QPR TWO Ron DeSantis Governor Joseph A. Ladapo, MD, PhD State Surgeon General QUARTERLY PERFORMANCE REPORT A Medical Quality Assurance Publication Florida Department of Health OCTOBER - DECEMBER 2022
To be the healthiest state in the nation. Mission Vision To protect, promote, and improve the health of all people in Florida through integrated state, county, and community efforts. Values We search for creative solutions and manage resources wisely. We use teamwork to achieve common goals and solve problems. We perform with integrity and respect. We achieve our mission by serving our customers. We promote quality outcomes through learning and continuous performance improvement. INNOVATION COLLABORATION Table of Contents Letter from the Director Executive Summary Around MQA Performance Statistics Enforcement Financial Summary Glossary Contact Us ACCOUNTABILITY RESPONSIVENESS EXCELLENCE 02 03 05 08 11 14 15 16 MEDICAL QUALITY ASSURANCE | FY 2022-23 QUARTERLY PERFORMANCE REPORT 2 01
It is with great pride that I present to you the Quarterly Performance Report (QPR) for the second quarter of FY 2022-23. This report captures accomplishments reflected by our key performance measures, in addition to the various quarterly activities and improvements completed by the Division of Medical Quality Assurance (MQA). Together, these items provide a clear and meaningful understanding of MQA’s operational status at the quarter's close while acknowledging the progress toward achieving key performance throughout the fiscal year. MQA experienced an exemplary second quarter, excelling in its performance and continuing to place quality as a priority. We not only met but exceeded our performance goals, many by more than double the desired target. I am proud of our consistent dedication to apply and renew best practices to improve health care regulation in Florida. We pushed new, innovative projects and took pre-existing initiatives to the next level this quarter, bringing more convenience and flexibility to licensees. We did this all while demonstrating our resourcefulness and dedication in the face of hurricanes impacting our state. The findings of this report show that MQA has closed this quarter in exemplary shape and is positioned to sustain the mission of protecting, promoting, and improving the health of all Floridians. I am confident that readers of this report will agree and join me in looking forward to seeing how else MQA can support our health care workforce through regulatory excellence. MQA experienced an exemplary second quarter. We not only met but exceeded our performance measures, many by more than double the desired target. " LETTER FROM THE DIRECTOR MEDICAL QUALITY ASSURANCE | FY 2022-23 QUARTERLY PERFORMANCE REPORT 2 02 JENNIFER L. WENHOLD, MSW, CPM
As required by section 456.005, Florida Statutes, the QPR details the latest performance statistics of MQA’s key functions and responsibilities as related to the goals of the Department of Health (Department). This report serves as an assessment of MQA’s operational health and performance during the second quarter of fiscal year 2022-23. Per section 456.065(3), Florida Statutes, all financial data resulting from the enforcement of unlicensed activity is included, as well as the latest summary of MQA’s financial status. EXECUTIVE SUMMARY LICENSE ENFORCE INFORM The information captured within this report represents MQA’s commitments to timely licensing qualified health care practitioners, enforcing a regulatory standard of care, and promoting meaningful information to practitioners, applicants, and consumers. MQA utilizes quarterly performance measures to assess the health of key business processes through specific, quantifiable goals. Meeting target goals indicate success toward achieving strategic measures. MQA 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. How We Work MEDICAL QUALITY ASSURANCE | FY 2022-23 QUARTERLY PERFORMANCE REPORT 2 03
$635,307.27 fines and fees imposed. 8,417 enforcement complaints received. 233 unlicensed activity cases referred for investigation. 25,801 initial licenses Issued. AT A GLANCE Quarter 2 0.9 5.3 7.0 Process an Initial Application Process a Renewal Application Complete a M.O.D.E. Inspection Complete a Pharmacy Inspection 0.4 For over five fiscal years, MQA has met the desired benchmarks in three of its key performance measures: the average time to process renewal applications, conduct inspections of massage, optical, dental lab, and electrolysis (M.O.D.E.) establishments, and conduct inspections of pharmacies. This quarter, MQA completed these activities in nearly half the time of the desired goal or less. MQA also surpassed the target goal of one day to process initial licenses for qualified applicants; 67% of applicants were issued an initial license, advancing over 25,000 new health care practitioners into Florida’s workforce. In the area of enforcement, MQA processed nearly 8,500 complaints in the second quarter. Nearly 1,000 cases were found to be legally sufficient to justify an investigation, and over 1,000 investigations were completed. Of the $635,000 in fines and fees imposed this quarter, 70% were collected. Over 350 instances of probable cause were found in the second quarter, and subsequently referred to the regulatory boards and councils for further disciplinary action. MQA issued 40 Emergency Orders, split almost evenly between Emergency Suspensions and Emergency Restrictions. 9 OUT OF 10 Renewal applications were processed online. MQA closed the second quarter with a total cash balance of $32,475,109. MEDICAL QUALITY ASSURANCE | FY 2022-23 QUARTERLY PERFORMANCE REPORT 2 04 Quarterly Averages In Days:
