Saying aye . Thank you, commissioners and item 3 is the directors report. Good afternoon, commissioners. Im the director of health and just highlighting a few of the items in your directors report. On november 20th, i was really pleased to accompany marilyn and breed in the leadership to announce 72 new residential stepdown beds on Treasure Island for people who are continuing outpatient Substance Abuse patient and who are at risk for hom homelessness. They will be operated by health right 360. They are onetype of Behavioral Health bed to help people on their journey of recovery and people can stay here in these units for up to 24 months so its really a key intervention and the hybrid, crossing over from the intensive behavioral treatment to permanent Supportive Housing and this is a key part of the puzzle that we continue to work on solving in our system and just to reiterate that we contract for Service Providers like health right 360 to operate facilities at various levels of care in our Behavioral Health system and the expansion of these beds added significantly to the 2,000 bed inventory and with investments in her budget, weve expanded the Behavioral Health system by over 200 beds, actually, since i started in early of last year. So making some progress there. And also a reminder that december 1st was the annual observance of World Aids Day and we announced this welcomed news in november, for the first time in history San Francisco recorded a loaf o low of 200hiv residents, and communities of colour and hiv infection rates continue to be high and we continue to work on that and we can look back to the commission with some promising data about how were making progress. I believe that will be mentioned today in the Health Equity presentation. And just touchdown upo touched. And next year as we think about World Aids Day expect contribution San Francisco has made, next summer, San Francisco and oakland will be cohosting the international aids conference. So a major spotlight on the bay area with regard to our efforts and hiv and what weve learned can expand to other communities and equally important is what can other communities and other parts of the world teach us about how we do better. And also highlighting the Chinatown Public Health Center is celebrating 50 years since breaking ground on the construction at the Current Location and a remarkable 90 years of service in the community of San Francisco. The clinical will celebrate on december 5th with healthcare and city leader luminaries, patients, staff and community partners, and commission chow will be speaking with the ambulatory leadership and its an important marker with regard to that anniversary. To highlight another piece and i take particular pleasure in reading the title of this one is medical clowns grand rounds. [ laughter ] so medical clowns held their Fourth Annual grand rounds fundraiser at laguna hospital and for a number of years, the medical clowns provides supplemental therapeutic patients with memorycare needs and this is an example of where theyre providing innovative programs for people and something that is really making a difference in peoples lives and wanting to highlight that and read that title. So i stand available for any additional questions or comments on the rest of the report or any detail that you require i didnt go into. No Public Comment requests for this item. Any questions or comments, commissioners . I have a question under the students who received the rapid hiv test at balboa in the health fair and there were 19 Behavioral Health referrals and nine medical referrals. Do we know if the referrals, especially the Behavioral Health referrals, if they, in fact, received services or do we know any followup from those referrals . Im concerned referrals were made versus were they able to Access Services. An important question and i dont know if dr. Hammer is here. inaudible could you just come to the podium so we can get it on tape . Thank you. Hi, im the director of the ambulatory care and i dont have the exact answer but i will get that to you. I think, for the most part, they were referred to Behavioral Health services in balboa so in all likelihood, they didnt have to wait or go to another place, but i can find out and get gag tbackto you. I dont mean to be a pain, but in their Wellness Center, i know that a lot of times, they are somewhat overwhelmed for Behavioral Health services and so, i am concerned if, in fact, the kids did reach out and say i wanted a Behavioral Health followup, that they were able to receive it either at the Wellness Center or that the social workers did connect the kids to specific Access Services versus, ill see you in three months. Thats all. Sure, and help them navigate to where they were referred. Completely with you and well get back to you. Thank you very much. Any questions or comments . Dr. Chow. I had a question and a comment. I think its commendable were able to get 72 health beds but im wondering how we would connect patients to the real world to speak because Treasure Island is fairly isolated in order to assist them in the transition that would be needed as were trying to move them into a more normal life. When i was out there, i asked that specific question, Health Rights 360 does a good job of making sure people are availing themselves linked to services, lifeskill training and also making sure theres appropriate transportation into the city, frequent transportation so that people are able to