Transcripts For SFGTV Government Access Programming 20240713

Are there Outcome Measures that you are going to i understand with Health Equity and what you said that theres very specific measures with the blood pressure, et, but with policy, process and practise, will there be Outcome Measures that youll be able to have in place . I think there are Outcome Measures possible in every stage. So ill give you a couple of examples. So were going to deploy a respect policy some time soon which delineates disrespectful behaviours and encourages us to move to using our standard discipline and other mechanisms to actually enforce our Workplace Culture to do something about disrespectful behaviour. And so, the outcome of that is measured in a few ways. The process of whether or not people make those complaints and how many there are and what the nature of them is. And are there an overconcentration in an area to give us a sense of where we go next but tells us about what the department is doing so thats a process measure but the outcome measure is why we ask that baseline question. Are you seeing disrespectful behaviour . Because our hope is that people who sigh i see it is see it res, over time be answering different to that question. We may see a spike as people see it responded to, which elevates the issue as it happens, but then looking longterm, were hoping that we would see people report back to us that they are seeing less of that, that they can agree or strongly agree that managers are respectful and that staff are respectful. A lot of things we dont have the baseline in order to establish where the policy has had an impact, but we are needing to put those in place. So another example ill give you, at mcah, theyre looking at why they have such discrepancies with their latinex and black american women and i think it was the nurse family partnership. So they looked at both the retention of patients and who leaves at what point so thats their outcome measure and they want people to remain in the program longer and equally across those groups but they looked at the process measure of, how are our staff interacting with patients and found there are differences and how many times theyll call you before they close their case or how long they stay on the phone. So looking at that to stay we looked at what our behaviour is and our behaviour became equal. So are people getting three calls and case is closed, still, after three years of changing the policy . So rather than having it be up to the nurse to just decide, actually deciding thats an area we need a policy and well do it the same way and set a standard so we can say when the standard is not being met. And then looking at, does that have an impact on people retained in the program and an impact on whether or not people have Health Outcomes from the children. Im always concerned with policy and practise change, that there is the outcome and the followup, because we all can create policies and wonderful emission, but whats the end product . And how are we measuring it versus our policy . And so as youre going through this, it would be just really helpful and i would be interested in the information . Well, what will help us on both fronts is that we have been marching forward as a department to increase our rigger around holding ourselves accountable for outcomes. So the a3s that people are producing that have processed measures and Outcome Measures in them and say we should be checking this at this cadence and have the display boards, having that underpinning of structure of how to go about it will help us if we can use that structure on this issue. And so, if were looking at er wait times, trying to get them to look at, is that wait time different, for different groups and is there a reason people are leaving earlier. So being able to use the increased rigger, wer were tro have in all areas apply to this issue and were trying to do that, even around policy. Thank you. No problem. Commissioner bernell. Thank you for your excellent, thoughtful presentation. I recall when you were here a little more than a year ago, we were talking about a normalization phase and there were a number of conversations, facilitated conversations happening across the department that were proven to be extremely valuele. In looking at some of the data youve shown or some of the ways at looking at this, like system change and the employee surveys and how there are some groups, of course, who have a favorable view of how things are than others, im wondering if over this period of time, when youve been having these normalizing conversations, you know, we, of course, all want to see those numbers get better. We want the perception in system change to look further along and we want higher percentage responses among the employee surveys and have you seen theres a value in, perhaps, some of the groups responding with higher favorable rates . Perhaps those rates are lowering and being more of a convergence where peoples perceptions are coming together so there may be some value in se seeing certn people changing their minds and seeing were not as far along or favorable . That is, in fact, our expectation, that somebody who thinks no disrespect is happening or seeing in the same department as someone who thinks its happening all of the time or somebody who sees us as a fix think things are worse as they become more aware of whats happening around them. So we dont expect everyone to stay the same and both sides are a problem. Its a problem if you see everything as terrible, because youre right and youre not seeing the positive changes but its a problem if youre seeing everything is great because it means youre not actively working to improve the problems because you dont see them. Theres some of that that has been seen. Mch is quite ahead of some of the other sections in the department and have been working on this for a couple of years in a concentrated way and has had feedback from their staff that they didnt see this and they started their