Transcripts For SFGTV Health Commission 81616 20160820

Breslin karshmer, present. Before we go on to the meeting itself id like to welcome our new commissioner commissioner jimmy royce. He is no stranger to the this department having worked here a full 20 years before retiring as Deputy Director back in 2007. We are happy to welcome him back and to assist us in developing the policy for the department that he worked for. So, welcome on board commissioner. Think you commissioner kalb next item please yes. Item 2 is the approval of the minutes of Mission Meeting of august 2, 2016 the minutes are before you for approval. Is there a motion for acceptance . Moved and seconded. Other corrections or additions to the minutes . If not we are prepared for the boat. All those in favor say, aye [chorus of ayes] opposed . The minutes have been approved item 3, directors report good afternoon commissioners and welcome to make commissioner royce. I wanted to just get a couple eight could i do about items on the agenda on the report in your welcome to ask any questions. One in particular with the health apartment investigating eight bible incident that second 19 people. Was candy that was at a Mission District on august 6 and was suspected and we believe to to be edible marijuana that [inaudible] found thc. The main psychoactive ingredient in marijuana in addition the lab work for 12 hospitalized patients was tested positive for thc. The most recent part of this was all of the 19 patients that were impacted by taking to the hospital on saturday, august 6 and were discharged by the following monday. But many of them were male, nine were female 13 of the patients were 18 or younger. The San Francisco office of California Poison Control Center has been working closely with hospital reading these patients were treated patients collected information on Patient Laboratory results. I do want to say the San Francisco Police Department is also conducting an investigation. Our Health Officer is here if theres questions but luckily, all of the patients were discharged and this ongoing investigation. A quick update on 12 San Francisco residence of those impossible for zika residence as august 12 contacted the patient will traveling in countries with zika viruses circulating. Theres no risk to the public and zika is not circulating in this area with al lawyer incompetent the department of Public Health informed the San Francisco of the bombing of positive test results in the council california continues to update public weekly tally of the numbers of cases by county and provide pregnancy information can as you might have seen in the paper recently, the entire area when rico is right now impacted by the zika virus. So, we keep our eyes on this. We know that mosquitoes are not as prevalent in San Francisco but we have this year added another Vector Control personnel to make sure that people know how to manage mosquitoes in the San Francisco entered so people get concerned about mosquitoes and wicked i know we have a long agenda tonight and if theres any questions on here im just wondering if dr. Aragon wants to give us an update on thisthe edible marijuana . Good afternoon. So, around 930 on saturday evening this was i believe august 6, at a teasing you in the Mission District several children became ill. 19 people were hospitalized. 13 of them were actually minors. Fortunately, for us, the people the patients were covered relatively quickly and what we do know is that they consumed a gummy ring that contained cannabis. So, we were able to identify both through the urine toxicology screen in the hospital. Were positive for thc. We were also able to identify in the gummy rings was also positive for thc. We were able to trace back and identify how that made it to thebecause of the Police Investigation were not saying anything else because there are are still questioning people to figure out exactly what happened. I got involved on the next day which was sunday, and we made sure that what occurred there and what occurred that night would not happen again. Of course, arrest witnesses are concerned we have around cannabis edibles becoming available to children and we know that around the world theres actually products actually treated in a way that are theres cookies and brownies and candy, so theyre attracted to children get in San Francisco, any edibles they have to be packaged in that hope a package that is not look at all like candy. The other thing thats happening in San Francisco do we do have a task force thats been working on preparing if the proposition passes to legalize recreational use, that we arethese are the kinds of issues that are going to be addressed to make sure that, if cannabis is legalized, that we ensure product safety. In the experience of other states that have legalized marijuana, has there been such incidences . There has. So colorado come i think has captured most of the experience around children eating edibles. Fortunately, adverse outcomes like death is very very rare. So, these when these patients become sick they require Supportive Care in a healthcare facility. But, it isyes, this has been an issue. I believe, probably this maybe actually the biggest outbreak that we know of involving that number of people could 19 people want on is pretty big. Actually can i want to give a big shout out to the ucsf Poison Control Center. They were phenomenal. Theyve been really helpful in these types of