get that work. Its very different from being sort of in an isolated place and the thing thats striking about it, the houses have shared rooms and a shared common room and theres a shared sense of community and thats a big sense of the therapeutic program. But theres multiple Transportation Options from Treasure Island to San Francisco and so forth, back to the rest of San Francisco, i should say. Excuse me. I just wanted to make the comment regarding the Chinatown Public Health Center and wanted to thank the department and the commission for maintaining that center. It wasnt that many years ago, several decades ago, when in the face of adverse Financial Issues here at the department, we were looking at closing centers and i think that the department saw the wisdom of maintaining the Chinatown Center as an important point of service that, as you pointed out, has been there for 90 years and that it is really, i think, a forerunner of what we actually now have in the Health Network, which is really a fullfledged primary care neighborhood units that are available for the immediate neighborhoods rather than all having to go either to general or wherever we were concentrating our services. So i think its noteworthy, not so much that the 50 years have sat on top of the broadway tunnel. [ laughter ] not exactly sure, but i guess it did pass earthquake Safety Inspection in the preliminary, but the fact that this actually was a type of service that could have been lost during the financial crisis of the department, but the department and commission felt that it was important to keep it. Thank you, commissioner chou. With no further comments, ill return to the secretary. Item 4 is general Public Comment and we have two requests. I have krista duran and julie. And Public Commenters, as you know, ill have the timer when it buzzes. Hello, how are you . Im here again and im going to keep coming because i just want to advocate for our staff and patients. Yesterday was a really, really hard shift for a psychiatric nurse in psych emergency services. Shes a single mom with three kids and she was mandated for the second time this week, 30 minutes before her shift ended, mandated to work a 16hour shift. And yesterday they worked with five nurses. One of those is the charge nurse and then the other one is the triage nurse, which you know per title 22, they are not allowed to take an assignment. They dont count in the ratios. So thats three registered nurses taking care of 20 to 30 psych patients in Mental Health crisis. And this is a problem. And we need to address it. And the er is constantly understaffed and overcrowded and weve been getting paged out for experienced triage and trauma nurses, wher. Were a levelone trauma center. They dont have enough because were budgeting for nurses that have been there for less than two years. A crisithis is a crisis andwe. We have a surplus of 96. 5 million i dont understand all this math but i can see theres a surplus. So i dont understand where the staffing is coming from. Whats going on . I mean, this is bad our patients are not getting the care that they need. Also, were supposed to be on the agenda for the joint commission, starting december 10th. Im excited that the er will be on the agenda, but i was also not excited to hear that it was just going to be our managers giving powerpoint presentations and not us having a seat at the table. So i would love for you to reconsider that. Thank you. Hi, im julie from the emergency room and ive worked there for 20 years. I started working in the department of Public Health to do Public Health and i dont know what were doing any more. Im having a moral crisis almost everyday i work. Im not alone. Ill actually submit preliminary data. We did a survey of staff and stress levels, 80 are having pstd symptoms. Near 50 of the respondents say they have retired early, decreased their hours or have taken a leave of absence and 86 to 92 have anxiety because of violence and they feel unable to provide the best care they can provide. 65 of our staff feel hopeless because of the situation and i dont understand why we keep coming here and i have not seen anybody from here come to our department and walk around. But anyhow, im submitting for the record the written statements from the past department of Public Health hr director, the statement from the pr nurse yesterday that krista was talking about and preliminary data from our survey, as well as not all inclusive list of things we need to deal with and things to help make this better. Weve gone to regulatory agencies and i think maybe we need to Start Talking to some legal authorities and justice departments because theres money thats unaccounted for and were scrimping and were i scra thirdworld countries. I have people from thirdworld countries look at us like were crazy, were asking for help. Were failing. The department of Public Health is sick. If it was a patient in the emergency room, wed be coding it. Those are the requests ive received, commissioners, and as noted, the december 10th jcc meeting will have an agenda item and youre welcome to attend. Im 5 is a report back from the finance and planning committees and commissioner chou chairs today. In the contracts report, there was an item for crosscountry staffing which is a contract for the registry personnel and its one of three contracts in order to provide red street personnel and we heard the rationale for this and they are the prime contract for approximately an