Transcripts For SFGTV Health Commission 20240713

Our very best, and we ask for your patience as were learning this new way to Work Together. Commissioners and presenters, if you have not already done so, please mute your microphones to minimize the background noise. When you speak, youll have to unmute yourselves. And the commissioners, raise your hand to ask a question. And we can switch presentation indescernable . And well ask everyone to please be patient as we make these adjustments. Lastly, we would like to thank all of the people who have been working very long hours to make this meeting possible. Starting, of course, with mr. Mark moore, and jeff burton, and d. P. H. Directors office staff, and s. F. Gov. Tv, and the board of supervisors, which drafted the best remote meeting practices. The commission is truly grateful for all of your great work. So thank you very much. Thank you, commissioner. This meeting is being televised this meeting is being televised by s. F. Gov. Tv, and for those of you watching live stream, please be aware there is a 30second to twominute delay. If youre watching the video at s. F. Gov. Tv, and youre interested in making a Public Comment, make sure that you call in at the beginning of the item called. For instance, if you were making general Public Comment, as soon as the item is called, call in so that youre sure to get in line for that. Let me post the number, so you can see it again. Give me one second. So the number is on the screen right now, for you all to call in. It will be in about three seconds. Here we go. The number to call in is 8883634734, and the access code is 2241310. If you would like to make compliPublic Comment any time during this meeting, call in any time. And you can listen to the meeting live without any delay, as we move forward. A couple of points about the Public Comment, since this is a new technology for us, every individual is able to make comments once per item. Even though technologically you could get back in line, if i recognize your number or hear your voice, i will disallow you from commenting more than once. Each individual can speak up to two minutes, as is our normal rule, and after two minutes, we will have to cut you off so we can take the next call. If youre on the phone line, using the number that i just gave you, you will press 10 to actually get in line for an item. 10 activates you to stand in line to be in for Public Comment, otherwise youre just listening into the meeting. If youre making Public Comment, make sure everything around you is muted and quiet, especially if youre watching on the computer because it will reverberate, and it is very difficult for us to hear you. I hope that information is helpful. And then i will repeat this information throughout the meeting, in case folks come in late for the meeting, i want to pacsure thamake sure that the pc understands how to make Public Comment. [indescernable] commissioners, i think we can move on to item 2. Let me get there. Thank you, mark. We have some Unfinished Business from our last meeting, a motion to disclose or not enclosed session in our march 24th, 2020, meeting. Do we have a motion to disclose or not to disclose . Motion to disclose. Second. Mr. Mar, would you do roll call . Yes. Actually, before we do that, i want to just note that the issues that the item that you all actually discussed and considered enclosed session was the s. F. G. Credentially support. Commissioner chung . Yes. [roll call] all right. Thank you very much. Item 3is the approval of the minutes of the march 24th, 2020, meeting. Upon reviewing the minutes, do commissioners have the amendments . I ask that you speak to the meeting being at 101 grove, is that correct, or are we supposed to put virtual or what . Commissioners, the meeting at a time was at 101 grove, and it felt thats fine. No problem. Motion to approve . So moved. Second. All right. So ill do roll call. [roll call] great. Thank you. The next item on the agenda is the directs report, and i am not sure if director kofax is with us . I am here. Oh, great. Can you see me . I can see me. I can see you. Okay. You have the commissioner indescernable . Do you have the directors report . [indescernable] the next item is going to focus on our covid19 response. I am not going to go into the detail, as described in the report, but i did want to mention that im very pleased that we have our new c. E. O. , who is in honda hospital, michael thorps. He has joined the v. P. H. Team in this unprecedented time, and has come up from southern california, and has lots of outstanding experience in Skilled Nursing facilities and other types of hospitals. He has jumped right in, and im very pleased that he has joined the team. He will continue to be working with actin the acting director, as he becomes on board and becomes familiar with the issues at hand with regards to honda, and the institution itself, and the amazing committee of residents and staff that work there. Great. Welcome. Commissioners, any questions . I believe, mr. Cofax, if there is any other else youre going to say . I was going to go into more detail of the directors report, in the next agenda item. As know, there have been a number of across the accounts and other information historically just for the commission that has been added to this report, but i dont have any additional details, unless the commission has questions from me. Commissioners, if you would like to ask any questions, could you raise your hand so we can recognize you . Commissioner chow. Thank you, dr. Cofax. I can see i was going to ask, on mr. Phillips, who is coming, to look in on honda. And you mentioned he would have it sounded like a transition period. About what period of time would you think that was, that we would have maggie still as our acting director, and are you looking at several weeks our months . What would be the thinking yes, commissioner. Sorry to interrupt. The im sorry, were you finished with your question . Yes. Okay. So the plan at this time is for them to act as a team, as michael gets up to speed on the complexities of the situation, and the full transition would be completed by june 1st. Okay. Very good. A second question would we be picking up during the discussion on the covid, the way of triaging and moving patients . And therefore i would save my questions for that. Okay. And i believe they are in attendance at this meeting. Mark, can you confirm that . Yes. Theyll actually be joining later. I thought they would be on here. Maggie, are you here . Yes. Both michael and i are present. Oh, great. So theyre available to answer more detailed questions as we go through the presentation. And commissioner chu, it seems that your questions might fit in with question five, which is the coronavirus update. That would be fine with me, to discuss the triaging and the outboarding of patients as we move them away from the acute hospital. Thank you. Thank you. Commissioners, any other questions . If youre not on video, please speak up. All right. Thank you very much, and thank you, maggie, for your help with the transition, and welcome to michael phillips. Your conference is now in question and answer mode. To summon each question, press one and then zero. Moderate, go ahead and put the first call through. Caller, are you on the line . Is there a caller on the line . You have two questions remaining. Caller, please start speaking. Caller yes, hi. This is michael petrellous calling in and im watching on your microsoft screen, but it doesnt tell me what agenda item were discussing. Yes. I verbally announced. Were on the directors report. Okay. On the directors report. Here are my two minutes of comment. I want to salute the department of Public Health for doing an excellent job of slowly and methodically rolling out the quarantine that we are living under. I also want to take this occasion to thank all San Francisco citizens, who are practicing physical distancing. I think it is terrific that we have flattened the curve, and that we are seeing the infection rates are not alarmingly high. I think it is very important that we, the citizens, who are observing physical distancing, continue to do this and continue to receive praise from the Health Department. And, finally, i want to say, i would have liked in dr. Cofaxs report here, a little bit more information about current coordination with other regional Public Health departments. Thank you. All right. Thank you. Next caller, please. Caller you have one questn remaining. Hi, welcome. Please say your name and your two minutes will begin. Caller hi, my name is Teresa Palmer, im a physician and a geri geriatrition. I feel like the lack of testing of asymptomatic contact at the nursing home is a form of rationing. It is a statement that nursing home patients lives are not worthwhile, and the lives of the is staff are not worthwhile. I would like some answers as to why were not ramping up testing at Nursing Homes, as we know we should in all congregate settings. Were setting ourselves up for a second wave, and were going to have massive dieoffs in Nursing Homes. Thank you. You have zero questions remaining. All right. Thank you. Those who made Public Comment. I think we can go on to the next item, item 5, the Coronavirus Preparedness update. Dr. Cofax, i cant see you. Can other folks see dr. Cofax . I can hear him he seems to have disappeared off the scene here. You can hear me, right . I can hear you. My video is on, and i can see oh oh, there we go. Hi, everyone. We can see you now. Hello. I had to share. Okay. Im sorry, im not able to see you. But just continue. Ill figure this stuff out later. Thank you. Okay. So good afternoon, commissioners, again, and secretary morris. Thank you for joining with regard to this report. Before we go to the slide, i just wanted to express my gratitude for the residents of San Francisco with regard to their collective response in addressing this unprecedented pandemic. From the beginning, we knew that our ability as a community to mitigate the spread of the virus was really dependent on our collective response. And thanks to the leadership of mayor breed and the aggressive actions that she supported, both locally and i think regionally as well, they continue to certainly mitigate the affects of this pandemic in San Francisco. So just to reinforce the gratitude, and also to acknowledge the tremendous effort and strength that this pandemic has put on the Health Department and the incredible work and efforts of people across the department with regard to particularly the last eight weeks in ensuring that we listen, are responsive based on data, science, and facts. And if we are flexible in our response, as more information comes in, and we do the right thing for our community. So this collective response is really focused on the priorities that i spoke to you about, which seems long ago, a very different time now, in february, with regard to slowing the spread of the coronavirus in communities, and that really is around flattening the curve. And i have provided some slides here for you just to remind us about where we have been and where we are going. But with regard to fightinflattening the curve, i think two things stand out. One is the declaration of a local Health Emergency after the mayor, in february, declared a city emergency. That really allowed us to prepare a city emergency declaration, which was done in february, which really helped us to harness our resources across the department, and, frankly, across the city, to be as prepared as possible. The shelterinplace order, which was put into affect march 16th, that initial order was key in terms of developing social distancing reinforcing the social distancing intervention, which was so key to slowing the spread of the virus. Other key things that we have done that i think remind you indescernable , just the emphasis on hygiene, with regard to washing ones hands, avoiding touching ones face. I think we all remember perhaps we remember the day or the person where we didnt shake hands for the first time, and we started practicing more triple hygiene with regard to reducing the spread of the risk of the virus. And then most recently, just the recommendations around facial coverings and the order that was just released last friday, that increased the requirement with regards to wearing fascial masks facial. I think they were all key, these socalled nonpharmaceutical interventions. You can see that we did it within the context of the broader population context, as well as, as you can see, from several of these orders, there is much focus being on vulnerable populations. And thats our second key priority, that, again, we started articulately months ago, really ensuring that were doing everything we can to protect the most vulnerable to this disease. We know, unfortunately, people over the age of 60, people with morbid health conditions, are more likely to die from this disease. We saw that happening internationally. Unfortunately, those patterns held in the u. S. , including here in San Francisco. So i will get into more details around that, but that certainly has been one of our key priorities Going Forward. As well as protecting Health Care Workers and first responders. The people on the frontlines, the people whos focus is on caring for people most at risk for covid19, making sure that they