The Crossroads Between Workforce, Education, and Licensing MQA’s Virtual Agent, ELI, continues to revolutionize the way MQA delivers licensing, renewal, and informational services to health care practitioners and licensees. Since expanding online, voice, and text capabilities in October 2022, ELI has processed license renewal requests and related payments by practitioners, all without the need by practitioners to access MQA’s Online Services Portal. ELI answers complex questions in lieu of a live agent and is available after hours, over weekends, and on holidays, providing more flexibility to renewing practitioners outside of 8:00 a.m. to 5:00 p.m. More professions will be able to enjoy this benefit in the coming months as the renewal dates approach. Find ELI on the various board and council pages at FLHealthSource.gov, or learn more at FLHealthSource.gov/ELI. In October 2022, Board of Medicine staff supported student transition into the workforce by virtually presenting the licensure process to the graduating class of the Physician Assistant Studies Program at Florida Gulf Coast University. By describing the steps and requirements involved with completing an initial and renewal application for licensure, MQA advances graduate preparedness, encourages employability, and empowers future health care practitioners to immediately contribute to the workforce with proper credentialing upon graduation. What's New with ELI? AROUND MQA MEDICAL QUALITY ASSURANCE | FY 2022-23 QUARTERLY PERFORMANCE REPORT 2 05
MQA is pleased to announce a new licensure experience for health care practitioners. Starting in the summer of 2023, electronic licenses (e-licenses) will replace the current practice of printing and mailing paper-based licenses. For each profession regulated by MQA, the transition to paperless licensing means seamlessly retrieving licenses through the MQA Online Services Portal within two business days of an approved application. The electronic process will allow practitioners to obtain a newly issued or newly renewed license free of charge and 7-10 days earlier than the previously mailed versions. The e-licenses include QR codes that increase the information security of licenses and enable users, such as employers and consumers, to access and verify the credentials of health care practitioners. Combining the growing health care workforce and the use of mobile devices, it is critical that MQA continues to develop innovative strategies to meet the needs of practitioners and streamline access to key documents that provide credibility to entering the workforce. e-Licensing demonstrates the commitment of the Department to expedite licensure and verification processes so that health care practitioners can get to work quickly and continue working through successful licensure renewal cycles without interruption. Licensed health care practitioners are encouraged to visit MQA’s Online Services Portal to ensure contact information is updated and accurately displayed within their account. To learn more, please visit the electronic license Frequently Asked Questions page or ask MQA’s Virtual Agent, ELI, by visiting FLHealthSource.gov/ELI. MEDICAL QUALITY ASSURANCE | FY 2022-23 QUARTERLY PERFORMANCE REPORT 2 06 e-Licensing: A New Licensure Experience for Health Care Practitioners
On September 28, 2022, Hurricane Ian made landfall as a high-end category 4 storm in Southwest Florida, tying for the fifth-strongest hurricane to strike the continental United States. The storm posed great uncertainty to the state of Florida, yet MQA remained equipped to prepare health care practitioners with timely information and quality licensure services against an emerging public health threat. MQA leveraged its partnerships with health care practitioners, associations, and regulatory boards and councils to deliver urgent notifications about emergency directives affecting professions via mass email communications, web-based alerts, and realtime chat services. This communication empowered health care practitioners with the information needed to continue serving on the frontlines and provided health care consumers with the resources needed to ensure health and well-being during the event. Realizing the immediate need to mobilize medical personnel to areas