Transcripts For SFGTV Health Commission 11315 20151107

Hearing no correctionsthere were just misspelling of words under the presenters if i could correct the prepters under the resolution for screening for type 2, that is doctor lawrence ng rather than kg and doctor eric [inaudible] is a l rath er than a j. Since they took the time to come thought we could identify that correctly. Yes, i apologize for my inaccuracy i have a problem reading these and they are doctors. That is the only correction i have. If there are no corrections all enfaiv say aye. Opposed . The minutes have been adopted. Thank you. Item 3, directors report. Good afternoon commissioners. Wanted to start off with the agreement for medicaid and medical regarding renewal of california [inaudible] waver. The currents waver provides 200 million to dph. This maintains [inaudible] smckted to decline in the out years mptd we have expected this now for many years ourselves so we are prepared to continue to plan for this potential decline. The two largest componentss are the successor to the District Program called prime and the uncompensated care pool. The prime care program is flat funded for years 1 through 3 and decline by 15 percent in year 4 and 5. The pool funding is man tained in [inaudible] based upon two studies on med kale access and compensated state care wide. The details of the studies are not known yet, they will determine future funding decisions for uncompensated years 25 in the waver. [inaudible] two biggest federal Funding Sources countnuity is good news. Oretd good new is the [inaudible] the demarmt is in the good possession to be successful at but it does intend to provide care for high risk population and off set [inaudible] it is a very complex program and trying to keep frac of this and it is a state wide, nation wide praess. Mayor gogo on to mayor lee announces 1. 2 Million Dollars supporting getting to zeer owith mac 8 fund. Getting to zero is focused on 34 pillars to acheechb the goals of goatic to zero. [inaudible] prep expaction, [inaudible] same day linkage and treatment for hiv diagnoses and retention of care. 1. 2 Million Dollar funding is leverages to increase the number of hiv positive patients to increase care. We announced the opening oaf our [inaudible] program in San Francisco and it began yesterday. Assisted outpatient treatment roughered [inaudible] Court Ordered out patient treatment with suvive mental illness. [inaudible] not engaged in care or deteariated condition and have a history of failing to comply with treatment. The person must be agadult tw serious mentsal illness and [inaudible] in the past 3 years over result in threats or acts of violent behavior to themselves. We anticipate there will be fewer than 100 people in San Francisco eligible each year but do anticipate many more who will call to determine whether or not their family members qualify and we are committed to those calling us to engage with them for service so that is a important outreach. This weekend i had a text from a person asking about the level in the hospital and referred them to the web list around that and i think again this is unusually in the past we couldnt engage as much with family members due to hipaa but this allows family members to get access to systems of care which they didnt have available before. Just to note that dens mechan tire is appoint today San Francisco Health Network dweckter of accountable care. Also we have a Health Care Foundation leadership fellowship z want to congratulate madonna vulensia and did she grimes and wanted to recognize him in the audience and i willjust to [inaudible] 2015 latino heritage celebration. We have people from planning and finance if you have additional 1115 waver questions. Commissions question to the director . I guess the question about the 1115because you just got this information, when would we have sort of a more comp rehensive evaluation and how it effects us in termsf othe ill ask [inaudible] may i break that into 2 parts, when does the Service Obligation become implementable and when do the financial obligations or the reimbursements occur . I assume there are different dates . The current waver expired october 31 and the agreement was reached at a high level last friday squu nounced saturday. The details are still yet to be worked out so they havent been affirmed between the state and cms. Cms granted a extension of the waver through december 31 and the new waver elements began jan 1 of 2016. Caph, California Association of Public Hospitals is working closely with the state to develop the detailoffs sth waver rks the special terms and conditions agreed upon by the kait and cms and [inaudible] myself represent the department at the boretd and will mead this week to talk more in detail about how the allocations will occur and what the details the study we would like to propose would be. That will be occurring in the next month and a half before 2016 . That is correct, all of that is done before 2016. We can get a more detailed report at the begin thofg year . Absolutely. Thank you. Any other questions, commissioners . If not was there public cominstant no Public Comment re quested. Item 4 is general Public Comment and notd received Public Comment requests. We should move on to item 5 is the finance and Planning Committee report. Mr. Chung good afternoon. The finance and Planning Committee met before this Commission Meeting and it was a short meeting for us today and what we were able to discuss and took action on is approve the contracts report and 4 new contracts that all added to the consent calendar for your approval. It chs a short meeting but we had a very kind of like deep discussion around like some the policy issues. One of the contracts on the contract report is relatively large like contract and it is likeit is a little over 92 Million Dollars for 5 years and so we had a lot of questions and i think we are going tohave like have a presentation later on hopefully somewhere in the beginning of the year to really look at the history of that specific program on how they bundle the services that not necessarily directly contract would department of Public Health and looking at the efficiency the programs and what kind of like qualative indicators we have for those like programs. We look forward to that discussion. With that said, we have some consent calendar items for you to all approve. Any questions to the chair of the finance committee at this point before we go tothe consent calendar . I believe on your consent calendar you have the contracts report but was that not modify today a 2 Year Contract . That is correct. That is one thing we didit was originally a 5 Year Contract and after the discussion you know, like we have approved provisional 2 Year Contract and the rest would be coming back to us with the presentations and the discussions, so hopefully sometime next year. Just to know that is the health right 360 contract for 92 Million Dollars . Commissioner singer. I think it is now for 34, 600, 00 because it is only 2 years. I the one thing that is different is the one contract is modified to a shorter term. Are there any extractions flaum consent calendar . Seeing none we are prepared to vote on the consenlt calendar. All in favor aaye. Opposed . The consent calendar sudopted there isnt Public Comment on finance committee or consent calendar. Item 7 is compliance and [inaudible] update. Hi commissioners. Maria martinez and drecktder of office of compliance and chief integ rity officer. Some i know and some i dont, i have been here in 18 years. I will present to you the new office. We have worked together for about 6 months now and introduce you to the department, what our purpose is, what we have found out and hope to accomplish and answer any questions you might have about the compliance and privacy. Last year your well aware of the southerland breach we had that was complex and wide spread and involved technology and really showed us that we need today think differently and broadly about our security of our information and as we implemented aca and the new laws about coffin fudential, we looked at privacy and Compliance Department wide. We had people who addressed compliance and privacy in the department but they are in separate siloed in the Department Working very hard, these are individuals who carried a lot of responsibility for both of these functions and now we bring them all together into 1 umbrella. What i will talk about is all thesethis. I wont go through all of it. I give the idea of the scope of the work we are doing and what we found out and where are going. I will give the bad new. First of all, what is compliance . Compliance is regulated by a number of federal, state and local legislations mostly boils down to are we preventing illegal and unethical conduct in our workplace and make sure the people who where working in the department are allowed to work here if they have certain kinds of criminal background they are not allowed to work on site. To make sure that there is a place where people and staff can call to report violations, it is called the wistal blower program. Ultimately reduce the financial risk and loss we haveill talk more about that as we move aheadbasically we are trying to implement best practices to make sure we ethics and integrity in the workplace. That is our purpose for compliance. Privacy, we