As reported the foundation has maintained several of the recommendations and added a receptionist. In past hearings the commission encouraged easy the easy to proe Additional Information regarding staff standards such as demographics. C. P. M. C. Provided a summary which you received last week. We will continue to Work Together to gain a deeper understanding of compliance and will include more information in future hearings and compliance reports. This concludes this portion of the presentation. Thank you. Setter health is in compliance with the requirements of the c. P. M. C. Development agreement. They met hiring and local contracting goals. Areas of concern include enrollment with the tender highway loin medcal provider and hiring of journeymen and add prentices. For 2019 it indicates continued compliance. Staffs recommendation is to find that c. P. M. C. Is in compliance for the 2018 reporting year. That concludes staff presentation. We will be available for questions. Sutter health is also available for comments. Does Sutter Health wish to make a presentation as well . We are good. I have a few speaker cards. Catcrachel, gloria. There is an organized opposition. Okay. Good morning, commissioners. I am a professor of law at university of California Hastings College of law. I am here to present the comments today of the San Francisco for healthcare, housing and jobs and justice, a coalition which is an organization active for the last 10 years, more than 10 years. They were instrumental in if Community Benefit package that is part of the Development Agreement. We are not a party to the agreement but actively involved in the drafting by participating in public proceedings, and it also has been monitoring the agreements, and implementation. We presentd written comments back in june and those are at the end of your package. There are two statements, one on the Development Agreement overall and also a statement on the subacute care issues in San Francisco. A lot of time is invested in this process, and it is important time. It is an opportunity to review the c. P. M. C. And city reports. It is also an opportunity to look at the c. P. M. C. As the largest fee for Service Private provider of Hospital Services in california as it relates to the needs of sa san san franciscansr healthcare and civic concerns. It is an opportunity to look seriously not just at the Development Agreement compliance but at the c. P. M. C. Performance overall. Today orally i want to make two points. First, to say that the Development Agreement even when it addresses specific actions does not prohibit or limit c. P. M. C. From doing more than what is specifically stated. Second, there is ren is recent a that indicates c. P. M. C. Is doing less to meet the healthcare needs of lower income san franciscans than in 2017. I will look at not the overall benefit of the community but looking at the actual patients being served by c. P. M. C. With respect to the first point, c. P. M. C. Repeatedly mentioned the da for not taking sufficient action to address an identified problem. This has particularly come up with respect to the demise of subacute care Skilled Nursing facilities in San Francisco. The da states c. P. M. C. Tha c. P. Ml work in good faith to develop specific proposals to provide subacute Care Services in San Francisco. Now, it does indicate an Expiration Date for that provision but that is not the end of the matter. It explicitly states c. P. M. C. Is not obligated to expands funds or resources. These provisions do not mean that c. P. M. C. Is prohibited from committing and spending funds or resources. It is just not mandated by the Development Agreement. Nothing in the d. A. Limits the city from suppressing c. P. M. C. From doing more than it is now regarding the need for quality subacute care units in San Francisco. Nothing prohibits them from fully participating. Subacute care is the most intensive form of postacute care. It is for patients who cant survive on their own, as was referenced previously, like those who need a ventilator. Because of the expense most longterm subacute patients receive medcal. Hospitals regard it too low to meet cost and medcal recipien recipients. C. P. M. C. Agreed almost two years ago to transfer existing patients from st. Lukes hospital subacute care unit to a new unit at davies campus. At that time in late 2017, there were 23 patients in the st. Lukes unit with no new patients having been accepted since 2016. In august of 2018, patients in the saint looks unit st. Lukes unit excuse me. In august of 2018, when st. Lukes was closed and the new hospital opened, there were 17 patients transferred to the davies campus. As of now there are eight remaining patients. When they die, c. P. M. C. Will close the unit and there be no subacute beds in San Francisco. This is a crisis now. C. P. M. C. Must be part of the solution whether it provides space and staffing at davies, at the proposed new medical Office Building on the mission burnell campus as part of the undevelopment space in the vanness campus or in support of Chinese Hospital interest in having subacute care unit. Another area where c. P. M. C. Needs to step up more than set out in the d. A. Is meeting the spirit and letter of the commitment to serve 