MQA Quarterly Performance Report

QPR FOUR Ron DeSantis Governor Joseph A. Ladapo, MD, PhD State Surgeon General MARCH - JUNE 2023 QUARTERLY PERFORMANCE REPORT A Medical Quality Assurance Publication Florida Department of Health

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. MEDICAL QUALITY ASSURANCE | FY 2022-23 QUARTERLY PERFORMANCE REPORT 4 01 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 04 07 11 13 14 15

I am excited to present to you the Division of Medical Quality Assurance (MQA) Quarterly Performance Report (QPR) for the fourth quarter of FY 2022-23. Contained in this report are stories and statistics that illustrate the progress of MQA in fulfilling its commitment to protect, promote, and improve the health of all people in Florida. Key to achieving the mission of the Department of Health (Department) is the embrace of new technologies that modernize regulatory processes, partnerships and strengthen the collective impact we can have on public health in Florida, and the passion that each employee embodies to protect the public. Readers of this report will discover some exciting updates on MQA’s innovations in licensing and effectiveness in enforcement, such as the launch of a new renewal experience for nursing professions with MQA’s Virtual Agent, ELI. With ELI, Registered Nurse and Licensed Practical Nurse applicants can complete applications and receive real-time status updates while MQA staff redirects attention to aid customers with complex inquiries. As you flip through the pages, please join me in reflecting on our 20year partnership with CE Broker, which revolutionized the landscape of continuing education (CE) that benefits thousands of Florida health care practitioners. Celebrating this anniversary of bringing a leading electronic CE tracking system to Florida is a milestone achievement itself, but the journey would not have been possible without the dedicated commitment and support of all involved, including each employee and partner. Accompanying impressive case management performance by MQA enforcement staff, readers will also enjoy recognizing MQA for its involvement in the fight against human trafficking. MQA will always remain committed to ensuring safety among health care consumers, providing seamless licensure experiences for health care applicants, and bringing the health care workforce new and sustained improvements so that Florida may continue becoming the healthiest state in the nation. LETTER FROM THE DIRECTOR Accompanying impressive case management performance by MQA enforcement staff, readers will also enjoy recognizing MQA for its involvement in the fight against human trafficking. " JENNIFER L. WENHOLD, MSW, CPM MEDICAL QUALITY ASSURANCE | FY 2022-23 QUARTERLY PERFORMANCE REPORT 4 02

As required by section 456.025(9), Florida Statutes, the Quarterly Performance Report (QPR) details the latest performance statistics of MQA’s key functions and responsibilities as related to the goals of the Department. This report serves as an assessment of MQA’s operational health and performance during the fourth quarter of FY 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 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. MEDICAL QUALITY ASSURANCE | FY 2022-23 QUARTERLY PERFORMANCE REPORT 4 03 LICENSE ENFORCE INFORM How We Work MQA's Virtual Agent, ELI, handled over 50,000 web chats and 175,000 voice conversations with health care applicants and practitioners during Quarter Four. The total number of active complaint cases for Quarter Four is 27,140, which is a 4.8% decrease from Quarter Three. MQA completed 325 unlicensed activity investigations, issued 109 cease and desist orders, and escalated 121 cases to law enforcement for further investigation. As of Quarter Four, 1,478,142 health care practitioners are licensed in Florida. In Quarter Four, MQA received 42,709 initial applications and issued 36,036 initial licenses. On average, MQA processed initial applications within one day. As the number of applications received increased, the amount of time taken to issue licenses decreased.