own discussion group, a tea Time Discussion Group about what is our role in this and how do we see this and doing some selfeducation of themselves about how racism and how it plays out in their department. Spouso we have seen some element over time and i expect that is what well see in departments that really take this forward. So in some ways, seeing less favorable responses is a good thing. Right. The other question you touched on was soji data. I know the department put forward a report, i think, in july and there was a hearing at the board of supervisors in november where we had shown progress and set some, i think, pretty strong and Ambitious Goals for the future. Now that we have epic in place and everything like that, is there a good time where you think it would be good to come back to the commission to talk about some of that progress, where we are in meeting goals that have been laid out . We know epic has reset us to some degree and were right now in the process of looking at now that weve had it a few months trying to figure out where the conversion of our workflow from our many different systems into a single workflow in epic, where that happened and carried through and we have issues about how the data flowed across and right now, were in a stabilization phase with the rest of epic. Once thats done and weve done retraining, we will have to move forward to do another phase of training and engagement with patients and with staff. So were expecting that will happen sometime in the beginning of next year. So i would say about next fall at the earliest. So thats a good time to come back to the commission to do your report. Yes. Thank you. Thank you for the excellent presentation and your leadership. This is really terrific. I have three questions and theyre connect the. Connected. The first is you discussed programs you thought were excellent but they hadnt been scaled or spread because they were siloed and i wonder if you can tell us what those are . The second is, i guess i was surprised that nearly a third of the people you surveyed that didnt think it contributed and how does that respond compared to other city departments or other municipalities and organizations participating in that gar . The third was, you talked about a dashboard and i think this reflects what the commissioner brought up, sounds like some of the things we want to measure in terminterms of metrics and im wondering when we would get a sense of what would be included and those are three different things. The first is, i think there are a couple of highlighted areas. The first, i would say, the work that i described in mcah, where theyre thrilling down to look at what is happening at the individual staff level and where staff behaviour aligns with Different Community forces that make people not take up programs that we want them to be involved in. I think that work has been stellar. There is a pathway to scale that, though, because as we build infrastructure and we ha. Weve seen that happen. That happened at mch and in primary care they took that forward and looked at their hypertension goal was to make sure they had two blood pressures for every patient. Well, then, they looked at they were getting it, great success. When they disagregated that, they werent getting that. They were getting it less often. They had ok performance. But looking at that as a standard of behaviour, now we have an infrastructure to do that on. The other is, i think the hepc work in particular has taken a really Community Engagement focus that is not seen often in the department. They have real Authentic Community involvement in their decisionmaking process, getting to zeros and doing that, as well. And both of them have focused on overrecruitment and targeted recruitment of africanamericans. So that both of them overrecruit africanamericans into the program. So theyre proportion far outweighs their proportion of the disease. Hepc is seen at a higher curate and higher than that proportion are the ones getting to a prepped to a higher proportion of people and retaining them longer and being able to show outcomes because theyre showing that concentrated effort. What was the second question . The context of a third of people its not that different. That question is used across the country and so, we have had staff here who did not know what redlining was or segregation happened outside of mississippi or somewhere they saw in a movie. So that lack of knowledge is actually quite widespread. Weve had staff here. I think its partly just the taboo name of the topic. It is just not described well in much of our educational system and many of our staff are immigrants and so theyre absorbing our racial history from tv shows and we havent done a concentrated way of letting they know, actually, what happened here. And so i think thats not a bad number. I think people are overestimating naturoverestimatn detail, im not sure many could understand the depth of what that means, that it means whether there are enough bus stops or fewer parks or the scores on Peoples School grades. So all of those things, i think, are widespread and not that unusual here, actually. And then the dashboard plan. So we have not what were trying to do is correct something that happened in baji. So we imposed some measures and we had years of struggle getting thegettinguptake from the diffes of department who did not participate in that choosing process. Now every part of the department has been asked to set their own measures and their own outcome and process measures and they are in the process of doing that. For some departments who have been doing that for years, like mcah, that is easy and they have given them to me and for other departments, because its across the board, so it and finance who have issues that could be dealt with, they have not done that and i dont have them yet. Im basing on that our headline indicators for health and what people are telling me they can work on from where their effort is. Thats why i dont have