1500 new medcal or healthy San Francisco patients in the tenderloin. With the opening of the vanness campus in march this year, an important geographic proximatity issue is now eliminated. As of may of 2019, as you saw in the report you just heard, only 174 such patients are receiving services from c. P. M. C. A number which is actually two patients lower than in may of 2018. C. P. M. C. Has to be an active parties pant i participant in reaching out to serve the tenderloin in three respects. First in insuring that the vanness hospital is culturally and linguistically welcoming to lower income individuals from diverse family. Second, aggressive efforts to encourage tenderloin residents to use st. Anthonys as primary care clinic. Third, providing financial and technological support in whatever ways are most needed to facilitate highquality primary care providers in the tenderloin to referpatients to c. P. M. C. For specialty and Hospital Services. With respect to the second point i want to call your attention to the San Francisco charity care report for 2017. The latest report available. This report provides data and information from all San Francisco hospitals on traditional charity care which covers only nonmedcal patients who are uninsured or who are healthy San Francisco beneficiaries. Though the definition for the charity care for this report does not include individuals on medcal, the report does inclu e relevant data on the medcal shortfall. That is the difference between what hospitals set as the fee rates for specific services which are much higher than private Health Insurance reimbursement and not the same as the actual cost of those services and what medcalorie im buses for the beneficiaries. Reimburses for the beneficiaries. Since obamacare, the cost of charity care patients, not medcal patients have gone down. Generally speaking, this correspondses with the number of individuals with private insurance through california exchanges over the expanded medcal coverage. One major result is reported medcal dollar amounts for most San Francisco hospitals. I have a minute left. That is your time, 10 minutes. I still have 10 minutes . That is your time, sir. Let me emphasize for most Hospitals Charity care costs have gone down, but at the same time the medcal shortfall amounts have gone up sometimes two or three times that amount because Previous Charity care patients are now receiving medcal. The one anthe is c. P. M. C. That a decline in charity care and medcal shortfall costs. Something is not addressed by the measures and procedures used with respect to the Development Agreement. Thank you so much. Thank you. So we will now open it up for Public Comment. I have Theresa Palmer and gloria. Anyone else who wishes to provide Public Comment, please line up on my left. Good morning, thank you for the opportunity to speak today. I am the director of programs and administration at northeast medical services. C. P. M. C. And nems have a partnership s. We serve 32000 medcal patients. We provide Specialty Care and care coordination. While c. P. M. C. Serves as the Hospital Partner and provides diagnostic services. We have worked together to serve the tenderloin in our contract with st. Anthonys but through contracts with three independent providers in the tenderloin area. C. P. M. C. Is the partner for all four providers as well as the clinic on ellis street. In total we serve a little over 2600 in the area. We will Work Together to serve our patients and residents of the tenderloin. Thank you. Next speaker, please. If you could line up on the left, we wont lose time between speakers. Please come up. Thank you. [please stand by] they want to refrain from the longterm commitment and caring for these fragile patients. The inexperience and unfamiliar staff, inattentiveness, lack of stimulation, are always to ensure they dont last. This is why we need the subacute unit reopened. These rooms have already been specifically retrofitted for 17 subacute patients. In the best interest for cpmcs current patients and the community, cpmc should maintain and admit new patients so that there is an adequate level of staffing and continuity of care at all times. My sister, sandy, as well as the other patients, do not deserve to be treated so inhumanely. They deserve to live as long as they showed with the best entitlement of care. The only way that this will happen is to commit cpmc to reopen the subacute unit and accept new patients in order to maintain an adequate level of experienced staff at all times. Thank you. Thank you. Next speaker, please. Im very sorry. We just lost one of our members of planning. Can we keep going . Unfortunately not. We should pause. We will give a couple minutes pause. I think it is a bio break and we didnt realize. Thank you. Okay, welcome back to the San FranciscoPlanning Commission and Health Commission joint hearing for thursday october 3 rd, 2019. We left off under Public Comment if any member of the public wishes to submit their testimony , please. I wouldnt i am so sorry to have interrupt you to have interrupted you. I am one of the patients in subacute. Cpmc speaks about adequate staffing of the unit, but let me say this. It shouldnt take a patient to use her cell phone to call the front desk to