Transcripts For SFGTV Government Access Programming 20240714

252,500 as of january 27th. Those totals will change slightly as we close the books on fiscal year 1819. Our approach to budgeting is to aim high so we have have flexibility and meet the needs of our residents. However, we maintain mindfulness and we maintain financial stewardship of this valuable resource. And i wish to take my direction from you as the information you require or what you are most interested. Any Public Comment . No Public Comment requested. Its in the hands of the commission. Commissioners please. Thank you. The year to date is actually the full fiscal year to june 30th so a number of these items were not fully expended. Thats correct. And so is there some reason that youve maintained the level that you think theyre at . I mean there were reasons that you believe those programs need that much allocations and are there any new programs you all considered and did or did not well, you obviously didnt fund them because theyre not in here. No new programs. We have some of the challenges that we face in expending the budget fully. And are also opportunities for i improvement. We have the implementation of people soft. We were unable to access funds until after august 24th this past fiscal year because of a budget rollover maneuver. Another element is the friends of la gon laguna honda have chad their modes. Instead of paying for services and materials directly they have made donations to the gift fund. Because of the extent, we have to get a board of supervisors approval and we go the extra mile by getting your approval before we do that. Some of these programs are going to be a carry over such as in memory care. Were looking to work on a Music Program that will enhance cognitive function and memory in our dementia residents. Our Technology Programs we are taking that over into the new fiscal year and some of the things that were working on, some of the challenges that were facing with that is Program Management or account management, we have several ipads at the hospital available for resident use but to manage those accounts has been piecemeal in the past and were seeing if we can get a comprehensive approach to that. Centers of excellence wish list shows b that we meet halfway on that. Bit end, when the books are closed, well finish off at about 35,000 expenditure for that. There was one piece of equipment on our wish list which was over 10,000 and that is forcing us to take that into Capital Equipment process. Those are some of the challenges that we face. Again, we do shoot high, in case we need to the needs a arrive. Some of the programs i want to point out to you and the endoflife care, we developed programs over the past year. That is a transportation assistance program. We would allow a resident at the end of life, if they wish to, to return to their Home Community outside of the bay area to pass or they could have a Family Member come to San Francisco to be with them at the end of life. We also started a program this year to provide cremation assistance to a resident who dont have the means to pay for burial. In this past year, we didnt have the opportunity the need did not come but we still budget for that in case it does. I home im explaining myself well. I think i understand. You actually have developed these programs and theyre fully funded last year and you are asking that these be continued to be funded because were going to educate the reasons why it took a while to get some of them started. You would like to be able to continue these programs that have been ready for action. The nature of the gift is considered a continuing fund its not an appropriated fund so its always there and its that pot of money thats always there. Our expenditures over the past five years have risen by my calculations 43 . A little bit skewed this year because of the influx of money that came from the friends of laguna honda. The Previous Year 1518, the increase has been 25 . We are diligent at spending the money to benefit our residents and were increasing that commitment and we look forward to continuing that process. Im done with questions. Commissioners. Commissioner grown many of. Thank you. Im really curious if you have a sense of which of these programs you think have the greatest impact on residents or perhaps those in which more residents participate. Is there a relationship between the budget and the number of residents that really benefit from the programs . Are there any that you really would prioritize as the most effective top programs that improved the call o quality of r the residents . The programs that are most impactful on the residents are the active therapy programs. I want you to keep in mind that these are programs above and beyond what the department usually provides because they have been operating funds. So i think those programs reach more residents. I also think that the special foods is another program that is enjoyed by the residents and impact quite a few. Some of the programs i want to point out to you are contracted programs. They have a long history and laguna honda hospital its not an art therapy program, its an art experience program and its a wonderful presence there at the hospital and we always look to expand resident participation there and one of the newer programs that we have is we feel like its cutting edge is the medical Clown Program and its all about Receipt Department engagement so we have clowns come to engage our residents to bring them out and can have them engage. I hope im answering your question as far as those are the ones that i believe that are impactful. Certainly, again, going back to the activity therapy programs, the community doubting programs and i think are very important and i know that department strives to make sure that residents have good opportunities to get out. So its not just a few. Its as many as possible that are able to get out to the community. Thank you, very much. The one that we over spent on in the rehabilitation program. We went over budget