Put recommended, the august 2015 contact report and one new contract with environmental logistic and in the amount of 1. 7 million dollars. Which covers from august 1, 2016 through june 30 2018. Its an eight year country. Those are two items on the consent calendar for the commission to approve. The item is before you ready for a motion. We are talking about items six consent calendar . Betwixt correct motion to approve second is there further discussion on this item . All those in favor say, aye speak [chorus of ayes] proposed . The item passes. We did thank you commission. Item 7 is the fiscal year16something approval request of the it ministration for the laguna honda gift fund. Hi. This is, from laguna honda. Good afternoon commissioners and dir. Garcia. I am here to represent the laguna honda gift Fund Management community to ask for your approval. The laguna honda resident gift Fund Proposed budget for this oh year 20162017. The provider list of the budget that we proposed, you can see we ask for total budget for the 201620 something in the amount of 297,000. Its about 2. 7 increase from the Previous Year budget of 289,000. Most of the line items are pretty much in line with what we had in the prior years. Except for one new item that is the last one on the list. Assistive technology. This is from the new donation from the donor Molly Flesher of the 100,000 donation which came to in front of this committee for a approval several months ago and it just went to the Mayors Office for their inspection last week. We budget for 10,000 donation dedicated to the purchase of assistive technology. Services for the laguna honda resident. So, one thing you might ask, why the budget was at 289 for last year and actually expenditures only 180,000. Numbers that were provided to me. These know that the Actual Expenditures at a time would wait some and this report because we are not quite close they get good its only for until the end of the may 30 2016 and so there were actually about another 5000 more expenses good its going to hit the final expenditure report. Also, a couple reasons why some of the errors we understood last year because the second fund to the bottom of the list is endoflife program was a new program. A new donation from dr. Rose last year. We do not get our final Mayors Office board of supervisors [inaudible] approval into the end of september. So there was a delay starting the project and also we spent some time to do the planning and also finding of trying to get a contract establish contact purchase order. So, theres a reason why we havent been able to spend the actual june what you see in this line item get weve about 2000 in expenditures. Still substantially under than what we budgeted but we will catch up next year. So, im ready to if theres any questions . For approval . On locus of Public Comment request for this item when we take Public Comment and then we will come back. Dr. Kerr . Hello again. Dr. Derek kirk. This budget for laguna honda this Patient Gift Fund was not disclosed at laguna honda joint conference committee. Its precisely the kind of laguna honda specific information that lh jcc meetings were designed to convey. Had it been presented at laguna hondas jcc meeting, someone would have noticed the remarkable decline in the funds allotted to the positive care aids program. If you just look at the budget, you will see that last year positive care was allocated 5500 from the gift fund and spent 4000 of it. So, how much is budgeted for this year . 3000. Out of 15 programs, positive care is the only one that is receiving less than it spent last year. This unique and unprecedented anomaly should be explained before you approve the Patient Gift Fund budget. Thank you very much thank you. Commissioner karshmer i just want to make sure i have this right. We have been guided by the City Attorney that this gift fund comes to the full commission for approval . If i can expand on that is because budget decisions are made by the full commission and not by any committee. So the City Attorney thought and guided us last year the second time this is happening it made sense to come to the full commission. Thank you. Any other questions . I had to. One, can you remind us the process that you go through to decide what the budget is for this so, we do have a gift Fund Management committee that consists of several executive staff at laguna honda and also on button. Also residents represented. We do meet every other month to go through not only the budget also the Actual Expenditures and the different programs suggestions. So, we typically closed to year end, will prepare the balance report and present to the committee exactly what you see here. Was last years budget, what was the expenditure, and what other new programs new donations coming in then suggestions of the based on the stork number of the budget and we tend to budget on the high side so that we dont have to keep coming back every time to ask for a new spending for the gift fund so that way we can provide better Resident Services and then have an effective way to be able to fund any of the new programs. So, once the Committee Approves and then i will bring the proposed budget back to the committee for their review again then bring it to this Health Commission for your approval. Thanks. I mean, i am always amazed the generosity of former staff, former patients to laguna honda. But, some of these gifts come with restrictions that they want to be spend on certain things. So, i just want to check and ask this list and the proposed budget conforms to the donors, . That is correct. Thats why we created give and grant proposals in the second column you actually see the Funding Source for this specific grand codes the positive is a good example to we get donation specifically for [inaudible] programs could unfortunate acronym code the money is declared only about 3000 left so thats why the budget went down to 3000 but that does not mean we dont provide the service. The service will still be provided but we will be coming out of different grand codes. Thats why the comparison you see a drop in basically based on the remaining balance of that grants. Think. Did everyone follow that . Great, think. Thats the end of my questions. Do we need to approve this six yes. This is an action item. Can i have a motion . So moved any further discussion . I kind of do that backwards. I apologize. All those in favor . Opposed . Thank you very much. Think. Item 8 San Francisco Health Network update. Slideshow. Good afternoon, commissioners. Bolan pickens directive San Francisco Health Network. It is my pleasure this afternoon to provide you with a note update on the San Francisco Health Network. This slide displays with the network sits within the weaponization will structure of the department of Public Health. Todays presentation will provide you with a summary of the highlevel strategic operations at the Network Level. The presentation will review where we are without previously identified fiscal year 1617 priorities, which i will note rashly done before we engaged in our Strategic Planning process. We will still report and talk about those today. But we will also give you an update of our activities including an update to our Strategic Plan also referred to as the x matrix our Team Charters and are true north metrics. So, when i previously presented to you back in january of 2016, i shared these were the 201617 highpriority areas that were identified by the Network Leadership team and those are depicted here. These were the nine priority areas. First was stabilized sf age in leadership. As you know, we hired dr. Susan ehrlich as the ceo and zuckerberg evangelical. We also brought on we subtract the new director of jill health to replace dr. Jewell golden sun. I also reported back to you that are long serving director behavioral jewell robinson, was retiring. We have an active search underway for her replacement and interviews are currently scheduled for that to fill that position. The second priority was operational the new San Francisco zuckerberg San Francisco General Hospital which we know we opened on the 21st. At 6 am. It continues to operate efficiently. The other priority was develop marketing and branding strategy for the network. Which, we have done and at the last presentation in may, you heard from mark marketing and Communications Director rachel kagan, and patty our Mayors Office on marketing unbranded. In addition the monster using the many outreach activities for zuckerberg San Francisco general around the city that we were also able to partner and have those advertisements also promote outreach for patients into the San Francisco Health Network. We, the leaders of the network, continue to participate at the dph wide level in terms of capital planning. You are aware that the new rondo was passed a few months ago. That bond will be reported to you at the full Commission Level Going Forward but the network is very much involved in that process because the bond funds work facilities at se. Health ctr. Are Mental Health clinics around the city, and for the building five and zuckerberg San Francisco general. Our staff continues in terms of developing staff continue to participate in the four Leadership Series trainings throughout the department of Public Health. The cultural humility training, the trauma informed assistance training, the lien education and collective impact training. The other priority was to expand our payer base and you will hear ashley more details about this in october when cfo greg wagner attends your planning session. Youll go into details in terms of our contacting roadmap. But you should know, we have an implement in the roadmap that we developed with our consultants oliver lyman and mercer get weve actually renegotiated whatever existing contracts and have added a new additional medical managed care contracts. Also more importantly, we also establish infrastructure with our managedcare office to actually be able to be more effective in terms how we approach managedcare business. The other priority was to integrate standardize operational procedures across network. As you know, we are bringing to the other previously disparate organizations mainly laguna honda hospital, Behavioral Health services, and zuckerberg San Francisco general. A prime example each of those entities have its own medical staff reduce process. As we got to managedcare, one of the things we quickly found is when you negotiated with payers they dont want to go to three different entities for medical staff information to they want onestop shopping so weve had to retool ourselves to provide that coordinated centralization of those services. The other priority was and continues to be to implement the new medicaid 2020 waiver. You were a little bit about that from the primary care perspective at the last presentation when hallie hammer presented the primary care specific focus of cns. But we continue to implement the program and we will continue to update you on our progress across the network. And, the final priority that was set prior to our being Strategic Planning process was to plan for the Electronic Health record. I say that one for last because is