it yet because i want it to come out of the staff and not just be imposed from above. But i expect we should have that in the next two or three months, at the most. Thank you. Commissioner chow. Thank you. And thank you for the presentation. I guess initially i was the office of Health Equity title is a little confusing because not only are you talking about Health Equity as an illness or a measure of health and wellness, but then youre dealing with racial equity. So once i got that into my mind and i could see in your presentation, which was excellent, the separation that occurs. So the title is a little hard to initially grasp because first you just think initially of Health Equity and therefore, were talking about the subject being the recipients of health. And then adding the task of also addressing the issue of racial equity, which is what the city was creating, then created two paths that you have really demonstrated very well. So i think the workplace program, i would look forward to how well youll be able to help change that because you clearly now have a baseline and you know areas in which as commissioner bernell said, weve talked about before. And i think thats definitely something that your division or office certainly has a grasp on. Im a learn more concerned about backtoHealth Equity. It took a generation to even start moving the needle after focusing on one population that had enormous despairties, our africanamerican population. And even as the population got smaller, the despairty probably got worse for many reasons, but it did. And now youre showing a change. Several had been done with the communities and wasnt very successful an and even though yu didnt present the data, we got a glimpse of it in the initial handout that showed that we were beginning to make progress. Yes. And so it required a concentration to focus. Going back to Health Equity, how will we be sure to continue that focus because now it is within a Larger Office and hasnt got the spotlight on it as it has for the last several years and also, i think that the charge now is that we shouldnt just stop at that population, but that there are other populations as we know. If we begin to disagregate better, i think its clear that some of the Pacific Islander populations, although small, is still a population that needs to be considered. How do we do that within this limited resource that we have without diluting this effort that finally is seeming to begin to show outcomes in our Africanamerican Community . So i would say that our resources are not limited. They are limited in the larger sense that we as a department are limited, but i am not the resource that will cure the hypertension despairty. That remains in primary care and health. Theyve been working together on this issue for years and they continue that work. So we are not diverting focus from them. Were asking everybody who is standing in this circle watching them to turn around and do their own work so that we have more than one place. And whats really been helpful is to have more people at that table. So ten years ago, that might have been primary care and its been helpful to have Population Health there to talk about what roles some of our cbo players can have in that and how do we include Food Security and other issues that have been really important to that patient population. The fact that that project has been successful is partly based on it not done classically and it has not been about that. Having patients in the decisionmaking body so doing things differently than they have been doing is the secret sauce of that program. And then, expanding that so that laguna honda has the same focus and that the general is taken heart readmissions which is a part of the same spectrum as their focus and so that the community contracts were doing around Community Focus groups and Community Outreach are all focused on heart health and that focus has grown from the classic doctor and patient and lets see what the nurses do to include quite a lot of the department and that work will continue. And hopefully that work will sinnesinsynergize. Work in ph. D. To move all of their programs to have the same thing and patients are in families and communities. If were focused on heart health, we need soda taxes and security resources, those are all the same patients and having them be well cared for in our clinic but food insecure and not having other issues cared for will only thank our other efforts. Were getting to a point of synergism and it will accentuate the efforts rather than take focus from them. So weve identified in the Africanamerican Community many disparities already and you were describing processes identifying others that have become hidden because we didnt disagregate the data. We know that happened in diabetes and the Asian Community and so forth. So so when would it be, going back to commissioner bernells question, we might hear of other disparities were working on and giving them that spotlight to say that we would expect that you have identified, lets say, group x in this area and how are we going to be able to follow that to understand that we are actually addressing and creating within your framework that you are describing a product that then allows us to have process and then gets to the outcome. We are including other groups. So the dula program is africanamerican and Pacific Islander. Some of the food programs are the same and there is not theres a diversity of focus across the department depending on the issue, but i would say that the data shows us that the difference between the distarity of the black africanamerican patients and everybody else is one that is nearly exponential. So any standard medical and Public Health practise of triage would say that that is where our focus remains and i dont think it will change from that if we use data as our guide for 40 years. We hey do something with somebody else, we should, but the difference between our chinese or lat the difference between those groups is