Then also the new contracts. Can i do that all at once . Usds he was there is a new contact, which i like to describe an point out why this is sounds mundane but is actually important. It is a contract with guttural Healthcare Laundry and Linen Services for pounds of laundry i learned today that5. 4 we generate at the Zuckerberg San Francisco General Hospital in laguna honda hospital in a year. It should take care that in the finance Committee Also recommended to the full commission that we approve this. The thing that is interesting about this and very encouraging, is an example of a consolidation of vendors could be of vendors for each of the hospitals separate contracts and through doing is theres a number of ways which it looks like we will be able to reduce what would have been the projected cost of laundry. So congratulations to the staff on that and hopefully its the first of many contract consolidations that will come before us. So do we move approval for these . First asked if theres any questions offers as if theres any questions from the committee any Public Comment any questions from the committee to that change the rules on how we do [inaudible] its an example of how they took through the normal process and decided to use one vendor instead of two. But it went through the normal procedural hoops that contract has to go through. Thank you. A good question. Question through the chair. I just was looking at this this afternoon and just wondered these are significant dollars that as you said, evidently theres been integration consolidation which is about a threeyear grant. I guess the question i have because i cant understand how, in fact, this operates because number one, before laguna honda and general both have their own laundry facilities. This quote was not effective, quote unquote to costly quote unquote etc. Etc. Then the con department contracted out and some of the Hotel Industries got the contractor so they were literally getting the laundry from general and tracking them down to monterey, monterey peninsula and getting it done and when they came back they really had problems with the quality of the work. Then there were other things being done. At the same time there were a number of small laundries in the city there were trying to consolidate especially minority communities that small laundry succumbing forbids and so one effort would always be why can we build hospitals which run higher local contractors and local workers etc. Etc. Do you know, then it seems like as i read through this, this is a large collaboration based in wayne pennsylvania and its part of an International Worldwide contract. Wow. Have we gone from our small neighborhood communities to try and encourage Job Opportunities and Small Businesses, etc. In order to provide jobs and keep families here for, what is this. Its what are my . Number of contacts [inaudible] the went to saudi arabia and china so forth and so on. I guess my question is, if in fact you look at the board of directors and it can go up to 30. I dont are these people all pleased here or are they based out of the home port in wayne pennsylvania . Or are they part of the international corp. In who really is the international corp. . Thats what i want to know and i assume our staff has reviewed it. We can certainly give you understand i understand your point of view we can surly give you more information about this particular project or you can also recognize that we also do have [inaudible] required to minority owned businesses as part are confident this just happens to not be one but is really born for us in terms of bulk costs and how do weand we had very sizable purchasing power going on throughout the department in fact that does not give his i think the end result of what we need to do is really try to use our purchasing power to build lower our cost. This is one of the ways we can try to do that. But i do understand a position but we are still required to follow lb fuels which we do for many of our services have minority owned contractors or providers. But this in particular one is one in which i really support to ensure we try to reduce our cost overall by using our purchasing power for large processes like we have to have. As you know, weve gone in out, in out in terms of the services. So this is also a nationwide for all Public Hospitals in which we are trying to purchase together and trying to reduce our overall cost. Then, i understand i understand your position. Its a different protocol as we dont look at your diligence and i mean its the [inaudible] when we look at the building of the hospital were always so proud are hiring rate was above 20 even 2829, 30 and look at the contractors should i mean laguna honda the same. Something the department of Public Health was so proud of and whatever they could take a look at we are doing some great things but i guess as i said, normally long before we used everything on ethnic eight bracco and dont sometimes the directors came in from germany to tell us why theyre bidding here when its a german based company. We have special interviews on that. So i just wondered [inaudible] can also address this doctor sanchez thank you for asking that question in terms of our local Business Enterprises, one of the things as we are beginning to utilize these Group Purchasing contracts that director garcia mentioned as a component where we can actually have our local Business Enterprises become members of that gpl. As we are bringing on these new larger were guys asians we are also working with her obe to give it got him on the same list we get the same pricing for those service. We are doing both at the same time. Thats very helpful. Thank you for clearing that. Thank you. So opening up. Okay. Good thank you. We can move on to item 6 which is the consent calendar which you all can vote on. To approve good should we vote on the consent calendar . All those in favor say, aye [chorus of ayes] any objections . Did i do that right . Yes, thanks next agenda item item 7 is the healthcare accountability vinton this item was introduced at the last meeting and today you will be voting on this. Good afternoon to visit my name is patrick jane and secretary [inaudible] said we presented on this on Alaska Missions on happy to take any comments or questions you may have about its. Mister chang, can you review the changes made so even though the commissioners of the package not necessarily everyone but maybe scuttled i apologize. Thank you. Whether any changes since the last meeting . There were no changes. No substantive changes. Since the last