there. I may have discussed with you last year or at least you may remember donation from a private citizen of 180,000 for assisted technology. This provides technology, ipads, other forms of technology to residents specifically the most disabled residents that we have so they can have a greater control over there environment. The first year or two, we struggled because were taking the opportunity that was presented to us and trying to create an infrastructure and i am quite proud of what were able to do this past year. With that, weve got a lot of equipment in the hands of residents and its making a big difference to them. Weve tried to be as lean as possible and that is one program that im especially proud of of our accomplishments there. Thank you for your presentation. Twopart question, first of all, you talked about how your budget aims high as aspirational and you mentioned some of the challenges and the barriers that you have in making those expenditures. The first question is that consistent over the years that youve had sort of this difference between the budgeted amount and your expenditures and the second part would be are there any things that can be done to help remove the barriers or charge thats you could be facing and delivering these as budgeted . I believe that we have consistently come in well under budget over the years but weve always maintained that approach. So we dont necessarily are procedure indicates that anything that is unbudgeted we need to com come back to you. Thats why we aim high. I cant think of anything in forecast we have our everyday challenges, again, people soft has been a challenge and new funding approach with the friends of laguna honda. I cant think of anything that would contribute and that we already dont know and we need to improve on and we welcome to you come to laguna honda. We have a meeting every month on the third friday and we would love to have you. We would love you be part of the process and ask questions there. Thank you. Did i answer your question . Thank you. Commissioners, if there are no other questions, theres a motion to adopt and approve of the request for administration of laguna honda gift fund is in order. So moved. Second. All those in favor signify by saying aye. Aye. Thank you, very much. Thank you, everyone. Item 9 and ill note there was no Public Comment request. Number nine is dph it and epic project update. Good afternoon, im so happy this afternoon to say that i am no longer the acting c. I. O. Im delighted to welcome eric as our new c. I. O. Im looking forward to personally helping him on his journey and seeing his vision go forward as i know all of i. T. Does. Welcome to you. So i want to start out with our where we are with epic and im very happy today to be able to present this because we actually have good news for you. To start out with, our i. T. Accomplishments and in terms of what i reported to you our average network time for 2019 is at 99. 98 of the time. We have updates on these device roll outs so weve been deploying our goal is to have actually now were at 4,755 devices that we will roll out in preparation for epic. We currently have 4,565, roughly about 190 left to do and they were delayed in delivery and those are going out for laguna honda and well complete those this week. Were completing our roll out of devices by the end of this week and also our testing. So just to give you a taste of what the testing is, its every single end point its in the department of publichealth that will talk to epic whether its a printer, work station, bar code scanner or scanner so we have scenarioses 2 to test those ande have tested over 44,000 scripts on those devices over the last few months to make sure theyre going to work in preparation for epic. We also rolled out our service now which is our new ticketing system that is robust enough to handle the epic ticketing when we go live. It gives our staff a lot better in sight into the tickets and management of them. So our timeline, which youve been seeing all along, we did have some delays of our configuration. We did have some delays of our integrated testing. Our training remained on track and continues to be on track and will wrapup at the end of this week. I do want to point out the blue stabilization bar. We will be in a stabilization period from the go live until the end of december. We will be making anything that involves safety or regulatory changes during that time period and we have two epic upgrades to do. So its important time that we all reflect and look at how were using the system before we begin optimization of epic. So some of the accomplishments over 24,000 configuration changes to make it unique for d. P. H. To function the way we node to. During our direction setting we made almost 2,000 decisions, 120 interfaces in and out of epic and during our testing we identified 2100 problems we corrected in preparation of being 100 ready and we have 18 days to go live. I did tell you we would make august 3rd and we will make august 3rd. Our training, justify to give you a taste of this, as of july 8th, we had trained 6,827 out of a total of 7,297 and you may say i thought you had 10,000 people to train and as you duplicated our u credit sf staff they were 7,297. We have more than one class so you see the total of 9,206 classes and a pre wreck what sit is that they do elearnings and there are 97,000elearnings as of july 8th. The Training Team really accomplished this in the time they needed through some significant hurdles. So thank you to eric shaffer. Key activities, status, this is the part im happy to report on because i had to tell you, last time we were a little behind. So i will say what our current outgoing epic Program Director said which is its nail biting when you have a team who is the Fourth Quarter team. Our team really rallied and we finished these up. We finished up our configuration. Our testing was done and our training is on target. Interfaces are all tested and infrastructure you see were completing bit 19th of this month and nile biting