really a quarter or less of the difference between africanamericans and everybody else. So while we need to keep the focus nimble, so that when we find things, we address them and thats why we need with race but not stop there. Because we have problems that need to be addressed in our transcommunity and gender issues in some places and we need to maintain that nimbleness but we need to use our standard process of triage and say where the problem is the worst th is where well focus and it will stay the worst there for some time. So for those others that you have identified and brought them in, where would we hear about those, understanding that they are not necessarily going to be the primary focus because of the major disparities say in the chimero or the latin american that we find, another block, less severe, not as intense. But what would be our process to understanding that were working on these levels, too . We should be reporting on whats happened to every group and most of that work is going to happen at the level of the different departments. So as you hear about the dula program talking about mch or hypertension, that should be the standard that youre hearing about that program in terms of how it looks across the board. What we do is set the standard and having people disagregate their outcomes and dont tell us about it. That kind of transformation of how we go about the work so people are aware of that as an issue is the part that we have been missing. So we have that happen within an area around a particular area but not at every program and not all of the time so the mindset isnt there. Its a practise that happened one time. You should be hearing that more and more as people change their mind how to approach the work, not just that we picked a group to focus on. Dr. Bennet and i talked before the presentation about her coming twice a year as a model so maybe in six months, you could see baseline data and possibly a dashboard and begin to ask questions on that, because obviously, she and her team are building this effort. I do think that is possibly very good, you know, process that youre describing. We have seen that in general, in terms of the reports that have shown that some of the data was disagregated and im just wondering, within these reports that we sort of also see it as a larger picture and not just within some separate studies that are done within certain areas. And somehow that gets drawn back together so that you could see that this was being done in a more uniform and throughout the department. Well, we will get there. So its policy by policy and the different sections are quite at different places and some have done nothing and others have been work on this for areas. But i would encourage you that is something you have a role in this, too. What kinds of questions are you asking people . If you ask them how does this look disagregated eventually well get the message and we should all play our role and what is our expectation from people . So our expectation centrally is that you have now a plan and that changes peoples thinking, i hope, about how they go about their equity work, that its a plan and not just that you do good but i want you to do some kind of rigorous work with an outcome and youll measure and look at it and it will be something official and not just something that you did and get applause for. That we want this to be rigorous. So having our expectations change is really the underlying message that were doing, that our expectation has changed on how you do this work. Commissioner giermo. In the interest of time and acknowledging its been five weeks that you have actually put together a wonderful presentation but High Expectations with regard to what the office is. So what i prefer to do is present my questions to you and give you time to answer those questions in a written form. Thank you. For all of us, as im sure there will be additional questions from folks. This is a very very, very impord of high interest subject matter to the commission and to the constituencies. So here are a few questions. Is someone writing them down . [ laughter ] some of them are related and not. One has to do with referring back to dr. Chows question around the two different paths of equity and workforce equity. I know you wont achieve one without the other. Yes, theyre the same. Im wondering how will we find a way to measure the effect or impact an increasingly or achievement on the workforce equity goals and its impact on Health Equity and vice versa. Thats one question. The other is so thats an intersectionalty question and cannot be measured and then with our external partnerships. So with this alliance across the government, how do we both benefit that alliance and benefit from that over time so were not just sort of following standards that are set but, obviously, this is something that will be growing and experiencing over time and San Francisco is a unique environment in which to apply a lot of the things coming out of this. How does that relationship have some neutral benefit and is that something that we are going to be able to hear about and somehow influence . The relationship between us and other city departments . Yes. Us and other cities. To ask the question appropriately, but obviously, were part of a larger experience in standardsetting and goal setting. This is a collective and we are in this collective with the i think all nine counties plus whos and there was a cohort of 20 institutings or municipalities in the Northern California cohort and there were nine state departments in the capital cohort and i think next year will be Something Like 18 and there are some in the teens in Southern California and thats just the state of california and so it is a group where we can look online and answer a question from arizona and look at somebody elses work that theyre doing in florida or other places, but also its linking the city departments through the human rights commission. So my question is what is the larger benefit