MQA Quarterly Performance Report

A Medical Quality Assurance Publication April - June 2022 QUARTERLY Florida Department of Health PERFORMANCE REPORT QPR • FOUR

MISSION To protect, promote, and improve the health of all people in Florida through integrated state, county, and community efforts. VISION: TO 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. INFORM ENFORCE LICENSE

4 Letter from the Director 4 Executive Summary 5 Performance Statistics 5 Initial Applications 6 License Renewals 7 M.O.D.E. Inspections 8 Pharmacy Inspections 9 Enforcement Data 11 Unlicensed Activity 12 Financial Summary 13 Glossary 14 Contact Us

Q4 • Quarterly Performance Report 2021-22 4 It is my pleasure to present to you the Quarterly Performance Report for the fourth quarter of the fiscal year 20212022. During this quarter, the Division of Medical Quality Assurance (MQA) celebrated many great successes that are included in the pages of this report. This report also includes information on key performance measures and highlights available consumer information. MQA constantly seeks improvement opportunities of our business processes to better serve licensees, practitioners, and health care consumers. Our staff works in conjunction with 22 regulatory boards and four councils to uphold the Department of Health's mission to protect, promote and improve the health of all people in Florida. We have been able to accomplish this through multiple initiatives as outlined below, ranging from educational presentations for graduates entering the workforce, to improvements in our customer service strategies. I am confident that the readers of this report will see our commitment to our mission and the health care practitioners, applicants and consumers we serve. Sincerely, Jennifer L. Wenhold, MSW, CPM • In April, the Boards of Medicine and Osteopathic Medicine hosted an online seminar for medical school program coordinators and doctors transitioning into their residencies. This online presentation, in cooperation with the Council of Florida Medical School Deans Graduate Medical Education Task Force, provided licensees with key information to expedite their licensing processes. • MQA is placing customers first as a result of installing a call-back assistant tool on the primary MQA Customer Contact Center phone line. Rather than waiting in the queue, this feature allows customers to schedule a returned phone call at a time convenient to them, saving time for customers and resources for the organization. The new enhancement also reduces the time to answer and call-abandonment rates and provides a better customer experience during periods of high call volume and longer wait times. • This quarter, MQA enhanced the artificial intelligence of our chatbot, ELI, to provide faster, more accurate responses to a wider variety of customer inquiries. As a result, ELI can conduct business at a higher level of performance, increasing customer satisfaction and using fewer resources to do so. Also, MQA positioned ELI to respond to changing customer needs by expanding the chat function to include online, voice, and text interfaces. Customers can now experience greater self-service through their preferred method of communication when conducting business, like processing payments for address and name changes or requesting a duplicate license. Letter From the Director Executive Summary MQA contributes to the mission of the Department of Health 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.

Q4 • 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 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 1.1

Q4 • 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 2.2. 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). TIME TO RENEW Revise Revise Deficient Complete Apply for Renewal Approved Denied Deficiency Letter Sent 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 0.4

Q4 • 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 code rules, 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 4.89

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, 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. 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). Q4 • 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 8.1

Q4 • Quarterly Performance Report 2021-22 9 Enforcement Data Figure 5.1: Enforcement Process Explained Final Order Imposing Discipline Filed Full Board Action and Deposition Informal Board Hearing (No Dispute) Board Hearing Waived (No Dispute) DOAH Hearing Settlement for Board Approval Appeal Procedures Compliance Monitoring Election of Rights Administrative Complaint Filed Complaints Received Analysis Legally Non-Sufficient Investigation Disputed Citation Issued Attorney Review Probable Cause Review Non-Disputed Final Order Referral Complaint Closed Dismissal (No Probable Cause) Probable Cause Prosecution Emergency Action Mediation 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 12,133 complaints alleging the improper practice of a health care profession or the operation of establishments without an appropriate license. Of those complaints, 1,392 were deemed legally sufficient. As the investigative arm of MQA, ISU tasks professional investigators and licensed dentists, nurses, and pharmacists with conducting inspections, interviews, and evidence collection. During the fourth quarter, a total of 1,340 investigations were completed and then presented to PSU with the corresponding Investigative Reports. 330 Instances of probable cause and 749 instances of no probable cause were determined, 56 cases were dismissed, and 49 citations were issued. 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. Of the 59 Emergency Orders issued during the fourth quarter, 68% were Emergency Suspension Orders whereas 32% 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, 291 final orders were imposed and, of the $642,067.73 fines and costs imposed by final orders, 61% or $392,187.40 was collected. The majority of active cases that remain are located in CSU at 10,065 active cases, followed by CMU at 5,484, PSU at 4,760, and ISU at 704.

and as compared to FY 2021-2022 QPR-3 data. Q4 • Quarterly Performance Report 2021-22 10 FINES AND COST DATA FOR CURRENT LICENSEES $642,067.73 FINES AND COSTS IMPOSED NUMBER OF ACTIVE CASES $249,880.33 $392,187.40 EMERGENCY ORDERS ISSUED INVESTIGATIONS COMPLETED Dollar Amount Uncollected Dollar Amount Collected No Probable Cause Probable Cause Citations Issued Dismissed 749 56 330 49 158 28 12 6 59 EMERGENCY ORDERS ISSUED Emergency Suspension Emergency Restriction ● 68% ● 32% 12% 4% CSU CMU PSU ISU ● 10,065 ● 5,484 ● 4,760 ● 704 846 543 91 19 $241,920.61 1,340 INVESTIGATIONS COMPLETED ICU PSU CMU CSU Active Cases 9219 5393 4217 685 Active Cases ICU PSU CMU CSU Emergency Orders Issued Emergency Orders Issued $8,992.42 An increase of $232,928.19 A decrease of 54

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 Number of Cease-and-Desist Orders Issued Against Unlicensed Persons Q4 • 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 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 2020-21 162 101 102 55 35 40 131 125 162 119 156 164 146 120 179 146 118 172 110 138 136 Data source: MQA Licensing and Enforcement Information Database System (LEIDS). 155 Quarter One Quarter Two Quarter Three Quarter Four 261Investigations Completed by the division. 136Cease-and-Desist Orders issued to unlicensed practitioners. 139Complaints Referred to law enforcement agencies. 205ULA Complaints Received in the fourth quarter. 248Complaints Referred for further investigation. 136 0.0

Q4 • 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 Summary Title Licensed Unlicensed Total Beginning Cash Balance $32,209,758 $5,405,925 $37,615,683 07/01/2021 Total Revenues $96,088,265 $3,170,471 $99,258,736 6/30/2022 Total Expenditures $90,206,796 $4,443,346 $94,650,142 6/30/2022 Ending Cash Balance $38,088,177 $4,133,050 $42,221,227 2022 Figure 7.1: Financial Data MQA licenses qualified applicants in conjunction with the regulatory board that oversees each profession.

Q4 • 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

WHAT IS ELI? 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. (850) 245-4224 Department of Health Medical Quality Assurance 4052 Bald Cypress Way Bin C-00 Tallahassee, FL 32399-3250 Contact Us Your feedback is important to us. If you have questions or suggestions about this report, please let us know. CHAT NOW