A Fight Against Human Trafficking Human trafficking is the second largest criminal enterprise globally (after drug trafficking) and the victims of these crimes often develop health conditions from their ordeal. Health care practitioners are especially important in identifying trafficking victims and connecting them to helpful community resources. On May 5, MQA investigators helped to uncover human trafficking with the Ocala Police Department. As a result, the Ocala Police Department will continue its investigation with the assistance of the Department of Health, and regulatory cases will follow. The Department continues to maintain a resource library to help practitioners obtain training in servicing the needs of human trafficking victims and connecting them to helpful resources. AROUND MQA MEDICAL QUALITY ASSURANCE | FY 2022-23 QUARTERLY PERFORMANCE REPORT 4 04 In May, the Florida Boards of Osteopathic Medicine and Medicine were represented at the annual meetings of Administrators in Medicine (AIM) and the Federation of State Medical Boards (FSMB), in Minneapolis, Minnesota. Meeting attendees shared knowledge of industry best practices and exchanged recent developments in medical board regulation. Board Executive Directors brought this information back to MQA for consideration in daily operations and long-term planning including emerging trends in guidelines and policies for prescribing opioids, digital credentialing and regulation, handling sexual misconduct cases, and navigating state legislative issues. Board of Massage Therapy staff participated in a tabling event and discussion about Florida laws and rules at the Florida State Massage Therapy (FSMT) Association meeting in June. United under the mission to promote standards of excellence in health care, MQA regularly engages in outreach at meetings with association partners such as FSMT to put a friendly face to the Department and provide licensees with opportunities to interact with and have their questions answered by central office staff. MQA On the Go June 2023 marks 20 years since MQA entered its partnership with CE Broker to develop a centralized system for managing CE and CE provider applications. As a result, manual processes for CE management have decreased by 300%, and the audit rate of the Department increased from 3% to 100%, leading to an annual cost savings of $500,000. Additionally, the Prosecution Services Unit (PSU) efficiently prioritized cases and the number of CE audit cases against health care practitioners dramatically decreased. For more information on CE at MQA, visit FloridaHealth.gov/Licensing-and-Regulation/CE. Celebrating 20 Years with CE Broker

FY 2017-18 FY 2018-19 FY 2019-20 FY 2020-21 FY 2021-22 29,673 26,881 22,485 35,623 29,521 25,583 29,524 34,962 29,446 25,748 29,277 32,006 34,412 29,655 38,121 44,716 42,364 Figure 1: Initial Applications Received v. Average Days to Process FY 2022-23 34,928 44,353 38,857 33,201 37,856 42,709 Initial Applications Practitioners are expected to obtain the requisite subject matter knowledge and skills required of their profession prior to application for licensure. MQA verifies the qualifications of practitioners and issues licenses accordingly. In Quarter Four, MQA received 42,709 initial applications and issued 36,036 initial licenses. While MQA receives more applications in Quarter Four than in any other quarter, average processing times for applications have decreased overall. Whereas individual professions determine their scope of practice and licensure requirements, MQA ensures the licensure of qualified applicants through the timely processing of initial applications. PERFORMANCE STATISTICS MEASURE TARGET ACTUAL Average days to process an initial application 1 day 1.0 days Q: What does it mean to be a qualified applicant? A: A qualified applicant is one who meets all prerequisites for licensure. 0 46,167 1 2 3 Target Average Days MEDICAL QUALITY ASSURANCE | FY 2022-23 QUARTERLY PERFORMANCE REPORT 4 07

License Renewals MQA received 184,422 renewal applications in Quarter Four. Of those applications, 98.37% were processed online. On average, the processing time for renewal applications is 0.25 days, which is a slight increase from the average Quarter Four processing time of 0.22 days over the past six fiscal years. Boards that receive the highest number of late applications will identify processes that increase efficiency in application processing. As MQA receives its highest number of applications in Quarter Four, ELI can be used to further decrease renewal application approval times for future quarters. In addition to providing a platform for users to submit their applications, ELI also provides applicants with opportunities to check application statuses and address deficiencies that could lead to delays in processing. MEASURE TARGET ACTUAL Average days to process a renewal application 1 day 0.06 days Q: What is a deficiency? A: A deficiency is any missing or inaccurate component of the application. All licensure applications are required to have complete, accurate information for quick and easy processing. For more information about renewal requirements and renewal dates by profession, visit FLHealthSource.gov/requirements. FY 2017-18 FY 2018-19 FY 2019-20 FY 2022-23 0.2 0.2 0.2 0.5 0.4 0.4 0.5 0.3 0.3 0.2 0.3 0.2 0.1 0.7 0.2 0.2 0.2 0.1 0.1 0.1 0.04 0 1 0.5 Figure 2: Average Days to Process a Renewal Application Target FY 2021-22 FY 2020-21 0.4 0.1 0.06 MEDICAL QUALITY ASSURANCE | FY 2022-23 QUARTERLY PERFORMANCE REPORT 4 08