but were there and go live is still on august 3rd. Our contract and budgeting, i reported yellow 100 of the time because were diligently monitoring our contracts and i want to manage those consultant dollars. So our go live will have a hub and pub model of command centers. I. T. Will be the hub and well have a command center and am bough lar tory so with the exception of revenue cycle, these are 24 hour command centers. Were looking at going 24 7 the first two weeks and well evaluate the tickets and the volume of tickets to determine if we can start to scale down, however, we are prepared to step all the way through the month of august. In our command centers, we have a set time that well be doing communications, communication lines that are open and we have a Patient Safety coordinators that each of the command centers as well as in the i. T. Command centers and theres specific k. P. I. S theyll be looking for and a Patient Safety dashboard theyll be looking for to help monitor them. Were going live on august 3rd but were starting early. On july 20th, were over that weekend, its a saturday, our staff will come in and we begin to do entry into epic for our future appointments after augus. 70 of the future appointments we were able to automate but the 30 need interpretation from the people that are doing the appointments and so theyre coming in which is great practice for them because come monday, every patient who needs an appointment, those people will put those appointments in epic. Were actually a live on appointments. Yeah, and for laguna honda we begin the back load of their inhouse patients pulling data out of our system so they can enter medications and along with orders and allergies and things like that that they need to have in their epic instance when we go live. We start the back load for sucker burg on august 2nd for all of their inhouse patients and then august 3rd at 12 00 a. M. , well flip those third party, 120 interfaces in and out of epic over from the previous systems into epic. Well be validating those and validating everything is back loaded to our final safety checks and if all goes well, well go live at 7 00 a. M. On august 3rd. Were doing a dry run of that. How long it takes for people to enter the data of doing the chart ab traction so w abstract. But right now thats our timeframe. So, i wanted to give you a sam sampling of the k. P. I. And dashboard for Patient Safety and just sort of a. Our leadership was asked what they want as a benefit and what benefit do they want to realize implementing epic. We have done some baselining on these with our count systems and well be comparing when we go live on epic how were doing on these metrics over time. At this point, im going to ask rolland to talk about to preparing for future. This is a transformational in d. P. H. And how are we doing, rolland . Good afternoon. Were doing fine. Were great. So, as you remember, when we started the discussion about moving towards a new e. H. R. Six years ago, we did our Due Diligence and spoke to many of the organizations that have gone before us like ucsf and several of the other institutions in the city and they all said the same thing. Make sure you structure this so its not an i. T. Project but one of operations of the clinical enterprise and thats exactly what weve done. So to that extent, this slide really represents a recent safety. Recently, we did a work flow walk through event at zuckerberg where we have that first opportunity to show extravaganza what working in the epic environment would look like. Doing this epic work flow walk through, dr. Jeff critchfield, who many of you know, memorialized experiences when he reflected on the story about his 105yearold grandmother at the celebration of her latest birthday. At that event, she shared with her guest about the time her whole small town gathered to see the first airplane fly over the town. And she described it as they all stood there together at the small light went across the sky. And so the doctor like end this epic walk through to her experience that were all standing together as the d. P. H. Team watching the future of epic fly right before us. While our staff is anxious about the implementations, they also have remained very excited through this whole process and so were really looking forward to a successful operational implementation of epic projects. Thank you. I have one last person who is extremely important to not only our implementation now as he observes that and participates and i went to interest our new epic Program Director. We have chad who has been with us a year but he is a contractor so im delighted to say we have a permanent director and he is many years doing epic implementation so i want to welcome him. Thats the conclusion of my presentation. Do you have questions for me . Any Public Comment . I have not received any requests. Before we put it in the hands i want to thank you for the service as a c. I. O. For zuckerberg. We know doing two jobs can be a real challenge and you did them and you did them well. Thank you, very much. [applause] commissioners i am wondering, i think the benefit realization metrics is really neat. Is that kind of a score card for the future to see what is happening and what efficiencies and savings we are reaching . If so, im trying to figure out which ones are clinically orient and which ones are cost oriented and versus what is good Patient Experience and is that how you chose these. I want to be clear i did not chose them theyre chosen by leadership but these are not the only metrics that were looking at. When you look to the screen prior to that, when we talked about monitoring success, there are a lot of Key Performance indicators that the hospitals have chosen that theyre going to monitor overtime and they are more safety oriented as well as organizational efficiency. While some of these benefits realizations look a little heavy on the revenue side, there are many other metrics that were looking at. All right. So that leads to the question of the followup, in terms of