annual amount of 7 million. We heard several new contracts. The first one was the second contract for nursing, for registry and thats for a total amount of about 2 million and this would be the second registry used if the first was unable to provide the services needed. A third registry is also being contemplated as needed. We also then heard a new contract called health space u. S. A. This actually is a new database for the environMental Health section and you probably, im sure, saw the items that it actually will be covering, which includes doing permit issuance, complaint and investigation management and field and tablets, scheduling for employees in order to be efficient in their various environmental investigations that they have to make and that includes, for example, the reference. And they are a company that actually specializes in these. The contract is coming before us as being the second next important item according to the department for it after epic. In order to bring the Environmental Services recording into the 21st century, i think would be the best way to describe it. Apparently its being done by paper at the moment and created from, basically, microsoft, and they set up 17 different programs, which, obviously, i see everybody is homegrown and really, it is at this point outdated and must be why the program uses this as the next biggest item for operations in the environmental department. As you know, the Environmental Services need to pay for themselves, so the hope here is that this will be much more efficient and will be customer and consumerfriendly and brings us towards the 21st century. And that item will be before you aand cost 5 million over a fiveyear period. It will take three years to create it and implement it and they have a twoyear period for the maintenance. So those are the five items we heard and there was also an informational item from our emerging issues in which we actually, as a department, use a conglomerate for doing a number of purchasing, called a Group Purchasing organization. The administrative code are several years behind in terms of being more accurate as to the methodology and the department is proposing administrative code changes over at city hall to the citys code in order to bring that up to date. Essentially, this was the Old University coop that became visiant. With Group Purchasing, were able to get better pricing than those who come to the department and the commission doesnt change the process or the authority that any of us have including the board, but it helps clarify what is the current situation. So we will hear a further report at the finance committee as to the success of the previous contract which was called for in the old ordinance and theyre calling for that type of review every five years to the commission to inform us o of the purchasing contracts. That ends my report and i would happy to answer any questions. Commissioners . Item 6 is a consent calendar containing all items that commissioner chou just noted and recommended for approval. The consent calendar is before the commission and ill call for a vote. So moved, seconded. All those favour . Aye. Thank you, commissioners. And we have an item order change for today, and with your permission and item 7 and then well move to the Population Division health, two north. Dr. Bennett. Do you need assistance with me pulling this up . Im dr. Bennett, here seeing you in a slightly changed role and the director of the office of Health Equity which has existed for five whole weeks. This presentation will give you some background on what that is, why we did it and what you can expect from that office Going Forward. So what ill going to tell you will be both familiar because were consolidating work were already doing and new, as were changing our vision and direction and you already know that equity is a true north and there are many people in the department who will tell you that equity is their work and equity is the thing that brought them to the department but if you look at our data at the black Health Report and many other data reports, we know the current work is not doing the job, right . We still have inequities despite generations of work on these issues and so we are going to talk about some successes, but this talk is really been our efforts to look for a different kind of success, to move from transactional to transformational and look at sustained change and not just moving the needle on a number but leaving the system intact and so, ill be talking about a little bit of answering that what by what kind of structures and activities were going to do. But also, the why, what function that structure is meant to achieve. So that is our new chart. I sit exactly in the same position i was before but weve changed the title. And that is similar to our office. Policy and planning or compliance, an office that sits with the director expect structure that were building initially and i expect this may change over time as we go forward, fits the function were looking for. There are infrastructure bodies, a couple of convenings of staff focused on decisionmaking and sharing best practises. Theres some direct programming. The hope fs program and individual contracts, and theres Health Equity work across the Department Supporting individual departments an in soe specific programs and Health Equity workforce related stuff and staff under thie each of th. That consolidates staff here and one fulltime person and two halftime