devastated by Hurricane Ian, the Department joined forces with Volunteer Florida to promote an online portal for licensed health care practitioners, both in-state and out-of-state, to volunteer expertise, skills, and time in areas impacted by Hurricane Ian. As a result, over 34,000 practitioners who indicated a willingness to serve in a disaster or emergency were more readily positioned to deploy through a trusted organization in an organized and tactical manner. MQA also deployed nearly 10% of its workforce and redirected resources to maintain critical licensure processes. Teams concentrated efforts to drastically reduce the time to license practitioners of emergent professions, such as nurses, emergency medical services, and mental health practitioners. The Board of Nursing was one unit that demonstrated this commitment to reducing processing times, as associated initial applications were processed in under 24 hours. Hurricane Ian Response Efforts September - October 2022 The storm posed great uncertainty to the state of Florida, yet MQA remained equipped to prepare health care practitioners with timely information and quality licensure services... " MEDICAL QUALITY ASSURANCE | FY 2022-23 QUARTERLY PERFORMANCE REPORT 2 07
MQA continues to assess the efficiency of its licensure process by measuring the average number of days to process a license for a qualified applicant. Important distinctions exist between qualified applicants and approved applicants. Qualified applicants are defined as those who meet all the prerequisites for licensure, whereas approved applicants may still be required to satisfy supplementary requirements such as examinations. These requirements reflect the standard of care expected by practitioners in each profession. When missing key pieces of information that are required for processing, an application is considered deficient and returned to the applicant for corrections. Application requirements vary by profession, ranging from possessing a certain level of education to passing numerous competency examinations. The measurement of processing time does not begin until a completed application with all critical items has been received by MQA. MQA aims to process initial licensure applications for qualified applicants in one day or less, and met its goal in the second quarter as the average processing time was less than one day per application-a decrease when compared to the processing time of 1.12 days of the first quarter (Figure 1). MQA has kept this processing time at 1.6 days or less for the past four fiscal years, moving over 464,000 new practitioners into the workforce quickly and efficiently. PERFORMANCE STATISTICS Initial Applications MEDICAL QUALITY ASSURANCE | FY 2022-23 QUARTERLY PERFORMANCE REPORT 2 08 In the second quarter, MQA received 38,545 initial applications for licensure and issued 25,801 initial licenses to new practitioners. Figure 1: Average Days to Process an Initial Application
Most health care licensees and facilities are required to renew their license biennially in order to maintain the right to practice; however, some professions require annual renewal of the license. To learn more about the renewal process, visit: FLHealth Source.gov/ requirements. Individual practitioners are responsible for meeting ongoing license requirements and seeking renewal as appropriate. Each regulated profession has its own set of renewal requirements, such as the length of time between renewals, as well as continuing education credit requirements to update and reinforce knowledge of the profession(s). MQA continually improves its operations to provide an expeditious license renewal experience for applicants, including providing the convenience of applying for renewal online through MQA's Virtual Agent, ELI, and a more comprehensive online service account experience by applying system changes. As shown by Figure 2, MQA processes renewal applications from qualified applicants within an average of one day and has consistently met this goal for the past five fiscal years. The processing time for renewal applications averaged 0.4 days, a slight increase from the previous quarter but still well within MQA’s goal of one day or less. Online has remained the preferred method to submit renewal applications, as over 90% of applications received since FY 2013-14 were submitted digitally. Thousands of licensees have benefitted from shorter processing times without additional postal processing. In fact, 120,086 licensure renewals were processed online during the second quarter, which is a 20% increase from the previous quarter. MEDICAL QUALITY ASSURANCE | FY 2022-23 QUARTERLY PERFORMANCE REPORT 2 08 License Renewals Figure 2: Average Days to Process a Renewal Application