MEASURE TARGET ACTUAL Average days to complete a M.O.D.E. inspection 10 days 5.2 days Massage, Optical, Dental Lab, and Electrolysis Establishment Inspections Massage, optical, dental lab, and electrolysis establishments, also referred to as M.O.D.E. facilities, are routinely inspected to ensure that facility owners follow all applicable Florida Statutes, administrative code rules, and federal regulations. These inspections may be conducted throughout the life cycle of a facility and upon receipt of a request for inspection. During Quarter Four, M.O.D.E. inspections were completed within an average of 5.2 days, which is a slight decrease from its performance last quarter. Target Q: How often are M.O.D.E. facilities inspected? A: Inspections for M.O.D.E. facilities are required at specific intervals during a facility’s lifecycle, including the opening of a new establishment, upon a change in ownership or address, and on an annual or biennial basis. Figure 3: Average Days to Complete a M.O.D.E. Inspection FY 2017-18 FY 2018-19 FY 2019-20 FY 2020-21 FY 2021-22 FY 2022-23 4.3 4.4 5.4 7.6 5.6 5.1 5.9 5.2 4.8 4.3 4.6 4.8 5.0 4.2 5.3 4.9 4.7 4.5 4.9 4.7 0 10.0 5.0 9.0 5.3 5.4 5.2 MEDICAL QUALITY ASSURANCE | FY 2022-23 QUARTERLY PERFORMANCE REPORT 4 09

Pharmacy Inspections 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. In Quarter Four, pharmacies were inspected within an average of 7.7 days, which is well below the goal of 14 days. MEASURE TARGET ACTUAL Average days to complete a pharmacy inspection 14 days 7.7 days Q: Who are the facility inspectors? A: Pharmacy inspections are conducted by experienced pharmacists. Their knowledge and skills are invaluable tools in the inspection of pharmacy facilities. For the past five fiscal years, MQA has completed pharmacy inspections well below the goal inspection period of 14 days. This high level of performance indicates that the facility tracking mechanisms and crosstraining procedures employed by MQA inspection teams are optimized for the completion of new facility inspections as quickly as possible. Target Figure 4: Average Days to Complete a Pharmacy Inspection FY 2017-18 FY 2018-19 FY 2019-20 FY 2020-21 FY 2021-22 FY 2022-23 0 10.9 7.0 9.5 11.5 8.0 9.0 8.5 8.2 9.4 9.1 7.8 7.4 10.0 6.5 8.8 9.1 8.8 6.7 8.5 8.2 8.8 14.0 7.0 7.0 7.1 7.7 MEDICAL QUALITY ASSURANCE | FY 2022-23 QUARTERLY PERFORMANCE REPORT 4 10

FY 2020-21 FY 2021-22 2022-23 Q1 Q2 Q3 Q4 20,000 15,000 10,000 5,000 0 were issued to suspend the practice of a practitioner. 55% were issued to restrict the practice of a practitioner. 45% Emergency Orders Issued Per Florida Statutes, MQA is tasked with the enforcement of all applicable statutes, laws, and rules. To carry out this duty, MQA established the BOE, which comprises the Consumer Services Unit (CSU), Investigative Services Unit (ISU), and Compliance Management Unit (CMU). Together, BOE investigates allegations against practitioners and forwards evidence to the Prosecution Services Unit (PSU) as appropriate. Upon receipt of evidence for cases that require litigation, PSU determines whether cases are sufficient to warrant disciplinary action. After relevant disciplinary action is taken, CMU ensures that licensees comply with the disciplinary terms and penalties. ENFORCEMENT PSU is authorized to issue Emergency Orders to demand the immediate stop of activities that suspect to pose an imminent threat to the public. This authority is sanctioned in section 456.074, Florida Statutes, and the orders are signed by the State Surgeon General. Emergency Restriction Orders establish restrictions on the professional activities of a suspect practitioner while Emergency Suspension Orders suspend the practitioner’s license for the duration of the order. Of the 49 Emergency Orders issued this quarter, 55% were suspensions and 45% were restrictions (or 27 and 22, respectively). In Quarter Four, 10,850 complaints were received. While this is a 35.6% decrease from the previous quarter, this volume is consistent with that received during the fourth quarter of the last three fiscal years. When reviewing cases this quarter, MQA determined 1,275 cases were legally sufficient. Probable cause was found in 400 cases, whereas no probable cause was found in 875 cases. Disciplinary actions levied in these cases include 27 citations, 82 dismissals, and 350 Final Orders. Number of Active Cases CSU 16,341 CMU 5,153 PSU 4,892 ISU 754 Q: What makes a complaint legally sufficient? A: A complaint becomes legally sufficient when it is believed that the facts presented in the complaint are true and the allegation would be a violation of the practice act. Complaints Received MEDICAL QUALITY ASSURANCE | FY 2022-23 QUARTERLY PERFORMANCE REPORT 4 1 1