people added to that staff. So how did we get here . So many of you were around for some of this and you know that it starts well before 2014, as i have it on this board. It starts as far back as 2008, when dr. Aragonne First Published data about years of life lost between African American residents and the rest of San Francisco. It goes back to more National Research from the jackson heart study and other things shows massive racial despairties. And some data from the institute of medicine showed us not just race but racism was the relevant factor and theres plenty of data now to establish that. So when we arrived at 2014, with the director having the idea about the black africanAmerican Health initiative, both of those things were wellknown in the department. It was looking at health force and work force expect cultural things that underpin those, so cultural humility and what keeps those two things going. We started with the black American Health initiative in 2014 with those intentions and we started the trainings with dr. Hardy over 500 staff have now taken 32 hours of training with him and thats Something Like 16,000 hours of training across staff. Its quite a few. And then baji leadership changed and expanded so that the individual projects of the baji program were of cours expanded n expectation that all sections would take part in some way, not just around the designated Health Issues but around their work more broadly and then we had equity convenings of staff in 2018 which determined we needed different infrastructure and thats where the ineffective office was brought up. At that same time we were going through that developmental path, the city was doing its own development. It joins a network on government, race and equity and that is alliance that has committed to eliminating residential and equity ielimina. Several systems have gone through that training and it has established the expectation that different parts of the City Government will make changes. So agencies all over the city have participated and that includes dph, all three years the city has been involved, only allowing us to send two staff a year and in a staff this large, it has not had the depth of impact you would like, but that did lead the city towards the idea of establishing october 1st of this year an office of Racial Equity for the city of San Francisco. So that office of Racial Equity announced on october 1st and we announced our office of Health Equity a few weeks later. Just to give you background, that San Francisco office of Racial Equity is an ordinance that establishes requirements for the departments of our size. So it requires a designated staff person for each area and were interpreting that to be sectioned. We have already some established staff and theres an established equity lead for Behavioral Health, for the sfg, for l lagua hohonda and there are leadership that hasnt been hired yet. But the expectation of whether its a new staff person or not, someone in each section will take the lead around equity. And that means that we as a department are supposed to have a lead and that is me is the department. Theres supposed to be annual goals and plans registered with Racial Equity from each of the large departments and we will be expected in 2022 to put in our first plan and have and annual plan after that. Were supposed to participate in citywide training and that is yet to be developed and there will be goals, achievement of our goals will be tied to budgeting and hiring approval from the board of supervisors and that has not been delineated about what that means, but that is the broad statement that was made. So what is the mission of this office . Its Health Equity, work castfoe and Workplace Equity and direct force and it will be clearly leading with race but not stopping there and leading with race for lots of reasons. We talked about racism as a key driver for health and p w we knw from our data, and in particular, ourace gives usa br. Its an original organizing principle and its baked into policies and procedures and when we go which correct those, rewere correcting inequities for other groups. Theres huge intersectionalty between policies and practises that uphold racism and those that uphold the other isms that oppress people or keep them from having Health Equity. Were looking for a curbcut effect and by that i mean, thats the one intervention intended for one group and actually smooths the way for everybody else. So if we are doing our best for the people who we are showing the worst outcomes for, it will increase access, increase quality of care for everybody else. We are going to focus on systems change and im going to talk about the framework that leads us there in a few minutes but that means that we will not just be looking at transactional program development. What were looking at is changing our underlying policies and practises and the way we go about our work. Focusing on alignment and that means collaboration. Well take that into our equity work, as well. There are several reasons, social determinants of health are important. We know that the underpinnings of racism that lead to Health Outcome differences do that through changes this the conditions through which people live and so their housing, their transportation, their access to care and all of those things are not the purview of any one group. So it will take Population Health and the Health Network and also agencies outside of dph in order to actively