were able to protect themselves, so they are better protected and can help others. As well as protecting their families and their loved ones as much as possible. The First Priority is really around medical surge, ensuring that we brought forward capacity in order to meet, in essence, a surge. It is still very possible that a surge will be seen in San Francisco. So we remain vigilant in our focus on ensuring that there is Hospital Capacity to meet not only what were managing today, but in the event of a moderate surge, that we do have that capacity. And then also being clear, unfortunately, as happened in new york city, that there are scenarios where there were no there would not be plausible ways that a local response would be adequate. And we would need to be clear with state and federal partners that more help would be needed. I think the other key piece of our focus has been on testing and Contact Tracing. And the fundamental principle in Public Health, and something that has really come to the forefront as we have confronted this pandemic. And the testing pieces have been very challenging. But i think were making steady progress now. And then ill talk a bit about the Contact Tracing that we anticipate to be able to be affective in a relatively short future. Before we go on to the next slide, i want to also emphasize the help, the support, the collaboration with other City Departments and community partners. This is a truly citywide responsresponse. Not only do we have hundreds of d. P. H. Staff working on this, the department of operations center, the Emergency Operations center, which is headed by director Mary Ellen Carroll has been a remarkable partner, and has ensured that our response is more than just a department of Public Health response, it is truly a city response. The controllers office, the homeless department, housing department, and others really are coming together and working handinhand, and in many cases 2 24 7, to ensure were doing everything we can and to meet the needs of our citizens. Can we go to the next slide, please . Sure. Im sorry, i just got you on camera. Go to the beginning, dr. Cofax . On my drean th screen, the Health Orders are coming up. Would you like to go to the test cases . Yes. Give me one second. Sorry. Sorry, everybody. Im a little slow on the uptake on that. Okay, here we go. All right. Mark, may i just ask a process question . I have a i dont know if anyone can answer this question. Im having some challenges with this program whats wrong . The video is the bar that shows the microphone and the camera is super imposed on the eye, so i cant see the slide. I dont know if the other commissioners are having that problem. Jeff burton is on, who is an i. T. Guy. Jeff, is there any response you have to that to help dr. Kofax . Im not sure exactly what is happening, but it seems like something technical. Yeah. Mark, it appears that the control bar is obstructing the view of the dates along the bottom of the charts. Is that happening for other people, too . Well, on my screen, it doesnt. And then the control bar, you can actually it sort of disappears if youre not using it. And it would otherwise so i guess it depends on how it is being viewed. Because it sounds like for dr. C cofax, the control bar is in his way, and for me, it is below the slide. Mr. Kelly, if you move your mouse curse ser so curser y from the control bar, give it a second and it will disappear. You need to move your cursor off the control bar. Does that work, dr. Cofax . Im following the instructions, and it is not working all of the time. But i will as part yes, i will be flexible and work with what weve got, how is that . Okay. Sorry about that. Can everyone see the slide . Yes. Commissioner be careful to mute yourself because were hearing the conversation. Mr. Cofax, do you want to continue . Yes. Commissioners, i wanted to provide you with information about where weve been and where we are going. And just review data so that there is sort of an understanding of what things stand. This is our total number of diagnosed cases in San Francisco, 1231 total cases. And it represents the people who are positive who have been tested. So it doesnt represent all the cases because we know many people havent been tested. But of the people tested, weve had 1231 cases. Weve, unfortunately, have had 20 deaths. And you can see from early march, when our first cases were detected, weve had a steady increase in that number. Compared to other regional neighboring counties, we do have the highest prevalence rate of people who have been tested, testing positive. And i think that really reflects the greater density of San Francisco. Our relative death rate is still well within the surrounding counties, but our numbers are quite small and that could change very quickly. Go to the next slide. Okay. Give me one second. It takes a second to show up. Sorry. I apologize, something is stuck. Give me one second to try to unblock it. Scroll to the next. Okay. Here we go. Thank you. Yes, and then you can see here, this is our these are our data with regard to cases. Weve done nearly 12,000 tests. Our Positivity Rate does vary day to day. It has been ranging from about 11 to 15 overall, and then you can see the racial ethnic breakdown of the positive cases. We do see here that indescernable population is overrepresented, compared to the population of San Francisco as a whole, and the africanamerican. Again, these numbers are updated on a daily basis on your covid19 response tracker. Next slide, please. These are the data on the deaths. I will say that we see here that just as in other jurisdictions, we see a larger number of males, compared to females, who have died. You can see the deaths by each group. Weve had a preponderance of people over 16. The deaths by race and ethnicity show a higher proportion of asian deaths, and i can talk a little bit about that and why we think that is. That has been tied to a higher portion of older age, and then there are a couple of cases linked to indescernable . With regard to underlying conditions, this is an error in the slide. All 20 deaths have been associated with underlying conditions. So where you see the data on the 20 deaths that we have had, unfortunately the patterns of larger groups of deaths in other jurisdictions i would be very cautious about interpreting too much about the Race Ethnicity death rate here, especially because, again, this is a very small number of deaths, which is ae death is too many, but these numbers are quite small. I certainly hope that they stay this way, but, obviously, we dont know. Next slide, please. So this is a really key slide with regard to what were what we looked at in terms of the burden of covid19 in the hospital system. And the reason that this is very important is that we really need to ensure that our systems are have capacity to take care of the sickest people. And so this is the green the upper green row is data on the number of people confirmed positive across our nine Hospital Systems in the city. And you can see here, while the numbers substantially increase from the march 23rd, when we were first able to report this data, to the 19th, the latest data that has been available, this curve, starting around april 1st, is quite flat. So when we talk about flattening the curve, it is really the curve that were working to flatten is our ability to take care of the sickest people. And right now this curve is pretty flat. And i say that with all respect for the fact that this could change quickly. It could change if we have outbreaks in particularily vulnerable populations. But right now we need to look at the data, and were looking at the data, and here is where we are. The darker green shows the medical surgery beds occupied. And the lighter greens are the i. C. U. Beds, and those are the intensive care unit beds. And they remain relatively stable over the past 10 days. The blue im sorry. The purple area between the suspected covid19 patient count is also a key indicator to watch. Because these are people who who have tested positive for covid19, and are in the hospital. Those are the people in intensive care units, suspected of covid19. And those numbers have, again, remained relatively stable the last few weeks. You do see some increases in the numbers, for instance on april 5th and 6th, and we were testing a number of residents at honda for the c. D. C. Recommendations. Thankfully, not many of those cases were found covid19 positive. Next slide. So those are the key slides that i wanted to share with the commission. Commission as part of this report. I also wanted to emphasize, with regard to our medical surge planning, because of remarkable efforts across the city Health Systems and i really want to acknowledge dr. Susan ehrlich and the c. E. O. Of zuckerberg hospital, and the chief operating officer of the hospital. They really led our surgeplanning efforts, not only within the department, but across the city. And we made remarkable progress in ensuring that our hospitals were, as much as possible, not taking patients for nonessential surgeries, because that opened up capacity. That patients were discharged as appropriately appropriately discharged from the hospital to other facilities so we could free up beds. And then we greatly expanded our medical surge and intensive care unit capacity in additional ways, so that we had exceeded the states goal of increasing local capacity by 40 . Currently, we have 1252 acute care beds, and 460 i. C. U. Beds across the city to meet the demands of a surge. So really important and strong work there. So we do have that capacity now, and we continue to build out that capacity as we go forward. So i did want to talk a little bit about vulnerable populations, and provide the commission with an overview of our work in that area. We have very much focused on ill talk a little bit about the population experiencing homelessness. We know that that has been a key area of focus. And from the start, we have focused on people who are experiencing homelessness, who are most likely to have negative outcomes from the virus. And those are, again, the people over 60 or with comorbid conditions. And were working with our partners at h. S. A. And h. S. H. , and at this point, over 750 people have been placed in hotel rooms, with those chronic conditions, to help them social distance and so they can be monitored and observed for any symptoms and tested appropriately. The other thing that i think is important to emphasize is that we have developed and refined our system for People Living with covid19, or people under investigation, who cannot safely isolate or quarantine either because they are in a shelter or navigation center, an s. R. O. , or other such congregate settings, that we have stood up with multiple hotel rooms for those people. On any given day, we have approximately 200 people in those hotel rooms. So ensuring that people have what they need to stay either out of the hospital, if they do not need a hospital bed, which frees up a hospital bed for somebody else, or if they are not able to care for themselves or for reasons in such a way they can stay safe and also isolate from potentially contacting others. So we really set up a very good system there that is,again, working hard every day to even increase that capacity. Right now we have about 200 People Living with covid19 or under investigation for covid19, plus we have over 750 people who are experiencing homelessness, who have been placed in hotel rooms, to keep them as safe as possible. I also want to mention with regard to the outbreak we had at m. S. C. , one of our largest shelters. We had an outbreak there. As a result, we had 96 guests and 10 Staff Members who tested positive for covid19 there. All of the guests from that shelter have been moved to hotels, isolation, shelter, or quarantine in place, depending on their need. And all staff were also offered Isolation Hotel rooms if they needed them. And, again, we were preparing for this scenario, and we responded quickly. The staff the street medicine steam worked literally day and night to ensure that the people got the care that they needed. And that shelter has been closed and is being cleaned. Iwithin these highrisk settings, our response is driven by the best Public Health methods we have at our disposal to make an informed decision on how that response needs to be in the face of multiple other competing priorities. So i will also mention that at the Division Circle navigation center, where ive had a clinic, weve had a positive case there. An aggressive contact Case Investigation and contact investigation, there were people who were determined to be at risk were tested. And through that process, a decision was made, based on the information data that we had, that we would not close that navigation center. So my point here is that we are based on c. D. C. Guidelines, were testing vulnerable populations, providing them with care and support, ensuring that we are flexible and appropriate in our response. I also want to talk in more detail about the lag laguna honda hospital. We took a course of action with the leadership of mccowski and her team and staff early on. We ordered we issued a health order restricting visitors to the facility on march 6th. We practiced and we prepared a health order to restrict residents from