definitely not the least of our priorities could it actually are number one in our biggest priority. Where most of us are spending more and more of our time as of late. So, the priorities from the previously presented slides, as i mentioned about were identified prior to our strategic learning process good also known as [inaudible] in mean terms. During that Strategic Planning process we engaged in back in march, we identified nine critical areas for our Strategic Initiatives. I will refer you to both slides seven, which i will go to hear, did you see Strategic Initiatives 19 and also in your reference binder capital one, it will actually show our Strategic Plan for the network. We are getting back to this matrix, this is our attempt to show you the correlation and overlap of the previously identified priorities for the fiscal year and how they are represented within our current lien Strategic Plan. Either they were adopted as a Strategic Initiative in and of itself, or it appears in our one of our 803 Team Charters were as one of our true north metrics. So, as weve gone through the lien Strategic Planning process, and also as we begin to engage with our partners at ucsf on implementation of the emr, it became quite good to us that we need to be very strategic about where we spend our limited time and resources. Most notably, we determined we needed to have a phase rollout of our Strategic Plan given the many competing priorities that we are working on. You see some of those here. Again, i mentioned the dhr, which is epic but also ucsf product is called apex did you see that at the center of this diagram but also some of the other competing priorities we are working on waiver limitation, which in and of itself has for individual subcomponents which youve heard about. The prime project, the gpd, global payment program, also drug medical for reimbursement for Substance Abuse services. So, i guess the big take away here is that all the work we did prior to eileen ross s was not lost. We were actually able to use much of that to inform the priorities that we set in our new lean methodology Strategic Plan. This slide present you with an overall timeline for a 3 developments. You know through your lien education that the letter eight ivan three are really the tactical maneuvers we will take to actually implement our Strategic Plan. Copies of those a 3 are in your reference binder. So, just in terms about to read this slide the little dotted black line represents where we were in terms of back in march when we started our Strategic Planning process. You will note, each of our a 3 teams have at least four a 3 clinics with our consultants to really help us flesh out each component of the a 3 charter. The orange line represents where we are right now. You will notice Strategic Initiative number one is called right information anytime anywhere. Which is also really are dhr initiative. Just the terminology right information anytime anywhere is actually represented in the evolution of the Strategic Plan as a teams guidance in developing each of their a 3 charters. With that much was in integrated process and just saying implemented needed wasnt reflected what we were trying to do. What we were really trying to do is make sure that we have the right information anytime everywhere for all of our patients. So, again, this presents a timeline in terms of where we are for each of our nine Strategic Initiatives. So, i mentioned there are a 3 teams and the fact that we have clinics with our roanoke consultants. Those clinics each of the a 3 each has a team lead, and you see that team lead identified here and the members of the team did these are the people really doing the hard work of really doing the analysis of data, doing the fishbone diagrams to highlight what those salient issues are and processes that need to be addressed in order to improve our performance in those individual areas. So, at the heart of lien is our x matrix which is our Strategic Plan that we have our a 3 charter. Then we have our lodging combos of the steam that drives what we do as a network. We talk to you about thats referred to our true north. These are the things that really should not change very much overtime. While elements of the Strategic Plan will change as conditions change, the true north matrix of those things the leadership within the networks met and decided would be our overall guiding compass across our multiple varied divisions. As you know, there is a lot of attention on measurement within healthcare. As a network, we are still evolving in that process. We believe that our lean methodology, between our x matrix re a 3 charter with its goals and targets and proposed outcomes in our true north represent our ability, at least our journey to become a more data driven informed organization. So, these are the true north metrics that at the Network Level we settled on. You will find that these are not necessarily unique to San Francisco particularly many Healthcare Organizations have all of these except we find that to the best of knowledge are the only ones who included equity is one of our true north guiding metrics. So, we have chosen to in terms of our outcomes, have a target of achieving 70 of the true north targets in each of those categories. There was a lot of discussion about how we came up with a 70 targets. As you can imagine, given the varied scope of services that we provide across the network from longterm care to Substance Abuse, that its many times not possible to have one measure that cuts across all of those areas. So, for example, a longterm care measure may be to decrease the incidence of hospital acquired incidents which honestly is not one you would use in terms of measuring quality of care and methadone outpatient treatment program. So in essence, we let each of the divisions or Service Lines propose measures that were relevant to them and then as a Leadership Group come out we actually discussed all of them and vetted and agreed upon these were the ones we have for each division. You will see some of the breakdown here in terms of safety among you will see the measures the measuring at zuckerberg luca honda, both at home, primary care Bureau Health services, and this goes across all six of our true north areas. Similar, here, the true north workforce. Youll notice, you dont see financial metrics here but they actually do exist. When you look at the letter 83 for finance you actually do see metrics and targets on their. The reason they are not here is because of our most recent discussions with our team. They have decided that with the originally proposed is not adequate. They want to propose new measures and particularly, working with the divisions who had already propose their own measures. Now that we are doing this as a Network Level we find ourselves in a situation where weve actually had the chicken before the egg. As you know we had some divisions like zuckerberg actually been on this journey before we start our network so they only have their targets. So we are now since were focusing at the Network Level, are trying to set up a process where we can provide the direction at the Network Level and share that with the division and it may mean that some of the measures that they are doing will change in order to better inform what were doing at the Network Level. So, these are just some of the leaders who really have taken an active part in leading our process tragically with true north because, again, this is the to north is really our the heart of our improvement prostate so a special thanks to alice chang and sarah lynn, critically sarah, who put together this presentation and is also in our liaison to our corona consultant keeping us on track. So, with that i am happy to answer any questions you might have. Theres no Public Comment requested thank you. Commissioners, questions . Just so i can understand if im reading this. On page 7, the right information anytime anywhereby the way, thank you for keeping us updated on this and i am glad we had the opportunity to talk about your lien process. So, we are more i think basso in understanding some of this. I get the fact that he moved away from the Electronic Health record to this. It makes perfect sense because that can be an ongoing goal that might look a little different five years from now than now. But, this targets where you are now, it looks like this is going to be a accomplished by the firsti dont understand the green and blue. I guess thats the problem. So, the colors are meant to represent just the transitory nature of the progressive nature of the process. So, again, the oneshot line is where we are right now. So, youre talking about strategic number one, thats the dhr. Where we are right now, where it are actually in the negotiation discovery process with ucsf. By december, we should have a decision one way or the other as to actually weather will be able to enter into a contract with them and that will start the actual Implementation Phase december or january to understand this have to go to these other ones that actually have a specific target exactly and specific roles. And again, some of those youll find dhr once we consider that the most developed and the most complete. Is it has a 95 Completion Rate because that is again one of the ones we spent most of our time on. Whereas, some of the others like the finance again, stuff they needed to retool their targets. Its not as far along in the process. Wafers that it look like 95 of the whole shebang with that. Electronic [inaudible] 95 the planning exactly. Sorry. We wish. No. As the carpenters will say its only just begun. Yes, i just wish we would have not wished but in some of our discussion we had on the gcc both between thats a look in ondo and sfgh, i know there was some that cross my mind the last gcc meeting and that was the concept of quality of care and Patient Safety. There was something that flag falls and i said, yes it falls lets take a look at these did i know at laguna honda we been discussing etc. Etc. And here on page 11, you know, when we talk about the different north metrics and we see safety here as our lh age luca honda talk about reducing again falls for patients and that cross our radar at sfgh. Somehow, i asked the question later whatever. Anyway in never really wasnt very clear. But this is very helpful. As we take a look. As our colleague has at them i think there are some variables that will be floating across each of the subsets. As we try to increase or go to the 70 level. I think this is very helpful because the priorities and what were looking at in different weatherby sfgh or zuckerberg sfgh or laguna honda or the whole network it gives us a chance to take a look at at how in fact they may be crossing onto the scope and we can sort of address that based on some of the measured outcomes or plans of improvement or whenever. That weve done within a unit. So this is really really helpful. Pertaining to we take a look at our overall picture. Am i making sense of . Absolutely. I appreciate your saying that. Because one of the things we have discussions with our consultants at roanoke about their not accustomed to working with someone as unique as we are in terms of