MEDICAL QUALITY ASSURANCE | FY 2022-23 QUARTERLY PERFORMANCE REPORT 2 09 Massage, Optical, Dental Lab, and Electrolysis Establishment Inspections MQA completed M.O.D.E. inspections in an average of 5.3 days this quarter, reflecting its commitment to regulatory efficiency. MQA is tasked with regulating massage, optical, dental lab, and electrolysis establishments, also referred to as M.O.D.E. By deploying teams of inspectors, MQA monitors the compliance of over 11,300 active M.O.D.E. facilities across Florida. Inspections occur following several qualifying events, such as the creation of a new establishment, change in ownership or address, or on an annual or biennial basis. Teams routinely travel within Florida's 11 investigative services regions to ensure establishments and practitioners follow all relevant state statutes, administrative codes, and federal regulations. MQA measures the average number of days needed to complete a M.O.D.E. inspection from start to finish (often from the date an establishment is ready to begin practice). MQA regularly completes these inspections below the target (10 days), which includes initial inspections prior to the start of practice that do not include a formal request of delay by the applicant. Teams maintain a standard process for conducting inspections, including implementing best practices to identify, monitor, and execute the tasks associated with the inspection process through immediate goals and timelines. The tasks and best practices are documented and evaluated regularly through tools such as process guides, qualify checklists, and performance reports to encourage improvement and innovation. Figure 3: Average Days to Complete a M.O.D.E. Inspection
MEDICAL QUALITY ASSURANCE | FY 2022-23 QUARTERLY PERFORMANCE REPORT 2 10 Sections 456.069 and 465.017, Florida Statutes, grant MQA the authority to inspect the procedures and conditions of pharmacies such as proper signage, staffing, policies and procedures, and dispensing practices to ensure facilities meet the standard of practice prior to opening or continuing operating. MQA conducts pharmacy inspections following certain qualifying events such as the application for a new establishment, a change in location or ownership, routine regulatory compliance, and when investigating complaints. New pharmacies are required to undergo an inspection prior to the issuance of a facility license. Inspection teams consist of pharmacists with prior experience in the pharmaceutical field. As subject matter experts, these inspectors provide additional context to the inspection process gained from years of serving as working practitioners. As shown by Figure 4, the average time to complete a pharmacy inspection has remained under 10 days for over five fiscal yearsa result consistently better than the target goal (14 days). MQA continued to exceed its goal this quarter, completing inspections nearly two days sooner than the previous quarter (7.0 versus 8.8, respectively). Pharmacy Inspections Figure 4: Average Days to Complete a Pharmacy Inspection
8,417 Restriction Suspension MEDICAL QUALITY ASSURANCE | FY 22-23 QUARTERLY PERFORMANCE REPORT 2 1 1 ENFORCEMENT The Bureau of Enforcement (BOE) comprises of three units: the Consumer Services Unit (CSU), Investigative Services Unit (ISU), and Compliance Management Unit (CMU). In conjunction with the Prosecution Services Unit (PSU), BOE is tasked with enforcing the regulatory standards for health care practice as established by Florida’s statutes, rules, and laws. As the first point of contact, CSU identifies and receives all complaints submitted to MQA. This unit performs the initial analyses of complaints to determine legal sufficiency. In the second quarter, CSU received 8,417 complaints alleging the improper practice of a health care profession or the operation of establishments without an appropriate license-a 38% decrease from the previous quarter. Of those complaints, 973 were deemed legally sufficient and forwarded to an investigative team. CSU recorded the highest number of active complaints this quarter at 12,216, reflecting its position as the central intake point of the enforcement process. The other units followed with 5,060 cases in CMU, 4,387 cases in PSU, and 617 cases in ISU. Once complaints are deemed legally sufficient, ISU deploys investigators to gather evidence through conducting witness interviews or collecting documentation. In the second quarter, 1,044 total investigations were completed and presented to PSU with the corresponding investigative reports. 42% 58% After receiving ISU referrals, PSU attorneys research and litigate the cases on behalf of the health care regulatory boards and councils, including drafting emergency orders, reviewing investigations, and presenting disciplinary recommendations to the boards and councils. For suspected violations that pose an immediate and severe threat to the public, PSU may issue Emergency Orders, per section 456.074, Florida Statutes, which are signed by the State Surgeon General and provide immediate action. Emergency Restrictions Orders limit the professional activities of a suspect practitioner, whereas Emergency Suspensions Orders suspend a license for the duration of the order. During the second quarter, 58% of the 40 Emergency Orders issued were Emergency Suspension Orders whereas 42% were Emergency Restriction Orders (or 23 and 17, respectively). CMU works with licensees to ensure continued compliance with the imposed terms and penalties. In the second quarter, 312 Final Orders were imposed and, of the $635,307.27 fines and fees incurred by Final Orders, 70% (or $442,605.69) were collected. EMERGENCY ORDERS ISSUED