leaving the building, and that went into affect march 15th, and we ensured we were screening staff for any signs or symptoms as they entered the facility. Despite those efforts, people will know there was an outbreak among residents in the 5 southward. We quarantined that ward. And we took aggressive additional infectioncontrol steps. At this time weve had 19 laguna honda cases 19 cases of covid19 at laguna honda. Four have been amongst residents. Those residents have all been located in the 5 south neighborhood. There have been staff at 4 south who have tested positive, but we have not had any residents in that neighborhood who have tested positive. And maggie mccowski and the laguna honda team can talk in more detail about that, if the commission has questions. The point is, after bringing in c. D. C. , we had a remarkable team from the c. D. C. In the state. And i want to thank our local leaders, our federally and locallyelected leaders, who really helped ensure that the c. D. C. Deployed a team to laguna honda early in this outbreak, to help us and to reinforce our aggressive efforts. The c. D. C. Made a number of recommendations, and we were report that out. But after staying for two weeks and summarizing their recommendations, they emphasized that the aggressive actions that the staff took early on literally saved lives, and were likely to continue to mitigate the spread of the virus in the institution. And then were obviously, not obviously, but i should also say one of the other key issues at laguna honda was ensur ensuring that the staff was supported. It is an incredibly challenging time for staff across the departments, and we have ensured that staff across the department have access to Behavioral Health care and support, if and when needed. And we redoubled those efforts at laguna honda hospital, ensuring that there was access to the Behavioral Health services. For those staff, and also that those staff were communicating in an ongoing way about the status of the investigations. So the additional piece that i wanted to cover before i took questions from the commission was to talk a little bit about our testing. As you know, we have struggled as a nation, with regard the capacity at the beginning of the epidemic and Going Forward. I really want to acknowledge the laboratory under the leadership of dr. Susan, our Communicable Disease director. We were one of the first laboratories in the state to Start Testing for covid19. Right now we are focused on testing on people who have a number of symptoms consistent with covid19, Health Care Workers who are symptomatic, and who have come into sustained contact with covid19 positive cases, and on our contact investigation, people who are symptomatic and meet additional criteria. bia big issue has been our lack of supplies. We hav have developed a capacity in terms of running the actual tests, so we have enough machines to run the tests. Our limitations have been as basic as needing more swabs and Culture Media in order to do the testing. That supply chain, due to a lack of federal supply chain, has been very unstable. In the last few days, our supply chain has increased the stability. And the supply chain looks to be increasing. So we will be expanding our Testing Capacity and our testing eligibility. They are not close to the situation where testing is available on demand. And there are lots of reasons right now that we would expand our testing in an evidencebased way, in accordance with guidelines that the state recently issued around what the testing priorities should be. And ill be happy to share that with the commission when we release that information. The other key piece to testing is Contact Tracing. And we are building our Contact Tracing capacity, because that is not only important for now, but it is important as we enter the next phase of the epidemic. We need our Contact Tracing response to be robust. In the moment, as we look it up, as we investigate outbreaks and not only talk to the persons who are infected, but also to ensure we are able to follow up with contacts. And we have partnered with ucsf, to use an app with a Company Called demagi, which will allow us to build a team and data system that is really unprecedented in terms of our ability to do Contact Tracing in an efficient and affective and datadriven way, and also make available to the indexeindex case, the person diagnosed with covid19, and the people were contacting, making sure they have the support, the resources, and the knowledge necessary to protect themselves and their family. We are moving from a staff of contact investigators at the beginning of this epidemic. That number was in the single digits. So that was in the single digits. And we expect in the next couple of weeks that we will have a team in San Francisco of over 150 Contact Tracing investigators. So unprecedented expansion. And we will probably expand even further those numbers as needed. So, um in addition, i talked about the challenges around the testing supplies. I think in terms of worker safety and the need to protect workers, another huge chel challenge in this epidemic has been the need for a stable supply of personal protective equipment, or p. P. E. The lack of a centralized visible supply chain for local jurisdictions has created unprecedented. We have worked hard along particularly with the city administrator, to ensure that our workers, d. P. H. Workers and city workers, have the protection that they need per c. D. C. Recommendations to do their work. Im pleased to say that has been the case. We have done everything we can to ensure that people are getting the masks, the gowns, protective eyewear and facial shields. Weve come very close to running out of those, but we have found a way. At this time, those supply chains appear to be growing, despite the lack of a centralized and visible supply through the federal government. So i will i have one other piece to cover, because i do think the focus on vulnerable populations and equity is really key here. Go to the data tracker website, and you will see that we, yesterday the mayor announced that we released cases of covid19 diagnosed cases of covid19 by zip code. And, unfortunately, we are seeing maps that look very similar to other maps, with regard to health, that the commission has seen in the past. These maps generally overlay the maps with regard to health inequities, preterm birth, food insecurity. We knew this virus would fall on the fault shrine of other health inequities, including income, food insecurity, homelessness and housing insecurity. This is no different, but weve been vigilant in our response. And weve anticipated this, and we have a score of workers, community providers, and others doing everything we can to mitigate the inequities that this pandemic is continuing to expose in our community. I do just want to add, as another part of the vulnerable population, are the People Living in singleoccupancy buildings. [please stand by]. So i will stop there and i will also see if the commission has any questions and then if there is time, i would like to just provide a very brief summary of the general stage of what we need to think about. The next stage and in other words, what would be some of the things that we need to consider if and when the shelter in place order is lifted. But i know that is a lot of information. So i will stop for now and answer the commissioners questions. A commissioner, if i may, usually the procedure is to take Public Comment before we have questions. I would advise we continue with that if you are okay with that. Commissioners . Commissioner bernard, i think your mic is off. That is fine. Thank you. Moderator, could we start the public line call . You have three questions remaining. Great. So please state your name and i will start your two minutes. Hi, jessica. Can you hear me . Yes. Great, thank you. So i am with senior and disability action. First, i want to say i know that San Franciscos leadership has been aggressive on this and in a lot of ways and i really appreciate all the hard work. We have some concerns specific to seniors and people with disabilities living in congregate facilities, not only Nursing Homes, but boarding care homes and other longterm care facilities. And we have a few recommendations that we just put in a letter that we sent to the city yesterday, and were really hoping to have real conversation about how we can Work Together to make these things happen. So we have six recommendations that are to immediately test all staff and residents at any facility with any confirmed or suspected case of covid19. So that we can make sure that things dont spread as quickly as a place like Central Gardens. We think testing on demand at congregate settings is important. We know that on demand testing is not available everywhere, but congregate settings is particularly important. And transparency about this is so important to regularly post a list of all congregate facilities and details the cases and deaths of staff and residents. And were also interested in whether people can be housed with a Family Member or a friend during the crisis to reduce their risk of contracting covid19. And so for the city to make sure that they get all supports needed to be able to leave the facility temporarily. And of course, we want to see ppe for staff for all facilities. I dont believe that is happening yet. I was a little inclear on that in the report now. And when residents test positive for covid19, we are hoping that they get moved to a hospital since right now it looks like those beds are available, and we know that people in Nursing Homes and other facilities are at serious risk of death. So im not sure if that is happening yet. And again, senior disability action really looking forward to having more conversation with the department to make sure that our folks are as sauf as possible. Thank you. Thank you. Your time is up. Next call please. You have four questions remaining. Please state your name and your two minutes will begin. Yes. This is leticia with senior action. I just wanted to say that it is great that you are giving this presentation, but i would like to see more on a numbers because when you said there is no capacity to have the tests on demand, i would like to see what the capacity is really because we see that the only country that is managing this is because they are doing more testing on demand in germany. We would like to see what that capacity is in San Francisco so we can expect how we can see how the city is going to be managing this crisis. Thank you. Thank you for your call. Next call please. You have three questions remaining. Please state your name. This is Teresa Palmer and again, i am a doctor and i agree with senior and disability action. And if we dont have Testing Capacity in Nursing Homes, what are we doing opening up a covid ward at the jewish home of San Francisco . We cant test if they are exposing the vulnerable population there. It doesnt make any sense to me. And it is like says those lives are not worthwhile and we just want to get these covid people out of the hospital to someplace else. It is just totally irrational and i would like director of Public Health to stop admissions to the covid ward at the jewish home until you can expand the capacity for testing there. Were not even testing the contacts of the one infected staff member that has been found at the jewish home. It doesnt make any sense. Families are frantic. We cant visit our parents. And youre jeopardizing them. And please act on this. Please stop covid positive admissions from the outside if you cant test on the inside. Thanks a lot. Thank you for your call, dr. Palmer. Next call please. You have two questions remaining. Please start with your name. Hi. Just let me turn on my timer. Hi, Michael Petrellis here. I am interested in talking about a question i keep asking. Where are the tests . Especially where are the tests for folks like my husband and i. We are in the vulnerable populations. We are both over 60. We are both h. I. V. Positive. And we both have Underlying Health challenges. And i believe that an effort must be made for folks over 60 in the vulnerable population to be a higher priority for covid19 testing. I also want to point out that in addition to those things, we also live in the 94103 zip code, which according to the d. P. H. Data shows that this zip code has the highest concentration of positive test results and cases, so we are very nervous and very much want to get tested. Finally, regarding this information that dr. Grant has presented, i believe it is time for and to hold regular town Hall Meetings on zoom for citizens to pose questions to you. It is good, dr. Grant, that you participate in those briefings, but you dont take questions from we, the people, at those briefings. So a zoom town hall please. Thank you. Thank you for your call. You have two questions remaining. Please state your name. Sorry. This is michael. I am with senior with disability action and highly support all of the recommendations in the letter which you have gotten. Covering Covid Patients in Nursing Homes is just uncredibly dangerous. Is incredibly dangerous. I cant imagine what you are thinking of. Jewish home is already said they cant assure that there is separate staff or separation that would be needed. And the issues with regard