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 intersectioy 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 youre putting in place have made a difference . 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, seeg 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
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