as we go live and it becomes a reality, what would be you anticipate would be the next report that we would receive. You are scheduled to have a report in september. So that you will see how did we actually doing during live. Even with all this preparation what happened to us during live with our organization being ready from our training. I did want to mention too when we do the roll out here when we go live, we will have Something Like 383 super users that are deployed and we have another 300 or so, 308 at the elbow which are contractors that come in and help organizations go live and assist at the elbow so theyre help us. Despite all this preparations, we still need to report back to you what was the experience like and how did it go and what are we doing on our next wave . Ok. Thank you. I look forward to that. Thank you. Any other questions . Congratulations on this massive undertaking in the way youve really come up from behind and made this a reality. This is a remarkable accomplishment. Very, very impressive echoing what the commissioner said about us understanding better the metrics that you will focus on and the timetable for the medicine tricks, providing a productivity will fall before it rises and i wonder if in addition to giving us a report, we can get a time table for the Research Building and the expectation and get the metrics and get this data and have a volume of date and share them and i think dividing clinical from financial would also be very helpful. So, we will net that and look at the metrics and from their perspective and we can bring this back and show you what was base lined and some of these are happening pretty real time around safety. A lot of it will be overtime. It will be monitoring that and trying to do improvements. Yes, there may be. We scheduled for that. Its very minor in terms of the provider the expectation pretty much is well be back. Theyre automated right now. Most providers are using a system today. Thank you. Mr. Chow. I have a followup but commissioner green reminded us theres a huge task behind this. You have shown that your timetable has stayed right on the target as she said, you know, we come from behind but weve done actually even better by taking our time and were really merging this as part of the culture rather than just imposing an i. T. Solution upon practice which seems to be what wove done with private practice, right. This sounds like its going to be quite different. I do think that we need to think of a way of measuring the remaining costs. Where have we been. How much we primed w promised we going to be using. How much money is in the allocated budget for the whole i. T. Project which i think was over a 10year program so now that weve got this will done, just like following bond issues we should follow how well were doing. Having a look at cost and projection over the life of the contract. I just wanted to join my colleague thanking you. Youve been a fixture here since i joined the commissioner and its been a ride. Im getting goose bumps thinking about august 3rd coming up and while our next commissioner meeting is too early to get up dates. Thank you for everything. We really loved having you and welcome to jeff and jeff to join the team. Thank you for everything. Thank you so much. Its been great hearing for you regularly as we prepare for this. Even though you may not be prepared to give us a report on august, just tell us were live. [laughter] we can do that. I just wanted to add to that question about each worked for the office of health in order to develop their own dash boards and epic. These are standards reports so they got to define one of the key metrics clinical and operational that they want to see and theyll be able to produce out of this multimillion dollar project that weve put forward. Those have already been established and theyll be going as time goes by and readily available to report. Thank you. I just really want to acknowledge her leadership and her perseverance and her courage moving things forward and also to acknowledge that she had a little bit to do with attracting our new talent. So i just really want to acknowledge that. As someone that came into this department with this huge epic piece, she really educated me in a way that was extremely helpful and im really excited shes going to continue to work with a team to ensure that theres success and she has not only passion for this and deep commitment but just unwavering belief this is the right thing to do and the inparticular rit e shows is inspiring to me. Commissioner grown. Thank you, next item. Item 10 is the San Francisco publichealth Emergency Preparedness and response annual update. Dr. Gurly. Good afternoon. Im just going to make a couple of opening comments before dr. Gurly speaks. Good afternoon commissioners. Director of health. Ive been with the Health Department since 1996 and after 211 it was our introduction to this world of Disaster Preparedness. We were focusing on terrorism and bio terrorism and in 2003 we deal with sars and in 2009 it was h1n1 pandemic. Having been here this long, nothing has been like its been the last couple of years. Im going to share a couple of comments. A couple things that ive realls that weve learned is we prepare for the big events by practicing on the small events. And the small events are not just things that involve just a few people but its just involved a small team of people working on things that are big. You are going to see that in a second with dr. Gurly when she talks about Climate Change and extreme weather which is the other big thing happening now. And the third thing that goes along with extreme weather is really that we learn a lot about not just human physicalology and physical infrastructure and how important it is to make sure the physical infrastructure is there not only to take care of the community but also to take care of our workers so when our workers are working own heat or air quality its a challenge to be working on that while we are actually having to work in conditions when they