address any of these things. Also, were doing many things right but theyre sa siloed andt spreading. We have examples of programs that are not scaled or spread because of the nature of our sigsilos and if we want to havea good effect on the department as a whole, which we have to do to have an effect on whole populations, then were going to have to have some mechanism to get passed that silo. Well focus on achieving Health Equity and thats a core part of this activity. Our mission is to improve the health of all of San Francisco and we know that if you take our average, we are doing that very well in lots of places. If you break down that average by race, were doing it some, not all. So we want that for all groups, not just some of the groups and not just an average. So that means pushing ourselves as we have been to have clear quantitative outcomes. We have been doing that with our lien work, with resultsbased accountability and accreditation and thats a principle happening across the department. We want to make sure that principle is applied to equity, as well, so were not just trying to make things feel better or sound better but looking at what is everybodys Blood Pressure pressure and what are we doing for life expectancy. That helps us by leveraging investments weve made in Quality Improvement and business improvement. We want to focus on workforce. That has been a call from our staff the entire time weve had that project, back to before baji. That staff has told us we dont have equity in our workforce. The same underpinnings of workforce is passed through to patients. So the kind of people who are here, not here, the way people treat patients with respect, the same way theyre treating each other. We know we cant do one without the other. Our intention is to have all staff giving their best and we know if we look at the average, thats true some places and if we disagregate, thats not true. So we want to be sure were doing the same for everybody. And also, because racism is Health Related and its important to health, that means that its a professional interest for everybody here. It should be a professional skill to deal with anything that is a healthrelated condition and so, just like we want people to be knowledgeable about food or poverty, we want them to be knowledgeable and versatile around racism. One thing thats not on here, because this came together a bit quickly, last minute, is that we want to focus on centering the community. We talk about being patient centered but we need to be both centered on the individual and the communities in which they come from and thats partly because racism is deeply geographic and because the impact that we want to have is beyond the individual. We know the drivers of health are things that impact at the community level, not just at the individual level and so thats why we talk about racism as interpersonal, meaning the relationship between two people, but also structural and institutional, things that affect everybody who comes through or the entire family or community. So the activities were going to do to make those things happen include developing the annual plan that were required to have. Weve done that as an a3 over the last two years. Supporting inequity infrastructure and that means having standing, ongoing bodies of people who will make decisions and keep focus on equity as we go forward. Were going to align with the office of Racial Equity, both were required to, and we need to build relationships with other departments if we want to make bigger changes. Well provide training. And then develop policies and practises. And both training and policies and practises are both about equity specifically, but also about things Like Community engagement, communication between staff, so not just inequity 101 but whats the body people need to do this practise . So the framework comes from the Government Alliance on race and equity and what youre looking at is the way in which it lays out what they think of as the trainingtransformational journe. Theres a law say you cant do this or that, theres a rule about who can do things. And then structural transformation i dont know weve seen but its where they dont exist and weve redressed or problems. So we have done a version of this with about 1500 of our staff, have done this very, very selfassessment or some part of it. And most of the time, we end up somewhere between three, which is transactional, which is that policies and practises are in place to promote Something Like multiculturalism or diversity, but they dont yield the results. So we celebrate different cultures but dont specifically talk about race and racism overtly. Our cultural shift where policies and practises call out race, theres an intentional review of policies and practises and things are starting to shift. And we get to that sort of three and a half average score somewhere around there, by staff saying that were a two and those staff tend to be black or latinex and staff saying were a four or five, very rarely a six and those staff are white or asian. So were not all sharing the same view of the department or same experience of our work here. Were not where we need to be. Were in the middle, on a journey. The framework is to help us understand where we are but also to help us understand where we are as a place in a journey, that there will be lots of activities required to move from one place to the next and our job is not to flip some switch that doesnt exist but to move everybody from 3. 