to Quality Assurance are not being allowed into Nursing Homes. The governor is considering immunizing the Nursing Homes from covidrelated liability, so theyre already trying to get out from under the responsibility of this. In covering Covid Patients absolutely need separate facilities and i have to say the Health Commission bears some responsibility for this for letting the hospitals reduce this and all the locations where covering Covid Patients could have been housed. And it was it resolved and became acute care. Once again, it is the thats all. Thank you for your call. You have one question remaining. Please start with your name and your two minutes will start. Hello. This is betty trainer. I am a resident of the western addition, and only live about a block from Central Gardens convalescent where i was shocked to find out this weekend that they had 36 residents tested positive and 26 staff, and there are now even more. I think its just imperative as others before me have said that we test this very vulnerable population of seniors and the other care facilities and it seems like they have been a forgotten population, so i urge dr. Colfax to make them a highest priority in testing for the virus because this is the population as shown on the charts that are going to be dieing from this. So please make them the top priority. Thank you very much. Thank you for your call. You have zero questions remaining. An all right, commissioners. That is the last item. And i believe just as a point of information that the longterm care facilities such as a jewish home are under the jurisdiction of the state and not the city. And not that thats something that you will get into, but just as a point of reference for you. Commissioner bernard, i am not sure how you want to proceed. A commissioner, if you have questions, please either raise your hand or indicate by voice. A commissioner chung has a question. Yes, i have a couple of questions, and thank you, dr. Colfax. I think that is a very detailed report that you just gave. It seemed that the public has some misunderstanding of the positions of the Health Department and the relationship with some of the private convalescent homes. Maybe i will start there and see if we can address that a little bit. I believe that central garden is a private nursing home, and i was wondering how do we as Public Health Department Help keep them accountable . For not waiting so long to communicate with us about the situation. And there is a second question but i would like you to address that one first. Thank you, commissioner, for your question. So we have been first of all, i think its important to state, again, that residents of Skilled Nursing facilities and other people in congregate settings and particularly people over the age of 60. I spoke about the position of covid19 and certainly before we had a case and the priority and so we have been working very closely with Key Stakeholders in terms of doing everything that we can informed by data, science, and facts to help protect the vulnerable population including those in Skilled Nursing homes and other congregate settings. This virus is very transmissable. Some of the settings as we have seen, unfortunately, it goes through the settings very quickly. And particularly in the population over 60. It causes great morbidity and often great fatal tis. The state has jurisdiction over the homes. We obviously have jurisdiction over the largest Skilled Nursing facility in the city, and one of the largest, if not the largest, within the honda hospital. And one of the key things that we have been doing is taking the information, the work that we have done at laguna honda in ensuring that the other Skilled Nursing fail fails and Nursing Homes in the city are able to take the recommendations that we made and that the c. D. C. Made in response to the laguna honda investigation and applying it to both keeping their staff safe and their residents as safe as possible. The c. D. C. Issued a number of recommendations including aggressive symptoms, screening for staff, and ensuring and reinforcing to staff that they need to just stay at home if they were sick, ensuring that staff had available ppe to protect patients to mask residents whenever possible and tolerated, and to do targeted testing based on potential outbreaks in the facility. The c. D. C. Did not make recommendations to do widespread testing of staff, and they really focused on how to mitigate and prevent the outbreaks Going Forward. The state has sent inspectors to the Nursing Homes with outbreaks in the city. We have been in close collaboration with the residents and with that with the residences and with the findings of what those inspectors have made and we have been working with those nursing home, but the state really has the authority there, and we are providing a supportive role. And when there is a case, we do have the jurisdiction of doing the Case Investigation and Contact Tracing. That is our role as the Health Department and we will continue in that role. As in any contact investigation situation as we do with covid19 cases and across the city, we make recommendations about who should be testing specific to that Contact Tracing investigation. Commissioner looking at the data that there is a High Percentage of folks in the hispanic and Latino Community being tested positive for covid19 and setting up hot spot testing in the mission area to, like you said, trying to follow the data and do more targeted intervention. About the Contact Tracing and with immigration issues and nothing like the fear of being with the security and privacy issues among the Latino Community. And we are telling the community that we assure them that it is completely safe and even with the Contact Tracing it is completely confidential. Yes. So we have been very foes kued on Community Outreach and engagement from the beginning of the epidemic. There is a whole group that is the e. O. C. , the Emergency Operations center, and the d. O. C. , department of operations center, focussing specifically on this issue. They have engaged Community Stakeholders and done a number of Virtual Events with regard to involving Community Stakeholder rs and Community Leaders in this collective response. We have been clear thatment u great lakes status certainly does not that immigration status certainly does not Effect People and the information collected is confidential. And through a health lens and also a socioeconomic lens and insuring a need for food, need for other pieces that are being supported. And the marriage has been very clear about needing to wrap around services for the vulnerable populations. Specific to the Contact Tracing and the app that i described earlier, that will be done in multiple languages including spanish. We have also provided materials in indigenous languages, particularly in the mission and in order to reach native speakers. The last thing i wanted to clarify is the study that i think you referenced with regard to testing in the mission and that is a ucsf study. It is not a program that will be done over a series of days and that is a study being led by ucsf. Thank you for the clarification. I did get confused because of my other information floating around. Commissioner, other questions . Mark, just to clarify, i cant always see all the commissioners on the screen, so i will leave it to you to let us know. It looks like everyone has a question, by the way, so two down and everyone has raised their hand, so call by order. Commissioner guillermo. Thank you. And thank you, dr. Colfax, for your report. I think there is a new information that was released today that the state department of health has now loosened its requirements for testing of asymptomatic or nonsymptomatic persons that will be starting in los angeles county. That is information that was released today and that is an indication, i think, of the fact that there is more widespread Testing Available and coming online particularly with the private labs and counties being able to use their own labs. If that is information that you have available to you, do you know whether this roll out of testing, which is going to focus i think primarily first on Nursing Homes and prisons, will that be rolled out based on the supply or ability of counties to respond . Or is there some other criteria . And i will ask a second question at the same time. You had shown on your data that number of deaths in the Asian Community was higher than any other population, and you said that you had some information about why that might be, and it might have to do with the age of the population or something related to the the cruise ships that were based here. Those are the two questions i have at this time. So with regard to the report on l. A. I cant speculate on that because i havent seen that report. But it certainly is something we will look into and have conversations with the l. A. Leaders and with the state about. The state did, i believe it was yesterday, release recommendations for prioritizing of testing asymptomatic members of the general public were on the list but they were pretty far down on the list in terms of when one would test. I can certainly get more information about that. Again, as i said as our supply chain stabilizes in terms of testing, we will be expanding Testing Capacity but doing so in a way that is consistent with the needs of the most vulnerable population and our Health Care Workers. With regard to the deaths that unfortunately we have had and i may not has been as clear as i should have been. If one death is too many t numbers are not small, and so i dont think we can draw any statistical conclusions from what we are seeing there. Because the number of deaths among people who identified as asian was higher, i did ask for a little more information there about why that might be. This is qualitative information and shouldnt be seen as a statistical analysis. But compared to the other people who died, and deaths among asians, several were linked to having taken a cruise. That was not the case for the other deaths. And then the death among the asians and people tended to have on older age compared to the other deaths overall. Thank you. Commissioner green. You for the exhaustive report and all the incredible work you have done and the multiple eventualties that you so thoughtfully considered and planned for. And i wondered if you might elaborate a little bit more about the manpower. And will definitely be prioritizing vulnerable populations especially those in congregate living situations and those may require testing more than once within the settings and if you have concerns about the manpower to be able to really focus on those living situations and also the volume of tests and correlate to that how we are bringing some of these testing opportunities that, for example, are pro proprietary into the system. We are continuing to build that out. I think where we are now and where we need to be in the future, the answer is we need more people in the future, so were building that out. I anticipate no snare joe where we would basically if were fortunate enough, and i dont know whether we will be or not, but if were fortunate enough to make it into june or july and can start considering what it would look like to focus more on easing the i dont know when this would be, but easing the shelter in place orders, right . And thinking through how one needs to emphasize the testing and Contract Tracing there. We will need a robust work force built out in order to do that. I think nationally i have been seen 300,000 to 500,000 people need to be trained for that. And we are ahead to that curve in San Francisco, but i think youre not going to return back to the prior days with a small team of incredibly hardworking people. We will have an incredibly large team and that will take substantial investment and sustainability over the long term. I think in terms of the expansion of testing, there are lots of possibilities and one can think about the ability to rapidly test people and what indications that would be with very, very few in San Francisco and very few to use. But over time as those become more available and one does one need to get a test result quickly to make a decision about where that person goes in the hospital or where that is that person can that person go and work with highly vulnerable populations . And not expose them. I think we also, though, have to be very careful about thinking about the idea that a negative test is gives one a false sense of security. That negative test in the current environment in which we live in, that negative test is only if you get up in the morning and you are somehow able to get a test and you are negative, it is probably reasonable until you have some other exposure, right . So we have to be very thoughtful about that. The other big testing claim that has not been fully understood and there is a lot of topics and the quality is very question sbl the antibody test. And the the antibodies truly going to last and what does that mean . Those can be potential game changeers and the third question was with regard to the populations and where they go after being in the hospital. One of our focuses has been, again, on moving the population back to congregate setting to place them in hotel rooms with some support. Our Street Medicine