ask for assistance it shouldnt take a patient to have the call light on and wait for an hour for assistance. It shouldnt take that when i went to go see my sister and i saw something was wrong with her , and the socalled experienced nurse stated, theres nothing wrong with your sister, gloria, she is fine. So i went and got the doctor myself. After he evaluated sandy, he rushed her to icu immediately. She was in icu for several weeks with pneumonia and every other breathing issue. Cpmc is giving the minimum care of the subacute patients and this is why i feel that there is a reduction of these patients left, and i also feel that if the rate goes on this way, in december we will probably just have two patients left. We need a permanent subacute in San Francisco so there can be adequate staffing to protect these patients. You think about if something happened to your family member, your loved ones, your son, your daughter, and they needed subacute care, how would you feel sending them out of county to los angeles or sacramento . Please help us protect our san franciscans who pay taxes and voted for everyone here. Please take care of our family in San Francisco. Thank you. Thank you. Next speaker, please. Good morning. I am the executive director of jobs with justice and Labor Organization in San Francisco. I want to talk a bit about this hearing, which is that its not just a discussion of the Development Agreement, it really comes back to the goals of why we even have this Development Agreement, and that is to remind cpmc of their obligation to our communities around jobs, around healthcare, and thank you to the families for fighting, literally for the family members in the hospital. So we can come to this agreement and hearing, we are not just trying to check a box. When we say tenderloin lies, it literally is a lie. So on the subacute, we can look at this report in terms of specific proposals for providing subacute Care Services in San Francisco and presented to the Health Commission. It says the obligation is completed on 2016. This obligation is not completed we need to subacute. This is a crisis. Another piece that i think this hearing actually has been helpful, when i came here last year, and thank you to oewd for presenting this information, there was a question on retention and promotion. Not only was there not enough jobs coming up for people coming from the communities, and there was a decrease in the total number of jobs, which means that percentage was very low overall, but also the question of retention and promotion. I remember the commissioners raising that. I see the improvement from last year to this year. Based on your actions as a commission, and investigating this question of retention and promotion so people who get in the door actually stay in their jobs. I just want to lift that up as an example of how this hearing can make a difference and ask that you, as commissioners, hold cpmc and, not just to the Development Agreement, but to the goal and the spirit of the Development Agreement. Thank you. Next speaker, please. Hello. I am a Community Organizer with Community Housing partnership. We provide affordable housing, Supportive Housing for over 1500 folks in the central city. Our clientele have many traumatic barriers from experiencing homelessness, and i want to call attention to something that i heard today, which is kind of interesting. We have a goal of serving 1500 people on medical, and it sounds like we have backslid over the six years that i have been aware of cpmc. We backslid from not even reaching 200. I heard today that the reason is because folks are unable to reach out to people because their phone number isnt working or their address may have slipped. As a Community Organizer, if i just gave up on everybody that didnt have an address or a phone number in my community, then i wouldnt be doing anything. So im going to ask you guys to dig deeper and do better. Thank you. Thank you. Next speaker, please. Hello, my name is Melanie Grossman and im with the coalition. I am a retired social worker and i am especially interested in the center of excellence for senior care, and we have a small group which has worked with that center to make sure that its more than a centre of excellence in name only. The center is charged with making sure that people stay in the community, live in the community, and to reduce hospitalizations. In order to do that, the center has to know the community, know the resources that are there, and work with the community. So the ace unit is a fairly selfcontained unit. It is run by dr. Zachary who has been extremely helpful to us in welcoming, and also welcoming of the community, but we have to do a lot of the work for her because she doesnt have the staff, she doesnt have a social worker, she doesnt have people who can do this outreach for her , and that is especially important. Same with discharge. I had a neighbor who was hospitalized on the unit and i asked a dr. Zachary to make sure that my husband and i were called before she was discharged , and again, it is not dr. Zacharys job to set up discharge, but my neighbor was sent home over the 4th of july weekend. We were never called, even though her number was plastered all over her room. She called me and told