all heard about hipaa. There are many many laws and legislations and Institution Codes that regulate who can tom to whom, how they can talk to each other and we are bound to implement these rules and regulations. They are very complex and as a department that is very diverse we have hospitals to residential programs out in the boondocks. How you handle confuditionaltyi have 2 or 3 things a day that stump the panel and have to find out about them. The goal of privacy is to protect the con fudentionalty of the pakess and make sure the department is in a place we dont have to pay fines for breaching of the confudentionalty. In addition the goal is to make sure that the protected Health Information gets to people in such a way that helps them change and improve what we do so we are also making sure that data gets where it should go to help us make decisions about the care and services that we provide. This is the department, i wont go through of iti work very closely with quality manenment, Human Resources, and it. I work with bill a lot on it security and i probably see our city attorneys talk to them much more than you would hope i have to talk to them. We organized in 2 different ways. We havewe are trying to get to the place where the people who are located on site at the hospitalon one side you see institutional care and primary care and the other side Behavioral Health, ambultory care and population helts. We are trying to get it so the folks located there are focused on preventing things from going wrong and that means doing Risk Assessment and audit and corrective action plan wg the administrators in those areas. Over in the hospital we have magy [inaudible] and jill account in the 2 institutions who have been carrying the load of privacy for those 2 big institutions and we also havemy god, i lost your name. Evon yescarrying the whole load for compliance in the hospitals so we hope to fill position there. On this side we have [inaudible] who is carrying the compliance and i have been carrying the privacy for the rest the institution there. In the middle we have a new staff who have been barbara is really adept at mubing people around and moved good people to knh in and help us look at whistle blowers, breaches complaint and that is a investigative units. I have a planner here, kim nob nub who is able to help me do all of the policy and planning. It is very complicated and i hope to have someone help do the data trading. This is a very big piece of what we do and will grow and grow and grow and that is how we take the data and match with Human Service agency or dcys. We are trading data so it is very complex and the thing that wakes me up in the midolf the night in terms of how we do that. Hr i have arleana win who does the whistle blowers in hr and well talk about that because all most every whistle blower involved employee conduct. I will share a little about thrie areas, one is whit whistle blower complaints and privacy. Some of this is tough to look at. We had 80 whistle blower complaints that kim through the Controllers Office or us. Half are Human Resource related and other half having to do with fraud and abuse of the 65 that are closed, about half were not substantiateed so it is important to know that. The other half were substantiateed in hole and resulted ichb corrective action plans with whatever department we worked with and ultimately for 5 employees it impacted their status here in the department. In terms of privacy breaches we anticipate there is a little less than 500 thousand dollars that assigned this last fiscal year but it takes 2 or 3 years to receive a fine. For example, we got a fine last week for 3 years ago, so it takes a while for the feds to catch up with us. 13 breaches we reported in 3 quarters of them were due to people taking phi off the work place, put it in the usb or laptop and put it in the car and going to the supermarket and while they are gone somebody is stealing it. I put in the packet you see a notice i sent out that said you may not do it and have to have approval so we are trying to mitigate that in the future. Three were intentional and unozerized a woman came into the Emergency Department percentinating a medical student. We had a social worker who looked opperson who was hospitalized and you know the cybercase where we are up to like 66 thousand documents that were stolen. Each of those documents had to be looked by magy and her staff to determine what left. Just a huge huge project and impacting many many people. We are still working on that. We anticipate the fines to be millions there. In terms of compliance that would be for bills that went forward to whom ever pays us and between chona and evon either finding out in the audits or informed a bill that went forward needs to be repaid. It is all most 10 Million Dollar frz the last fiscal year including some of the Behavioral Health programs and adult clinic. They are here if you want to ask more questions. In terms of where we are going, we are putting a lot of work into the types of efforts to change behavior through knowledge and that would be through our training. Laguna and General Hospital have a good rate of getting the staff and making sure they are doing their training. Community ambultory care is not doing quite as well so we will focus on improving the way in which peoplesupervisors know when their staff havent completed the training. We are also looking at the training itself to make sure we are conveying how to act or handle protective Health Information opposed to being able to type out hipaa correctly which very few people can do. In terms of communication we have one hotline number so people can call toll free whether tay have a whistle blower complaint or concern about a breach or question, it all comes into one place. General hospital has been doing a privacy [inaudible] i have seen it for years, but we have taken that on and been able to push that out to the rest of the department. Fast facts i put examples in the packet where woo have a corner and discuss things come up up to get that out. Lagoona honda has a Good Practice of acknowledging Good Behavior for privacy and complianceo hope to implement that as well. Policies it is important they are easy to read and understand. In terms of data breach, our two institutions have 15 days to be notified of a breach, investigate and be able to report back to the federal state government, so any time you have a large groobreach we need to be able to kick into a incident command and so we are we have a guide that was created by magy and jill and other people who have worked on privacy and now we need to implement that. In terms of sharing data, we will create a data sharing guv rns committee where it isnt just me getting a request and trying to decide if that is appropriate to have it and the best way to get it. We will create a structure where we look at requests and Research Requests for evaluation and improve care coordination and that is very complicated. Mou and [inaudible] is very complex and hope to be able to hire someone shoon to help with that. Data security, privacy looks who should look at it and data [inaudible] this is where i work with it. We have over the past few months created a [inaudible] we have stations now where our contractors have to sign that they are in fact in compliance with privacy, security and compliance. Data security, privacy and compliance. Not only do they sign it but also the chairman of the board will have to do that. We created new forms and user agreements. We looked at who is using our system and who should be off of it, how often should passwords be changed so this is work it is workic le safely and squur securely. The challenges are hiring. 5 3 4 f1budgeted posit we are moving to new emi so we have staff working with it to help codeify preventing privacy and compliance issues before they happen. In terms of legislation we have spent a lot of time on 42 cfr part 2 which is a problem with sharing substense abuse and history and treatment with the rest the team. Probably one the biggest things that i see coming across my desk are issues around the nation and urld with world and that is people who are smarter than we are in terms of getting into our data and exposing it and using it. Staying ahead of that is where im sure bill and his staff are spend a lot of time trying to look at ways to avoid that. Thats our folks up there and they are back here if you want to have any questions for them. Or me. There is one Public Comment request. There is one Public Comment and well take that first and then well get to your questions. Thank you for your presentation. Doctor [inaudible] this for all folks that make Public Comment, i have a buzzer with 3 minutes on it. Good afternoon commissioners and director gar [inaudible] relieved the Compliance Office disclosed 80 whistle blower complaints were investigated last year. Finally the dph is recognizing those who report wrong doing. Thats important because ignoring wrong doing fosters a culture of dishonesty where cronees are promoted and good people are driven out of public service. Your Compliance Office faces two pit falls or challenges. First, investigations seem to be conducted by your own Hr Department thus creating a potential conflict of interest because hr is a arm of management, the investigation of management misconduct may