Q3 • Quarterly Performance Report 2021-22 13 Emergency Action An action taken by the State Surgeon General to suspend or restrict the ability to practice when a licensed health care practitioner poses an immediate and serious threat to the health, safety, and welfare of the public. Emergency Suspension Order (ESO) An order issued by the Florida Department of Health suspending the license of a practitioner. A practitioner may not practice in the state of Florida while under an emergency suspension order. Emergency Restriction Order (ERO) An order issued by the Florida Department of Health restricting the practice of a practitioner in the state of Florida under conditions specified by the Department. Final Order An order of a regulatory board or the Department of Health outlining the finding of facts, and penalties in a disciplinary case against a licensee. The administrative complaint outlining the charges against the licensee is attached and becomes part of the final order when it is filed with the agency clerk. Investigations Completed Investigations are initiated when a complaint is considered legally sufficient. All completed investigations are presented to the Prosecution Services Unit with an Investigative Report and all documents related to the complaint. Legally Sufficient Complaints that, if found to be true, show a potential violation of Florida Statutes or Rules. LEIDS Licensing and Enforcement Information Database System. MQA’s licensure and enforcement database. MQA Trust Fund Unlicensed Activity Fee A five dollar fee collected at initial and renewal licensing that funds the investigation and enforcement of unlicensed activities, according to Florida law. Probable Cause A determination that there is a reasonable basis to suspect that a person has violated or is violating the law. Qualified Applicant A qualified applicant has met all requirements to become licensed and could essentially be licensed on the day they become qualified. This is different from an approved applicant who may still have to pass an examination or meet an additional requirement outside of having their application approved. Unlicensed Activity (ULA) Potentially dangerous activity by an unauthorized person that could cause injury, disease, or death. Glossary
(850) 245-4224 www.flhealthsource.gov MedicalQualityAssurance@flhealth.gov Department of Health Medical Quality Assurance 4052 Bald Cypress Way Bin C-00 Tallahassee, FL 32399-3250 Medical Quality Assurance leverages cuttingedge technology to power the enforcement, licensure, and information chatbot, ELI. ELI is the best way to learn about licensure requirements, initial application status, renewal requirements, fees, address updates, background screening processes, and public records requests. HOW IT WORKS Immediate ELI is just a tap away so that customers can get in touch from anywhere, at any time of day – chat is available 24/7. Personal ELI’s simple, intuitive design combined with an insight engine guides users through the customer journey to create custom conversations in minutes – and it does so on any device. Actionable ELI takes the guesswork and waiting out of the process and navigates customers to the right answers at the right time by delivering accurate, real-time advice and direction. IN A NUTSHELL Through a conversational platform powered by trusted content, ELI leverages data and efficient workflows to interpret the user’s questions and give actionable recommendations. The platform runs as a chatbot and voice-based application to provide customers with an additional method to contact MQA. Use the ‘chat now’ button to begin your discussion with ELI or look for ELI’s image in the bottom right corner of your device as you navigate the board and MQA pages. Who is ELI? Contact Us Your feedback is important to us. If you have questions or suggestions about this report, please let us know.
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