me she was going home. We were out of town. I had to set up a ride for her to get home, call the home care agency, make sure they were there to greet her, get her keys to her. My neighbor didnt even have her keys. And to make sure that that transition went smoothly, which it did. The unit did give her a referral for home health care, and they didnt call her until the middle of next week. I dont consider that a smooth transition to home. Thank you. Next speaker, please. Hello, my name is teresa palmer, im a geriatrician. I work with senior and disability action at san franciscans for housing, healthcare, jobs and justice. My feeling is that cpmc is noncompliant and having a centre of excellence in senior care. They have an acute Hospital Unit , but theyre planned for discharge is sponging off nonprofits and volunteer organizations, and not doing any Real Community outreach or discharge planning on their own. Their primary goal seems to be saving payroll, not having their own dedicated employees, and getting people out of the hospital as quickly as possible so they can make a profit on the medicare dollars. This is pretty much the same with subacute. The d. P. H. Has estimated that we have a dearth of 50 to 80 subacute beds in the subacute unit. We have none for the surviving patients at cpmc. Davies, who are rapidly dying. The least cpmc could do is make the 17 retrofitted beds at davies into permanent subacute beds so we could get permanent staff because you cant this is a very high level of skill and it is very difficult to recruit the Skilled Staff for temporary jobs as these patients die, and which may be one of the explanations of the high death rate. In general, cpmcs approach to tenderloin it lives, to everything, has been passive. Blaming st. Anthonys for not doing enough to get patients to them is ironic and ridiculous. Cpmc should be doing what it needs to do to make these patients welcome and to recruit these patients and even to case manage these patients. This is the same with the center of excellence in geriatric. To not have a hospitalbased Skilled Nursing facility to send these patients to after a complex at geriatric patient has a stake, is ridiculous. The medical staff Office Building at st. Lukes or the 30 shelf beds at davies could be used for subacute or hospitalbased care. It is all about revenue, it is all about profit, even though this is a Nonprofit Organization that isnt paying taxes. Thank you. Thank you. Next speaker, please. Good morning, my name is heavier and i am with Community Housing partnership and jobs with justice. We work with Supportive Housing residents who were formerly homeless and the people in our building have severe medical needs that require many trips to the hospital and lots of them that i have worked with have to go long distances to get their care. We have several buildings that are in very close proximity to the new van ness facility and i have heard of little to no enrolment in that facility, which would be a lot easier for our residents who are disabled. Also, as far as the outreach to the tenderloin residence, the people in our buildings and the tenderloin atlarge, as you know , a lot of their first languages are not english, and its almost impossible for them to be able to take that step without some really serious and intentional outreach on the part of cpmc. A lot of times, to keep people enrolled and to have them get the medical need that they deserve, we are relying they are relying on our residential case managers who are not familiar with the Health System, were having to scramble and figure out this paperwork that they are not familiar with, but they are the ones that are having to take on the job that cpmc should be doing as far as outreach and enrolling people. So i ask that the commission make the changes that are needed to hold cpmc accountable and to do what needs to be done. Thank you. Thank you. Next speaker, please. Hi, my name is sylvia. I work at van ness. I was here last year and i will say hi again. One of my patients told me to say hi for you because he had breast cancer. Once again, im talking about short staffing. Once again, we want arbitration and we will never go back in there. But i am here to give you a story, a reallife real life story of my experience on the floor. Right now, i am taking 13 patients because my doctor put me on modified. That is the only thing i take his 13 patients. Not 50, not above that because of my ankle that is really hurting. So i am working in pain, but one thing, the night shift is always short. Overall, it is short staffing, but what i do is check the patients, if they are breathing, and things like that. I walk around. If anybody wants to go to van ness, the tenth floor is too big i am the only one who has a short hallway, 13 patients. To make sure that when they arent drug, to make sure they are breathing and things like that. Our code blue, since we moved in there, is skyhigh, in my opinion , because i am grading them because they are grading me and i am grading them. I am doing 100 and 10 of my time to make sure my patient is safe and breathing because they are on drugs, heavy drugs, medication. If i dont do it, my legs will hurt. My patient will die. And it is so bad for my heart and my mind when my