get too hot or the air quality is not as good. Dr. Gurly has a lot of experience and expertise in disaster response, not just locally but globally. And so, shes going to give you an update and shes taking over this new world of Disaster Preparedness and response and im excited to have her as part of our team. Thank you for the kind words. Good afternoon. Directoill be talking today abk thats been done by what i can say is a highly dedicated group of individuals. Im having trouble with my go over to view and it should say full slowe slide show. Got it. So, not only is winona a hard act to follow, but i would say a lot of the work im going to present here builds on an Amazing Foundation built by Deputy Director baba who was in this position before me. As you may be aware, publichealth Emergency Preparedness and response lives in the population of health division. It is a branch thats responsible for publichealth Emergency Preparedness and response not just for d. P. H. But for all of San Francisco. Today, well talk about how our acronym and one of the word things about Disaster Work is theres an acronym for everything. Its even worse than medicine. If i mention one without saying the full words, please dont hesitate to ask me about it. We are known as fepr. So ill talk about how fepr works with the citys Emergency Response activities. Ill talk about how our work is a really important balance of proactive and reactive responses and cover and in that ill review and well talk about the reactive forced to give you a flavor of them, theyll include commune i canal diseases, cyber i. T. Events and they activate an Emergency Operation center and an emergency and sometimes for plan events like as we sit under the umbrella, however, they have hospitals across the city, Skilled Nursing facilities which are a new development this past year, members of our dialysis clinic, private clinics and across the Broad Service Delivery System within d. P. M. Including San Francisco general and our Population Health division including key functions like Environmental Health and disease and especially our Emergency Medical Services authority partners. Who oversee our e. M. S. Services within the Fire Department it includes ambulatory care. How are we doing . If we gave ourselves a qualitative report card, here are some of the pluses in the areas for opportunity and both our preparedness work and our response work. We have had extensive exercise partnerships which have been deepening in the past year. Weve had to do and perform solid communication and messaging around some complex topics including receipt per rer eight or and a strong healthcare coalition. We can improve by working to improve our Community Engagement more and we have taken mini strides recently. We could also move towards more d. P. H. Involvement and training in these disaster issues and our numerous activations and responses do impact planning because we have the same small group of people to do both activities. In terms of our responses we had strong response activity across a broad range of areas giving us a lot of experience in areas to prepare for the big event. Those experiences foster a city wide team and deep connections. However, we could improve by expanding our response experience within our own department and having a small team carrying a large number of responses means they suffer burnout and get stretched thin and one of our goals is to unite what we call the planning response cycle which means you dont just respond to an event like a cyber terrorism threat but you can change your plan so that the next time it happens its better and you are activities get improved every single cycle. So how are some of the ways weve done the things i just mentioned . In terms of preparing, last fall we had a large city wide medical needs disaster shelter exercise. It was done at saint marys cathedral and involved a large number of partners at the local state and federal level including n. G. O. S like the American Red Cross and the salvation army. It was a really successful event looking at what it takes to put together a very large shelter focused on medical needs. We also did last fall a large state wide medical Health Exercise is what we call it and we chose to focus it and the state tells us what to do and we did it for i for in flew ends as impacted by influenza epidemic. We had 75 participants and we have both the tabletop where we talk through the problem and how we Work Together and then we do what is called a functional exercise where we pretend its actually happening. We included all of our local hospitals and had a focus on managing scarce resources such as receipt per eightors or anti viral medications. In preparing in terms of our Community Training and information, we had training for psychological first aid and training for 300 participants. We moved into continuity of operations training, in other words, if you only have your minimum staff, what are you going to keep going in an urgent setting and we focused in on our methadone providers and there were 18 different clinics participating. We have a critical partners list which say list of agencies that serve our most vulnerable communities in San Francisco. We engage with them frequently. So we were training the trainers and we worked with media, especially big shout out to our Public Information officers here in the d. P. H. And we had an extreme weather media workshop where over 15 bay area media tv radio and electronic representatives attended. We have our healthcare coalition, which in nights are hospital and other Healthcare Facilities across the city and this year we launched a a quarterly bulletin and we also won a Natural Association of seeing county Health Officers National Award for a Promising Program in their Model Program division because of our meth tone Disaster Workgroup. Where we have pulled together all of our medication assistant treatment clinics and they have actually begun to decide how they would distribute scarce resources in a disaster situation and how they would