Team is making rounds in the buildings where the most medically vulnerable and are placed and they have a large capacity to respond to Behavioral Health needs. I will say as we iterate and learn more about needs that we have to the covid19 responses and the commissioner knows our i will say baseline Behavioral Health challenges within the city. Those are only reinforced again by covid19. We are looking to use the hotels now and then we are also working with h. S. And h. S. H. To set people up in a shelter with broader support and more capacity to take care of people who are covid positive who are also lean towards developing capacity and facilities to care for people who are covid recovered. And once people move through the covid positive recovery and it is important to emphasize 80 of people do okay. So in the congregate setting, this percentage will vary depending on the population. The bottom line is we need to also support people who are in the covid19 recovery past the infectious period. And that is something that we have been keeping hard on with the Housing Agency and those are support questions and those questions. I have two questions with the manpower of the Contact Tracing and when you stated that you are hoping to get up to a capacity of 150 people of being able to do the Contact Tracing and when do you see that might be possible . Is question one. Question two, one of my concerns as we are Going Forward is you had just mentioned Behavioral Health issues not only during the crisis and as things ease up and longterm in the aftermath. With relooking at increasing xas within the Department Training . What are the is there planning now going on to be able to address these needs which are rather significant across all age groups . Thank you, commissioner. And we do have people identified to the City Attorneys Office has made available scores of investigators who will be training this with a way that is culturally appropriate and we have had remarkable interest in this program with scores of emails who want to join this effort. We will meet the 150 threshold fairly quickly. The other City Department wills go back to their other work. And we are doing aggressive recruitment and will fill that out. I meant to say in the presentation we are this pandemic has forced us to do things in new ways and build new teams and capacity faster than was even imaginable. And one of the things to acknowledge with the department of Human Resources and our new h. R. Director is we hire as many as 200 nurses in the last four weeks to strengthen the medical approach and applying it to the Contact Tracing, staffing and thinking that through. And also with regard to Behavioral Health, the acting director are the leads and thinking through not only what we need now and with the shelter in place which is, lets face it,s treatmently challenging and also what do we need to think through what is the intersection of the Pandemic Response so that should be part of one of the key colors that we build out. Thank you. I am most interested in the Behavioral Health because in my work the need is increasing significantly. Commissioners, any other questions . Hi. I had actually one or two questions and first, of course, i want to thank dr. Colfax who and with the show he does with the Mayors Office and the press conferences which he handles so very well. And thank you. I think you help show a very thoughtful and very compassionate department. Obviously also grounded as you continue to say. And the chronicle notes that you always have science right there and that is the type of image we all want in this type of crisis, so i appreciate that. I understood when there was a request of the jewish home that this was going to be a fairly selfcontained unit, so that might just be a simple yes, no, or thats not the way it works. And the new guidelines have seemed to come down also from the president ial task force and seem to ls a talk about as you are moving towards having, lets say, less Surge Capacity, would there be the opportunity to then other areas in an acute hospital that would be sort of selfcontained . Or perhaps certainly covid that is selfcontained. And second question since we are all giving two questions actually does relate to the sros and i wont get into the article that you i am sure have seen in the examiner that discussed the issue of a particular family in china town that was trying to reach some sort of accommodation by way of also the sro and all and that clearly operational level becomes sometimes very problematic with regards to how we would like to do things. I would like to know if what you mentioned and to help try to answer some of the questions with the patient privacy which is true on p. H. I. A with patients permission and it may well relate to how a patient then relates late we are their being discharged and needing to go home, or the patients relatives can certainly be some sort of way in which there is a dialogue because those patients would be interested in that. And the approach being taken and made it appear our department was not working together to protect those sros along with the availability of the housing that you have put together so well. So i didnt know if you would be able to give some comments on those. And i wanted to certainly have you have enough time to give us an insight into the future, whatever that may be. The information that i have is that the state, again, the state came out and visited the home. Did an assessment. And from my understanding from my understanding made the assessment that the home was meeting infection Disease Control guidelines and so forth for the state. And they authorized i want to be cautious with the words i am using but my understanding is they basically authorized the jewish homes plan and thought it was adequate to protect residents. Im sorry. I am running out of the battery. And in any case, thats the information i have with regard to the jewish home and the state with regard to their plans for covid positive. With regard to the sros, we have been very active as i iterated in my review with the community [inaudible] can you hear me okay . I think your wifi was going in and out, so like the last minute we didnt hear you. It was going in and out. Now we see and hear you. Director colfax, perhaps where you were standing earlier had better reception if you would like to move your plug. Well, also you can take off video to use less bandwidth if you want to do that. Is that better . Yes. We can hear you. Thank you. I was going back to i was responding to commissioner chows second question with regard to the sro work. Again, we have from te beginning identified sros as a key vulnerable population with regard to ensuring they get their resources to help mitigate the spread of the virus. We have an sro task force which is not only made up of Public Health teams and also other City Departments. We have been with the health order and with inspections and we have been effectively enforcing the sro order. And we reached out to the residents in multiple languages and offer people hotel rooms where they can stay and be supported with food and other basic necessity if they so choose to go into the hotel rooms. So were doing everything that we can as a system. And as quickly as we learn about that, we iterate the system and that can improve. And there are specific examples. I am sorry for that, and we will continue that those are rare. And they get the services to take care of themselves and mid gait the spread of the virus to mitigate the spread of the virus. I think that is a reasonable response that these occurred within about, oh, two weeks ago and obviously everything was still moving and trying to get that under control. But i appreciate your last response there that if such did occur or had occurred, it is not our routine and we are looking to try to ensure they are all accommodated. Thank you. And to give you an opportunity to talk about there is no need to go back to the slide, but the data and number of covid positive patients who are both in who are in intensive care versus nonintensive care, do we know what percentage are currently on ventilators . And my second question regarding that data is, to what do you attribute the redubs in the number of p. U. I. S . That expanded testing or is it something happening in the hospital setting . Can you hear me okay . I am getting an echo. In general, the i. C. U. Patients, about 3 4 of those are on ventilators. Its challenging to update that data on a regular basis because the ventilator status can change rapidly and this is from nine different hospitals. But just on sort of a monitoring level, the real question is whats our i. C. U. Capacity . And in those i. C. U. S, most of those represent beds with more capacity. We expanhandled the i. C. U. And Ventilator Capacity as part of the surge planning by 91 , so we almost doubled the capacity there. And that was a key concern as we looked at the situation in new york. And again, people really responded tremendously to that. Commissioner, im sorry, i forgot your second question. The reduction in the number of p. U. I. The p. U. I. Number is one that i watch with caution in terms of interpretation about what will happen in the next coup of days. And likely that will depend on things like a neighborhood in laguna honda is all being tested and it is when the c. D. C. Was here or if there is specific things that certain hospitals are doing where they may be testing a large number of people for a very specific reason. There are so many heterogenuous reasons why the p. U. I. Can go up and down that i have been focused on the hospitalizations of confirmed positives. Unless i start seeing a consistent trend in the p. U. I. And i think you can see as from that graphic it is hard to see that yet. Director colfax, would you like to go into possible future steps or defer that to another meeting . I know you do have a hard stop. Well, i think that i just as we think through where we would go from this stage, and i think its important, one, to emphasize the importance of physical distancing, wearing the mask, the shelter in place, compared to where we started march, there is more covid19 circulating in the community. So even though to some extent while its been a month, over a month, and it is challenging, but i want to emphasize that those pharmaceutical, Public Health interventions remain really key in addition to basic hygiene. But as were looking at our approach Going Forward, we really need to think about what are the key and we are starting to think about with other partners across the region and the state and what are the key things we need to be looking at for potential relaxation of some of the social distancing protocols. Where would that be most necessary . What is the balance in terms of the risk and benefits of that . And i think there are real Health Questions as well that need to be considered because we know the aggressive shelter in place that we have done while its been the right thing, there are certainly Health Consequences including of that. And what are the key things we need to be looking at in terms of expansion of our Contact Tracing capabilities, a change in not just a flattening of the curve but a potential decrease in the curve, and then how do we develop a system that is flexibility so that if there are outbreaks that we are able to turn certain switches on and off. That is a general answer to a complex question and the Health Commission and may want to add a few words to this because hes been thinking a lot about this with some of the other health officers. I dont know if you have anything else to add from my general interview and i know we only have a few more minutes. Thank you very much. Can everyone hear me . Yes. Yes, so let me just summarize it and just really quickly the big ideas. Dr. Colfax covered most of it. There are basically three phases the way this is being thought about in the country. We are currently in phase one which is slow down the infectionened, prevent hospital surge, and start preparing for the next phase. The next phase is when we begin to open up and pull back on the shelter in place. To do that we have to have all the systems in place that dr. Colfax mentioned. We need to have a good testing system, Case Investigations, Contact Tracing, being able to deal with all our vulnerable populations. Having all that in place. The third phase is far off and that is going to be when we have good therapeutics and we have a vaccine. So that is probably were not going to have a vaccine for probably a year and a half, so thats at the highest level, that is how were thinking about it. And were also waiting for the state. The state has given us some initial guidance in how they are thinking about it, but we need more specifics because we want to align as much as possible to the state so that were able to focus on the Public Health role and less about the challenges of picking and doing the sheltering in place the sheltering in place which affects so many different businesses. Thank you. Move on to the next item on the agenda. A give me one second to put a slide up, if you wouldnt mind. Certainly. Were going to move on to item 6 which is general Public Comment. Before we begin, i want to put the slide up so people have the information. Just give me a second to get there. I