well see . So its a Reference Point and it is sharing environment, but sort of from were trying to catalyze big change here. So what does the participation in that tell us . And i know its an esoteric question. Its not, were not ahead. Were ahead in some areas but this isnt one and we have lots of models to use. The third question is, were part of a larger effort now within the city. Yes. My question would be similar, how does what were doing, very particularly in the department of Public Health inform and relate to efforts that are happening in the other departments of the city . Because im sure theyll have processes there. They do and how does that all come together and again, not a question you have to answer now but something you would probably need to be able to consult with others. And the last question had to do with, because we are a department that does a lot of our work with outside contractors, nonprofits and we are also in a rich environment in health in the private sector a lot of crosssectionalty of the providers and care and their systems, how does our even with ucsf, for instance, how does what were trying to do here. That we dont get siloed and we put our heads down and do the work, which is important work and we forget that there is a larger sphere of influence both external and internal that we could have . Ill answer at length, but i will say that that is the point of centralizing. So when primary care is doing hypertension, theres virtually no way for them to really do that with an awareness of what even ph. D. Is doing, let alone what hsa is doing or what other institutions are doing. Thats my role. So thats the role of us centrally, to maintain awareness of where the other departments are doing and to bring in resources from other cities and municipalities so that were not reinventing the wheel. We took our respect policy and modeled it after one of the park and rec and were using our mta, just came to me to about some f the work were doing there. Thats the role of having a Central Office so that dph can be represented in those spaces and thats always a struggle for us, because if you send someone from the network, they represent the network and if you send someone from Behavioral Health, they represent Behavioral Health. We were not able to do that before. The point of centralizing is to do that and to be ail t able toe the department and alignment with everybody else and move it in alignment with each other and to take that whole department effort and then make sure it actually has some view of the outside world. Just in response, i would like to say you representing that central role very well. Thank you. Thank you. From my point of view, i want to acknowledge the work that you have done. I thought it way insightful and helpful in terms of our discussion today and there will be more discussion based on the questions that my colleagues have asked you. So i dont want to repeat any of their questions, but i do want you to answer in writing because i also am i ware of your time to us, the notion of hiring, recruitment, hiring, retention and disciplinary effects on black africanamericans and the question of retention is the critical cal. One. If you recruit and hire and put folks in discipline and leave here, thats not doing much for the bottom line in terms of equity. So i want to make sure we have a strategy to address that. So along with all of the other questions that were asked, i had another question, but im not going to ask it. Ill wait for the responses from the one weve given you. But again, thank you for your insightful report. Im really excited to see so much energy and interest and really thoughtful engagement with this issue because the more that you hold us to account about that were doing about it, the easier it is to move the work along. So its an inside, outside strategy and we need pressure from both sides. Pressure from staff asking for change and pressure from above and outside looking for change and i think we will benefit from both and i will get squished in the middle and im comfortable there and we need both. Your interest, i hope it continues and challenges us and challenges not just me, because equity is not just me but every other person who comes through with something to say. Thank you. The last thing, if, in fact, you run across some articles that would be helpful to understand both ger and Health Equity means for San Francisco, would you forward them to mark and he can send them to us. So were compiling that for the champions that have to do 20 hours of education and were compiling a list to choose from and ill include that with my answers. Thank you. Youre welcome. Thank you. Commissioners, thanks for that great discussion. Item 8 is the Population Health division true north and thank you, doctor, for being patient and mr. Wagner for being more patient. Good evening. Im the Health Officer of San Francisco and the director of the Health Division and today what im going to do, just because of the time, ill im gg to move quickly and do a high cover of the true north and how it fits with our Performance Improvement and ill go through a couple of examples and we wont have time to go into detail with all of the different metric areas but ill introduce you, primarily, to the framework. First, i want to point out according to our departmental annual report, the Population Health division represents about 4 of the Health Department. So we provide core Public Health services for the city of San Francisco and together with maternal child and adolescent health, we use that for accreditations. And back in 2011, when i started this position, canya and kramer published an article called collective impact. And that really had a big influence because it really helped us reframe on how to address complex social health problems. And we took that on and we went ahead and embraced results as a primary approach that were using for collective impact and in 2013, 2014, we started our lean training at San Francisco general