communicate effectively with each other about people who maybe in desperate need of these medications. We have also worked to expand the training and exercising within d. P. H. And we developed 18 training over 146 participants. One thing to keep in mind is this is happening while people have full time jobs and are often over stretched so its quite a commitment for our department. Now were going to move to what kind of emergencies we have responded to and these are just some examples. As a snapshot, to speak to what the doctor mentioned, in all of 2018, we had 12 total full activations that means we declared that theres an emergency. We organize ourselves in an instant command structure and we do all the documentation from beginning to end including our q. I. Processes for what happened and how it should be improved. That was 87 days of activation and 2018 representing about a quarter of the days of the year and a little over a third of the work days of the year but we work during the weekend also. So, however so far in 2019, weve had 15 full activations having 12 last year with the same group of people. What things do we see . Weve had two different u. C. Labor activations where we activate to make sure theres no negative impacts to our hospitals and medical a search that might happen and monitor whether or not theres an event that could be impacted during a labor action. We also had a kaiser labor action and then you may remember the day where there were multiple bitcoin bomb threats sent across the city include something of our own facilities but we manage it city wide and not just for d. P. H. And our i. T. Department and its been in the directors report a chiller failure when we had an i. T. Shut down for a day. We have activated for a t. B. Contact investigation which was 60 days of planning and 16 days of operations to identify exposures and get them tested and treated in a very effective manner and we were activated for a prolonged period of time to prevent the hepatitis a epidemic coming up the coast towards San Francisco. That was five months total of 2017 and 30 days in january of 2018. Im sure all of you remember the beaut campfire where they were activated for 14 Straight Days and then we had our extreme heat activation recently of four days where our e. M. S. System was significantly impacted as were many of our facilities and within d. P. H. I just like to say thank you all of the work that i just mentioned and shared with you is actually the very hard work from this very small group of people who deserve a big shout out. Thank you for your time today Public Comment. I have not received questions. Its in the hands of the commission. Any questions or comments . Thank you. Commissioner. All right. Thank you. Curious, where do the Community Disaster Response Teams come in . For many years there have been discussions and parliament began in china town with the 1989 earthquake. The mission created something and not sure whether that is still around. You talk about critical partners but what is now the mechanism to use these and are we still doing trainings or anything like that as part of the over all programs . Yes, thank you for the question. So, we work closely with the Fire Department. At the time, nert, the neighborhood Emergency Response teams live within the Fire Department. They have a great group there that does the training and the organization. When we activate, we coordinate through them. Our Community Group and our Community Work tends to focus heavily on the publichealth as aspect of disaster. In that sense, we have been very involved in our medical health core, volunteer responses and we sent volunteers out to the beaut campfire for for example, from that group. That group of living within nerts upset and with the state is deeply a part of the work that we do right now. In addition, were working to develop specific Agency Collaborations around Emergency Responses that are somewhat neighborhood specific. During the recent heatwave, we worked with Senior Centers and meals on wheels to define Wellness Checks and how we were reaching out to the most vulnerable. I dont know if that fully answers your question but i would be happy to get back to you with more information. Im interested in understanding whether its in the first part doing all nerd training but communities were, like i said, specifically english and chinatown were creating kind of a multi task agency so that if with you needed publichealth sponsor they needed transportation, or they needed food or something in two areas they could mobilize internally some of the already existing nonprofit and have that work. I didnt know if that was till continuing or it is only nerd that is still part of the legacy that remains from the 89 earthquake. I would be happy to get back to you with more on that. Right now its nert. Theres a coalition in the bay view where we have joined them to do some exercises that sound exactly like that. Theres a plan within the department of Emergency Management to expand those. Its community resilience, its a capability called esf16. I mention it because we are willing and active participants in those efforts. We dont own them. I think it is in the area where we hope to improve on going forward. Because within our large city wide plan, if a big disaster happened, those organizations would exist within a battalion chiefs district. And that is how it would be organized. So, that has not been exercised in a while and im not sure, other than the one i mentioned in the bay view, how many are still active and separate from the nert program. Well, yeah. This is sort of a 30year warning that never gets any traction all the way from the very top when the admiral used to head Emergency Services here to what looks like a great response from publichealth is not integrated with the rest of the local community. I find this is a little distressing that each one of these great plans dont include the community or. It may be my lack of communication. I feel like that sort of hub is what we call it and