Unlicensed Activity While responsible for the licensing and regulation of over 200 health care professions, MQA also identifies and inspects health care activities occurring outside the bounds of licensed practice. MQA is tasked with curbing such unauthorized practice and spreading awareness of the dangers of unlicensed activity through ISU's Unlicensed Activity Program (ULA). MQA monitors for and investigates unlicensed activity ranging from I.V. hangover bars to unsanctioned pain management clinics. MQA acts when unlicensed activity is discovered and legal sufficiency is found by issuing fines, citations, and cease-and-desist orders. Many forms of unlicensed activity are potentially dangerous enough to be classed as a felony criminal offense under section 456.065, Florida Statutes. Accordingly, investigators apprise law enforcement of suspected criminal misconduct. Law enforcement agencies are key partners of the ULA program, providing information and mutual assistance during investigations. ULA staff frequently present to agencies such as police departments and sheriff’s offices to educate officers on the nuances of unlicensed activity and encourage open communication with investigators. ULA also utilizes robust marketing and outreach initiatives to educate the public on unlicensed activity signs, dangers, and reporting processes. ULA outreach varies from attending local community events to creating mass-marketing digital campaigns that target large metropolitan areas. ULA program activities, such as marketing initiatives, are funded through an earmarked $5 fee that is paid by prospective licensees and renewing practitioners when submitting an initial or renewal application. MEDICAL QUALITY ASSURANCE | FY 22-23 QUARTERLY PERFORMANCE REPORT 2 1 2
Consumers may verify the license of a practitioner through MQA’s License Verification Portal to ensure that the individual offering services possesses a valid and active license to practice. MQA continually tracks the number of cease-and-desist orders issued against unlicensed persons to better assess the impact of ULA’s enforcement processes. ULA investigators issued 94 cease-and-desist orders in the second quarter against individuals and businesses that posed an immediate threat to the health of all people in Florida. During this period, MQA received 164 complaints of suspected unlicensed activity and 223 cases were referred for investigation. ULA completed 212 investigations in the second quarter while referring 99 cases to law enforcement for potential criminal investigations. ULA Complaints Received 164 99 94 223 Complaints Referred for Investigation Complaints Referred to Law Enforcement Investigations Completed Cease-and-Desist Orders Issued 212 Figure 5: Cease-and-Desist Orders Issued MEDICAL QUALITY ASSURANCE | FY 22-23 QUARTERLY PERFORMANCE REPORT 2 1 3
Licensed Unlicensed Total Beginning Cash Balance 07/01/2022 $38,088,177 $4,133,050 $42,221,227 Total Revenues 12/31/2022 $32,222,214 $1,068,592 $33,290,806 Total Expenditures 12/31/2022 $41,836,410 $1,200,514 $43,036,924 Ending Cash Balance 12/31/2022 $28,473,981 $4,001,128 $32,475,109 MEDICAL QUALITY ASSURANCE | FY 22-23 QUARTERLY PERFORMANCE REPORT 2 14 FINANCIAL SUMMARY This report provides the most current financial data available to illustrate MQA’s fiscal status. As required by section 456.025(9), Florida Statutes, the quarterly report includes revenues and expenditures, in addition to fees collected and expenses paid by the trust fund. MQA is funded through the MQA Trust Fund which comprises fines and fees that are collected throughout the fiscal year including application fees, unlicensed activity fees, and disciplinary fines. These funds are distributed between the 22 regulatory boards and councils, and MQA, to support the administrative functions of health care practitioner licensing and regulation. The costs to regulate each profession are reassessed annually to determine if the associated fees provide adequate revenue to maintain support and regulatory services. The following data include cumulative totals for revenues and expenditures from the start of FY 2022-23 to the end of the second quarter. Also included is MQA’s cash balance at the start of the fiscal year and cash balance as of the conclusion of the second quarter. The financial data are segmented between funds associated with licensed health care practice, and funds relating to the prevention and investigation of ULA, to monitor funding adequacy for the latter.