patient dies i see a lot of them in my years since 2003. Im asking again, i am crying here and asking again, we need more staffing on the floor. Thats it. Thank you. Thank you. Next speaker, please. Good morning, commissioners. I and the union rep and we represent workers at cpmcs davies, pacific, and van ness campuses. I heard a lot about talk about numbers, and it looked good from cpmcs account. They were doing everything on the up and up. I want to tell another side to that. They said they hired so many people. I would like to ask the question of where . Because i represent the tax, i represent the food service workers, i represent the p. C. A. , i represent pretty much everybody but the nurses and they are all shortstaffed, even Central Distribution departments that deliver cotton balls around nurses, nurses cant even get cotton balls because they dont have the stuff to actually delivered those. I wonder where are all of these people hired . Probably in management. The Food Service Department has like 12 managers just to manage one shift, the day shift in the kitchen on any given day. That is probably where all their hiring comes from. Speaking of the subacute, i would like i dont want to spoil anybodys hopes, but i dont think that they will ever have adequate staffing in the subacute because they dont have adequate staffing anywhere. Cpmc does not have any intention to actually comply. We have an open grievance right now because the contract, the cba obligates cpmc to keep an adequate level of casual per diem employees. We have an open agreement because they actually have none in most of the departments. Absolutely zero per diem employees, and as of recent, they may have hired probably about three, and i know because i watched the Staffing Levels there, so hold them accountable. I would like to speak about the spirit of this agreement. I would like for this commission to hold tm accountable to that spirit as well as make sure that this is adequately staffed for the patients and workers alike. Thank you. Thank you. Next speaker, please. Good morning, my name is jennifer. I am one of the nurses from st. Anthony medical clinic. Im here to provide a few comments about the challenges our clinic has had in enrolling new patients. We welcome the partnership that we were invited to enter with San Francisco health to provide cpmc as one of those options for our patients. Since the other option was San Francisco general, when we presented just the options to our patients about which Service Provider they can choose, most of them were very familiar with San Francisco general. When we talked about cpmc, a lot of them did not know about cpmc or where places were located. So when we had to explain to them where they would have to go to the lab, xrays, specialists, it was very confusing for them. It was easier for them to choose somewhere like San Francisco general where things are centrally located and where they are much more familiar with the services. One of the other challenges that we had was that last year in 2018, we lost three of our primary care providers. Two of them moved out of the area and one of them retired. Since then, we have had staffing challenges and have had different per diem staff coming in and out of the clinic, and with different schedules. We have been trying to maintain the panel of patients that we have and provide care to them, which doesnt always allow for new patients to join because of our access. In terms of recruitment, we have been trying to recruit new permanent care providers and we are also contending with Different Centers and organizations that can maybe offer more bonuses or bigger salaries then we can, unfortunately offer them. We still strive to provide the level of care that we always have, but we have been faced with a few challenges in the last couple of years. Thats all i have to say. Thank you. Next speaker, please. Kim tell villani, San Francisco labor council. I am deeply saddened. I feel like this is the greatest issue of all time. I dont even know where to begin one, cpmc has not fulfilled its obligations, and despite the boxes that you all check off. I work one block away. My old office looks out at cpmc van ness. When i pull my car out or in of the garage, there is a tent city right there exactly one block. In fact, the smokers from cpmc smoke in the same alley. There is a tent city. Theres lives that could be taken care of cpmc a block away. There is no excuse why they cant be taking on more. We have been here, we have testified. They can hire navigators, they can partner with Community Housing partnerships who have residents in their hotels. Tenderloin housing, for example. But cpmc chooses not to do any of its because they really dont want to do it. They are perfectly fine sending more and more people to San Francisco general on a taxpayer dime and it limits the capacity of San Francisco general. I need the commissioners to really holistically look at the Health System and make the private hospital, cpmc, do more. This is a sad, sad day. When you walk out of here, there are people without Health Insurance. That is not an excuse. They need to do more. They can do more, they are choosing not to, and we are letting them get away with it. These are the options. They are