5 to 4 or 4. 5 or whatever the area is to make things better. So were advancing equity, not striving to arrive at some finish line tomorrow. The next part of the framework is how do you move from 3 to 4 or 4 to 5 . And the way they recommend it and thats what were using, you go through three phasing. You normalize and that means that you set the priority. Thats the same thing as weve done with setting this as a true north, making statements about it, establishing things like an office, giving people the idea that this is a priority for the department through specific training, skills training, knowledge training and all of the things you need to get people used to and talking about this and using this as part of their daily job. The next is to organize, to actually put in infrastructure, groups, decisionmakers, set roles, established resources and that doesnt always mean a formal department, but making sure that people know whose job it is, what kind of of outcomes youre looking for. So actually get the data systems to give you the data you need to be able to monitor. So organizing around it in the last is operationallizing and actually making a policy change and making a practise change and changing the way you do things. So weve been doing all of those things all at once and they want you to do somewhat in order but weve been doing them at the same time to some degree. So training has been something that we have slowly developed. So we have been training in different ways, in different parts of the department. The general training, we all have slightly different training. Were doing an allstaff with hrc so that were in consistency with the rest of the city and we have not quite established that yet, but it is coming. That training will have foundations of racial and government policy history so that people actually understand the context in which theyre working and we have many staff who this was not something they learned in school and dont have a deep understanding of why things are the way they are. We need to catch people up so were on the same page and whats the actual status quo were asking them to work on. And then skills training. So managers working on communication, working on how to establish goals, have our epidemiologist aggregate data and how they relate to our goal achievement policy makers and how it has an unintended consequence of exacerbating Racial Equity. So all of that is happening over time and some has already happening. Fast facts is a way of normalizing and giving people information and then ill talk about the Champions Program in a moment but the learning a catch to that new program, well do a Fellowship Program in the spring for people who might be more intensive practitioners, epidemiologists and other people developing policy. Were working with that to set a curriculum so we can do a sixmonth program or so that at the end, they have expertise and we can see expertise across the department to move everybody along. So what do we know about where we are and whats our status in the chart youre about to see, ill orient you to, because its confusing. Our Staff Engagement survey this spring, we added six questions that are based on questions that they use to assess municipalities and those questions are here. The first is looking at whether people understand what institutional and Structural Racism is. So policies contribute to differences in health between racial groups and then several are about what work do you see happening . Im actively involved or my department is working on this. One is a question about skill. I feel comfortable talking about race and racism in the workplace and two are about respect and thats put in there based on staff feedback. So managers treat staff of all racial groups and staff in my department Treat Community departments from all en ethnic groups. The darker the colour means the higher the score and more people answer agree or strongly agree. So if we look at the top line, somewhere around 70 agree thats true. But there is difference by race in that answer and if you look at all of them, we have a few conclusions, so some staff dont have any more information about racism and what its impact is. If you dont believe that government policy has any impact, you are actually purveyors of government policy. You were actors or creators and if you dont think that has an impact, how do you envision your role . So many staff arent involved in the work and half say theyre actively involved or their department is actively involved and many staff dont have the skills to discuss this topic. You cant be working on something that you cant discuss. And so we need to have more discussions that people feel more comfortable doing that. Some amount of disrespectful behaviour is happening and people answered that three quarters of the time they agreed but we would like that to be higher and means one out of four answered that, seeing disrespectful things happening. If you look at that throughline in the middle, its lighter on most questions because our black africanamerican staff answered lower for many of the questions. And so, they were much less likely, so 7457 saying managers were respectful and saying staff were respectful to community. They are also also comfortable e talking about race and racism. Whether thats im not comfortable talking about it, because its not a topic i talk about, which is true for some people or because i dont feel safe talking about that