having this broader range of services across many different Service Lines in clinical areas. So, this is their best attempted to work with us to try to bring some awarded nation, integration particularly when it comes to our Strategic Planning and monitoring and reporting. Thank you. Very helpful. Thanks for the update. The question i have is how does this going to integrate into like the monthly gcc meetings princess . Like laguna honda take that as an example because i remember that when they do annual reports they talked about the number of like, residents like falls or injuries in a set goals like how many percent they want to improve on that. I think that is part of the reasons they get the fivestar. Fivestar, yes. So, are we going to expect that as well for whatever we said here that is going to be how we are going to receive updates in terms of the report . Very timely good i think was last weeks laguna honda gcc the Team Presented their lien plan and it actually shows the dashboard of these particular quality measures. So, the laguna honda gcc will receive that similar to the same at zuckerberg San Francisco general where they have begun to utilize the lien to north measures and their x matrix to do reporting to the jcc. Mr. Pickens is thinking that much for a wonderful presentation. I am interested in the true north. Im really glad were moving forward with getting the indicators compiled and agreed on at the micro level and i assume we will sum them up and will be looking at the macro level. My question is, really, how does the true north metrics either influence or positively or negatively, in terms of risk or gain, potential financial exposure . As we better integrate with higher quality, and certainly good patient care, but does it increase our value as a Accountable Care organization with brass higher medicare rating or are there other potential benefits to north other than we are the filling division we have . So, i will spot when you look at these categories safety, quality, care experience, workforce, financial stewardship, all of those are right in line with where particularly the government is going in terms of valuebased purchasing them a pay for performance. All of those elements of the true north are directly tied to the new reimbursement methodologies that are coming down. So, i see it very much being in accord with our ability to become more Accountable Care organization. If we are able to achieve the true north metrics, then i think well be well on our way to operating with these new alternative payment models that we are seeing. Related to the alternative payment models animal where of the medicare star system, is that relate to the whole Health Network both outpatient and the hospitals or is that just the hospital waiting and is there something that measures the whole system orhow are those buckets determined on a in terms of payment level of the medicare level . So, the new star rating that youve heard about is specifically just for zuckerberg San Francisco general acute care hospital. To my knowledge, just for people who were not so, cms now has a new ratings tool they are using. Similar to what had been used in longterm care is now being used for acute care facilities. They have released the first set of data and it shows hospitals and where they are 15 rating. One being the lowest and five being the highest. The report shows zuckerberg San Francisco general in first of four with one star out of five. Thats very gentle of all the Public Hospitals was late among Public Hospitals were five among Public Hospitals. So, that aside, with regards to Affordable Care act and stars, ratings, and are true north metrics as a system is all, what is the interaction between were what is the relationship between our two n. Metrics in any of the kinds of ratings we would have as a whole system . Its a combo mentoring. Commentary. There are hundreds of if not thousands of both clinical and operational indicators that we measure. Either on our own for our own fruition or required as part of our Regulatory Oversight and quality oversight. So, many of these are things that we already record onto various accrediting and quality organizations. But, some are once we feel are really important for our Patient Population as we include those. Im not sure youre getting on my question and im looking at will be resulting in more im trying to figure out what we should be watching and am wondering whether this year few more indicators on the true north report when we combine it. Elected to north indicators that i want to let you know that but as we talked about at San Francisco general for example, it would be nice to also track the stars, waiting and wondering as a Health Network we have is a similar kind of measure. It are Something Like our, you know move towards becoming a Accountable Care organizations in our overall medicare read spin rate. . Is there some oregano also go with us to north rating when you essentially reported out to us the one if im understanding your question is there a network wide benchmark we can use . Suggested in terms of value base [inaudible] to my knowledge there is no systemwide network could bench National Benchmark. Its usually done on service line specific areas like acutecare hospital longterm care hospitals. The rural health. I am not aware that any group has put together one that has four integrated through every system with a National Benchmark cms we coming up on medical rate on those different Service Lines so when i get to north when each of of those to optimize the medicare payment within each of those buckets. Is that what you are saying . Yes. Does that make sense . I think there are some plans that are also ranked in that plans, yes. As we go into having the discussion of our plans for to actually have a plan that this will the metrics will become more apparent because theres a set of those from cms. I also know in Accountable Care model theyre looking at how well for example integrate your behavioral homes and how the vehicle homes are connected to the medical clinic, connected to another hospital. That creates your ac oh system but i dont understand the Payment System how does the quality of your ac oh system reflect in terms of medicares positive rating of terms of giving us more money for the quality of service in terms of the valuebased option. I think that would be something that be worth exploring in the future. Yes. It would be nice to have that as retract those medicare reimbursement rates as part of the true north so we can see the quality part and then the Financial Impact sidebyside. Even in terms of stars or whatever measure thats being used. Through the chair, if i can followup. I just want to make just a brief statement pertaining to this new quote, ranking, quote unquote that has caused some discussion and already the association of american oncologists and also the association of hospitals has shot one or two across the bow here already saying when the cms came out with the original subsets of how we are going to take a look at certain patterns, variables, of care, whether be from all servers to remember it was like five pages long than with 24 pages long than three pages long and now it is the most onepage. What they are saying is, this is the first profile and we really needthey really need to love and meet and a task force to discuss the unique uniqueness of the patients, the institutions see a specific area, the type of institution, and when in fact resources they have in order to serve populations, and then the measured outcomes based on the number of other variables that will be discussed which were part of the institute of medicine now called the National Academy of medicine. So what we are saying is this was like the first here we are and dont take it as a bottom could of course, the next day to other major groups came out with their rankings of quote, hospitals. Whether whatever paper you read whether be the chronicle to the new york times, to the journal of whatever you see fullpage ads. We arrange here. We arrange here. We arranged there. The bottom line is, each area is been a very unique and we have to take a look at where we are, when was the Data Collected and more importantly, what has been done from point a in order to is sure we are providing the highest level of quality care given our new configuration of what the missions are of hospitals today, especially those that are teaching hospitals. We have graduate medical education and residency programs in nursing programs, pharmacy, etc. Etc. So all these things are in the store again and really i would not use any these quote, benchmark saying wow, lets wait and see. Because is critical while before it shakes down in him sure will come in with some excellent qualitative measures on how we take a look at hospitals and service to populations in the area and im sort of throwing this out because i know theres already been scuttlebutt forget it. Lets be patient you. With thicker look at it. The content and comments. Thank you. Did you i was can respond. So, thank you for sharing your perspective. I think that you thoughts on that. First, as you probably know both the American Hospital association, american of hospitals and the is those issue of medical colleges and universities all have raised concerns you just raised. Having said that, also, in my 25 year expensive healthcare executive, i know there are many variables that contribute particularly for new rating systems. What we have typically found over the years when a new system gets introduced those players that have more robust data systems, Electronic Health records of the past 10 years, data mining, data in a latex am tend to score better. We have that experience battaglia zuckerberg San Francisco general. Many years ago were quality scores were not as good as they are today, but it required us to do a lot of work in terms of cleaning up our data systems, putting in Additional Data scrubs and making sure were coding a properly documenting appropriately. To make sure that we were getting credit for the good work we were actually doing. So, i think its an opportunity. It gives us a starting point and one star where no one wants to be and no one wants to stay. We will do everything we can to make sure that we go up in that rating. Thank you for that. I mean in the knowledge meant of the importance of that. Because i think we all as a group have a lot of work to do. None of us are satisfied with that but i think if we step way back in the narrative of healthcare, what is going on and we talked about it before. It will lead into a couple questions i have. Is that, the federal government is genuinely trying to figure out how to control a crisis in healthcare spending and concerned about the quality and care delivered. Thats where valuebased pricing, valuebased purchasing and pricing and all that comes from. It is legal and i think we ought to assume its coming like an incredible freight train. We have seen it in the gcc in reports at San Francisco general zuckerberg q3 and the fines were getting i mean not sorting quality benchmarks and for sure as you suggested their tweaking them to make them fairer and to understand the