hospital. By 2016, we had incorporated both lean and rba into the Population Health division, first in Environmental Health and you see there in 2016 and in 2017, we received our Public Health accreditation. And so the general framework for Public Health accreditation is based on Ten Essential Services of Public Health and with a domains of the administration and governance, we have 12 domains that were upped by. Judged by. Im showing you this slide is something one of the commissioners brought up earlier, is the issue of policy. The Population Health division says r does mor does more than. We also work this the area of assessment which includes evaluation, research, epidemiology and also in the area of policy development. So later on, ill give you a couple of examples so you can see how that fits in. The lense that were going to use is a lense of Performance Improvement and thats under where it says there evaluate. So dr. Bennett talked about normalizing and one of the ways to normalize is everybody will show you a lean triangle. This is a lean triangle for the population and Health Division. Starting from the top, we have the vision of the Health Department making San Francisco the healthiest place on earth and our mission at dph is to protect and promote health and wellbeing for all in San Francisco and our logo represents the diversity of community, clients, patients and staff. The next is the true north goals, metrics. They need to be healthy, thriving and in line with our mission and vision. We have our principles and we have our values. And then humility, compassion and dignity. Ill be focusing on the true north goals. The other question that we have is, how does results heavbased accountability connect to lean . This is from rba and what you see here is four different quadrants that can be divided by quantity, quality effort and effect and lean has amazing tools for processes and eliminating waste, especially in the area of where it says how much do we do and how well do we do it. Rba is relentlessly focusing on outcomes and under that category here, you see where it says effect and the question we ask, is anyone better off . So if you dont remember anything else from this presentation, i want you to remember three questions that i want you to hold this accountable to every time, which is you want to ask us, how much did we do and how well did we do it and is anyone better off . Im going to focus on, is anyone better off . Im going to briefly touch upon those areas, but im going to dive into a couple of areas in Health Impact. You had a presentation on equity so i wont spend any time there. Under workforce development, the key metric, percentage of staff recommending ph. D. As a place to work, for service experience, increasing the percentage of our programs that collect service data and use that data to improve Services Based on what they learn . Under the area of financial stewardship, the key one to point out to you is increasing the use of priority setting and resource allocation methods. This is a tool that we use to help set priorities around budgets and try to focus investing or limited resources in those activities that we think that will have the biggest impact. The other area that i want to point out is in the area of decision quality and increasing the percentage of staff that are decision competent and use decision quality criteria in problemsolving and Performance Improvement. These are draft indicators and were still working on them. And the areas to spend more time is in the area of Health Impact. You see at the top we have maternal and child adolescent help. We take a framework with the development of children and intergenerational processes, include the social and biological transmission of the effects of trauma and toxic stress and family and Community Centric approaches and environmental stresses including social and cultural. And continuing in the area of Health Impact, im going to give an example from the middle one, which is preventing infection and preserving health. And im going to give you an example of social, emotional and Behavioral Health into o to givn idea of the complexity of the problem but to summarize where we as a city in San Francisco, weve had a big impact nationally and also around the world. Ill briefly just highlight getting to zero. I wont focus on the data youve heard but really on why getting to zero is so special. And why i think San Francisco really stands out. And then i also wanted to spend a few minutes on a Public Health crisis that were having right now with a vaping epidemic and sort of paint to you the picture of how much San Francisco has actually accomplished when you ask those questions, how much, how well and is anyone better off . So you see this from this is sort of the iconic graft that we have here and where you see the number of new hiv infections are at an historic low for San Francisco. The number of people who are surviving is high and also the mortality rate has become more stable here. Focuses othis gets them virals to the viral load and decreasing commission in the community. This requires everybody on board where we have a medical intervention with a public human Health Impact. The way we measure how well did we do, we have a framework thats called hiv care cascade, where you look at different leveled. So ivlevels. Of people hiv positive, 94 know their status and weve linked 91 of them, in terms of retention, were at 64 and virally suppressed, were at 78 . In terms of the standards that we have globally which is 909090, 90 aware, 90 to care and 90 suppressed, even though were doing tremendous, we have room to improve. The other area where we have room to improve is in the area of lati nx, especially with the intersections of Mental Illness and substance use. Those most vulnerable populations are the area were moving into next and we need to do more. So yes, the wow, we have made tremendous strides and this model of collective impact is unique, we still have areas that we need