will work on it, but moderator, we can start the Public Comment. Do we have any calls on general Public Comment, item six . Moderator . Are you still with us . Oh, i see. No calls. There is nothing on this for item six. We can move on to item seven which is an action item and resolution honoring the San Francisco department of Public Health for its ongoing response to the covid19 health crisis. And commissioner, i will read the draft resolution and i will include and note the clause that commissioner chow is going to suggest through an amendment. And excuse me if this is long. Those of you who are in the d. P. H. Executive team, take this in because this is a time of gratitude. Whereas dr. Grant colfax, San Francisco department of health, director of health, initiating d. H. P. Planning efforts to respond to covid19 in late january 2020 and began reporting to Health Commission on covid19 related activities at that time. And whereas, on february 25, 2020, ma mayor breed with input from dr. Colfax and dr. Aragon was one of the first cities in the United States to declare a local emergency due to the threat posed by covid19. The San Francisco board of supervisors concluded and in the mayors emergency proclamation on. And whereas, march 4, 2020, the california Governor Newsom declared a state of emergency due to covid19. And whereas, march 6, 2020, dr. Aragon declared a local emergency and board of supervisors con curd. And whereas, on march 6t city issued Public Health guidance to encourage social distancing to disrupt the spread of covid19. And whereas, march 7, 2020, dr. Aragon ordered city facilities to cancel nonessential group events of more than 50 people and prohibited visitors z lagun hospital. And whereas on march 11, an order was issued of 1,000 people or more in public gatherings. March 13, 2020, he issued and order prohibiting gathering of 100 people or more. And whereas dr. Colfax and dr. Arrgon worked closely with several counties to align the area in a uniquely coordinated covid19 prevention and response effort. And whereas, on march 16, 2020, dr. Aragon issued an order coordinated with five other bay area counties for residents to stay at home through april 7, 2020. And on march 31, 2020, dr. Aragon expended to may 3, 2020. And whereas on march 19, 2020, Governor Newsom following the leadership of San Francisco and five other bay areas counties issued an executive orreder to require californians to stay at home and whereas, dr. Aragon continued to put forth a series of innovative Health Orders to outline necessary measures to protect the health and well being of all San Francisco residents and to focus on the most Vulnerable Health population. And whereas dr. Colfax and other d. H. P. Leadership have worked closely with state and local leaders in the complex procurement to expand the hospital and medical shelter capacity and purchasing personal protective equipment and testing supplies. And whereas, dr. Colfax, dr. Aragon and other d. P. H. Leadership has coordinated with nonprofit organizations and businesses to develop the San Francisco community of care including sharing of medical staff and precious resources to increase medical Surge Capacity and resources devoted to the covid19 responses. And whereas the effort to provide transparency and keep the public informed, dr. Colfax and dr. Aragon and others continue to lead the pace to coordinate important covid19 case data, testing data and give updates on the Public Health response. Now, therefore, be it resolved that the San Francisco Health Commission commends dr. Grant colfax for his steadfast and compassionate leadership during the covid19 pandemic. He continues to lead the d. P. H. Through the ultimate challenge of temporarily repurposing 2 billion department to respond to the Ongoing Health crisis. And further more, we extend our gratitude to dr. Aragon whose orders having progressive and clear for residents to protect their health and save their lives. Therefore, be it resolved, that the Health Commission acknowledges the staff of d. H. P. And Incident Managers and the Emergency Operation center and include d. P. H. Director of health, dr. Susan phillip, Deputy Health officer, and director of d. P. H. Prevention and control. And others. Zuckerberg San Francisco General Hospital chief operating officer. And further resolve that the Health Commissioner recognizes the leadership of dr. Susan urlich, chief executive officer of zuckerberg San Francisco General Hospital. We thank them for their inkrenl leadership and hard work to ensure each object continues to implement covid19 response. And further, we express our deep gratitude for every Health Employee for the final contributions made each day to benefit the health and well being of all San Francisco residents. And in labs, and testing center, shelter, hotels and on the street. And further resolve that the Health Commission thanks the staff of all d. P. H. Partner, especially other department, local hospitals and special appreciation to ucsf, and communitybased organizations for the ongoing work implemented each day to impact and save live. The next clause is suggested by commissioner chow. Further be it resolved that the Commission Urges the department to continue their collaboration to successfully combat the pandemic and further resolve that the Health Commission thank members for their requirements and protecting the most vulnerable individuals in San Francisco. And further resolve that the Health Commission expresses deep appreciation to mayor breed for her bravery and skill in leading the city during the crisis. And to the San Francisco board of supervisors for their support on Public Health related issues and leading us during this time. I hereby certify this Health Commission at the meeting of april 21, 2020. Commissioners, the resolution is put before you. Thank you, mark. Before we go, i understand that members of the department of executive team may have another pressing item they need to attend to. If that is indeed the case, would it be appropriate to give them an opportunity or for us to thank them specifically for their fantastic work and allow them to move on to where they need to be. Director colfax . Absolutely. Yes, i will stay, but other staff should feel free to attend other matters. Mark, i would like to offer one quick amendment in the second whereas clause to follow consistency and acknowledge the extraordinary leadership of mayor breed in the bold, early, and aggressive action. Later in the sen ten, mayor london breed was one of the first mayors rather than cities in the United States to declare a local emergency. Great. Thank you. I will note that. Thank you. And before opening the floor do we need a motion first, mark . You can get all of the amendments and then do a motion per amendment or take it one by one. That is up to you, commissioner. Commissioner i think we can do them all together. Are there any and is this an appropriate time for comments from other commissioners . You should go well, if you are going to do amendments, you can do that now. And then in terms of comments and discussion, wait until we see if there is Public Comment first. Are there amendments and if not, does someone have a motion to approve as amended . So moved. Second. Mark, please take a role call. Actually, first you take Public Comment. Moderator, any Public Comment . Any Public Comment, moderator . No. No, so i will do a role call, commissioners. I will show my face so we can look at that. [role call vote] commissioner, if you want to end this item gore to see if the commissioners have any more comments or do any personally thanking. I would like to offer the opportunity for commissioners to offer comments. First, i would like to begin in addition to acknowledging the people of San Francisco for the sacrifices they have made in order to comply with the orders that have been placed, that are literally saving lives every day. We cannot express in an appropriate depth of gratitude that we feel to the employees of the San Francisco department of Public Health, so many of whom are working 24 hours seven days a week in order to protect all of the people of San Francisco, particularly those who are most vulnerabled a at risk nor pandemic. All the way from director colfax throughout the entire department and Outreach Teams on the street, we are inspired every day by your leadershy and commitment. And the behavior that we can only hope to model as commissioners in upholding our role to support you and your fantastic work. Words cannot express the gratitude that i personally feel for you and like to offer an opportunity for my colleagues on the commission to add their words. Commissioner, please raise your hand if you would like to speak. Commissioner chow. Yes, thank you. I also wanted to express beyond the former resolution and gratitude and absolute joy. This has been perhaps the most horrendous Public Health event that we have faced as a city maybe in at least certainly within my time on the commission, and probably extends all the way back to 1918 if we were to read the history. I can only be astonished at how well our department has responded. I have not seen the department as unified as it is today in trying to answer our great public need. This resolution doesnt really do justice to the work that the 8,000 members of our Health Department does and how the citys other departments as dr. Colfax has noted, have stepped up and really responded to understand the health needs and need for us to protect our community as such. So unselfishly. I wanted to say that i was very proud that i was able to actually be a part of this commission during the time and this is the First Quarter that we are at least ahead in the First Quarter. Thank you. Other commissioners . Commissioner chung. Yes, thank you for directtors and dr. Aragon for your work and leadership. Personally i dont think anybody should have to have the experience of going through two deadly pandemics and unfortunately it seems to be the burden of our generation. With that said, i am so glad that i live in San Francisco, a city that provides not only Compassionate Care but also voial support to the most impacted and the vital support to the most impacted and the most vulnerable to the virus. It is not just gratitude. I think that for me there is a sense of pride to be able to brag to other colleagues about how well we are doing. And i express my deep appreciation to all of you. Thank you, commissioner. And a unified force, there is nothing we have ever seen. My only reference is my dear grandmother was here in the 1918 spanish flu. And she had given me some of the Horror Stories but how at that time in 1918 that the city of San Francisco did really come together as we are doing now. Thank you to all of you for your wonderful efforts. Thank you. I just want to reinforce what everybody else has shared on my colleagues. I cant express enough how much respect i have for the whole department. Also knowing that you are at the start of this short of executive staff and short of resources to need in a normal time to have responded to quickly and to work so closely in coordinating with all of the different departments under the leadership of mayor breed. And i think across the country of all of the different places and the tragedies that many of our vulnerable population and community are experiencing, i just wish that there was a way to transport the kind of leadership in community and sense of common good that we have here in San Francisco. Even with all the questions and all the kind of wanting to be better sentiments that are expressed by many of our advocates. I do feel that San Francisco is most fortunate. Words cant quite express, but again, justice want to express thanks and gratitude, respect, and i know that we have a lot more to go. A lot more road to go and we will be there. We are all in this together. A commissioner green. Yes. It was said so eloquently by all of you. I am on the front line. I am in the hospital every day. And the example that this department has set and our mayor and our staff has set for how to be compassionate and how to Work Together as a Cohesive Community has been so reassuring for those of us who are potentially exposed to the disease on a daily basis. I am so impressed and incredibly grateful for the speed with this which this department has acted, for the speed with which the mayor identified this problem, and in the face of potentially a lot of controversy and question from national sources. I think its resulted in so many lives saved. I think every person in this community and particularly everyone at the d. P. H. And mayor and department of supervisors and Mayors Office can take credit for keeping citizens alive and healthy. I feel that deeply and personally as someone who is an age that could potentially make me vulnerable. I just cant say enough about how proud and humble and grateful i am for everything thats been done. Thank you for your comments, commissioners. Mark, shall we move on . Item 8, actually, and give me one second to post try to post there we go. See if that is going to work. I want to post the Public Comment info for you all. Were going to move on to item 8 which is the contracts report. Mark . Yes. An i would just like to thank the commission. Thank you, director colfax. Please, feel free to say