meeting the draft resolution is just expanded to include include all 16 resolutions. The previous one had only the 14 number subject to change given that the full consensus of the workgroup. So this draft resolution includes all 16. As a rule is a resolution would thank you. There are several Public Comment request for this item. So our questions as commissioner, after those yes, sir. Albright. The first person is greg brown. Thank you for taking the time to come talk to us. Everyone is making public on. Ive 3 min. On the egg timer. When the buzzer buzzes that means your time is up the was thank you for letting me come talk today about this. Its my first time serving on this group and it was probably of all the things ive ever done before the most interesting. It was a lot of different viewpoints and we went through every single point. Ive never seen a more thorough review of anything before in my life. All viewpoints were discussed and we turned around and came to recommendations based on the needs of the Business Community as well as i represent labor could labor community, and nonprofit do we all just kind of sit here are our needs and we can up with our own proposal based on those needs. The proposal basically we do not go to a basic sewer plan in order discovering that a lot of of our members are going through their own doctors for healthcare preventative but not for when they get sick. Because that costs money. So they did not go. That defeats the purpose of having healthcare. Now we are paying premiums in employer are paying premiums for deductibles and its not being getting their moneys worth out of it because people were not going to the doctor. We discovered this through our own workers. Ive my own people tell me that. So yet, we can up with a solution of raising the deductible to 2000, raising the insurance 27030 and raising the top eighttop outofpocket 26853 at having the hra hsa cover the first 2000 basically deductible. That weight should solve most of our members concerns, lower to keep the cost down for the employer and was kind of a winwin for everybody. We all discussed it and we all happy we came up with something bounced everything up. Met all of our needs could so actually was a very good consensus. We were able to find a winwin women all the way around for everybody and that was our recommendation based on meeting everybodys needs. I represent a group of women predominately women group several hundred members at the airport that are predominately85 female. Predominately minority. Even though we are in a more progressive liberal city in the state most of the work still falls on the women, the wife, the mother and these women are working there as a fulltime job. I got an education that have by working with them and helping with her problems in im just amazed with these women can do. The working fulltime and they go home and they take care of their kids make sure they go to school they take have some other inlaws with him there taken on their almost superwoman and they dont give up. Just every day do what they have to do. And they carry one massive work load to that quite a few single moms carrying the load all by themselves. Theyre paying rent 2600 month for a onebedroom apartment that is green but not in the best neighborhood. So this helps them tremendously. Thank you for pathos and keeps double they can stay healthy and ask for your support on this one. I think needs a lot of peoples needs will help a lawful lot of people. Thank you. And the gerald. The microphone is all yours. Good afternoon commissioners. My name is emma gerald and im with seiu 1021 we represent city workers but we also represented by the thousand nonprofit workers in the city. I spoke here last week regarding our priorities around reducing the burden of the deductible and how that affects our members. It really is a barrier to health care and thats why we work so hard to have the hra or the hsa cover that amount because we feel like that will have our members utilize the healthcare. I would like to read a statement from the labor council. All right. This is a statement from the executive director from the San Francisco labor council. I want to be in rate fellow Committee Members recommendations to accept and implement the workgroups plan in updates the workgroups spend much time three multihour meetings in allies in data plans prices and trends in this everchanging world of healthcare plans and premiums. We feel with consensus that we came up with changes that reflects the intent of this historic legislation to provide the best healthcare for employees of vendors and contractors do business with the city and county of San Francisco. In the era of obama care we need to be thoughtful about the values of our city and not just make decisions that appear to be simple bureaucratic fixes. That is what this workgroup accomplish. It should be noted that whoever is elected president next week is pledged to address healthcare in one way or another and we expect that our group under the guidance and facilitation of the great team that are dph will be meeting again with the adjustments that might be needed. On behalf of the 150 units 100,000 workers representing in San Francisco i highly urge your adoption of the recommendations. Thank you. Karl cramer. Karl cramer is San Francisco living wage coalition. The San Francisco Health Department did a study this year that found that deductibles were one of the chief concerns of employees. Also the metlife 14th annual us employees benefits trends study 2016 found that 55 of the employees reported that there were worse Financial Fears and worries included not having enough money to cover outofpocket medical costs that were not covered by their Health Insurance. The Health Departments study found that recent surveys indicate that nearly a quarter of adults with insurance are still unable to cover their deductible. The Commonwealth Fund provides a useful measure for underinsurance is having a planned the dockable that is higher than the 5 of income. Insured persons would plan deductibles greater than 5 of income are considered underinsured. Which may lead to forgoing needed care. The current minimum wage under the minimum compensation ordinance which is a ordinance that we organize workers back in the late 90s to pass as well as a companion measure the healthcare accountability ordinance, under the minimum compensation ordinance which covers many of the same workers at the airport and on city Service Contracts, is currently 13. 34 per hour. Many of the workers at the airport are at that wage. The 1500 deductible that is currently in the minimum standards is 5. 