be compromised. Complaints against high level dph officials cannot be safely investigated internally. Therefore, commissioners should ask how the system works with high level offenders. Secondly, whistle blowing i retaliation go hand and hand. In our case for example, Health Commissioners smiled when the dph issued a press release calling us detractors who make false statements. One commissioner even labeled our complaints red harings until we sued and then the retraction came in. Therefore, commissioners should ask whether dph investigations include warnings against retaliation. Also, please ask how many complaintants mysteriously resign or receive layoffs after reporting misconduct. Thank you. Thank you. Commissioners we are prepared for questions now. Please, commissioner. You mentioned [inaudible] what are you doing . [inaudible] there are a couple ways you can get into protective Health Information and that is if i say you are a nurse and authorize you to open the door and look at john doughs record because you are treating that person that is one way to do it. Another way is say ill send all this nrfgz oo a Billing Company and they will use that information to bill for us and so you are taking data and sending it to them in sets and that transfer of information is the one that wakes me up in the middle of the night. [mic not working] it could be. Im not so certained about it figuring out the safest way to do it, im more concerned about the person who downloads the information from their database and theyre going to look at it to do a evaluation of something and put it in their usb and leave. Im not soi talk about that because we are out of control of it. It the data going out of our secure areas that you have to rely somewhat on behavior. For example, the ucsf, a doctor who took the data didnt open up the door and then take a piece of data, she took it off site so it is the taking the data off site im speaking to. We do a lot of it and trying to get in front of it. Commissioner. Thank you very much for the excellent presentation. I admire people doing compliance and learned to welcome it. The knock on the door saying this needs to be checked because i know you are keeping us out of trouble and risk free and improving quality cay. My question is you said address legal barrier or legislative barriers regarding 42 cfr. What do you do to address legal barriers regarding that . It is a federal statute, are you addressing it at that level or more at the implementation level 1234 we are looking how taaddress it with what is on the legislative ajnda nationally to how do we do whole person care when a big piece of it cant be shared and so how do we get people to come in and say this the way we work and how authorization that allow us to share that information. From here to here. Okay, thank you. [mic not working] [inaudible] folks together. I think this is a important consolidation of effort so thank you for making that happen. I have one question. You pointed out the training the contractors is much less than the training of the dph staff, what liability do contractors have if it is their responsibility for the data breach . I think it is nowwhen i first started implementing hipaa in 198 it was very clear if you find something and said that you were going to do it and dont you are soly going to be accountable for a problem and that changed recently so there is a shared accountability i make sure you dowhat you say you will do in addition to making sure you say you are going to do it. So, there is much more of a shared accountability now. Yeah. Because i think because it is our dataif they were to do something with their own data they are soly accountable for it but because we are the holder of it if they are the contractor and generate the data are they doing it on our behalf and libel they would be. They would have to help pay some the fines . Im not sure. Magy do you know if we ever had yes, they would be. And then just a comment, the notion that this is about moving toward yes oppose today xum pliance being all about saying no, i think it is important mide set adjustment particularly with the data sharing governance, the welths of information researchers can use to learn how to advance health care and i think it is so important and have to encourage that oppose today putting up road blocks so congratulations on that. I think that should be a high priority for us. I agree. Commissioner sanchez i also eco it is a great model when you integrate the different units within one system and brings up a number of challenges, some of which you articulated and some you may undertake as you are more under way. You have 6 vacancies in one area [inaudible] grants, contracts and i know that in other oversight areas especially academic helths science centers, a lot of times we need to look at more closely percent of times per taining to both faculty whether the senior faculty, geneier faculty, post oxs were involved in quality of care and research in our facilities whether it is the hospital and or the primary care clinics or whatever. We need be very cognisant about it fwauz over the years the feds have taken a close look at percent of times. I go having in this commission we had a couple cases over the years both in consulting and this is a area where that takes a lot oaf Due Diligence. It takes a integrated approach and integration across which we are doing now and will give us even more dep lth in order to Due Diligence per taining to a lot of these unique collaborations we have with partnerships, other institutions, foundations providing x number of dollars, us paying part of it, other units paying part of it. This is a area i think will be very challenging and hope we will be able to fill that position soon because i think who ever gets that position will have a unique opportunity to work collectively in a positive manner and at the same time it is a area growing by leaps and bounds. You take a look at the [inaudible] funding and the department and ucsf and others we are way out there and really need to make sure that this is in full operation. Look forward to the challenge. I know you folks will do a great job. Thank you. Any furtheri had one which was related toyou looked at the whistle blower complaints and a part maybe about half are Human Resource related and the other part was cu78 pliance which is privacy and compliance is the main focus of where you are going in the presentation today as i see it and the laws all are kind of pointing that way. On the whistle blower side of the Human Resource, i did recall that there were protocols thatas i read the Controllers Office guideline that you had put, it said basically the complains office is evaluating this but there were protocols we had for various levels or are you not using that since we have 2 units at lugona and general . Are you delegating those . The whistle blower comes in through our office, robi [inaudible] who is the primary person who handles the whistle blowers that can come from the Controllers Office or directly through our hot line and every one the footers and fast facts talks about where they come in with their whistle blower complaint and there is non retaliation so we are promoting that and expect because of that we would get more responses about it. It can come to either way. We can [inaudible] investigate it pretty much the same way and there is no sort of threshold for 1 coming from Controllers Office or internally. If it relates to one or the other departmentso von is at general[inaudible] how do they finally what happens is the investigator in my central unit bears the responsibility to make sure the investigation is done. It doesnt mean it isnt done in consert with evon or chonea dependent on if it has to do with typically billing fraud. If it has to do with hr we work are arleana. If 2 has to do a contractor will work with the whole team so dependent on the scopeusually with the whistle blower it is never one thing, it is a multifaceted things. [inaudible] and yourself . Yes. All the whistle blowers what is the procedure if the whistle blower relates to a Senior Office in the department . We ask a whole thingi dont have it memorized, but if a whistle blower complaints comes in about barb raw it is handled a certain way. If it come to the executive team it is handled a different way. If it comes with me and the staff and dont see it it is the Controllers Office and ourself. The Controllers Office will most likely take it so it is out of our hands. We set that up does that answer your question . Thank you. Really appreciative of the report. I think compliance and privacy are important issues that effect all of us and once you start filling in all the people i imagine in a appropriate time you could report back again where we are and how successful you have been in terms of not just your education but also being able to again help handle the improved privacy that our department has. Does that make sense . If i may commissioner chow, i may be a master of the staff but he is the master to put it together and soand she worked diligently with all the sections so this is reflective of the integration within the department and having silloes that havent communicated well together and have leverages all the abilities we have. I also want to recognize all the staff. They have done a tremendous job and many this is their