fairly simple options. Either you are for the people or you are with cpmc. Cpmc has failed. We have seen the deaths that have occurred in the subacute unit. They really dont care about patients and we really need to hold them obligated to do more in the city. It is disgusting and we should not allow them to continue to do their Business Model this way. A look at st. Francis, they do weigh more and they are just a few blocks away. You have the ability to make them do more, the question is, will you . Thank you. Any other Public Comment on this item . Okay. Public comment is closed. I will defer to my copresident as many of these issues are healthrelated, and then we will provide comments. It is now in the hands of the Health Commission. The commit are there commissioners who wish to speak on this item that have questions yes, first of all, thank you to the staff of the Planning Department and also the department of Public Health for your excellent presentations as well as for everyone who stood up for Public Comment today. I would like to dive a little deeper into the question of providing services in the tenderloin, the medical services. I know we are looking at this presentation and it is looking very similar to what we saw last year. Some of the numbers are confusing, so i would like to give the opportunity to clarify it because going back to what corey said about the spirit and the goals of this, it is not really just about the numbers, it is about the people, it is about the lives. Particularly when you are looking at the tenderloin, it is lifting up and bolstering services that are available in the tenderloin with the organizations that already exist in the neighborhood. When you look at some of this data challenges, which, of course, are legitimate challenges, these are things that could have been anticipated if you are looking at patient choice, that is something where you could do more outreach to the communities of people are more aware of the services that are available from cpmc. You are looking echolocation of services that make it more complicated for people to take advantage of whats available at cpmc. There are ways to address that as well. And then of course, staffing challenges for some of our nonprofit partners. That is something that can be anticipated as well when youre looking at the cost of living, the cost of housing, and the cost of soaring rent of nonprofits were trying to serve people in our community. I would just like to ask and also applaud them for stepping up and taking on some responsibility, but this looks very similar to the presentation we saw last year, and while we hear there are plans to put together a path to sustainability, we really want to ask more pointed questions about what those plans are and what has come from those discussions, so i dont know who is best suited to answer those questions, but those are ones that i think we would like to hear addressed. Thank you, good morning, commissioners. Im emily webb and director for Community Health for the bay area. I appreciate the question an opportunity to clarify. This is an example where i think cpmc has made some efforts towards the spirit of the agreement. The letter of the agreement said if there was not an mso with the tenderloin serving base by december 31st, 2015, then cpmc was to meet the obligation for additional lines through our existing partnership with northeast medical services. We hear the communitys concerns about wanting additional primary care options in the tenderloin with a pathway to hospital and Specialty Services at cpmc, hence we forged the contract with Saint Anthonys to provide that option to patients. As has been stated, we also have a clinic and three other independent primary care providers that contract with cpmc as the in network hospital. Although this challenges that have prevented the Saint Anthonys number from growing to 1500, despite actually quite a bit of funding and inkind effort on my behalf and my stuff s behalf, we have worked with the community and a whole host of partners to provide access to cpmc with primary care choice in the neighborhood. I think it is important to note that while there are acknowledge challenges that you heard from Saint Anthonys, we are working with multiple providers in the tenderloin to be the Hospital Partner and to serve about 2600 residents that have home zip codes in and around the tenderloin. Just a quick followup, when youre talking about path to sustainability and efforts that are happening now, what are you anticipating you can accomplish in the next year to fully meet the spirit and the goal of the agreement . Yeah, the effort with Saint Anthonys, i think our perspective is because we have multiple primary care providers, that can refer patients to cpmc, we are meeting the letter of the agreement and the spirit of the agreement, which is to allow tenderloin residents to have access to the hospital that is newly in their neighborhood. What we have done with Saint Anthonys is we have done quite a bit of work with them. They used to be a free clinic. They now accept reimbursement and we have funded them to get access to federal dollars for the health care for homeless grant to join the San FranciscoCommunity Clinic consortium and to begin to contract