implications and to really incense behavior that we all would like. But we they are real and theyre going to get bigger. The consequence of that is that the amount of funds flowing to performing hospitals will go on and allow them to invest in better systems and better data. So that they continue continue to perform and the one star places will get less funding and it will become a have and have not system. That is kind of what is out there and coming in i applaud you guys for keeping your eye on that. Because, to ignore it as at our peril and much deeper in this book you see how the amount of general fund increases dramatically over the next 10 years at current growth rates. That would be a vast underestimate if we cannot get to better scores. The consequence of that is we wont be able to do as much as we would all like for our population. So, that leads to a couple of questions. The first is, what are your concerns and our ability to improve . Like, what are the things, you know, we should be aware of and say these are barriers to us being successful in this . That if you are us, you would come back to repeatedly in our discussions . I would say number 1 2 we have the infrastructure to be successful. I would urge you to continually to ask us, do we have the resources that we need to produce the results we want and how are we using the resources that we have. I think that is something we have particularly over the last 23 years have taken very seriously. Because we all as Leaders Within the department recognize that our biggest priority was to get a new Electronic Health record, we all exercised extreme judicious fiscal restraint would last two years in terms of making sure that any new requests were ones that were going to either support the Electronic Health record or support our ability to be good financial stewards. Either revenue capture or expense reduction. So, again, i think with all the pressures particularly the extra pressures were getting in terms of moves towards valuebased purchasing, Accountable Care organizations, plus, the internal pressure in terms of decreasing our growth in the city general funds, is making us all more aware of the decisions we make that they have to be ones that propel us to being as financially sound as we can so that we can, again, continue to do as much of the good work are currently doing. Thanks. Another observation which i think is worth thinking about, which is, you guys live and breathe this wonderful lean philosophy and approach. Its really taken off and you and your team deserve great credit for it. Those of us up here have an instinct about it because you been educating us and some of the language, but we are not versed in the vernacular in any way. Then, you take who we are responsible to and this sounds like a foreign language. So, one of the challenges, i think, unfortunately, numbers help with that, is to really try and distill down, not just the process, but lets shine a light on what are the results . How are we doing against that . Entered is still much the thousands of things, which are required within the organization because of the complexity, but really come back to us with here are the 10 things that really capture and integrate all the other great things that are going on in these are the things which we ought to come back to frequently to know how we are doing on our journey to get us to a place where we can genuinely say, we are delivering the kind of care we are proud of. So, because its a challenge good when you come to this intermittently to really have a sense of, well, how are we doing . I appreciate your statement and i feel the same way having gone through this lean journey. I think we can get there, these two n. Measures, i think, are the more concise measurements that we will definitely either we will be bringing to you about 56 or 57 of them but we think the top five, 10, or 15 of those to determine which onesyou are going to see ongoing reports for all 56 of those measures within the true north and thats been the measurement to determine whether not we need are 70 go. We will figure out as a team what are the most important. When we start seeing those numbers against objectives . So youre already seen them get zuckerberg San Francisco general is already reporting others could they were the first ones to lead in laguna honda adjustable bears out. At our last jc. You will begin to see them there. But those parts of the network that dont have a gcc you will begin to hear them either to the reports they give at the Community Program committee or when i come to hear good when i come here i willwhen this thing is finally i could find today and were getting all the support topic presenting them here. So my request would be when you present them, if you could highlight those which represent significant indicators that would improve our valuebased services. So, which are the ones tied to us either bringing in more money or having money at risk because those are the ones that i think i would want to make sure we really hit particularly if the within reach and as working out one to prioritize all these allwe want them all but some will bring in more money. Some will improve another system thinking im kind of interested because of our aco environment rainout in the specific question of linking these performance outcomes to various either cms medicare stars or whatever financial drivers is i think that is mr. Singer is aimed the future of the game. A little asterix. Watch this one. Then commissioners thank you for the great feedback for network director. Also, i think as we have our planning process i know our cfo in the audience listening to the kinds of questions youre asking about finance. So we may be able to catch touch upon that when we do that conversation. In october. Well done. Should we move on commissioners . Sounds good. Thank you. Look forward to our next meeting. They do commissioners. Item 9 is the Health Impact assessment Single Room Occupancy Hotels in San Francisco. Theres a resolution doubly introduced today. Will not act on this until the Committee Meeting on september 6. I just note today is just discussion. Welcome. Cindy, thank you for presenting. It would be good to take a step back for a minute with a commissioners just to talk about assessments and the kind of assessment to do for that. Sure. I think everyone can everyone hear me okay . I have a little bit of a background in the report in all meant that if thats okay . Ingrates. Good evening commissioners. My name is Cindy Comerford and i will work in the office of policy and planning. Also direct our Health Impact Assessment Program. As you may know, we been an integral part of low Income Housing in San Francisco. Although tenants of as of those vintage bombs for a long time out rising rents affordability issues with building repairs increasing homelessness, and also spiraling drug epidemic, has caused a lot of issues with sro operators on sro tenants. We started this project in late 2013 at Health Commission about a year and a half ago i came and gave an update and here to today to present our final report. This is the draft of our Health Impact assessment did so today im here for three things to give you a status on the final reports. To get feedback and comments on the project and also to get feedback on our proposed resolution that we are hoping to get for our meeting in september thats going to be in the community at the tenderloin where there is a very high density of sros pacing problems today. Celebrate background on Health Impact assessment. What is a Health Impact assessment . Is also known as and hia and why did we do one on sro. They held Impact Assessment houses about what the potential Health Impacts in a policy plan or program before its built were implemented. As many of you know, the health of women has a very unique role in sros. When we started this project we were one of the only cost of funds in the us that housing program. We used sro rooms to place Homeless People off the street who are hot program. We put patients leaving our hospitals in sro rooms and we also have people grabbing Homeless People enrolled in care they go into sros. In addition, and other Mental Health branch we also have a Code Enforcement then inspects sros for Code Enforcement and habitability. So over the last three years the entire Mental Health branch was talking about ways to convene stakeholders to mitigate disease and issues with tenants. Disease and injuries and as i was good at the same time the whole commission started talking about Food Security in sros. So we came together and presented some of the work that weve been doing. We realized, because of the complicating factors about expanding Food Security within sros that included building conditions, Vector Control and supportive services, we were kind of take these two processes into different directions. So the San Francisco Food Security task force did a very specific survey of residents of sros around food access and we decided to take a very broad approach. Just looking at all the different policies that can really improve the health of tenants. Our goal of this project was to achieve Better Health for sro residents through public policy. So thats and what brought us here today. I am going to briefly talk about our process and outcomes are hia. Again, this project officially started in september of 2013. When the commission of commission, passed a resolution asking dph to do Health Impact assessment to see what can improve the health of tenants of sros. Typically, but not always, when we have and hia we usually start off with a policy proposal or program that were going to evaluate. In this case, we do is no discrete policy were target propose. So we went to a very extensive exploratory outreach process to determine which policies would benefit from the most from an examination from and hia. Upon section of this project, we reviewed a lot of material that was already in existence from hsa, different nonprofits that i published report and the health department. Many other parts of the that were barely old. So we were able to get a better sense of People Living in sros in the landscape for baseline conditions. Just to provide you with a little bit of background, on sros, the majority of sros in San Francisco were constructed right after the 1906 earthquake. The highest density of sros are located in the 94102 zip code which is the tenderloin and civic center and the second highest density is in the chinatown mob until area. The number of San Francisco residents that live in sros are somewhere between 18,00019,000 group weve approximately 580 sro buildings within San Francisco. 