here. So we dont fully know. These are just answers to questions, but they do mean that we have normalizing to do around the department about what people are expected to do and what we want them to know and about how we expect them to behave. So in terms of organizing, which is really an active of focusing on systems change and active alignment, we have two new groups that started earlier this year and are continuing once the equity governing council and thats an expansion of baji Steering Committee and that includes directors and from the jail and primary gear, from the laguna honda and includes different intentions. They developed their own departments and equity plans and goals and it helps to have people together, saying we want to get together around heart disease. They helped develop strategy and approved policy and that group is paired and they meet every other month and the governing Council Meets in the next month the Equity Leadership meets. So are managers, for the most part who are equity roles or focused program are the person in their area to learn something about this to get something going. Those are people who develop work and share best practises and who craft policy recommendations. So thats the group that said we dont have enough time to do this work and lots of people want to but arent given time. So we craft a policy to allow them to do that. Or that we see that theres some disrespect happening and then we add questions and then craft policy to address it. And then that policy goes to the governing council to get approved and then to the director. So the Champions Program is the first thing coming out of those two groups and its basically giving people five hours a month to work on equity work. The intention is that they would spend half that time learning and our expectation is that theres a low level of expertise around the department and people have a feeling they want to do this but in terms of how to go about it, its not as deep and people will spend half that time working on that and half of the time working on implementation that is not developing a Little Program in their area. We want people to be generating the foundational work that will keep them going longterm. Doing focus groups, observing patients with your staff and looking at the data about performance, when people have looked at it in the department and they have shown that some oe showing they dont offer the same as they do t. Our goal is to have 50 applicants in the first year to start and we got 70 or 75 and we got them from every section including it and finance and well work with those people to start generating what the new baseline for your area to understand what to do next. And operationallizing, were working on several fronts and were continuing with the baji work groups and weve extended passed that. Theres direct programming, the hope sf is under Health Equity, a new dula program in the community and those things are direct services to areas where we know we have an equity problem. But the larger goal is to have equity expectations in every area. So to have laguna honda has picked hypertension control and having each area pick something theyll focus on and devote time to and correct that. Rather than having discrete projects and thats moving from transactionional to transformational. The graph youre looking at is the hypertension run chart, the run chart from primary care from the beginning of that project. So in 2015, when it started, with that baji work group started, there were 53 of black africanamerican patients had hypertension under control and 61 of the general population did. And that was an 8 gap and today it is actually 67 point something percent of africanamerican patients actually 70 , they went over 70s. 67 of africanamerican patients and 70 of all patients and we expect this to happen, that when you raise the expectation, it actually raises it for all people. We did things that improved care, nurse visits, pharmacy visited, food pharmacy, all of those things were really thoughtfully directed at africanamerican patients but helped all patients so everybodys Blood Pressure got better. But because of that focus, the improvement was greater among black africanamerican patients and we were able to close the gap. If you look initially, that focus wasnt so exact and so, everybody got better at about the same amount and its in the last several years that its been more directed. Laguna honda had the same impact, they started later but brought hypertension control for africanamerican patients up to par. This is focused in the Youth Clinics to date and screening brought to 85 . In the first year, they had a dip when we had staff turnover and had to do retraining and theyre back up there and then baji preterm birth just starting. If you remember initially, that the idea had been to focus on Breast Cancer and then we shifted. The governing council asked us to shift, partly because thats where a lot of crossenergy across going and we wanted to harness that work to make sure its directed to our own health and different parts that werent part of that project were brought on board and its turned out that way. So part of that has developed a dual program and baji is supporting. They started in january and they have had 15 so far having started deliveries this summer. So what i did do im sorry, i took out what you might still have. I took out a lot of improvement stats from other areas of the department because this was getting