second job. Or third our 4th. I would like to recognize all the staff. Would you raise your hand or stand up, that is even better. [applause ]. They work really hard so want to recognize them i want to recognize the consistency and culture of safety you are generating is very apparent from had presentation and i look forward hearing more about your good works. Thank you very much. Thank you. [inaudible] follow up in 6 months. Thank you. Move to item 8 which is resolution of endorsing ethical pract was of Public Health. This was introduced at the last meeting and requested a revision and today yoi will vote on this resolution. Good afternoon. I want to spless gratitude the commissioners for the advise the last time we met so the resolution is completely rewritten and so it is here for your approval. Commissioners the resolution is before us for consideration. There is no Public Comment at this point. Yes no Public Comment. All there questions or doctor aragon or are we prepared to move the resolution . Resolution is moved is there a second. Is there futher discussion on the resolution . I like it. Okay. Thank you. It does read better. Thank you. Thank you. We are prepared for the vote. All in 235i6rb of the resolution say aye. Opposed . The resolution has been passed. Thank you very much. Thank you. There are no Public Comment requests. We move to item 9 which is dph Health Information system update. Good afternoon commissioners. Bill kim, cio. I am here to present to you dph it update. Full presentation and reference document that are the tactical objective dashbord was sent to you last week for your review and to avoid repeting what you have reviewed which is a sizable document, with your approval i would like to focus the attention to 2 Key Highlights that i think are the most important thing tooz discuss. I would thrike a go over the it structuring and leadership which is responsible for so many progress oirfb the last 2 years. Second would like to go over the objectives that many objectives are designed to support [inaudible] specifically the San Francisco [inaudible] and population helths Information Exchange. If you like i could go to any sections of the main deck or proceed and look at those 2 items to make best use of our 20 minutes why dont we proceed with the 2 you highlighted and we can go back and ask questions on the remaining part. Great. Thank you. Again this is basically what i will go over today. It will be the status report which page are you on . It isnt on the paper itself because this was actually modified to highlightthis is the abbreviated version however all these documents accept for this ajnda is in the main deck. Thank you. We emailed this to you after the meeting so you have a copy. I will go the it operations and the changes we had to make and inoperability which you recall is part the house diagram not included here is a main strategic objective for the organization. Then ill talk about barriers and challenges and answer questions. The it operation in project management making progress through changing foundational structure. The first thing i would like to do is bring your attention to the slide. This is what it used to look like in 20 13. It was a very siloed structure where many teams and functions did not cross into the other silloes. We had many missing capabilities including the pmo, security, budget, purchasing, reporting, integration, help desk, enterprise it architecture, [inaudible] and hr. Some of thes did exist, unfortunately it didnt exist across dph which menlt as a organization we couldnt function as one organization. To address this we have changed and transformed it to go across the organization, the two primary decisions, the San Francisco helt network and Population Health division. [inaudible] bearically see it, however on the paper i believe it looks better. Ill go ahead and speak to this. We have transformed the structure based on the 3 standard it framework. We created roles, responsibilities and more importantly capabilities with existing and new positions. Many the positions that exist today are actually filled by people who were here in 2013. They have very focused responsibilities. If you have seen in the full presentation deck, much work is being done to improve or planning, execution and support of it services to dph. At this time, i would like to introduce you to our new it leadership who are responsible for all the progress we are making. It should be noted combined it leadership represents 100 years of experience in it health care, application, structure and project management and customer service. First i would like to introduce mu lon a[inaudible] she is our new associate cio and responsible for population Health Information exchange and ehr program. More importantly, the transformation of it and the business to be more effective. Thank you. Next, jim [inaudible] is our new chief application officer. He is responsible for applications, the integration and reporting. Next is John Applegarth who is the chief technology officer. No one is standing up because he is deal wg a emergency at General Hospital at this time so he couldnt be here. He actually has a very new role which we never had before which he is architecting the design solution across the organization as one single effort opposed to having 3 separate architectural designs. One problem with integration because it was 33 silos we had 3 separate architecture and to combine those it was difficult. Next is kyle [inaudible] pmo director and is in charge of not only our Program Management but delivery of project management and execution of projects and measuring the effectiveness of those projicts and services implemented and the full life cycle that goes with it. Last but not least, is jeff jordanson and is the newest member to our team. He is from ucsf and formally apple. He is in charge of taking it operationally but working for the operational effectiveness for it sake but the operational effectiveness of the business. That is a very important thing we are trying to change culturally that it isnt about us in it, it is about the business. Retwonz form to meet the changing demands of it Health Market and beeve our structures is positioned to do that and the new deck speaks for itself. Any questions thus far, commissioners . Great. So, i would like to bring our attention to theprobably the most important effort by it which is interoperability across all systems. Opposed to saying this is about [inaudible] or Population Health exchange i would like to bring it as 1 effort because it is about data liquidity or the data ability to move effortlessly across dph is what we are aiming at. This is a new slide i added at the request the health commission. This is a timeline that reflectathize dask bords. As you can see the color actually matches windup the dashboard and you note the color yellow or orange is actually things that are delayed or time table has been changed. Blue means it is completed. Green means it is on track. As you could see the current day workflow is slightly delayed and part of that has to do with many the business and it folks are engaged in the againeral hospital rebuild so we are somewhat delayed but are making progrtss and expect to have this completed by october 2016. The ehr use case which deckitates what woe need frz the organization is completed. We have done a sthuro job working with vendors and solution organization as well as the newly hired ehr program director. The ehr guv rns is on track. We voothe exectev Leadership Group that is in place since april. We meet on a weeky basis and that represents the ecexative level throughout dph. It isnt just the directors cabinet but one level down. The ehr [inaudible] assessment isachy whael progressing at a nice pace. Once that is done we do the ehr preparation. Much of this about what we do it ood which is building the infrastructure and support team and building our culture. The next item that is also on track is the identification gaps. It is underpinning technology in this massive system of Health Information system. In order to make use of this we have to have other systems that allows the data the be used as information and are looking at what that can be. I believe the most important part the discussion today is really about the new ehr sole source recommendation we have been struggling for many months. Im happy to report at this time we have the cost estimate for multiple solutions, we have the support models, we know what it will take to get it done. Where we are is we are at a final 2 to 3 weeks to make a decision on which 1 we can afford to pay for. Now, having said that i would like to note that at the highest level of the organization for the city, the ucsf and foundation is involved in having this discussion and i believe in the next tw 2 week, 3 before thanksgiving we know what to suggest for sole source. The reason the implementation is yellow is because they are dependent on the sole source recommendation. Any questions . Yeah. Seems like you are plakeing Good Progress and i want to congratulate you on hire the staff and getting that organized. Rather than make you answer this here, maybe you could come back perhaps next time and explain to us what we can do to help you to shorten the 16 or 17 months that youre in a internal city process to get the contract done as opposed tolike