4 of their annual income. So according to the health determine study 40 of adults with these kinds of deductibles that amount to 5 or more of income reported that because of their deductible they had not gone to the doctor when sick but did not get Preventative Care test, skipped a recommended followup test or did not get heated special scare. We heard reports that the meetings of workers on city funded Service Contracts not opting for insurance. Instead using indigent care at the general. We know first our organization knows firsthand of workers who have healthwho have Health Insurance instead of going to the emergency room at general and saying that they are unemployed. This shifts the cost burden of healthcare to the city while the city is also providing tax dollars to pay for the Insurance Company premiums. The aca requires that city departments confirm in writing that they included in their budget cost for nonprofits to comply with the aca. So we reach this compromise and i think that this is one that does address high deductible plans. Thank you. Thank you. Debbie lerman. Good afternoon commissioners and Debbie Lerman from the San Francisco Human Services network in i did also speak last time. Im here just to reaffirm that the proposal before you does balance the needs of both lawyers and employees for Affordable Care am a affordable plans, and a wide choice of available plans and good access to healthcare for our workers and for all the workers on city contracts. From the employer perspective, over 50 of the plans that we studied on the Small Business market would be compliance under these new proposed standards. Under the old standards it was dipping below 30 which pushes everybody into the highest cost plants. As you know, nonprofits cannot raise our prices to pay for those plans but we would have to be knocking on the citys door to help us increase our cost to pay for them and even that would not completely cover the cost because we have many employees who also dont work on the contract. So it would put us in a real bind in force service cuts. So this proposal does represent the consensus of a very knowledgeable group of stakeholders from many different areas and most of us have been on this Stakeholders Group mobile times. So we have become experts at this and we do urge you to accept this current proposal. We will see what happens next with the Affordable Care act and 80 back before you next time around with some proposed changes. Hopefully, that would make it even better. In the meantime, it isi do want to say its late in the year. This process usually happens a bit earlier. So we are pushing up against the boundaries of employers needing to do their shopping for next year and hope you will move forward and approve this today and thank you for your consideration. Thank you. Any questions forits doctor chang, . It is now. [laughing] any questions bequest figure doctor chang [laughing] just calmly patrick was nice to see physical collective impact of labor and management working together as we try to find what affordable in the city. I think i mentioned last time you told me the reasons why couldnt we did not do this but i hope that Affordable Care act gets more because of more stable product in an American Economy that we will be able to meet even streamline this analysis hospital am really glad [inaudible]. My wish would bei support this. At the end of this is that we actually might send the findings of this to cover california. I think the issues of affordability and city like San Francisco both including our nonprofit partners and our Public Partners would be important for the state to hear. I just dont know if theyre getting this information to us, the regional report you produce an affordability related to the what was the other thing that scares security ordinance. I think is a really Important Information to share with the states. So just good work on this and thank you very much for pulling this together. Thank you, commissioner. Mission or sanchez commissioner sanchez i just had to comment phenomena e commissioner patings comments to Justin Bradford working group on taking disparate points of view that are often at odds on these very important issues good all from their own biological important perspective and coming to a working compromise. I thinki hope that in the future that as we look at these things we will also begin to think about how actually to do things to lower the cost, not just make sure that everyone is comfortable with how we share the cost of healthcare. I dont think were that have a solution in San Francisco were the countries can make much progress in less everyone is willing to kind of examined peoples behavior from going to the emergency room to diet and exercise good we are not to make much progress on that. This could take everyone working together like you guys have shown you can do. So in this second point is that i hope in the future when this comes up that as we talked about it that we have a better understanding of the code works and we talked about this last time the medical ward of san franciscans that this impact. Which businesses does this impact . Which employees . How many . I think thatll help us in context of this and many other policy decisions that we make as a group. So that something that would be helpful. That was it. Under figures and more Public Comment so is there a motion to approve was bequest motion to approve all those in favor say, aye [chorus of ayes] opposed . Congratulations. Thank you, commissioner. Open enrollment. Commissioners item 8 is the San Francisco Health Network update. Mister pickens the was good afternoon again. Hello. Commissioners in you are in front of you there is an updated couple of sheets that start pickens will review. Your paper copies. Sorry, commissioners. I will be back. It person. He was maybe he was maybe expand your preamble. [laughing] first celebrity mister pickens, hold on one second ive to these good one was in my packet that i got last week and the other one was presented today. Which is the most recent document . If i want to fall you i want to fall you. Sure. The two pager you got today represents updated slides for the last two slides in the presentation. The packet you got last week is accurate up until the last two slides. Okay. Thank you very much. It is on the way but i suggest we move forward. [inaudible] so good afternoon commissioners. Im Roland Pickens director of the San Francisco Health Network and its my pleasure to provide you with an update on the