lives under department of Emergency Management and we try to jump in. Thats why im offering to get back to you and i can find more information and i would be happy to share with you how its more formally structured and where it might be missing and where our hubs are in terms of development weve participated in the short time is in bay view. Right. And so, one time, the Chinatown Health Center for example was part of these response zoos if you are not really aware of what else is going on within that because its been going on for all these years, everyone thinks its a great idea to have neighbors involved but it seems sufficient infrastructure and resources to really allow the neighborhoods to blossom and i was asking, what is the status of this now because eventually, when we say you are on your own for 70 hours and there are people who cant be on their own and this is where some of the neighborhoods were going to try to take that up and we have a plan to take care of that have but it might be there and you are just the opportunity to ask about it. I fully appreciate it and i do want to make sure i that i that china town Health Center say great champion and theyre involved in this work. Just not feeling comfortable speaking for them about how embedded they are in the rest of their neighborhoods for this but we will definitely take this as a charge to improve and i appreciate it. Thank you green. On the next level in terms of the hospitals, i wonder if in the future you can give us more details about whether theres standardtation in a major emergency. How quickly can they react and how do we know which hospitals have which services, verdicts, if there were this great need what are we doing as a community to use the best resources of our hospital systems. Sure, we are in close touch with them. We have direct phone access with them if case theres an emergency. Obviously hospitals may not have access and we have radios positions at every hospital. We make sure and that is their partner and hospitals and where else they might need to be organizing or ak ta rate ising and and we also have a Communications Infrastructure that exists on multiple levels including the ready net system where we can do hospital polling and real time to find out how Emergency Departments are doing in our public healing medical respite and sobering center. During beaut campfire and another campfire, we were asked to provide numbers for how many Skilled Nursing facilities beds might be available in case they were out of jurisdiction disaster so we have a number of methods and a number of communication and a number of ways of interacting with our hospitals and our hope is to just expand that further out to other facilities and systems like dialysis clinics that serve very fragile populations and it would be very much needed in the setting of any serious or sustained dis as terse. I have one question that has to do with the psychological First Aid Training and provides a psychological first aid and what kind of training is involved. Sure. Great question. So as we all know, after a disaster, there can be many psychological ramifications including to the people who respond. And psychological first aid say training that can be done either for Behavioral Health clinician and goes deeper and to the issues of post disaster, psychological needs and treatment or it can be done for any lay person so theres kind of a intense training and a light training and so our goal is to both provide psyche long cal first aid trailing to any of the organizations that are interested in it including partners who are not necessarily clinicians but we have another innovative approach put into our m. O. U. S with all of the organizations that contract with the city and do Behavioral Health services that they need to be trained in. Were push particular further out into our communities and agencies so we can deepen the pool of people available to respond in any widespread disaster. Thank you. You mentioned your presentation that you maintained a list of 38 critical partner organizations, could you give an example of those organizations and is there a way for an organization to step forward to partner in these efforts . Great question. It includes meals on wheelstype organizations. It includes rams. Richmond Area Mental Health services. It includes a lot of Adult Day Health places. Many of the organizations within our critical partners list also work with our close City Partners at h. S. H. And the Housing Services agency and they do include ihss workers who are very important trying to reach the most vulnerable. In the past year we have new and deeper partnerships around issues like i mentioned and defining what a Wellness Check is for someone who is not necessarily a clinician. Several were honored by the mayor and we are willing to and eager to partner with anyone who would like to partner with us and we are actively trying to engage as many as possible. You might ask how we chose the people we started working with and we chose them particularly because we felt like they represented very Vulnerable People within our community. I did want to mention that another approach is we are working to develop what is called an empowered data base which the federal government can provide a list of people with medicare only who are medically dependent on medical devices. It can range from people who have home oxygen or home dial advertise to people who have devices so some people are living in essentially an i. C. U. At home and so were in the process of developing work flows for how to create a team of First Responders who can go out in a power outage. Thank you. I just want to thank you. I want to thank dr. Gurly for the key role of the department. Just to emphasize that ive asked dr. Gurly to focus on drills and training. I think we need to be as prepared as possible. Also to emphasize theres just a Climate Change report out today. It estimates that the days over 100 in San Francisco will double in the near future. Were also taking a very hard look at our infru