more if you would like. I just want to thank you for the kind words, the recognition, and really reinforce that the team has been has been working very hard. And the people that they are caring for every day will continue to need our help and support and one of the things that is so inspiring to me and the rest of the executive team are the people on the front lines who are caring for people in the hospital, going to the people who need to be interviewed and cared for in a supportive way, meeting peoples Behavioral Health needs and the concern of individuals and families and the communities. Going to places like the mse south shelter outbreak and people on the Street Medicine Team that worked all night to ensure that the guests and the staff of that shelter got the care they need. I just think every day im inspired by the work that the team is going and inspired by the work the city is doing across the various departments and collaborating like never before. I am grateful and honored to be able to support the department and thank you for your kind worted and recognition on behalf of all members of the department. Thank you, director colfax. That was beautifully said and the entire commission stands with you in gratitude and pride. Okay. Hard not to cry hearing all those lovely words. I am going to post the Public Comment information again as we move on to item 8 which is the monthly contracts report. There will be several contracts here with several presenters. Eeveryone on the line, only nine people can be on camera at a time and for instance, dr. Colfax, if you wouldnt mind taking the video off at this point, and dr. Aragon as well, if you could take your video off and i dont think we will need you for the contracts. Thank you. And put miss ruggles and on there we go. This will take a second. Some are on audio. The microphone is off. Thank you. D. H. P. , business office. This feels like the old world and there is a series of contracts and i will group them where they are groupable and go through them, but this first one is with the San Francisco Public Health edition and it is a new contract that has services that are ongoing and management of management, Program Administration of existing subcontractors and is an Ongoing Service that is the Public Health foundation has provided and continues to provide for many of our services. So this previously had been provided with the particular subcontractors under the San Francisco study center and moved to the San Francisco Public Health foundation as the result of slis sayings. And o solicitation. And the services in this contract are through the Public Health division and are providing several Community Capacity building and promotion work and this contract will be for a term of four and hah half years with a total contract amount of 3,610,930 and the annual amount is 665,383. I realize normally we include the prior annual amount so you have something to compare it to, which we did not. And missed that this time. So i added it to the ones where dr. Chow has specific questions, but if you have any programmatic questions and i believe and i believe that Patricia Irwin is on the phone if you do have questions. Commissioner, any questions about this contract . This is dr. Chow. The question really is, is this the same as selena health . Or why are we using two different titles for these things . That is a great point, which i didnt even the Public Health Foundation Actually now you have tote that is different. San francisco Public Health foundation is the Public Health foundation and Heluna Health is different and used to be Public Health foundation copolymer prizes. Foundation copolym enterpri. The first one is the San Francisco Public Health foundation. The Public Health foundation and started several years ago when dr. Mitch cass was director. And so that is separate than the Public Health Enterprise Foundation which was something completely different. So we are on the Public Health foundation contract right now. Commissioner that is different from the Public Health foundation. Yeah. Commissioner all right. Any other questions . We can move on to the next. The next one is Heluna Health, formally Public Health Foundation Enterprises inc. Now its doing business as Heluna Health. So contract is an amendment adding 1,027,708 and we are extending the current term by 18 months through june 30, 2024. You actually previously approved this contract on june 5, 2018. This contract provides i shouldnt gotten water. Program administration and support services to the Community Health equity and Promotion Section and so in this one they do have Heluna Health provides Administrative Services for the continuum of h. I. V. Prevention and care and treatment program, San Francisco ending the epidemic, and then hepatitis c virus Public Health services program. And the department has brought this contract back and received additional Grant Funding and so we just are increasing the not to exceed amount to include these additional funds and extending the term. A commissioner, any questions . If none, we can move on to the next one. We had three contracts with the San Francisco Health Authority that we also refer to as the San Francisco health plan. The first is the payment to private providers and the next two are Third Party Administrative contracts. You approved these are all been pretty recently approved. August 2019 and in one of them in november, but what were doing now because from the last years presentation and also the one in november you might recall that we reconfigured some contracts and consolidated them and started up new programming with the deactivated fund. You can hear me because i am on the phone. Awe it is fine. So anyway, these three contracts and what we are doing is extending them to multiyear instead of one year contracts because everything is in place and are going to the board of supervisors and back to approve the now new contract which were doing for four years. From reimbursement on nonhealth network care provideers and participating in the healthy San Francisco private provider network. And also payment to Ambulance Companies proprovide answer transport, pharmacy benefits for specific healthy San Francisco medical homes and reimbursement for providers providing gender confirming surgeries to the gender health San Francisco program. I can go through all three and you can ask questions and with the representation on the phone or maybe in a picture. Would you like to go one by one or all three . I would like to hear them all. And to start july 217 and this is providing that and language enrollment assistance and customer Third Party Administration for the healthy pedestrian program. The last contract is the Third Party Administrator city option. This contract also is a new contract multiyear going to the board of supervisors. With that, i would probably turn it over to alice if you have specific program. Commissioner, are there any questions . Seeing none, we can move on. The next question is Harm Reduction Therapy Center and is a Behavioral Health apt and extending the term by one year. The reason that the amount is bigger and we brought the contract to you in december 2018, you approved it as a new contract for the homeless treatment. Right after that, the mentally ill homeless treatment and funding was added to the contract and i think we brought the grant maybe separately as part of a broader discussion. But anyway, it got added into this contract and more recently some homeless outpatient treatment funding. The homeless mentally ill Outreach Team provides street medicine through the healthy streets operations center. And they have a mobile van, and then the Outpatient Treatment Services are to outreach and engage people who use drugs on the street. They have Harm Reduction model. It is an ongoing contact and realigning it and bringing it back because of the additional funding and extending the term to align this with the same end date. And i believe if you have questions, Marla Simmons is on the line. Any questions, commissioners . All right. Seeing none, we can continue. Okay. The next there are six contracts that are actually related to that power point that you have. Were not going over the power point today, but dean goodwin is on the line. We have tried throughout the last couple of years to Group Contracts when it was possible coming off as a solicitation so we could ground the explanation in a broader look at the program. So dean put together super comprehensive power point presentation about h. I. V. Health services and within that he set very specific contracts. So you have a group of five contracts that are part of the center of excellence on slides 8 through 15. It is all the next side except west side. West side is part of the Home Health Care and Home Community based Health Care Services on slides 20 through 22. They are all Ongoing Services providing the same doing the same thing essentially. I dont have this slide deck open, but slide 8 through 15, you can see what the center of excellence is. If you have specific questions about any of these contracts, dean is on the phone i am sure to answer. I did want to comment that i thought the presentation and the power points were really helpful and normally if we were at our usual committee meeting, we could get a better explanation, but it does assist us in understanding what the contracts are all about. And so i just want to commend staff for having put that together. And on top of that, and thank you, commissioner chow, i just like to remind commissioners and those who may be viewing from the public that although the governor and mayor did provide an opportunity to hold the meetings and the commission serves the roles as various committees as we consider things such as contract so all the work of the finance committee is being done by the full commission. So were grateful to commissioners and members of the public for your patience as well as to the staff for the hard work in putting together the presentations. Other questions, commissioners . While were looking at the whole block, i wanted to extend moi commendation to the information that they did provide me and the commission in regard to the contract what we commonly call the San Francisco health plan for their Administrative Services and we had to go back several times to get clarity, but we were able to do that. I really appreciate that. Thank you. So do i. And then the next contract is not part of that group is haluna health. I am not sick. And that one is im sorry. Dry. The approval of haluna health for the amount of 520,295 for the period of it is an amendment to extend the contract excuse me. It is actually an amendment to add funding into the contract and the funding is because we have received additional grants. We received 477,974 in additional federal c. D. C. Grant award, and then we had carryforward funding, and then the last part that is 42,000 is the contingency. It is a contract that you have seen before, but anyway, if you have questions, we have staff on the line. It is pretty straightforward and just adding money to an amendment. Miss ruggels, if we were in person, we would be offering you water. Do you need a moment . It is so dry in here. Am i allowed to suck on an lozenge . Yes, of course. All right. I am recovered. Good. Thank you. Do you have any questions on this one . A commissioners . Seeing none, we can move on to the next contract. Okay. And the last contract is the justice and diversity Bar Association of San Francisco. This is actually Ongoing Services but it is a new agreement following solicitation that was just completed. This contract does add legal work to help clients effectively document their disability claims and help them get back their disability claim helps them to be success nfl obtaining their benefits and provides advocacy in assisting them if they have challenges in order to attain those benefits or be reinstated. Again, it is an ongoing contract that we just did an r. S. P. Commissioners . An any questions from commissioners on the contract support . I believe that is the final contract, correct . We have two memos. But the two memos are separate items. A right. So commissioners, i am going to first check to see if we have any Public Comment. Moderator, do we have any Public Comment for this item . Any Public Comment . No, no Public Comment. So you all can vote on as a whole on this item and so ewith would need a motion for that. Is there a motion to i a prove . An i move to approve. I second. Thank you. I will do a role call vote. [role call vote] we can move on item 9 and get myself on here. Sorry about that. Item 9 is request for approval of new contract with prc baker places to support the creation of Behavioral Health respite center. Right. I will introduce it and if you have questions, Kelly Hiramoto is on the line for this. You might recall from recent hearing about this new program, prop i hearing, but this is the contract that comes with it. This is the request for approval and new contract with baker place and prc baker place for this service. This is the second of two programs they provide. This is the second one and opening up at 11 56 valencia street. It is a total contract amount over the term of 7,777,339 and annually about 2. 