Licensed Unlicensed Total Beginning Cash Balance 07/01/2022 $38,088,177 $4,133,050 $42,221,227 Total Revenues 12/31/2022 $32,222,214 $1,068,592 $33,290,806 Total Expenditures 12/31/2022 $41,836,410 $1,200,514 $43,036,924 Ending Cash Balance 12/31/2022 $28,473,981 $4,001,128 $32,475,109 MEDICAL QUALITY ASSURANCE | FY 22-23 QUARTERLY PERFORMANCE REPORT 2 14 FINANCIAL SUMMARY This report provides the most current financial data available to illustrate MQA’s fiscal status. As required by section 456.025(9), Florida Statutes, the quarterly report includes revenues and expenditures, in addition to fees collected and expenses paid by the trust fund. MQA is funded through the MQA Trust Fund which comprises fines and fees that are collected throughout the fiscal year including application fees, unlicensed activity fees, and disciplinary fines. These funds are distributed between the 22 regulatory boards and councils, and MQA, to support the administrative functions of health care practitioner licensing and regulation. The costs to regulate each profession are reassessed annually to determine if the associated fees provide adequate revenue to maintain support and regulatory services. The following data include cumulative totals for revenues and expenditures from the start of FY 2022-23 to the end of the second quarter. Also included is MQA’s cash balance at the start of the fiscal year and cash balance as of the conclusion of the second quarter. The financial data are segmented between funds associated with licensed health care practice, and funds relating to the prevention and investigation of ULA, to monitor funding adequacy for the latter.
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 of Health. FINAL ORDER An order of a regulatory board or the Florida 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 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 Florida Administrative Code. MQA TRUST FUND UNLICENSED ACTIVITY FEE A $5 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 may be licensed on the day an application has concluded processing. This is different from an approved applicant who may still have to pass an examination or meet an additional requirement outside of having an application approved. UNLICENSED ACTIVITY (ULA) Unauthorized practice of a health care profession or delivery of health care or medical services by an individual not in possession of a valid or active license to practice that could cause injury, disease, or death. GLOSSARY MEDICAL QUALITY ASSURANCE | FY 22-23 QUARTERLY PERFORMANCE REPORT 2 1 5
For more information or to contact us, please visit our website, FLHealthSource.gov, or chat online with our virtual agent, ELI. Look for the ELI icon on the board and council websites and FLHealthSource.gov to chat online. Leveraging cutting edge artificial intelligence to improve the consumer experience, ELI is the MQA virtual agent available to assist current and prospective health care licensees with immediate information and suggestions. ELI provides flexible support to licensees and consumers by fielding inquiries outside of normal business through voice and online chat options. FLHealthSource.gov MedicalQualityAssurance@FLHealth.gov 850-488-0595 Department of Health Medical Quality Assurance 4052 Bald Cypress Way, Bin C-00 Tallahassee, FL 32399-3250 MEDICAL QUALITY ASSURANCE | FY 22-23 QUARTERLY PERFORMANCE REPORT 2 16 CONTACT US
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