how you pick that apart . The areas we can improve because that gives more time on implementation and so we are likely to do a better job. Thank you i really appreciate that offer. Thank you. We do have one Public Comment. If you concluded the two points you wanted and then well take commissioner questions. Elo irks se patchen. Good evening. Thank you for had opportunity to address you. I want to qualify im coming to you as a soon to be Small Business lbe hopefully in San Francisco. I do not have technical experience, however im workic with groups of minory contractors and folks that do. After a conversation some questions came up and i said you know what, lets just go ask them. Im going to ask you some questions, im not expecting a answer but things to think about as you move forward in the process. Such a large contract should include local participation from Small Business. San francisco has a note worthy record of inclusion of Small Business and large contract jz there was no reason why there should not be an exception here. Doctors a pornts voice but not the only voice. Everyone involved will be interfacing with the system, so we need more than just physicians input in chuzing the system. Our sole source [inaudible] typically based on unique capabilities. Ucsf doesnt meet this criteria. There are other suppliers that can do this project including sturner who implemented the lacdhs or examples of 2 o organizations, the size of ucsf and sfdph with Different Service lines and governance structures share the cyst ucsf and sfdph have [inaudible] academic medicine versus safety net. This is a high risk approach from a governance approach. Sfdph patients be subject to resurp actirfbty without their snaun . In the event of separation how is dph data remuvlged . Is it practice to fix [inaudible] provide backstops on project cost, is this going to happen with isthe projsneckt it is also stand toord provide Service Level agreements with penalty things with system performance and up time, is this included . Is this a complete system . Does it offer solution frz all dph Service Lines such as long term care, lujoona haundsa, out behavioral helths and San Francisco jails. This is more than impactful more than the structure, this is impacting the population of San Francisco that cannot afford to move forward for themselves. It is worth it to dive deeper and to have a better understanding as we move forward that there is full inclusion for business as well as patient care. Thank you. Thank you very much. Furkter questions . I have a question concerning the timeline. Blue is what . Blue means complete. Okay. Green means . Not complete but on track. Each of the requirements are finished even though you rojected you needed that out to july 2015 . Yes we aggressive lee attacked it and finished it. Okay. In the ehr governance that is dependent upon how you make your selection . Actually commissioner you are right, there is governance structure that neesds to exist in the organization. We are looking at 2 levels, one is the executive level and tactical and operation lt chity. These are infended to be in place in perpetuity. But if you select a one solution, which may include such as ecsf purks csf we need another layer of governance and that is why the timeline is stretched into 2016. Right. Okay. So, then if we take your last line to which you have intd caed yellow means some delay . Yes and then there is another line that is green already that is stabilization . Yes. That is to show we are done with the nlsh implementation but there is a continuous effort required to optimize the system to workflow and workflow to had system. That is what we discovered a key issue in dph is that we put in a lot of investigatement into tasystem and dont put the investment into continuously optimizing the system and the workflow which basically means it doesnt work since we put it in 5 years ago for example. So if you stayed in the timeline you wont have a go live until january 2018. The first go live is end of 2018. End of that could change dependent ow how fast we get the contracting done. That is where we can build a buffer. So, that timeline is the problem in the yellow and the bottom working out the ccsf approval and vendor contracting. It does seem to show it takes a entire year to put in the ehr after that is done. It takes about a year and a half commissioner according to the top 2 vendors. Okay, so the area of trying to shorten is the first part the yellow part . It is amazing it takes all 18 months once you get it to implement it and that is where already some deep thought going on now but it takes just as long once they decide operationally they want to pick a system to sign a contract. A lot of it is the reality of the organization that we live and work in, but it is probably useful to see if we can pick it apart. We know for instance that dph has existed for quite some time with a hiring process that was not the most efficient. I think everyone will confess on every side oof that picture, but both dph internal folks and the City Department of Human Resources were really reacted to our request that we need to take a look at it the question of time and money and as you know from the General Hospital, everyone swarmed around the problem and asked questions how to do it differently and made a lot of progress. It is my hope that we can do the same thing here because in the end we will get an emr in sooner which we all agree will benefit the patients we serve and our financial integrity. But i think without us putting energy into that, then we are likely to be on a much more elongated timeframe as a result of it. Commissioner chung. Curious to know if we want to look at like the meaningful use regulation and look at this timeline, what are we exactly looking at it because we are not going to start implementing the new ehr until 2017 and for the [inaudible] meaningful use regulations there are certain requirements in order to like [inaudible] commissioner chung that is a good point. This timeline is what we believe is the fastest possible timeline, so this basically doesnt say we will meet meaningful use. The current emr we have dozen meet meaningful use but unforchfootly with the vendor processing it will take that much time to do that. Like i think there are like some part of those regulations are supposed to like comewe have to be on line by a certain deadline. Right now we are at stage 2, we will not be able to meet stage 3. We are very much aware. Unfortunately this is the timeline we have. The meaningful use requirement doesnt coinsid with what we need. Can you give a estimate of like the time and delay . When you think looking at this estimation where we should be able to meet meaningful use shortly after we go live. Meaningful use stage 3. That isnt until 2018. Yes. You may be interested in the Financial Impact and qu work that out and discuss that with you. I think understanding that would be helpful. I think commissioners chungs questions and line of thought are dead on with what we are all struggling with and thank you for highlighting it. I think my instinct is helping people understandi think people understand how to get better patient care. There is continuity and better patient care that are the reasons the whole country is trying to get with medical records, but i think also highlighting the financial consequences of having already been late on meaningful use and what woe gave up and the more punitive consequences of it which wree starting to see already at General Hospital. I dont know about lagoona hospital. Painting that picture for dph for us and for the city will help them understand why we are so exercised about trying to trunicate the process and get this tool embedded thip workflow. I think that is a very good ask. Ill put that information together to be shared. I do have one more slide. I want to take this question because this is a in depth discussion. Let me just add kind of theso i think everyone understands. It is more simple to add the financial consequences of what we missed and men the consequences will have in 18 and 19 if we dont get it. What concerns me the most is the impact of not having this wilg be only the volume as a system. We rin a environment where a lot more people have insurance which means they also have choices of places to go and if you ridelike if you leave here tonight and on your wayome look at the amount of advertising that stanford and dignity and suter are doing on our transit system, the whole reason for that is to get people to choose their systems and that will lead to a decrease in volume in our system that leads to a decrease in revenue. A system that already draws way too much from the general fund, if you walk out being worried that this could be unsustainable you should be. I think this is the right strategic move that director garcia has taken to push this forward and anything we can do to get it done sooner is all good. Commissioner you are absolutely right. It is a multifaceted challenge. If you cannot compete with the xhrmsh market oit there we will lose our membership and that will impablth the bottom line and will draw more [inaudible] the whole effort as you see in the closing remark is about kraissing this as a multifaceted solution so if i may. This is already in the slide deck. We talked about this. I wont kboe over it, however i do