9 million. Since we had the hearing, the two things that have happened were that, one, you can see that at lo. O funding for this program is funded by a grant by tipping point. And the board of supervisors approved that grant since we were last in front of you. And then the other thing is that theyre leasing their location through a city lease withle is Activation Army for this program. And that was also approve by the board of supervisors. But if you have other questions, i know kelly is there. Any questions, commissioners . If we have no questions, mark, we can move to a vote to approve. Mark, you are on mute. So we need a motion, commissioners. So moved. Second. All right. I will do a role call. [role call vote] item 10 is the request for approval with a new contract with Bardy Diagnostics to provide a cardiac rhythm monitoring device for patients of d. P. H. This is an agreement in 1,151,068 from may 1, 2020 through april 30, 2023 and this is a new contract to provide a cardiac rhythm ambulatory monitoring device that is a small wire free patch that can be worn continuously by patients. I am not going to go on because i only know what the words say, not to explain it, but there is staff online if you have any specific questions about how this system works or what the goal is beyond whats been written. This is sort of a contract for up to and then provides the ability to use the machines or i should say the ambulatory devices and keep the entire block. I dont believe they will expend anything that isnt used but i will let the staff respond to that. Good afternoon, everybody. Rosaly and the medical director is actually on board. Are you on the call . Can you clarify if you dont use the full amount . So we replenished stocks. That was my understanding and i wanted to be sure that you understood. Thank you. Any other questions, commissioners. We need a motion to approve. So moved. Second. Thank you. I will do a role call vote. [role call vote] item 11 is zuckerberg San Francisco General Hospital regulatory status report. Thank you to the team and everyone who joined the call for the contracts report as well as the new contracts. Thank you very much. Thank you for giving me time on the agenda to bring you up up with the things happening at zuckerberg San Francisco in the last coup of months. We selfreported three events and putting together responses to the events. If you remember last year the law changed around selfreport and they are investigating the reports we send to them and asking them to report them to the joint commission that occurred simultaneously. And that acute care and we have two teams of surveyors at the beginning of the covid issues there. Both were slated to go for five days. And on the fourth day of that survey process and we have our first positive patient with the state of deficiencies and with very few findings. A lot of what they were investigating they were not able to substantiate or not find any serious issues around the hospital and see the summary of those. From the course of the last six to eight months we have been working with a difficult Patient Population and had some issues with staff. We are at a point now where we are almost bringing those two complaints to an end. They had the list of citations they were planning to present to us and gave us an opportunity as an organization to respond and provide evidence to how to address them. And many of them we have done a lot of work in the last six to eight month and that is secondary to the work place violence headed out to do a phenomenal amount of work to standardize how we respond to violence towards staff at the General Hospital. So the fact that they are given an opportunity to curb the citations and respond to them before they issue the final statement i think speaks really well to the amount of work they saw that have been that had been done over the months they were working with us on the investigation. I will ask if there are any questions from the commissioners about the things on the report at this moment. Under the validation and do you know what they were citing . It is related for complaints. That is a great question and the governing body was not related to the complaint. What happens when the complaint validation survey is initiated is they address the complaints and also have a workbook with certain things they have to look through. One of the things was contracts and did not have all the required pieces to demonstrate in the meeting inches to the j. C. C. I feel very strongly it was a paper work issue and they acknowledged that during the survey. As part of the process we are looking at how to review were sorry. Your conference is ending now. Please hang up. Are the people still online . We are still here. I am still on the line. Still here. And what were doing with that is the way that we look at the Quality Metrics in each contract and we will have them presented to pip. Pips will report the metrics to the m. E. C. And bring it to you as an overview in our minutes. That way we wont miss the contract. It was purely an administrative miss, but it is still important to make sure the contracts are monitored by the governing body. Thank you. Any other questions . Moderator, is there any Public Comment on this item . No. No Public Comment. So commissioners, shall we move on to the next . Item 12 is zuckerberg San Francisco general Hospital Medical staff report. And several action items on this. Again, for the members of the public and those on the commission who usually are not on the joint committee, this is kind of business that is usually done at that committee. I am not sure if she is visually present or just audio. My intent was to be visually present as well. I dont know if anyone can see me. This is the first time and i can see all of you. We cannot. What number lets see. I dont think its vital that you see me as long as you can hear me. The other thing is that there is this delay when i am actually on the video. So it is my audio is via the phone so i can be simultaneous with the proceedings. Sure. I do not have power point slides and i do not think i have to have a visual if you are okay with me not having a visual. Please proceed, doctor. So thank you so much. Good evening. I have several items for you to review. And dr. Chow, thank you for your comments and your questions. I wanted to clarify that we changed the actual state of the privileges and have major revisions and do not change the dates at the title of the actual privileges or the sps. That was one question i know that you had. We have a revision to the privileges and the orthopedics privileges. And we have the p. A. Practice agreement and preamble. And there is one provision that addresses the idea of home visits and this is something that has come up recently. And we have recent Clinical Services have done home visits throughout the years. They have not always been cleared out clearly in the spelled out cloorly in the privilege. We wanted to be more specific and deliberate about that. But in addition with the covid situation, it does bring up a specific situation and we have had some of our patients who are pregnant and towards to end of the gestation and third trimester and needing patient care who have been in quarantine for covid and physically unable to come for visits. Both our nurse practice tigsers sorry, our certified nurse mid wives in the Ob Department as well as our faculty gynecologists have requested privileges to do home visits when those situations awe rise. So we discussed that at the credentials committee. I also discussed it with our contact with the City Attorneys Office and the Exec Committee approved those privileges and standardized procedures. Any questions about that . Commissioners . Looks like commissioner green does. Yes. Two things. One is does this include the townhouse visits . In other words, i was trying to find whether tele health is part of the previous privileges or whether it needs to be delineated. We are doing that extensively and i wondered what other options and you have a robust system at the hospital. I was wondering if that includes that. That is a great question. We have not we are actually all doing tele health right now. So we are we have not gone back to all of the privileges and specifically called out that tele health is a privilege. It seems to fall within the general privileges to me, but i think if we actually were to add that, we would need to add it to all the privileges and i dont know in that is necessary. And sterilization and i am sure has been banned and whether that is on the list or not, i am not sure, but it isnt been done. Just a little point. Thank you. I will take that off. That was again, this is not a major revision and we dont have to go back and go back to and any over questions about the procedures . If not, i will move on to the orthopedic privileges list. And the privileges list is a minor revision and we have specifically addresses when we have a podiatrist and orthopedics and the different skills that they and tasks they take on. And specifically asks orthotics and oversee and that is that definition to that privilege. It was actually in red and it is. When we are in the regular routine of thing, we plan on doing major revisions for the standardized items and these are the minor revisions to make sure we are crossing our ts and dotting the is in the case of the orthotics. Moving on. I know that this create some confusion and the p. A. Practice agreement and preamble are documents that the state licensing board for p. A. S have recommended that institutions adopt so that we know that we are following the guidelines for supervision and scope of service for p. A. S. And so i think there was a question that came up about the fact that there is these are what we adopted as a template for all of the services to use so that when they are using a standardized language and template for the p. A. Privileges in each of the departments. They continue to have state your department here and these are the templates that the credentialing Committee Approved and n. E. C. Approved for the Clinical Services to now use in their own sites when they have a p. A. Actually, we dont have p. A. S in many of our clinicals, but we wanted to have a standardized approach to the documentation for their oversight in their department when those departments did decide to hire them. Along the type of supervision and they have and updated in our own policy and procedures. As a template, these are like when you go to the standardized templates, and you take out the ones that arent pertaining to that particular person, is that it . Right. When we actually have if there is a clinical site, for example so if you look at the practice agreement, i think, the last page. It has a site where you can indicate all the p. A. S that are working in that practice site. We are recommending that a Clinical Service site has p. A. S working in that service site adopt this and lift the p. A. S and currently active members of the med staff in their service. And kind of having a blanket and with the inpatient unit. Commissioner on the standard procedure template and you can modify that in order to work on what the p. A. Is. Yes. Commissioner that is fine. Then we wouldnt recommend they do it per person but per that clinical unit. Commissioner okay. Any questions about those . I think we can move on, thank you. I believe we need to vote to approve all of those. Yes. We need a motion to approve all the protocols and policies that were just discussed. I so move to approve all the protocols. And is aekd please. Second. Great. I will do a role call vote. [role call vote] that item is passed. So those of you who were on the line from the public and in case you would like to make Public Comment, the line has been disconnected and reconnected. So you have to call in again. And i am going to say the number which is on the screen right now. To call in in case you would like to make comment for the next item. 8883634734 and 2241350 and press pound once you get in. Moderators, are there any questions or any Public Comments on this item . Okay. So i think we can move on to item 13 which is other business. Anything, commissioners . Item 14 is a consideration of a closed session. Is there a motion to move into closed session . So moved. Second. So commissioners, i will do a role call vote. [role call vote [ commissioner, and folks who are on line, here is whats going to happen. I will end this meeting and this is the d. P. H. Staff and will not be moving into closed session unless they have been authorized to do so. And first folks who go into closed session are the commissioners and is sfg staff because it is it is a credentialing matter. Once we are done with that t laguna honda folk cans sign on. For right now, i will end the call and go to the next either in your calendar or in the emails i sent you with another link to go to the next session. All right. Thank you, all, for joining us memb a we need a motion whether to disclose or not to disclose. I will do a role call. [role call vote] thank you. And then the last thing you all can do is adjourn. Is there a motion to adjourn . No, i want to keep going. I am ready to put my mask on and get out of here. Please adjourn. All right. Thank you, all, so much for your patience and for this long meeting. I will be in touch with you tomorrow. Thank you, mark. Good afternoon. Welcome