status of the Health Network today. Todays presentation will be at the Network Level. That you see highlighted on the left side of the organizational chart for the department. In todays presentation we will review three things. First, where we are with our Strategic Plan and our progress utilizing lean methodology in the implementation of that land. Second, we will review the status of the nine Strategic Initiatives of the city to plan using the lien 83 team charter format. Finally, we review the status of our true north metrics with our first report out at the Network Level on the status of those true north metrics. So on september 30 of this year to bring you up to date, the network and dph leaders can together for a oneday meeting your followup Strategic Planning retreat to our session back in march. Your member back in march we stuck to very first tricky dick plan for the Network Using the methodology. At the session a few weeks ago in september, we received some foundational being education from our roanoke consultants about the value of visual management and monitoring the status of lien improvement processes. In addition, at that september oneday session, we also spent time of we finding and bringing closer to completion of the unfinished athree Team Charters for a five phase 1 Strategic Initiatives. The slide here shows a depiction of that lien visual management. What you see here is called a visibility room. This is a are a visibility room for the network which is located here in room 220 at 101 grove and some lien organizations this visibility room is referred to as the war room. This is where we have our regularly scheduled Network Leadership meetings went completely functioning this visibility while uca this is just our first initial stab at it. It will have our Strategic Plan, the 83 Team Charters for nine initiatives and the true north metrics that only for the network but for the phd division and also for the dph. So this would be the one centralized place for all the improvement work across the departments comes together. You will recall when we est. The nine Strategic Initiatives we determined that five would have a focus in phase 1 which is this current fiscal year and the next. The other four we would focus on phase 2 in the following two fiscal years, 18, 19, and 1920 when i reported to back in august of this year none of those five athree Team Charters were complete. Today i can report do that to of the five denoted by the green colors you see here under phase 1 writein information anytime anywhere and stabilize finances are now complete and there in the Implementation Monitoring phase good the other three denoted by the yellow color moving towards being completed. As i mentioned before, moving forward were being very intentional about how we are prioritizing our work using the lien framework and we are aligning and coordinating our efforts across the Network Given the varying degrees of lien support and resources and Adoption Across the various divisions of the network. As you can imagine, the work of these nine Strategic Initiatives is occurring along with and is complementary to many of the major initiatives of the department and the network including the implementation of a new Electronic Health record them to take a break. [pause] mister pickens, if for some reason this is more than a minute about we go back to what we were doing. Because it looks like thank you. So picking up where i left off, as you can imagine, the work of these nine Strategic Initiatives is occurring along with many of the priorities of both the network and the departments. Those priorities include the implementation of the new Electronic Health record that we will talk more about. The limitation of the state medical 1115 waiver in its five individual programs being the prime program the global payment program, the whole first year program, the drug medical program. This is also going along with our work on the various workforce of element initiatives within the Department Cultural humility, collective impact in trauma informed systems. The of also got other initiatives like the replacement of the citys Financial System also going on as we are doing our initiatives. For phase 1, we are committed to continuing to develop all five of the 83 Team Charters. With the understanding that completing that competing priorities are allowing us to really focus on the top to utilizing full lean methodology. We just dont have the support system and the resources to do a full lean implementation for all five but it doesnt mean the work will go on for those other three. It will just be a more traditional Performance Improvement process. This slide shows our update on Strategic Initiative number one which is our number one priority. This was formerly known as implement and enterprise dhr. Its now titled, right information every time anywhere. The athree team charter has been completed this initiative is now in the implementation and monitoring phase. Some of the major highlights include that the work has been completed with Ucsf Medical Center to inform a gono go decision on epic with Ucsf Medical Center. We expect that decision to be reached and communicated within the next week or two at the latest. The other highlights are given that gono go decisions are Critical Path risks have been identified and mitigation activities are underway depending upon that decision. But we are also establishing and dhr governance structure that will need irrespective of whatever system we go to and we are also standing up in project Management Office to help manage the project. This, our second Strategic Initiative, number two, underwent a major revision in the alignment changing its original focus from implement the medical 1115 waiver to its new focus on aligning care finances and Clinical Operations for valuebased payments. As we went through the process as honing and try to complete the athree became clear as we questions just what it was we were trying to focus on, it became clear that the focus really was and just incrementing the waiver. Its really preparing our struggle payments hence the changing in and naming and the direction of the athree. That being the case, we would all the major revisions is not quite complete weeks that to have it completed within the next month and oust chen is the owner of that athree and she will not rest until it started i can assure you. Her and as she keeps us all up in night that it is not done. Finally, here is the status of our other three as one Strategic Initiatives. Initiativeinitiative number five stabilize