want to brink attention to an item that we talked about which is the other side of the house. The Population Health have been built an infrastructure a robust population Health Information exchange. For the first time in dph we scr High Performance [inaudible] that has development, test and production environment opposed to just production. It is in a data sentwer the ccsf. It is highly redundant and very scalable. That means as we grow our needs we will be able ouse it. That is completed. Where we are today is working out the workflow and integration of systems and work flow and the partners that need the information. The next we are looking at how is the Enterprise Data weir house that tays into the ehr and Information Exchange so we can have a true un with place when we choose to use the data mine that we can go to having to true data liquidity because without that you dont have the leverage the other organizations have. So, we have a lot of barriers and challenges but where believe you know what they are so wont go into details. We have taken actions and working towards that. Winonea and the team put together this nifty animation. I thought it is helpful to look at what we are trying to accomplish from a it perspective. As maria put it we want to gelt from no to yes but that doesnt mean we give yes with all the risks. We want you to have access to the information with the highest level of security. I know there is a request to talk about security. If you like i will have a closed session to talk about the architecture sknr design behind the scrurt framework but im hesitant to share that in public forum. I have a question mark for any questions you may have. Great. Thank you. [inaudible] just go back to the slide on population helths that you had up there which i thought was great. You are showing a green with the new objectives but havent determinedim curious because that is how this is going to make your infrastructure useful. What is the timeline . We arethat is what we are working on now. It looks like we have a pretty good approach we discussed with population heth but much of inwork is for the business to decide what they want to integrate first and what their workflow will be. From the it side, the infrastructure is built we just need to help them integrate it. Yes. If i want to thank you for the wonderful presentation and want to thank mr. Singer for working hard on the finance committee to track the timeline and had 24 best handle on this. I just want to comment with regards to the finance and the meaningful use issue i think that is significant. I want to speak to the the Service Issue because im interested in the issue of intigation and we made wond rbful achievements och integration and the patients receiving excellent care i dont think we will be able to deliver fully on complete integration untim we have a Electronic Health record. I believe because we dont have one we are behind and to put it out in 2019 and the people training and upgrading the system we are not looking until 2020 and it gets farther behind and neny go to third and 4th generation of integration and we are just starting. Igist just want to emphasize i know you are doing everything you can but it is dollars and lives and if there are ways we can spend days and hours and at them up. Every hour we save is a few dollars in our pocket and good quality care, so i do again speak to the issue oaf moving as fast as we can. I know the details are complicated but we are behind in the sestm and think we should try all means to move the ball ahead. I was looking for january 2018. I thought we could live with that. To me it seems like we are another year to 18 months out and that is getting way too long. Commission i agree with you. One of the things we are trying to do istrying to do what i call a leapfrog. For example Many Organizations have dhr but dont have a crm. Customer relation manager. They dont have things that bring value the clunitions and [inaudible] they dont have master data systems that index all the information so they can look at the nrfshz in the silos. We are looking at all of that so when wego live we will have it or have it shortly after. That is theonal only way we can catch up. This is all most like [inaudible] usability. I think that is where im a little bit baffled because i think when you talk about implementation i assume you are talking about the implementation of the infrastructure of the ehr but it isnt necessarily about patients and the new technology. I think that in itself is a big barrier that hasnt been like accounted for because like, when you have ehr and adapt that means you stair at the screen trying to figure what you are doing versus talking to the patient that you are supposed to be spending time on. That is my concern here is if we are stretching the timeline out and looking where the infrastructure will be integrated and perfect we may miss those pockets of like really essential whats the wordadapting and tayloring the software. One the questions that is one of the biggest questions is the adoption question or the champion of the adoption by the organization. So, we are very aware of it. A sig cant part the cost is devoteed to adoption. Building the system itself is ineasy part, it is getting people to use it and get tg usable is the hard part and that is what we are focusing on. I believe we can talk to this in detail of all the different factors but that is the biggest challenge for us, how do you get people to buy into a product this complex and make commitment to adopt it . Director garcia i was going to ask is it possible to shorten the yellow bar . Where do you think we are able to leverage to get the system sooner rather than later . There are a couple issues. One we are struggling with has been the cost of this system. We are all most figured that out so that has been a part of the delay. This is over a multiyear process several hundred Million Dollars. I think we have got more comfort with that. Part the issue is the reserve we talked about of insureing and save some the dollars as we move on in the Controllers Office and Mayors Office is very supportive of that. The second issue is can we look at how to really press on the vendor process and well work hard at that. It does take board of process and the city process and we are going to have to work hard at that. But i do have to say it has been a financial process that we had to go through in terms of one, we have to be very financially disciplined in terms of the future cost that we bring. As a example, the Compliance Office, we have got tomanage those risks that we have in and reduce the number of fineings we have to continue to capture and keep our general Fund Operating so that we can move forward with that and not depend on general fund. Any dollar going out the door not used for services and the work we are doing isnt used. We asked all the staff not to bring new budget initiatives and call it the realignment process. They Center Position squz new needs and center to realign just like we didnt the process of our Compliance Office. We did add a lot of positions. We aligned so we have to do tighten our Financial Systems to afford Going Forward but we are committed to that. We will work as commissioner singer asked to look at the contract process in the next couple weeks well make a decision and make sure to inform all of you to that decision and how we move forward. Thank you. Any further questions . Yes, commissioner chung. I think a part of it is like out of our control. The reason i say that is we look at the timeline like 4, 5, 6 years from now and talk 2 or 3 generations of new clinicians and nurses coming on line and my curiosity now is what are some of the courses they need to take about technology and how to integrate technology into care . It is all most like we have to like raise that question a little beyond justso, until then i think we will always have this [inaudible] and say we try to get everybody on board. Commissioner if you like once we make the recommendation ill be able to present to you as we go down the path a very well developed adoption plan including the education, the training, ongoing support. Ill be happy to share that with you because i think once you see it you will appreciate the complexity and resource required to provide that. That is actually part of our current model. Thank you for bringing it up because that is rarely discussed. Very good. Are there any other questions . Not i think you assisted us in understanding where we are today with not just it but ehr initiative and look forward to a further Progress Report once you made another decision point. Thank you for had 20 minutes, which was very long. Thank you. We move to item 10 which is the dph facilities master plan. Are you okay or would you like me to come over . We are having trouble with the presentation. Is it possible to move forward on the put the first part the capital facilities. We are making a case for capital. Need a better laptop. There we are. Thank you. Actually markthis is the plan. I think you all have a copy of the powerpoint. Mark brought up a copy of the plan so why dont we start. Good afternoon commissioners. Im not mark primo, im cathy [inaudible] director of facilities and capital plan frg the deparnlt. I think the last time you actually got a update where we are with capital was about 4 years ago and there have been a lot of changes and growth in the Department Since that time. The plan we present today is intended to give you a idea where we have been and where we are going. It is intended to be a 5 year road map that talks about where we need to go in terms of continued support, funding and improvements to dph infrastructure. He brought up the plan, i needed the powerpoint. Anyway, maybe i can continue. The plan is divided as you can see into 4 different section squz the first section under background we try today provide context and driver frz the department and planning processes. It provides summary of dph facilities and over view of capital funding. In the next section, port 2 which is on page 13 we go over where we are today highlighting accomplishments of projects we worked on over the past couple years. In the past decade about 65 percent of our facilities have been under some form of Capital Development in planning or construction. Represents 1. 