with medical. That did not exist prior to our building this relationship with them. We funded them towards that effort, as well as provided Technical Support and guidance. We have also funded them for outreach efforts pick we believe that them having people in their dining room and out in the neighborhood and they have quite a few programs around staff recruitment, they have a wonderful Security GuardTraining Program in the neighborhood, that those staff are better suited to engage with the neighborhood. We funded them towards that effort. Those are just some examples of the things we have done, and they also have had a leadership challenge and staffing challenge which plays into the ability to grow the partnership. With respect to the acknowledgement of the great work that is done by the folks at Saint Anthonys, the next time we get a report back we would like to see the results of some of these efforts and see that even more enhanced with Saint Anthonys and organizations in the community. Okay, thank you. Thank you. Commissioner child . Thank you. I have reviewed the document and its easier to review them as we sit here in these years, but it also becomes, i think now a real opportunity now that both hospitals have gone into operation. And we look for the future, and as i think much of our apostate public testimony spoke of, we then to need we then need to see how these hospitals actually meet the needs, not only of the Business Needs of cpmc and their desires to be more than just simply local and Community Hospital, but as the opportunity , as a city, to take to make use of these as providers for the residents. So most of my comments really, at this point, dont relate so much to how well you have come to check the boxes over the past , but what we would look forward to in the future. That is, for both hospitals. So as i am reading, i am reading the smaller one first, and we think cpmc for coming and stepping up to the issue of providing additional and patent inpatient and Outpatient Services for that district, which were, if it were not there , would certainly have overwhelmed general even more. That was a Real Community need. But as we see that the hospital is a Community Hospital in that sense, i think some of the areas that were in the d. A. , that really should then be those which the communities able to access, and that was one reason it was put in there. I believe that it appears that we have gone quite well in terms of moving a Diabetes Program. And i am somewhat concerned, but i think the d. A. Might be able to cover that even though it has been transferred out of the hospital, and no longer really within the realm of the Health Commissions purview as a service from the hospital, it still does, i believe, remain under our d. A. , and that we should be able to take comfort in the coming year as to what the Diabetes Program has been. So i would look forward that staff would be able to provide that to us in an x youre working with cpmc as to now a mature Diabetes Program with at the new hospital. I think the last speaker also brought up the question of the senior programs, and the senior excellence with both the ace unit and with outpatient programs. I think its our opportunity for the coming year to then ask that as part of the report, it is not checking off the box that you have those, but that the commissions be able to understand what has actually occurred, how many people are being taken care of, how many were from that community, and, in other words, to understand not just a quantity, which would be nice to know, but also the quality of the work that is going on. I would say that i am looking forward to a coming year and we could see the fruition of the reason these buildings were built. They are not built there just to be buildings, they are not built to just become Tertiary Centers for a very large system, they are built also for our community i think our new van ness avenue campus, we should see and, thank you, i guess it was just last weekend, and i understand that you have just opened up the new van ness campus, that you brought us data in terms of who are being served with in the system . That is helpful. That is demographics that we can then compare in the future as to what is going on, and i think an additional amount of demographics should also then indicate what is the demographic in regards to our zip code use from the tenderloin. What is the percentage that are now able to use and do use the hospital. I think that goes also to the clinic and yes it is not so necessary that we get the 1500 as an m. S. O. Or as a group that cpmc has sponsored, but that we see that what these efforts are, in fact, show that the communities using the hospital. So whether it be by way of the clinic, by Saint Anthonys, by the three independent practitioners, i think the key question is, county people are actually using van ness that are from our tenderloin . That, obviously will easily compare to what was at pacific, because that was quite far away and we understood that, but that , in fact, we should be able to see that a fair number of people from the tenderloin would find that services at the new van ness of a new are really accessible and are those which the Community Embraces and finds it just as convenient