50 of these received public funding through the city and the remainder are privately owned. The publicly funded buildings account for about 24 of the citys inventory of sros. The mean age of the residence of sros are 55 to about 6575 of people of color who live there. In 2008 when youre citing percentages are you sending buildings or percentage of residents [inaudible] blastocyst is examined to with the percentage of residents. How many residents and other sros in total and how many sros total . The number residents we dont have an exact number between 18 and 19,000 residents. Theres 580 buildings but the number of units is probably around you know it should not match technically the number of residents. Their single occupancy but we know that unfortunately, in areas such as chinatown the mission, we know we have families living there. Which kind of leads me to my next statistic. When we matched when the School District matched the addresses of students we knew there was about 1000 students living in sros. Also s [inaudible] is a Planning Department has a very distinct size of an sro. To qualify as a kgb biggeri dont remember but im glad to just an educated guess would be like a 10 x 10 room. [inaudible] it varies so much. There are some sros is like Tourist Hotels built six sro rooms in this entire buildings that will have to item 3 probably 200 would be the highest good to expand. Stanton also into 08 when hsa generally report we matched the addresses from our Substance Abuse treatment clinics that matched about 3500 addresses. From People Living in sros. Also, at that time, the cost to our Emergency Medical Services again this back in 2008 was 2. 15 million. Backup gives you a little bit of background about corn on in sros. Also, in a location within a fourth of a mile about 67 of our alcohol outlets are located. 70 or pedestrian vehicle injuries take place in also about 60 of our crime happens within the fourth of a mile. Its very harsh conditions in which these people are living. After we concluded our luminary baseline condition analysis, we did 22 key stakeholder interviews that with people of dph, other city agencies, nonprofits, sro tenant advocacy collaborators and also people who are privately within sros. Produce this kind of luminary report which is the appendix of our final report the kind of came out with five main themes that we saw. Which were really around building conditions, supportive services, housing fix, real estate pressure, and about healthy eating. Interview such a Broad Spectrum of stakeholders really enabled us to first better understand the common trends and policies that could benefit the health of residents in sros and also more efficiently lead and train sessions and research in scoping. Like i said, this final report is included in the appendix are hia. After we completed those 22 stakeholder key stakeholder interviews, we convened three advisory groups. One Advisor Group was made of of dph second one was made up of nonprofits and then i last one was made up of city agencies. This represented about 30 different city agencies and nonprofits that help this really identify key issues. What we do with these advisory groups is we asked them specifically what types of projects or plans or policies would most improve the tenants of sros. So from these advisory groups we ended up with over, i would say, 35, 40 different policy proposals that we could use for Health Impact assessment. So what we did is we took all of the policy proposals and we used a screening tool to score them. And rank them. We use the screening criteria that had used a matrix that was a screening criteria than 30 different criteria that we link to each policy proposal or program that was suggested. The first criterion always was, with the clear open decisionmaking process for this policy . Then we look at defending such as timing the resources, feasibility, whether cohealth benefits. Basically we had since we could not put this on a slide, we took each policy when a cross and we score them. We ended up doing is we came up with so many terrific oppose policies and projects and in our report we kind of documented the top 15 but what we decided we only will he were able to go through and look at a couple of them in the Health Impact assessment. So, last time i presented this was kind of where i left off. So we had yet to select the policy. Based on our Stakeholder Input and screening criteria, and what we thought was feasible, we came up with the three somewhat related policies to examine that one was a ordinance amending the San Francisco of code that would define sro and either require an sro operator education on compliance with Health Housing and fire codes as a condition for certification of sanitation. Basically, each year not sros, but Tourist Hotels have to do that compliance or certification. This would be kind of expanding this the criteria for this including sros in the which training would have to take place. The second would be a ordinance amending the San Francisco administrative code to require sro data on structural element of the building as part of the sro annual unit usage report. Sros rre required to do annual report with nato how many rooms they have, the average price of a room, but it would be helpful if we are able to collect more information to other rooms 88 accessible . To their microwaves . To that refrigerators . Is we can do Better Placement in sros. I last policy and want to look at was having dph engagement in data system with bdi. In addition to the health department, doing inspections of sros, theres two other departments. The department of Building Inspections and Fire Departments get three different data systems that dont talk to each other and we really thought that we could benefit not only the buildings operators and tenants by having increased compatibility in coordination. So, after we selected those three policies, we moved onto the scoping stage of the Health Impact assessment. The scoping establishes the foundation which Health Impact assessment is conducted. Its really about the designing and planning phase of hias. During the scoping phase the team kind of identified the key issues that need to be examined within the hia. The different populations going to be affected and the methods that we would use to do that. So we try to again engage stakeholders in this step. Two meetings were held to one was back in dph which included multiple representatives from the environment so health branch, housing and homeless services, and we had another meeting with the City Administrators Office department of environment and also why firms that represented a lot of tenants from sros. Due to the time constraints we had each content of either one would focus on sro operator training the other group focus on the Data Analytics and kind of the main goal of this meeting was to draft scoping diagram. Which is shown in this slide. We can look at the Health Outcomes that would focus hia on. So, if you look at the scoping diagram, it kind of breaks down this is just specifically for the operator education as an exampleit takes down the proposed policies and walks you through primary secondary and tertiary effects that would come to the house comes of trying to change or augment improve those types of policy i mentioned to slide to go. After completing the scoping phase we go into the assessments phase phase. This is the meat of the report where most of the analytics and analysis take place. This is where we look at the policy proposals and see if they would improve from the Health Impact from the scoping diagram i just showed. We are not really examining the specific Health Impact that what we are doing is kind of linking the mediating a fax to the Health Impacts. So we deployed mixed method approach which included Data Analysis empirical evidence from literature, focus groups and expert opinion. Next month going to discuss a couple of the outcomes from our assessment. We did a more Detailed Analysis on the baseline conditions. In the beginning of this presentation i mentioned the sro on average are a lot older than the building stock in San Francisco. So, the mean age of an sro was built in 1909 compared to the rest of the Housing Stock in San Francisco which was eating age was 1927. Again, the majority of sros, 80 of them are located within six zip codes. These codes often, the tenderloin, bob hill, south of market, patient, chinatown, north beach and russian hill. A large portion of analysis we did focus on Code Enforcement in sros. As you stop our policy proposals but dumbly focused on Code Enforcement so we look at a lot of stuff around the buildings and how better use of enforcement data can hope the city make better decisions. The most most of the violations in all zip codes had about between 05 violations issued between 2008 and 2012. Its very common for sros the violation issues. The higher zip codes which were in the titling and south of market at the highest proportion of violations receiving over 20 violations during the fiveyear period. The most common types of violations that the sros were cited for was around animals and pets. Things like that bugs , mold, refuge which is garbage, defendants of sanitation issues and also structural conditions. This map here that is shown, the larger circles kind of show the density of violations of the sros. Next, we look at the Neighborhood Health status and the specific Health Outcomes of sro residents cannot be measured directly so therefore, the sro health was assessed by calculating hospitalization and er room emission rates for the six zip codes that contain the majority of the sro rooms. Hospitalizations and er admission rates in those of codes that contain the majority of sros, show in visual art being treated at a higher rate than many of the same house outcomes associated with most common violation types i just mentioned so this includes adult asthma hospital hospitalization rate which were nearly twice the city average. Copd rates three times the city average. Er admission rates for falls which were 23 times the city average and also er admission rates for selfinflicted injuries were 34 times the city average. The zip codes which in the tenderloin experience but the highest rates of hospital hospitalizations as well as violations. While the same hospitalizations may not be all attributable to housing conditions, they do indicate the resident population in those neighborhoods may be particularly vulnerable to the impacts in the sros. We also met with the chief medical Examiners Office and they gave us data from 20142015 and we saw in 2014 35 41, 85 , of the accidental deaths that were investigated were from drug overdoses. In 25, that agrees to 95 . One of the concerns of the medical Examiners Office was these people were social isolation that these people were dying alone in their rooms. So, based on the Neighborhood Health status and the design conditions kind of supports that evidence that residents living in sros have numerous one ability factors which i just mentioned. The lower income, people of color, older age, as well as Living Conditions and buildings and communities with more concentrated environmental and behavioral we specters. That really contribute to adverse Health Outcomes. The combination of the demographic and environmental vulnerabilities we know judy to fourth Health Outcomes. Also increase hospitalization rates. We really feel like they could benefit from targeted policy changes to protect and promote the health of residents. So, last part of our assessment is we actually met with sro operators. We did some targeted focus groups to evaluate the effectiveness of an sro operator training. These were an efficient way to understand from the