finances. You see has a green dot. That athree chart is complete and much of that information was shared with you last month by greg wagner when he presented the fiveyear Financial Overview of the department and greg is the owner of that 83. For initiatives three and four with the yellow dots, due to changes in leadership and staffing for example you know [inaudible] left zuckerberg as the ceo. She was the coowner of develop our people we also change in the coownership of the right place, right time with Dennis Mcintyre the un medical director at zuckerbergs now been replaced by guttural as the coowner of that there are five and. We need one more workshop to finish development of those charters before they can move to the implementation and monitoring phase. Commissioner [inaudible] asked about the two new sheets. This world want to remind you that those sushi to receive today are updated versions for the last two slides could so please refer to those and this presentation today actually does have the one thats been displayed has the right information. As you know, there is an ever increasing focus on measurement and outcomes in health care. As a network, we are learning how to create a more integrated organization given her wide scope of services which is a strength but also a challenge when it comes to equitable measurements across our various Clinical Divisions which do different types of work. As we mentioned before, were using to north as our overarching unifying framework to create a culture of continuous data driven improvement. You can see the current status shows we have 55 total to north metrics across six dimensions. Of those 55, 16 are on target. 11 are off target and the vast majority of the other 28 are still in various stages of progress in terms of data validation. The timing and collection and reporting of that data. It prime example would be many of our Care Experience metrics are based upon Staff Experience and we currently do the staff expense survey biannually within the department. So the last one was done almost 2 years ago and we will be doing the current one now and be able to report on that once we get those results. And, again, i talked about some of the education we read we received from our roanoke consultants but the value of disability tools and heres another one of those two. This is essentially are to north metrics on one sheet, green shows the metric on target. Red are the ones that off and great are the ones that are still in development. So that is my overview in the former presentation and am happy to take comments and try to answer questions at this point. Ever seen no Public Comment request for this item. Thank you, market any questions, commissioners . They also to be thinking at the moment commissioner sanchez i just want to say it was a really welldocumented pertaining to ali areas where involving and also those that we are successful in those that we are not at this point and those that are still ahead of us. I guess as we continue on though and there is going to be more costcutting throughout Teaching Hospitals and they are looking for ways to save money and of course one way they are considering is it and the effects ofis that going to if in fact as does come to be whether it be the five Teaching Hospitals that in the uc system, with that affect our would that be a potential limitation for us or an area that we are going to plan b and plan c and is that does come to fruition . If in fact we do move forward on the totals. I know thats a long questionable what im saying because i guess this laundry thing hit me earlier and am thinking about the departments [inaudible] sign centers are going to save money so the departments of radiology other radiology film went to india and was reviewed their was cheaper Cost Effective because many of the radiologist seven trained boardcertified and you see hospitals are stanford or some of the other ones. So my question is, are we going to as we move forward, do we see any limitations where this might limit our ability pertaining to tracking our patients, both at the general followup and laguna honda. I guess i should not ask a hypothetical question i get some speaking fromits happened before different ways, as folks and institutions you try to cut and save over a fiveyear period and many times its come back again and then they rehire it may retrain and they do whatever. Does that make sense . I think so. From understand the question, please tomio, i think the question is, particularly with consolidation of it amazed if we do that is mise means of saving cockpit would that somehow that affect our ability to do some of the changes we are planning to have a more financially viable longterm horizon . Is that right. I will try to answer that. Particularly if your are you referring particularly to the phr or just in general . No. Yes. Im just try to save protector share with us as you work through as we work through this this is going to be an ongoing variable because i know that a number of staff in some different disciplines are already being reassigned and or illuminated. In order to save dollars because this is a very very expensive proposition for acting and Teaching Hospitals. And we are part of that. The department of Public Health and we made major commitments and we will follow those commands but we want to make sure the Quality Control is here. I noticed there was a governance units that is going to be considered. So this way we can have which is great. That really shows some good creative thinking as far as how we are going to navigate this. So it seems like we are well upon it. I dont want to get into the nuts and bolts. I just think that as long as we are aware and i think we are, i think we could come in with some alternate plans if necessary. So we are not my you know, i can misty was absolutely should governance is definitely a consideration that i think will be part of the gold though go decision as it affects our longterm ability to really be selfsufficient and financially viable. Thank you. Commissioner pating first of all thank you very much again for the overview. I really feel like be Strategic Planning that you have been doing particularly with plan together to north metrics and the r5 and regionally, together. Its good to see all the hard work and but also all the drivers that are monitoring can i just run want to commend you. Kind of reminds me on their driven a starship or enterprise but they always have those buttons and there was into control the whole shift from one keyboard. Is coming together not quite as fast as i like but