ULA Complaints Received 300 Complaints Referred for Investigation 321 Cease and Desist Orders Issued 109 Investigations Completed 325 Complaints Referred to Law Enforcement 121 FY 2020-21 REPORT VERIFY BEWARE CALL If you suspect unlicensed activity, you can report what you know by submitting information through MQA’s Online Complaint Portal or call 1-877-HALT-ULT to speak directly with an investigator. MQA also encourages you to know before you go; verify that your practitioner has a license by looking them up via MQA’s License Verification Portal and beware of the signs of unauthorized practice to detect when it may be happening, which can be found at FLHealthSource.gov/ULA. The Unlicensed Activity (ULA) program is a program within MQA that educates Floridians and visitors about the dangers of receiving health care services from unlicensed practitioners. Per section 456.072, Florida Statutes, administering medical care without a license can be punishable by fines, civil penalties, and even incarceration. ULA works in coordination with law enforcement agencies and state attorneys to investigate and prosecute unlicensed practitioners. In Quarter Four, 300 complaints of unlicensed activity were received, and 321 complaints were routed for investigation. Moreover, 325 unlicensed activity investigations were concluded, and 121 additional cases were escalated to law enforcement. Additionally, 109 cease and desist orders were issued for violations, which is a 53% decrease from Quarter Three. Figure 5: Cease and Desist Orders Issued FY 2018-19 FY 2019-20 FY 2021-22 FY 2022-23 146 Unlicensed Activity Call to Action 164 156 119 162 131 125 40 35 55 102 101 162 118 155 136 160 94 187 109 MEDICAL QUALITY ASSURANCE | FY 2022-23 QUARTERLY PERFORMANCE REPORT 4 1 2

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 MQA’s 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 at the close of the first quarter, as well as MQA’s cash balance. 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 $38,088,177 $4,133,050 $42,221,227 Revenues $82,993,475 $3,340,198 $86,333,673 Expenditures $85,782,417 $2,298,216 $88,080,633 Ending Cash Balance $35,299,236 $5,175,031 $40,474,267 Q: Why do practitioners have to pay a fee to regulate unlicensed activity? A: Unlicensed activity poses a serious danger to the welfare of the public. Enforcement and awareness of health care regulations are key to reducing and preventing unlicensed activity. These activities help MQA fulfill its mission and are often the first line of defense, protecting the health of Floridians and its visitors. MEDICAL QUALITY ASSURANCE | FY 2022-23 QUARTERLY PERFORMANCE REPORT 4 1 3

MEDICAL QUALITY ASSURANCE | FY 2022-23 QUARTERLY PERFORMANCE REPORT 4 14 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

For more information or to contact us, please visit MQA’s Virtual Agent, ELI, on the board and council websites. ELI uses artificial intelligence to improve the experience for health care applicants and practitioners by providing immediate information and suggestions and 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, Florida 32399-3250 CONTACT US MEDICAL QUALITY ASSURANCE | FY 2022-23 QUARTERLY PERFORMANCE REPORT 4 1 5

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