to make progress in. Thats the first example that i wanted to show because its a special example. The next example i want to show is with ecigarettes. Between 2006 and 2018, San Francisco has passed eight laws. Smokefree parks, smoke manufacturfreeentrances, cabs, outdoor seats, landlord disclosure of smoking status, smokefree outdoor events, ecigarette use regulate the jusregulated likecigarettes, toe baseball stadiums, prohibiting flavoured products, including menthol. These laws were passed in collaboration with the community and oftentimes with youth groups. So the question is is that how well do we do and is anybody better off . The answer to that is yes, no, no and yes. Yes was in the middle there is National Data. You see how the prevalence of smoking has going down dramatically and in california, we were making and in sanfrancisco, we were making tremendous progress in reducing the prevalence of smoking, especially in youth. Thats the first yes. And we were doing fantastic. But then, a San Franciscobased company figured out how to tweak nicotine into a nicotine salt and make it highly addictive, where people would have high levels of nicotine in their brain like this and get youth addicted. Were now in a new Public Health crisis and thats the National Data right there that you see the vaping, ecigarette vaping epidemic. San francisco right now has the highest rate of ecigarette use of in california for kids in high school. Among tenth and 12th grade were at 20 . Think about that, 15 in San Francisco, the highest in San Francisco. So while we were making tremendous progress, we fell behind. So what happened . In 2019, right when dr. Colfax came on, the City Attorney Dennis Herrera and mr. Walton passed prohibiting sales of ecigarettes that were not f. D. A. Approved. When that came out, nobody was expecting that. This was an example where the innovative leadership comes out where you least expect it. I heard on monday this would be announced on tuesday and dr. Colfax was talking with the City Attorney and we had to mobilize and get behind this. So dr. Colfax and myself coauthored an article for the medicine journal and we really went on the offense of really reshaping the narrative on how its really important to support this ban in terms of f. D. A. Approval. We have been so successful let me point out one thing, the next thing that happened was the epidemic of vaping lung injury. And so now we had the ordinance that just passed where San Francisco was alone. We had an epidemic. Lung injury happening in the country and all of a sudden, people are realizing that San Francisco has it correct. The policy that we passed was the right way to go. And so effective that even at the national level, the ama, the American Medical Association recently is recommending the banning of ecigarettes that are not f. D. A. Approved and this is an example of this this is policy development happening over years and this is now the nine laninth law passed since 2. Its hard to appreciate the impact its had. So while nationally, there are over 2,290 cases of lung injury from ecigarette vaping and 47 deaths, in california, there are 170 cases and four deaths and San Francisco has only had one case. One case. And the reason i think part of the reason why, in a sense, have been spared from this epidemic is because of all of the work done. When that flavour ban passed, just to give you an idea of what the staff did, they had two approaches. They had an education and outreach approach and they got almost 20 volunteers and they went out to over 800 retail establishments and educated them on the law and how it would be implemented. And then, our inspectors went out and inspected 693 tobacco retailers to make sure that they were compliant. When we measure how well did we do, over 92 compliant. I gave you an overview of the Population Health division approach and i summarized true north metrics and i dove into Health Impact and showed you the broad framework that we use that takes a life course into generational family centric and environmental perspective and i gave you a couple of examples that shows you the complexity of the issues that include policy as a major focus. Its hard to count policy and theres only nine laws, but they have a big impact and you saw some of the metrics as well. So i want to just thank you and turn it over oh, i have to remind you that the three questions that you always have to ask us, how much did we do . How well did we do it . And is anyone better off . Thats results thinking, resultsbased accountability and compliments lean which eliminates waste and we have an integrated approach and if you continue to ask us that question, well get better at the metrics. Commissioners . Commissioner green. Thank you for the presentation. In terms of the questions you just told us to ask, on some of your slides, you had decreased percentage of blank and one with the opiates in particular, you said decreased number of deaths from x to y. And i wonder if in the future or soon, you would share what your xs and ys are because you had goals but in terms of targets, i didnt see them. Which question was that one . That was just one of them. Were going to come back and so this was a highlevel overview and well come back and go into details. Some of the areas, you get details with the hiv folks go into excruciating detail with the hiv but thats what we plan to do. I mean, if we could get it after the meeting, because im sure you have some mapped out, it would help to have context so wwe can see how youre viewing the numbers associated with the goals. Commissioner gerardo. I would like to follow that from what commissioner green was saying. Under the Health Impact, let les say, decreasing the vaping. Decreasing the middleschool students who drink one ssb yesterday, ssb sold in San Francisco, how . I just, again, looking at the metrics, i understand those are great goals, but, then, again, with as i had mentioned in a conversation with you, with the high school studente