its coming. You are getting. Youll get work speed in no time. Well its kind of steering the Starship Enterprise in a new direction. Which is kind of hard. Big ship to steer. You are the captain, right . [laughing] captain Roland Pickens starship numbers start a number i can buy first question is in regards to the second athree on valuebased implement, it seems to me the definition of value is changing. I guess the question is, are we going to make up the value were defining the whole person metrics based on our own view of that . They really havent ruled out a cms in a conference of weight yet and i was wondering your thoughts on it. I like the direction this letter off i couldnt three but the definition of what valuable tool person care, im not sure what how that works my personal opinion on that. My opinion is the value is twofold. Value one first of all is the value defined by cms because for the most part they are a major payer. So like it or not they get to assign the value. But also value comes from the point of the customer that can be either our patients in terms of the care they are receiving or are they Getting Better are the outcomes better . The value is also from our workforce could our staff. Are they in environments in which they are thriving and want to be here and then therefore able to give Better Service to our patients and hopefully will increase their understanding of the value we provide to so i think its both. What are the external organizations that are driving and who are determined with the value is, based upon national benchmarks, measures, other things but i think its too full. Both of payer value and the value from the perspective of the customer. I feel like thats a good approach. We definitely need to follow cmss lead in areas that are not under cmss radar or that they are lagging we create our own measures in and we put forward her own in digby theres no reason we cant assert that we are providing our own measures to measure our sense of value and then just sell that to public payers or private payers as being credible. I think the question of how we prove it and so i like your answer. Thats one of the good things about the medical 1115 waived the prime program. There are 6759 measures that all the Public Hospitals in california are being held to and so these not all of them are ones that are sponsored by cms. Again, depending upon the agency were the body we are being measured prolifically and we justwe are under the gun to make sure we meet those pressures because its now tied to our payment. So its either meet them and survive or if not we wont. Im really glad youre on the ship and we sent it away team to explore the planets. [laughing] the second thing is about the scorecard good im not really sure whether we should go into too much detail but i just want to call out a couple of early progress indicators that i think are significant first of all i like the scorecard. Im wondering whether at some point in the future if we get more handles on this we should call out we should maybe like we do with the audience report to a narrative on things that are really significant achievements or significant deficits so that maybe we can meet out the bulk of the report and look at the red and green but things that either want to highlight as just needs working or this needsthis is a big improvement i think a narrative on this would be useful in the future. Although otherwise im a little worried you put data in front of commissioners is like me in front of dogs that will be all over this and may not leave much of the bone left. But i would like to know that you didnt throw this need to us throat a couple things. One, really pleased black african urban Health Initiative i just really really proud that were making progress with hypertension on the equity any Quality Initiative i think that stands out is extremely significant in our first equity marker that is turning. I also like the idea that we are increasing revenue through timely documentation you i think revenue capture for Public Health systems is him they were not always as good as because were always thinking as i can know not fee for service but you are doing significantly better than your 40 goal and up to 73 is significant. The other oneim working from the back forward. Thats under financial stewardship on page 3. I dont see much in workforce and Care Experience of the we do have positive Care Experiences at San Francisco general which i hope will continue with a new hospital. The last two real ones i want to just call out is that laguna honda and the health at home program reducing staff injuries in such a short time from 11. 6 per month or per interval, i guess, to 2. 8 on both of those is just really a wonderful reduction in i know where justin staff injuries at San Francisco general as well. So as i look across this those are really great early successes. The only one that had a question around with the health at home and the quality Measure Division where we arewe went up on reducing emissions through improved discharge followup to 19. 6 two 42. 9. Im just wondering im not actually sure what we are measured are we measuring reducing hospital admissions or discharge followup . That would be the one that i would be interested if you did write narratives in the future. Absolutely. Great scorecards. Scrabble can give you that answer. Okay. Good afternoon Vice President and director garcia and health commissioners. We will be our two n. Metrics that are direct Conference Committee for november 8 and will be explaining to our joint conference commissioners our green and red areas for our true north metrics. For the health at home metrics, as director dickens was saying, reviewing the data so that it matches what we have in the matches what cms has has been a challenge for us. When we are looking at the data based on our patients that we look at on a monthly basis it is verythe numerator and denominator are very different than what is posted from our from cms. So we are currently rectifying that and we hope to have the right data for you [inaudible] yes for the readmissions. These are medicare patients who have good we are seeing and working we admitted back to the hospital within 30 days. Thank you very much. Colleagues am sorry sparrow i guess we do we are reviewing at the commerce committees we dont need to review it twice. Maybe what we should do again in the narrative stakeout some of the summaries that were really at the joint conference and then that we can just highlightim just thinking that a future to make it simple so we dont have to