long, but a lot of the things are transactional changes and theyre happening as the same time as the longterm transformation change. Hiv and hepc has brought the curate to much better. Were work on a dashboard and we havent developed it fully yet. In terms of workforce, the operationallizing is in the same way. Theres focus and data where each department is in terms of their key areas of hiring and advancement. But then theres programmatic things like coaching that were worworking on developing. The biggest is changing policies, how we address hiring and review or discipline. And there is activities related to that. So our Workplace Equity metrics are in development. There are a lot there and fall into three areas. Primarily we are focused around hiring diversity and so theres activities that have happened in that area including adding some recruiters to the department is focusing on Racial Equity, but as of yet, were looking at how to set what our baselines are and how to set goals for the different areas. Our despairty issues are different from section to section and setting goals across the department is something in development. Looking at both whos in the interview pool and who gets hired. Workplace culture is an important one in terms of how people are treated, how theyre disciplined, how people feel about their work and so we want to get that number of people responding with respect. Were doing a Halfway Point assessment of that question and then were going to redo the Staff Engagement in two years. And that will tell us where were going. At the minimum, we want to get every area to 80 and eliminate racial despairty were seeing and were doing that through policy changes with standards of respect and how we discipline people for disrespectful behaviour. We want new staff because weve started orientation talking about what the definitions of racism and institutional racism are and were looking at new staff being able to define that after orientation. That should be a measure for all staff, but were sort of looking at trying to stay aligned with all staff training thats happening across the city, so we have not deployed that yet. So we want to look at the number of complaints about disrespectful behaviour. We still havent established a baseline because we havent established a policy. That data baseline was created this summer and we havent yet decided on what our goals are to change that. Staff training when it happens, well want to train 100 of the staff, at least in the basics and then do manager training specifically around communications and equity culture. So the timeframes are both dependent on the human rights commissioners work. Thank you. Any questions . We have one Public Comment request, commissioners. Jennifer epstein. Thank you all. Thank you, dr. Bennett, for the presentation of Racial Equity. There was a recent article in 48 hills that talked about something related to equity, which is patients being treated and cel spoken to in their natie language by reallife staff and theres a new hr policy enacted to discourage our staff from doing that. And in a moment well talk about savings and personnel and finances and the budget and theres a 90 million surplus from San Francisco general which is wonderful but should not be divine from saving 60 a pay period on language capacity. Language capacity is something that dr. Bennet didnt go into because most black people speak english. We have five languages that we typically try to reach. However, if a client is driverruousdeyearuous,deliriousl emergency and not the appropriate moment to go to a phone to get someone to talk for that person, thats a need. Regarding language and race, we have to think about peoples diagnoses. If a psychiatric patient is seen, they typically are seen as someone who has marginalization. Someone with heart disease, we wouldnt know and with a psychiatric ailment is seen differently. Folks who live at boarding care homes are pushed out of the city and it needs to be changed. The boarding care homes and at the aurora care home, theyre going out of business. Our people are being pushed out of the city and i dont know when it will be different or when the city will take the savings and invest it. It does not really make sense for these people who have lived in San Francisco their entire lives to be sent elsewhere. Im glad theyre not going to a shelter, but we need a permanent solution. People should be able to stay home. Thank you. Thank you. Director grant, do you have a comment . Well, just to emphasize that the focus on equity internally with our staff and our workforce is key, as well as improving equity outcomes and ive asked Michael Brown to work closely and then to emphasize that with mayor breed, directive to the hrc, the human rights commission, that were working closely in line with their efforts Going Forward and this will not only be an effort of the department but will align wit prioritiewith the prioritiee city. Our workforce can cross departments and this will be a cacatalytic. There is a catalytic office and to hold the division for the work but equity work is Going Forward. So just to emphasize that. And look forward to continuing the work. Commissioner gerardo. Thank you. My question is throughout your excellent presentation, we were talking about policy practise and process change as kind of a seam throughout the presentation. How, in fact, are you going to measure the change, especially within policy, that, in fact, the policies