various operators to test their knowledge, their attitudes and behaviors associated with sro conditions and tenant policy. The groups were able to identify best practices, challenges, and really help us suggest potential policies. These focus groups were also augmented by a couple of other key stakeholder findings where we needed additional information. But the focus groups revealed was that actually sro operators have adequate knowledge of the housing codes. So, it was unlikely that having a training that just focused on housing codes would improve the health of sro residents. The participants did speak about their fragmentation of the Health Housing and fire codes and they really expressed the need for more centralized information and a better understanding of each agencys role. Dsl operators did really lack knowledge and practice of how to work with tenants and housing issues that resulted in tenant behavior such as hoarding and bed bugs they were not really aware how primary Health Outcomes are poor Housing Quality work related. So such as asthma or allergies were fires or burns. Mental health was also seen as a Significant Health problem as well as the aging population and associated health issues, and drugs and alcohol. There was a consensus is the nature maddock increase in Mental Health issues over the last five years and that the notion of extreme tenants one tenant kind of causes most of the problems for sros. This was a big problem for the operators. So, next i want to the Assessment Part i forget next look at the data analytic part of our assessment and this was specifically just on by looking at case studies looking at our existing conditions and expert opinion. In case studies and existing literature on kind of open data strategies dont really demonstrate they have a direct impact on health. But these types of situations can lend themselves to increasing efficiency and Public Health operations, improve data quality, timeliness, usefulness improving data access also promote transparency to government agencies. Also, case studies demonstrated that didnt alone dont lead to a vast improvement whether interagency working groups informed to continue quality women coupled with Data Analytics and strong leadership are the approach that works best. So, based on this the outcomes for analysis we came up with five different recommendations and other Health Impact assessment. So the first was a mandatory training for sro operators that focused on successfully working with vs road tenant population. Increasing their knowledge of Health Outcomes in understanding the role of city agencies and management best practices. Sro operators really need to have the knowhow skill and tools to address problems that they are facing. Without adequate knowledge sro operators may not be confident enough to act to resolve the issues of that theyre having. In Research Really indicates mandatory training for much more successful and have in the past shown a reduction in violations. The second recommendation is the creation of a culturally competent and consolidated education materials for sro operators. That would serve as a onestop guide for them. Given the diversity of operators roles and responsibilities this onestop guide would touch upon code compliance, city Agency Information attendant support. For example, how to get in touch with Adult Services or something where they can go to one piece of information to quickly answer questions instead of typically they would ride on relationships they build with inspectors and they do not have anyone to handle the problems they have. The last three recommendations kind of our focused on the data analytic part. One, that the recommendation was to standardize and automatically push housing data including their collection of sro facility activities. As i mentioned before, theres no consolidated wait to find inspections and violations of housing let alone sros in San Francisco. Dbi nl department kind of have it separately on their respective websites. So, we think kind of consolidating this kind of data publication could improve in the visibility of activities in the housing inspection programs and then the kind of users of this would be the departments of health, Public Developers Property Management and also tenant advocates. The fourth recommendation is to include Data Analytics into our Business Operations we feel like performing analysis on this data will improve the inspection process and our internal business processes. Right now, were we can kind of measure violation detection rates abatement rates, and abatement fees, this way the department can better understand the capacity by reviewing this information and frequencies and adages and can help understand where the resources need to be targeted. The last recommendation is to create an interagency data housing data subcommittee to establish and track these metrics. Expanding the coordination between the Housing Inspection Department to facilitate the department to share best practices and observe whether activities overlap and improved enforcement and coordination of different pieces. Currently like i said theres not a form to kind of discuss these housing processes. Those are the five recommendations that were resulted from our Health Impact assessment. This was our fourth presentation formal presentation of this report. Our goal is to spend the next month presenting it to our different stakeholders and getting feedback on the report and the recommendations. Kind of our next steps is again, getting feedback from stakeholders on a recommendations. We want to finalize the report we need to get a little more information about the medical examiner on kind of the some of the best data were going to integrate into the final report and we want to communicate the findings and we are working on evaluating options for implementation and funding. For the sro. So that concludes my presentation. I am happy to take any questions you might have. Commissioners were getting ready to go into the coming meetings and one of the reasons want to focus on this is that because you may hear a lot about this in our meeting as well could also, can you keep close to the issue of drug abuse drug overdoses in a Mental Health issue and recommendations would come from it because thats an area i did not see heather recommendation, two. Yes. Thank you for the presentation. So, having been somebody who worked in sros in this data is not a surprise. Unfortunately, i think its kind of disheartening to hear the conditions since the days of hiv epidemic and the findings we find at the [inaudible] hotel have not changed that much. So, my first question is like, when it you were conducting these interviews and assessments, were there any sros that actually stood out . Lake the model as like the model as a row that others should follow best practices . Thats a great question. There wasnt a specifically and as i wrote that stood out with were best practices and promising practices that stood out. They did report like you remember all of them offhand but they did give some examples. The one example was around composting and recycling. How they were really able to successfully implement that within their programs they had a lot of support from that apartment of environment can they be training they gave finds. It was and they were saying how they successfully did that and change that. I know thats not reallyit does actually affect the tenant house and behavior. There was one example they gave as a best practices of making changes. I still have a few more questions. Another question i have is are these all as those call themselves hotels because i still think that is kind of in irony because hotel is not meant to be a permanent residence . So, the terminology for sros of berries. Where we are actually working with the planning diamond ring out to make sure we all have a standardized definition. Some people as arose. Then its residential hotels. Theres all these varying names but yes, i think this is one name that is common, may refer to and they still have different rules and regulations in terms of how long they can stay in one room for some of them they dont but after 30 days a residence that lives in and sro gets to be attendance. So, basically what happens is a lot of the sro operators, not a lot but some of the ones they tried to do some occult musical rooms where they try to shuffle them from room to room so they never get tenant rates. So, thats like, how does that affect stability affect their wellbeing . Im curious about that. Theres a lot of that happening as well. Right. That is something that im in the building inspection and there is an sro task force that is been working on that issue specifically. We didnt ask a lot of questions but im sure the unstable instability of having to move creates a lot of stress in the tenants alike. That is something that that is been an ongoing problem for a long time ago that the city has been trying to resolve that in making sure that does not happen to tenants. So we did try within this as a look at things that were policies that were in the jurisdiction of valve department. But, like you said there so many other problems we were not able to really touch upon. Yes. I get that sense im getting it so complex that we really need to really completely liked what is within our purview and what are some of the other issues that we really needed to invite partners to like, San Francisco family to really look into. So, i appreciate the report. I know that you also mentioned about pasts and what with the responsibility for the sro operators when there is like an infestation happening . Like these rooms are in such close proximity the one once it starts its like wildfire. Dsl operator to abate any of the past problems. Different issues arise from tenant behavior that sometimes make it difficult. Is as part of this transfer example recording the were people very reluctant to let people into the rooms or dont want to move or just very scared. So these are types of issues that we want to help people with so they can better resolve the past issue. The specific like test integrated management, we know how to do. Theres best practices out there. But a lot of times the problems with the tenants prolong the issue were not able to access one of the things we did do commissioners to we added a social worker to our environment a hulking two connected to our Mental Health system so when they do find some one thats worrying or an issue of Mental Health status post that connected work with them. Part of the Behavioral Health system. So they are able to bring more service to that individual and try to engage vertically around porting that could end up in being an addiction to so they work towards that. Saliva controversial question did because 50 of them are like city run at sorrows. The city gets funding two. Other comparisons to see the difference between those and those that are not supported by anything money . Thats a great question i know were looking at defining as osgood when our environment or Health Database were making sure with all the as is properly defined and were going to add those different ones in which one received city