8 billion dollars in Capital Improvements. Over 1. 2 billion dollars is underway nearing construction or in design. Most of that work is on going on San Francisco general. Part 3 which starts on page 29, we address major Capital Needs for the department. These include outstanding issues of real estate, seismic needs as well as focus on ambultory care as a priority. In the last section we overloaded everything and tried to give a idea of all the backgrounds particularly on the 10 year capital plan. List of dph facilities and sites. We have 4 aithd owned facilities, 28 leased. Historical finances information. Summaries of past Planning Efforts and a little more detailed information on the proposed San Francisco grad expansion project. So, the key differences from this plan and previous plans is we try today be more comprehensive and forwards looking in order to provide a better context with Decision Making as we go forwards. In the background section on page 4, we discuss what the new changing helths care environment in which we are trying to operate which created the Affordable Care act that has inturn had the deapartment transition to competitive market for medicaid and health care exchange. This has pushed us to establish greater collaboration and coordination across the department on how we spend the capital. [inaudible] looking at how to integrate our facilitiessorry. Our facilities operation and management better to serve the overall network. Starting on page 12 we look at the real estate needs. Obtaining affordable space to house dph staff and Clinical Services in areas we have generally served our clients in. On the past year [inaudible] integration continues with objective of [inaudible] integration. Director garcia established a executive fillty and capital Planning Committee. The charge thoch committee is provide ovsite of the Senior Leadership level of Capital Planning and projects. It compenalize Senior Leadership from Everything Division in the department. We meet twice monthy and go over hot issues, current status of projects and emerging issues. In september 2012, we had a first Capital Planning retreat to try to organize the department and overall perspective where we wanted to go. We are looking at doing a new retreat some Time Beginning of next year that will coincide with fiscal year 16 17 budget cycle. The reteat is in the plan strarting on page 4 fifen. There is a lot of funding constraints as you might amadgeage that go around capital in the city so on page 6 we talk about the constraints in greater detail. The citys capital plan proposes to fund the majority the pay as you go or annual on going [inaudible] with general fund dollars. These are generally smaller investments in10ed to maintain facilities and infrastructure and support project development and planning. The capital plan, however is financially constrain squd the general fund cannot support or cover all identified needs. The cities plan delineates over 32 billion dollars in capical needs and only provided 120 Million Dollars for this year and 1 28 million for 16 17. [inaudible] in addition, further compelling the constraints the city has a policy on on the general obkbaigz bond that is fixed at the 2006 tax rate so this slide here shows where those constraints fall in 2006. The orange bar represents dph and it is alsothe chart is represented of the Capital Bond Program from 20162026. We have 2 bonds on that 2016 and 2022. The general Obligation Bond hat we are currently working on for june 2016 is a joint werft the Fire Department and animal care. We are currently scheduled to receive 22,222 million. [inaudible] of the existing Hospital Building as well as include the ree location of the Public Health lab and the chronic dialysis program. The other 30 Million Dollars is designated for phase 2 of the south east Health Center ren ovation. The original bond did include ren ovation on [inaudible] as well as buildings 80 and 90 of the San Francisco general campus. The ren ovation of [inaudible] estimated at 150 million and the 80 and 90 are estimated at 100 million so it didnt fit in with the capacy of what the city had so they are removed from the bond. The city looked at certificate of participation of 59 Million Dollars for 101 grove street but this is still under consideration. The ren ovation och building 80 90 will happen in the 2022 bond. Over the past several months the departments work with sit a Controller Office to look for real estate and looked ed nob we will increase staff up to [inaudible] occupying buildings and in around the Civic Center Area by 2019. The controller exectev summary is included as part of this report. The need to find suitable clinical and office spait space is driven by there need for [inaudible] the city is selling 30 van ness where we have substantial space occupied by our amtory care program. They will use the proceeds for that to build a city building. The department has [inaudible] for Emergency Management service. We also have a major lease in the midmarket area that will expire in the near future and if we renew that lease it will be at market rate that will increase the [inaudible] therein near future and will have to vacate that space as well. So, we will work with the analysis we are working on trying to find options includes looking at reuse of San Francisco general and lagoona honda. We brought on consultant and in the process ofbriing them on to begin that assessment process. Regardless of which compination of strategies we go with the department will need to obtain more space and identify Additional Resources to pay for that. We anticipate if we go to market rate for space to house all the 1260 staff we will pay about 50 Million Dollars which is 9 million over what we currently pay. So, the Department Facilities Capital Needs are broad and multifaceted. The priorities are completion of seismic and reuse assessment of the buildings at lieu goona honda and San Francisco general. Finding space impacted in and around the civic center. Direct attention and resources toward ambultory care. Establish integrated dph wide Facility Management structure. Coordinating with ucsf with the expanded garage project. Once we finish work on the 2016 bond we will focus on the 2022 bond. That concludes my remarks. Happy to take questions you have. Pretty dense report. There are no Public Comment requests for this item. Commissioners. Thank you for your report. Something that i never hear in any of the reports when we talk about Capital Improvement plans is ada compliance t. Seems to me that it is understood and we assume all those buildings are ada compliant. It is a part the plan somehow integrated without being verbal about it and i want to know is that part of the master plan . Where does it fall into the master plan . We worked closely with the Mayors Office and disability and we have done a number of projects in the past several years, 5 or 6 years that improved compliance issues in many of the dph facilities and it is a code requirement and anything new has to meet ada standards. We have done a lot of work. The [inaudible] systems outside. In this building and a number of entrances at San Francisco general and worked on elevators so work on projects at the city clinic now and [inaudible] hall which improvers access. With all due respect this building is not ada compliant. The ramp is there, but the push button doesnt work, the bathrooms are not ada compliant and not handicapped accessible and want to raise that. For someone in a protective class this is problematic so i want to make sure we deal with that in some way fashion sooner than later. We agree with you commissioner. We agree fully with you on that point. We can have those button fixed so thank you for bringing that to our attention. This building has undergone all kinds of different iterations, so the latest is that we would then be looking or leasing space for the functions of central office. What our thought is now commissioners, is that due to the fact we have restricted funding we think we should basically focus on asts we have. Instead of look frg millions of dollars for a lease we should use that to leverage our ability at San Francisco General Hospital as well as lagoona honda. Already we are looking to have consultant on line and at first we had thought it may betoo expensive to renovate. Now as we compare the cost we believe it