go through the whole report twice. Yes. I love to get your feedback because if youre at the laguna honda for Zuckerberg Jcc you will see it but if you are not then its how do i struggle hadley keep the other commissioners inform. Im happy to take your suggestions on how to make that happen. We were suggesting that to roland may be highlighting several of these areas and going in deep that some of the other commissioners are not at the jcc for the zuckerberg area that may have the highest concern for you or overall in the network. He was sure. He was some of them might be quality bands around these numbers. Like a standard deviation either plus or minus maybe those would be the ones that you report out. The ones in the middle where youre working on, we will just you are right. I think i make sense of the deadly as beginning answers make sense of the ones that are missing and i think we easier for the ones more important wants to float up to the top. Thanks. Thank you. Commissioner hayeswhite thank you much for your report. I guess the question i really has to do with having its more general question and deep dive question like you just got. That has to do with when you say its in progress or for example the improved emergency overdose response, thats in front. To be determined and is also in progress. I think that following along commissioner pating another statement would be helpful to understand what that means. If you have a timeline than that would be helpful as well. I dont think its necessary to do bottomless work on a but a sentence or two will help me understand and iron with the rest of the commission, but help me understand what that means. Because right now it could mean anything this oldtime unassociated with it and i dont know whether this is an important issue for the work that you do but i would suggest that given the fact that its being reported out it is very important to the work you do and that being the case, we need to lift up in a narrative form explanation of that. Thank you for saying that and you should know we actually struggle with that. Because when we first put this together we actually did the expiration of one by one and what we found it booked it was kind of gobbledygook because of basically for reasons. One was either either the Key Stakeholders still cannot come to consensus on a measure but agree with was not a national benchmark. Second was just the ability to validate the data get as you know we have 16 67 different iis systems and some of these have been required to in order to get the reporting youve got people from different systems. So much any apples to apples and oranges to oranges. Then the other particularly the case of Behavioral Health because you know we been recruiting for new Behavioral Health director. So there just wasnt the cohesion there to really bring those together. So thats why you will see the more robust the more mature parts of the organization like laguna and zuckerberg we have more of their did the other parts of it are just coming onto their still struggling to really get up to that point given the variables you just described in terms of those between data points, it will be useful just at that distinction. There are too many data points which we have to pull together given an answer to this particular one we just say in progress were to be determined. But if you can say that exactly it would be very health. Will do. Thank you. I had a few comments in question. The first is that i really want to congratulate the team here at sort of the network and at the institution adopting lean. This a very heavy lift. It requires a lot of training and you have quote your day jobs at the same junk so it really seems like we made a progress adopting that powerful management tool. The caution and maybe suggestion i have for you in reporting out to this group is that we know you are doing this already. We hear about it at the jccs good we heard about it for years but we are interested in results. To the much later we can go on the process and the more time we can spend on these here are the areas that youre focused on. I think that would be more helpful to us to understand okay, how are we doing. And i will come back to that but i did , in looking over the metrics i would just give you a sense of how i think about them. So when we want to reduce patient time in the er we just open a billiondollar hospital with er much larger than we have and we talked about it this a lot and you guys are struggling with the changes in process and workflow for people but to see er times like this go out and for me to think, and i sit here and i look at this and i think, well if i took my cue to the er or if any one of the commissioners took their cue to the er or anybodys employed by the Health Department, took their wife or kids to the er, on their Insurance Plan and they had to wait this long they would blow their top. So i think that is the same lens and motivation with to think about the people who work spots for taking character likewise, i mean it is Good Progress duo from 44 days to 39 days on access to primary care but a target of 14 days. We would also kick and scream about that and be frustrated. I think weve got to remember that at the end of these numbers we have a lot of our citizens and most honorable and they ought to expect to have the same sort of care that we get. Sometimes these numbers i think are not ambitious enough. I know we are on a journey but i really want you to be ambitious which leads to my question. Which is, you said before that you are frustrated that some things are not going fast enough. What exactly is not going fast enough . Number one, just the development of visual Strategic Plan and the various a. I think the command and control manager was trained to be would say all these things should be done. We should all 55 of these metric should either be read or green. In the old days, make it so. But as we are learning to be this learning organization where we really try and define our problems, have multiple stakeholders involved in helping us number one identify with the real problem but also in terms of the countermeasures it takes time. Youll notice a lot of these athree have various version to summer and version 10 summary version four. The fact that thousands athree waiver to valuebased it just takes more time so thats the part thats frustrated you i like to say, okay, everybody has this done next week but in order to be true to the process, i cant force that kind of thing. That is fair but only out. As you look at all these metric second got a couple i was