funding, which ones are supportive housing. So, in the future we can do those types of comparisons and maybe develop more targeted programming. Thank you. Its an excellent report. I think especially the of the different agencies coronation of the different agencies and how youre proceeding in the whole history that is really really well done. The only thought i would throw out is sometimes whether the sro the sylvie or the owners or the manager, etc. , when there are certain things happening in this is true for a lot of seniors who are living in their homes were here in the city by themselves, and a problem happens like something dealing with the facts or issues, bed bugs, etc. Etc. , were electrical problems, etc. , were donal required pertaining to earthquake proofing at some point of homes, rooms etc. , but this city before especially we should provide a list of prevention or who would be good responders to help the situation . I mean, as an example, if your sidewalk was broken in front of their you get cited weatherby a hotel, home, and center at such a apartment and the city would list those companies that are then certified by the city and list the cost what it would be to fix like a flag like 125. Im using this because others will call, not seeing a list of knowing theres a list even available, and they may be charged 350 for a flag were to inspect that they will inspect call up someone from here and theres no list of saying who has worked with the agencys programs before who could be considered. The whole list. The same thing pertaining to theres a lot of concern about earthquakes and how do you find a good Structural Engineer or have you find whatever. All the focus is on the big apartment but it can be happening in the smaller ones, went out. So as we move towards this, i think if there could be a list like you that upon the public by dbi, whatever in i know theres been calls. I then asked my call them and find out if theres somebody who could come to work on the old the taurean house where they have some sick kids and elderly people and theres no list. Typical berkeley the school of architecture, whenever . As a discussions i think it might view helpful. So instead of getting the multi language information to owners of the sros and other agencies, perhaps that could also be like a consumer list certified like we do with our inspections food, etc. Because these are clinical pertaining to the house. If youre still if your stove goes wrong if your water is leaking, whos on the list saying that, they have worked under good rankings or they could call them and the list of whether there multiyou know what im saying. Yes, i do thats enough but it would be helpful both for the outcome of tenants living there were the families were the seniors who are living by themselves and their phrase to get anything fixed because theyre afraid they might be ripped off by some of the good its a real wheel problem. I think. A challenge. Absolutely. I cannot agree with you more and i know from last year on mold issues trying to put together a list of reputable contractors, we dont really have one. So, thats a really great suggestion. I think it something we should try to incorporate into summer Art Materials to help the sro operators make quicker and better decisions to fix their buildings. Thank you. Excellent report. Thank you. Thank you for this. For me, it is very always here when we first started talking about this issue and had this and decided this was something we needed more data around in this Needs Assessment needed to really take place. I remember thinking when we go tell those people to stop clean up those places and some is very straightforward certainly we can fix all the as are all operators and this is the rule and ill get penalized and will you been able to showcase this is not just about the rules. This is collective impact and it is harnessing the power of several different units in the city. I think that i very much like the idea of providing resources, addition to the resource my colleague just said but i think we need window for the residents. Once copies of information for them in different languages and who to call and what to do and those kinds of things. Maybe there already is Something Like that for them . But, it seems that would be the counterpart. As well as the same kind of those who want to come, educational classes about what is occupancy versus tennessee . How can you prevent that . What about those in place the really, some proactive just like because i think its a great idea to do it for thebecause the fact of the matter is, we do need to make some assumptions that people didnt want to live better and the managers do want to live better they want to collect if we do this that it anyway we can do that on all for that. I think this was cool. So thank you very much we do have and as a group that come together to advocate residence, get the place to think about doing that. You probably are several collaboratives provided resources. I think recently pdf had a special on sros and a lot of people that live there are immigrants populations are there not familiar with the laws. The teacher they know them and multiple languages i think is important. Notches giving it to them once. My own house i lose things and i dont know if it will is like. Going back i think theres a lot of people that are not part of theyou know, theyre not they need to have access to that so maybe there needs to be just a further push to continually provide material to the residence. Thank you. First of all i like i love this ecological approach. I think this is what the Council Endowment has talking about in terms of Healthy Communities and building our communities for a long time and youre focusing on our highrisk groups communities inasmuch is the as arrows represent blocks of our communities. I just really important. I love the heat map that you have. I love the scoping the which i think is a wonderful logic model that youve created. It will be clearly identifies us as primary prevention that youre targeting. I like the analysis you did in terms of how you went by methodically choose the legislation regulations guzzle was evolving questions i was hoping to ask of you considered kane changes various regulations and things and you really looked at that. So, because of that, i just want to make sure that you are going to be able to sustain this effort. This is again as mr. Karshmer talked about a collective impact which we know takes time. What kind of measures do you have for the sustainability of this project . Perhaps everyone jumped on board and agrees to sign this and i have one other comments after that so, my hope is that eventually as part of this project would get legislated. It would be institutionalized within the mandatory training. It would be something that operators would have to do every year but i do agree with you. And other commissioners. Something we just get you once did get to do it over and over again. I think its really important also since a lot of these proposals are new and have not been tested, that we have to create a very strong evaluation and Monitoring System whenever we put in place and make sure that we incorporate this in our funding in our workforce that we put towards that. I think thats one of the key tenants of the Health Impact assessment is that you continually evaluate and monitor the results. So i think that something were committed to doing. I hope you and dr. Percy will look to sustainability funds because you are for this month, my newest favorite dph initiative. [laughing] this month you are my. Letters from members of the resolution and if theres something also in that resolution if you like to add to that that is how we also will make sure it continues to be a priority with regard to that, i might ask that there be consideration for the next draft of continuation of funds or at least follow the next steps. I think you are reallythe program really entails following the primary prevention aspects of primary effect to secondary effects to you media fax it does the planning process i think will continue and that is that. The issue is the recommendation from this assessment because this has many different types of assessments that cindy has been involved in an these recognitions aware you could also in that resolution at a recommendation if you like. But the process, i believe, is already structured for it to continue. The recommendations you might want to look at. You can add that as a recommendation as well to insure the stability of the Health Impact assessment process. That could be added as well. But that is what cindy does it very well ill defer to you and staff whether you think that as anything. That was certainly my intent is to ask the staff is not to be a onetime report that goes on a shelf and we have continued efforts to focus on improvement. These 20,000 of our citizens that actually have Chronic Health problems in very large burden on her Health Network. The second thing id like to ask is that at the level of prevention, at least where we look at regulation and perhaps fines and inspections, it seems to me the crux of it it really is based on voluntary participation it i can go to a train but whether i do the work or not is going to be based on my market incentive as a landlord to wanting to improve my building was whether i help my landlord by giving them the right information as a tenant that is approves improves my eventual living condition. So that that somewhere in this meaning this is a fixed an issue that we may be the left problem focused to look at the ways in which this initiative can increase housing value both for the tenant and the landlords. In a way that at the end of this, there is an effort as a component to improve the housing for everyone by the limits get a better Building Work more tenants that take care and respect the property better which is great and then the tenants get the timely service. My understanding is we have an apartment when tenants paint the building achieves the water heater and dont do the rugs from those make for great incentives and the landlords that allow that make great landlords. Some way, guinness part of collective impact, we could find this not so much as prevention and problem solving but actually help promotion and genesis on a Community Level that would be something i do see might add value as a fixed resolution. We want Healthy Communities and not only tenderloin but throughout our sro system and in all the ways that we define health. Thank you. I do have another question it when we talk about azzarello operators are not necessarily the owners of the buildings correct. We did meet with owners that are focused by spoke about with specifically with operators could be but a twoday engagement with the tenants and also responsibility for fixing the operational issues. So, thats the question i have is what is the relationship between those sro owners and the as earl operators . I understand the recommendation itself about the training and get them more like knowledgeable about all the issues were resource for tenants, quote what is [inaudible] . To go back to the question is not one typology. Some of the sro owners