could be more affordable to just commit our sevl tooz the assets we have. We have plenty of buildings that need to be seismically upgraded on the campus and can be dual uses. We hope to look at the later bonds for more clinical but also for administrative and so thats the plan at the point. We are in discussion with the city how the building would be used, but at this point that is where we are. I do think that direction because i was going to suggest strongly and not clear in here we should look at our own properties again. [inaudible] cfo and i had a conversation severeral years ago and thought laguna honda would be a good place and thought it was too expensive and today that turned a corner. Trying to avenueolog or own assets the best strategy for the future and vote for San Francisco hospital for [inaudible] everybody is struggling with space in the city and it is issue and think as we think this through i fully think the facilities we are have are important and also think about different work models that allow for some invasion of expectations for office space or having the to come in space and i think there are some folks out there coming up with different ways of looking at that and that is one way forward so urge us to do that. Thank you we will. I think a challenge i want to reflect on is a lot of our patients are in the Civic Center Area so we have tom [inaudible] the clinic in the building and will have to find space to replace it so finding space in this area will be a challenge to continue some of our services. To add on the different ways to provide services, the whole 21st century of doing telehelths to take services to where they [inaudible] if any city should be able to do that with a very fragile population it should be San Francisco. We have made Major Investments in telemedicine and continue to do so, so thank you. So, wondering this is a dph facilities master plan, not the hospital master plan which of course [inaudible] requires every 5 years for approval. What type of approval is needed from here or is this a update as to the thoughts now that dph is considering for all of the facilsties . What do we need to do . I think that is what it is, i think it is a risk to reflect on what we are thinking and a update to you so there is really no approval required. I think we need to take your feedback and act on that one of the issues we want to highlight to you is the fact we integrated our conversations about Capital Needs and that is very helpful determining all needswe had 48 Community Sites correct, we own 48 buildings. Own, lease. Looking at it from a horestic point of view for integration and think commissioner [inaudible] the rowel of how to use this space, this is a traditional building and large offices. I think we are looking at we move people around and look at how we use our office space so it is poncht to do that for the future. Considering the fact that we have as you can see we are challenged as city around capital dollars and we want to [inaudible] and good recreational facilities and Good Health Facilities and benefited greatly and represent 40 percent the capital dollars from the city and so we do get our very fair share of those dollars and want to use those dollars efficiently. Just to add to commissioner casmers comments, i think it isnt just playing defense on the facilities that cram more people into place and have people telecommute t is how the new workforce want tooz work and things we value like a big office overlooking the beautiful square, it isnt clear the new generation will value that, so i think there is a rule opportunity how you think about configurations within buildsings and where you are if we have 2 central campuses where you may have a positive impact on who you attract and the culture have feel of integration. I know barbaras message is get rid the silos and one of the best way to do that is get everyone toorkt. I dont think it is just we can save money thing but build a department organized for a the future it is making buildings fung thengz way they should with the clients and staff and a great example is we just finished 50 percent cd for remodsal of Castro Mission Health Center and turned that on its head. We created space where there is no [inaudible] fewer private office and more shared space with interaction and have done research to see what the va has done to create efficiency in smaller space and get the dynamic and fewed process between staff and patient so the experience is different. We are definiteply welcoming and open to those kinds of ideas. If history can be or teacher here, we turned around lujoona honda and improved service and hope well see the same efficiency pop as well as the new way of providing services at the general. This is just a bigger more complicated version of that. We have new it systemess, new offices, and hopefully a more efficient streamline health system. Looking at the hard side which is the building and soft side which are people at the same time make perfect sense and they are all ada compliant and all the buttons everywhere will work. I do want to make a comment about the Public Health lab, we pushed the pause button and did a process with them to look where they center been. They have been in this building if you have seen the public helths lab it is very dismal so it was exciting for staff to come together and think outside the box how to make this more efficient. We took weeks of staff time and worked with them and worked with the design team to create that type of space you are talk about. That is our intent is to do more with that to engage the staff early on and do work differently in spaces. I just want to compliment staff and yourself for such a comprehensive report you brought forth summarizing what happened in the past, what we have not funded in the past, what has to be funding and having all the document in one document for us so thank you very much. No Public Comments request and we can move to item laevl which is other business. Commissioners any other business that anybody wants to bring up at this point in time . If not we can go to the next item. Item 12, report back on the october 27, 2015 San Francisco General Hospital jcc meeting. I think generally we reviewed the aneral report that you will be seeing at our next meeting and that included also look ath the environment of care and the Performance Improvement policy and provision of care policy which you will all see and be prepared to vote for. We did get a update on the rebuild and reminding everybody that november 21 is the Ribbon Cutting ceremony and more information will come with that. We also discussed a transition process going on after the stocking of the building and what the plans are to get to licensesure and move the patients which include a number of steps in order to train staff. We have gone over that chblt we also received the traditional administrative reports and the Patient Care Service report and took note the fact we are still having very high emergency deversion and hoping that the new process going on right now in looking at flow och the Emergency Rooms will work for us and workflow will help for this current building and for the new building. We also look at the very high psych emergency utilization and had discussions on that and are continuing to discuss what the issues may be and what we can do about that. We looked at the sfgh hiring program and it looks like it is on course at this time and received the immediateical staff report with a number of technical corrections and expediting approval for temporary privileges, revising a tv form which the city uses and standardizing a number of procedures particularly for non physician personnel and in close session we approved the [inaudible] commissioner singer had anything else to add. Otherwise that is my report from the sf general. Our next item move to item 13, Committee Agenda setting. Commissioners if i remind you on december 3 you have a special meet wg the Planning Commission about cpmc, 10 a. M. At city hall. December 3. Thank you. A thursday. I think that we will meet at sf general if our next meeting. Yes, on november 17. In december the second meeting is in lujoona honda. Yes. It is on your calendar just to remind you it is on those 2 sites. Now commissioners you can consider a vote to go into cloized session. Any Public Comments on closed session . I havent received anything. A motion to holds a closed session. All in favor say aye. Opposed . We now , we are back into open session and a motion in order was to disclose or not to close the information discussed during the closed session. Motion not to disclose. Second. All in favor say, aye. Aye. Any opposed . And therefore we will not disclose the discussions. Is there any further business . If not, a motion for adjournment is in order. So moved. Second. All in favor say, aye. Aye. Any opposed . This meeting is adjourned. Announcer b dreams and good grades arent enough to get into college. There are actual steps you need to take. Finding someone who can help is the first and most important. For the next steps, go to knowhow2go. Org. Good morning and welcome to the board of supervisors meeting of tuesday, november 3, 2015, election day madam clerk call the roll. Thank you madam president commissioner avalos supervisor president london breed supervisor campos supervisor christensen r