first it would pick out a couple that youre critically frustrated with. He was number one, the ed one. Number one that you wont get i think we all hoped and expected with the opening of the new ed that the times would go down. That is one. The other would be increased to Client Satisfaction rates for health at hunter ideally you think would want off 100 Client Satisfaction. Even though we are at 75 or rather at 72 , we actually went down from 75 but you would think we would be able to have 100 . So whenever we have those kinds of gaps degree in terms of service delivery, thats frustrating because we think we are equipping our employees and staff to provide Great Service as a why arent we seeing that reflected back in the responses from our patients. Thats always frustrated. As a person in charge, like in the lean methodology, if you pick out a few things that you are just like among no, we have to fix this, what other tools do we have two kind of motivate so that you can get the results you are trying to have . So within the lean methodology to actually go to that process under review the process owners a great. Here are your metrics which ones are green . Which ones are red . Once a red tommy what the issues are. What are the barriers . Can i help you resolve the barriers . Thats go take a look and see what this is really about. But you and i take a field trip and you can to meet in the real place. So that in the er for example, what should be our expectations about the ability to hit a little under a is 3. 5 hours waiting which is the goal at the end of year if we do a really well. What is your feel good about that . I feel good about that we have a process to get there. What i dont know is how quickly were going to get there. We are going to have to i think continue with the root cause analysis with the redefining of how they are using the three different pods within the er. Thats the work theyre doing out. How do they optimize pods one, two, and three in terms of making sure we got the greatest patient flow. Having said that, they also simultaneously need to then focus on the diversion rates good because all those things then applied affect how much time an individual patient spends with her within the ee. So its really trying to having said that, its where do we get the bang for our buck given the resources that we have. Do we need to redeploy resources from somewhere else on another lean project to put them on on the ed in or to the big bang affect . That something we will also want to consider in order for us to speed up the time on. So those are the kinds of things we are going to have to do in order to really move the dial i think faster than it might normally go through this process. Right. So if we walk away from this that thinking to under 10 min. Er wait time is a goal by the end of your thats probably can be hard to hit . Is that a fair conclusion from what you just said . Given we are in november now in the next two months come i think we are probably be difficult but i think we are you have until june on this bequest made. 167 and i thought you meant no. By then weve gotweve got enough eyes. The ed is the focal point for cfs g. All weve got other line lean implementation going to thats where the heart of the focus is. So every resource that theyve got is being pulled into that place. And the loop [inaudible] staff are doing interested in doing the change. So i think we will definitely be closer to meeting that goal were mediated by the end of june. Great. I think its important for the public to appreciate the complexity of the problem you are trying to solve. I spend a reasonable amount of time with a moment in the teeming er and it is sounds simple but its a very complicated place. I think the more people appreciate that the more support youre going to have and i also think the more everyone when we remind ourselves about the urgency of solving that one issue. Which requires a lot of other issues throughout the system to be solved. Thats when we are going to get itself absolutely. Any more questions, commissioners . Thank you then much for this report. Thank you and i will take your comments and try to hone this presentation better the next time. He was thank you commissioners i may remind you and Mister Pickett spoken comments when it comes back to you youre doing the best we can to meet your needs on that. Item 9 is other business. Other business, commissioners youd like to bring up to the commission . Lets move on to item 10. Commissioner sanchez can get the report back on the october 25 cfs g jcc meeting. This is identity jcc sfgh the committee reviewed the report approved of the environmental report sparrow care proxy and population for the annual meeting at on november 15. Committee also heard an update on the transfer of the good on a hospital patients were cfs g is sparrow this was discussed with their and also at the jcc at laguna honda. The Committee Also reviewed the records were a report Council Minutes hospital minutes [inaudible]. Committee also approved the ob gyn Community Service roles and regulated reviewed a modification to the permanent [inaudible] internal medicine inpatient units and revisions. Vice the pulmonary privilege list and listed labs that are approved. In closed session the Committee Approved the credentials report and minutes. Unless theres a new additions from our colleagues who were therethat is the jcc minutes great. Thanks. Item 11 is the committed agenda setting. Youre the master calendar investors in a question any questions . A reminder to measure Sanchez Joyce you of the joint meeting with the Planning Commission on november 17. 10 amnoon what time . 10 am until noon mister secretary are there any dates you worry about quorums . At this time there is not so we can move onto item 12 which is consideration of closed session at the receive any Public Comment for this item. Youre welcome to vote will to go into closed session. All those in favor say, aye all those in favor say, aye [chorus of ayes] we will go into closed session and thank you everyone for attending. Commissioners is no time to vote for not disclosing or disclosing could i move that we not disclose the item that was discussed in closed session. Second all those in favor say, aye the course no consideration for a vote for a german move for adjournment. Second all those in favor say, aye [chorus of ayes] thank you everyone. [gavel] [adjournment] commissioner president loftus id like to call roll is commissioner president loftus commissioner Vice President turman commissioner marshall commissioner mazzuco