to use, even more convenient than trying to take the buses or whatever transportation in order to get to general or up to st. Francis, which is now a little further away. I think that would show that the citys partnership with our cpmc organization actually has benefited the residents of our city, which i think is the purpose of the d. A. Those would be my requests. I might also add that it is a small one, but on the Senior Center that says that we are going to have an Advisory Board in the community, im hoping it is a mistaken comment that the community Advisory Board only meets once a year, because that wouldnt seem to be adequate input on the part of either the community or cpmc in terms of dialogue regarding the work of the Senior Center. Aside from that, i will conclude my remarks. Thank you. I would like to echo what the other commissioners have said, thinking you for your excellent presentations, and also to the public for your very insightful comments. I think, you know, my concern is that there are literal stipulations for the d. A. And then there are mandatory statistical reporting demands, but then theres this whole issue of how this translates into engagement with the neighborhood. Quite honestly, i spent a lot of time reviewing these documents and i find information quite opaque. I cant quite extract from this information what you are really doing to outreach the community. When i look at cultural competence and competency, i think of the entire realm, including making tenderloin patients feel comfortable entering the doors of that numbness. It is an imposing building. The van ness entrance closes promptly at 5 00 p. M. , it is up a hill to get to the emergency room. I mean, it is an imposing structure. Even beyond anything you might say, there needs to be a lot more sensitivity to how you can really welcomed the residents that are within footsteps of the buildings themselves. The other thing that i think is really important is how you do explain your footprint. The hospital tours for the pregnant patients say that the labor and delivery unit is actually at 1100 van ness not 1101. Even your efforts to help patients that are planning to have care at cpmc are not coming through your website they are not coming through. Your website is very confusing and even to patients who have used the services at cpmc before the other area is senior care. We understand you have these programs, but we dont have any idea who really participating and what the demographic is. Now you have been open for about a year plus at mission burnell, and 10 months at van nuys, i would like to see the next time we meet, real data, real demographics about the ethnicities, about the language, about the insurance coverage, and about the charity care that you are providing at your two different sights in these various programs because that will help us better understand that you are really meeting the spirit of this agreement, not just the stipulations of the agreements. I too would like to add my voice to a my colleagues have said in relationship to the comments from the public. The report from both cpmc and the department of Public Health and planning. I want to make sure were clear that equity is an issue, and we need to demonstrate equity, or you need to demonstrate equity in terms of the populations that you are serving. This is a great piece of paper, except i cant read it. The print is really way too small. Next year, in march, for those of us who wear glasses and still cant read it. The class information is critical and essential. Whats more critical and essential is the notion of equity and access to these services, and i understand what was presented in terms of Saint Anthonys and the issues and concerns that you have in relationship to acquiring new patients, we can, and you should do better. With that, i will defer to my colleague, the president of the Planning Commission, for their comments and questions. Thank you. Commissioner koppel . Thanks again to staff with all departments involved. A lot of things going on here. I appreciate your time to clarify everything. I wanted to address the workforce issue. More so on the temporary side, the construction and building of the projects. I would kind of be out of order if i was necessarily speaking as far as the longterm Permanent Employment at the hospital, but before being appointed to this position, part of my responsibilities were overseeing projects like this and meeting with the general contractor and their employees along with city build and trying to connect all the dots, at San Francisco residents building important San Francisco hospitals, ideally taking the bus or bicycling or walking to work, and as far as im concerned, cpmc is more than compliant. They have exceeded what would what was actually possible. A lot of this has to do with timing. This wasnt the only hospital being built at the time. Ucsf, mission bay was wrapping up, and ideally those residents and workers, everything was timed perfectly when mission bay would be completed. Those residents were transferred over to General Hospital and building the new trauma center, so after that was nearing completion, those workers were ideally going to move right over to van ness gary, and there was about a year hold