have their families working to some other times theyre both the same people. Its all over the place. There we could put a lot of time and effort when we were looking at who do we take our time speaking to a focus on people who we thought would have the most influence. Going back to the second, the training would be a mandatory training in order to get a certificate of dedication aged to continue in operation without larger fines. So, that is what i suspected. The second question i have is with the time how do i state markets in San Francisco rainout with that actually put tenants at risk . Like these owners would be decide to get out of the business . They can. In 198584 the San Francisco past eight rental sustainability ordinance where people who own sros cannot close down these housing sites. So, its good and bad. Unfortunately, its good because it maintains the Housing Stock. Its bad because a lot of them dont want to own these buildings they do want to invest in it. John what we are doing is other things were trying to deny me personallyother things the city has all our time to look at how we incentivize Capital Improvements in these types of buildings. So what our goal here is never to have anyone either could work the homeless that promoter style that helps you need give a voluntary system here and you need to really look at how youre going to develop those voluntary incentives i think as part of this the plan. First of all, [inaudible] it has a very large impact on [inaudible]. I would like to also follow up on commissioner patings suggestion that include to ask you guys to take a look at some language that ensures the Resources Available to continue the momentum. Because as we take this as a compliment. The study is a good thing but what we really want to do is now take what weve learned and change [inaudible]. You need resources to do that. Anyone here that . I just had to requests and that was it. Then we can im mindful of the clock. The one is, i would really i think would be great to actually see the real data comparing the performance of vs arose, which receive city funding or are any other sros. As controversial as that data might be, i think it would be good to see it in the near future. The second is to ask you to come back a year from now until is how its going. So, the comparable data probably in about im going to say about two months. I can put together some information to give to mark to give to see you can understand the differences and of course i be happy to come back in a you. Great i also just want to not only pursue work on this report died too quickly just like my colleagues worked on it with me. Megan walsh, she was a senior epidemiologist. Max s on Health Impact assessment coordinator that was with me. Devin was prison made all the beautiful mass in the report. Megan went, kristin rivera, page crews and also apologize. Into the Population Health division is that correct . I woken up and im still hoping to network with to the office of policy and planning in market Health Impact Assessment Program is now under the office of policy and plan but we still collaborate with a Population Health division the present purpose of that commissioners to make sure we connected the policy to the research. Please, send our congratulations to your colleagues. We get the full report was not done that is that correct . Michael b to give you a copy of the full report between september 6 tenderloin commission should also have not onsite mark disputed that to you. So you can have it in advance of that commission and i look forward to coming back to present the final resolution. Commissioners whom i will note that if you have any additional comments about the resolution. With taken into consideration in your requested a changeling was again back you to consider small improvement grants some of these operators to move beyond their threshold and making those commitments that . There were several policy proposals that focus on that. The puc and department of environment are looking at grants specifically on Energy Efficiency that can help improve the building great. The next item commissioners is other business. Surely if you have any other business . Okay. We can move to item 11 joined comments Committee Report on commissioner pating check the july 26 jcc meeting which i want to thank you for. Was my honor to chair the joint commission joint conference committee. The Committee Heard the regulatory of air Quality Council report the rebuild transition update the Hospital Administrator report and Patient Services reports. Hr report and medical staff report. The were no mockable new findings and reports are published on the website. In closed session the Committee Approved the credentials report and the minutes. That was the meeting. If item 12 is Committee Agendas the biking note on your calendar i in responding to your request to track your individual requests at the bottom of the last page of the document i now have a table that shows prisons commissioner singer asked her whether the item is on the date and i show when its going to show up at the committee or full commissions that you can see how it corresponds to future meetings. You are reviewing to everyone the magic of how you ensure that things get followed up . Yes. Its no longer a secret. Thank you. Item 13 is consideration for adjournment commissioners is there a motion . Moved and seconded. Any discussion . All those in favor say, aye [chorus of ayes] thank you. [gavel] [gavel] [adjournment] [gavel] working for the city and county of San Francisco will immerse you in a vibrant and dynamic city thats on the forefront of economic growth, the arts, and social change. Our city has always been on the edge of progress and innovation. After all, were at the meeting of land and sea. Our city is famous for its iconic scenery, historic designs, and world class style. Its the birthplace of blue jeans, and where the rock holds court over the largest natural harbor on the west coast. The citys Information Technology professionals work on revolutionary projects, like providing free wifi to residents and visitors, developing new programs to keep sfo humming, and ensuring Patient Safety at San Francisco general. Our it professionals make government accessible through awardwinning mobile apps, and support vital Infrastructure Projects like the hetch hetchy Regional Water system. Our employees enjoy competitive salaries, as well as generous benefits programs. But most importantly, working for the city and county of San Francisco gives employees an opportunity to contribute their ideas, energy, and commitment to shape the citys future. Thank you for considering a career with the city and county of San Francisco. Didnt o sound familiar do you keep on getting up theres an easier way. Of course theres easier way get rid of of mosquito they breed whatever this is water no water no mosquito mosquito feed on good blood the eggs hatch and stay near the waters San Francisco to breathe and the adult underlying mosquito waits on the as many until its sexuality hardens water pools in any areas and creates places youll not normally think of budget and any container that holds water and hidden in bushes or else were dump the water and do it over soil not into a drain the larva can continue growing in the pooled water is sewage disthe first of its kind the area if the sewage is two extreme have a licensed plumber assist water pools in rain gutters and snaking and cleaning out the water when keep the water from pooling and keep in mind that mosquito breed in other waters like catch balgsz and construction barriers interest crawl spaces with clmg is an issue you may have is week to cause the water to collect this is an sour of mosquito so for buildings just fix the Clean Air Act drains and catch basins can be mosquito ground it will eliminate it as a possible location keep shrubbery and growths estimated any water to can be seen and eliminated birdbath and fountains and uncovered hot tubs mosquito breed but it is difficult to dump the water out of a hot top cant dump the water adding mosquito finish rids the source of mosquito there are also traditionally methods to protect you installing screens on windows and doors and using a mosquito net and politically aau planet take the time to do the things weve mentioned to eliminate standing water and make sure that mosquito are not a problem on your property remember no water no mosquito ever wonder about programs the city it working think to make San Francisco the best place to work and will we bring shine to the programs and the people making them happen join us inside that edition of whats next sf sprech of Market Street between 6th is having a Cinderella Movement with the office of Economic Workforce Development is its fairy godmother Telegraph Hill engaged in the program and providing the reason to pass through the corridor and better reason to stay office of Economic Workforce Development work to support the economic vital of all of San Francisco we have 3 distinctions workforce and neighborhood investment i work in the tenderloin that has been the focus resulting in tax chgsz and 9 arts group totally around 2 hundred thousand square feet of office space as fits great as its moved forward it is some of the place businesses engaged for the people that have living there for a long time and people that are coming into to work in the the item you have before you companies and the Affordable Housing in general people want a safe and Clean Community they see did changed coming is excited for every. Oewd proits provides permits progress resulting in the growth of mid businesses hocking beggar has doubled in size. When we were just Getting Started we were a new Business People never saturday a Small Business owner and been in the bike industry a long needed help in finding at space and sxug the that is a oewd and others agencies were a huge helped walked us through the process we couldnt have done it without you this is sloped to be your grand boulevard if so typically a way to get one way to the other it is supposed to be a beautiful boulevard and fellowship it is started to look like that. We have one goal that was the night to the neighborhood while the bigger project of developments as underway and also to bring bring a sense of Community Back to the neighborhood. We wanted to use the says that a a gathering space for people to have experience whether watching movies or a yoga or coming to lecture. That sb caliber shift on the street is awarding walking down the street and seeing people sitting outside address this building has been vacate and seeing this change is inspiringing. Weve created a space where people walk in and have fun and it is great that as changed the neighborhood. Oewd is oak on aortas a driver for San Francisco. Weve got to 23ri7b9 market and sun setting piano and it was on the street weve seen companies we say used to have to accompanying come out and recruit now theyre coming to us. Today, we learned about the office of Economic Workforce Development and its effort to Foster Community and make the buyer Market Street corridor something that be proud of thanks to much for watching and tune in next time for