events in the collaboration with ucsf and us and our being there at the zuckerberg San Francisco General Hospital and then join following up on the test results they were really good. They have fellows following up to make on the clinical outcomes of the patient as well as the toxicology results and then their lab was involved in actually the testing of the gummy rings. I just want to say they were very good. If i may, our team internally in the Department Works really i think really well together and also informed the family, informed the family members, so i think another test to our Emergency Response could i think we did the job of making sure the public understood but more poorly the people that attended theas you know kids will take that kind of candy and take it home so we really did work closely with the families that commissioner singer i had a question relates not to the issue of cannabis into candy, but more our response as a city and what observations that we had and learnings we had in this incident and in particular, the question it seems to me that like with infections in these outbreaks, the issue of when like a seminal event is like a normal course event in an er and when someone in an er or Doctors Office across, there could be more of this and this is so nonstandard that i need to notify someone in Public Health so that someone here can say, oh god i got for calls from four different institutions. How fast, how did that work in this situation and how satisfied are you with that we have god, those notes out there sniffing if you will . So, for my perspective this is interesting for my perspective oftentimes we learn about outbreaks they often are associated with for example a restaurant were usually clinical site thats being in the case we hear. In this one it was really the ems system been alerted from the ems perspective they called a mass casual incident because they had several people that one time need to be transported to multiple hospitals. At the moment that we hear about Something Like this, is that we can consider it an outbreak because its more of aits more pieces of the sewing somewhat unusual than for a place and time. An at that moment, we think about how to find out the source. Is this a type of the iceberg . Are there more cases . If there circulated product out there that me getting more people becoming ill . If we go downwe dont know what happen we go down that route which is really an outraged investigation should its about mobilizing a team of investigators to help through that investigation. We are reallywe were very fortunate that we were able to figure this out relatively quickly, especially when the urine toxicology screen cannot positive we are able to identify the candidate able to trace back how it got in there. So, i was, by sunday afternoon, we felt very confident that we figured out what happened and it was did not spread further. But those are sort of the two different paths that things can happen. We just had a deep reef yesterday just reviewing everything because it involved us, the hospital, environmental hazmat was initially called out, so it involved a lot of different agencies and the Police Became involved as well. Fax. Any further questions at this point either to dr. Airey on what to the director on her report . If not, thank you. And i think that you are commendation to the Poison Control Center shows a number of years ago we talked about whether or not we were able to continue to be able to fund or have a Poison Control Center did i think this is just another very fine example of why its really important for a major city to have one. Thank you. Thank you. Next item commissioners yes next item please item for general public, good about received any request. I think we have one. Okay. Commissioners my name is double i usually tend up for one Second Opportunity minutes on the clock for you. Mr. Duffy, correct . Okay, 3 min. Hon. Dr. Chow. An honorable 10 sanchez and commissioners i normally can attend because i go to the board but on vacation for the month oh here it is august. I am on the tom odell advisory board. Press sometime we can do a more formal presentation because theres a lot of work and on Patient Advisory councils as part of the medical and Affordable Care act. Theres been a quite a bit of energy put into it and am pleased because were getting all of our support that weve got in recent years. A few years ago we got eight kind of an administrative hub because the Center Directors were eliminated in 2003. The minister backfilled at and we are getting a brand within a meet the new one. This is our second one, now. But enemy dumb on thursday. The kind of things that we can provide input on, the patient dr. Interface and the Human Factors being, is smooth. Those are the kinds of things that position can help with. A lot. I am very interested in the prime campaign and see what score to come out with that and how medical is can be optimized. Mr. Kaczynski here, also down because of interested in seeing how for example the hakim is going to fit in. I know they have a clinic and theres been some talk that the hot clinic by combined with that, without urban healthcare urgent care clinic downstairs. I dont know what happened with that. So im kind of interested in that as well. About two years ago there was a retreat and it turns out that your commission at a retreat. It turns out because of the open meeting laws of the public had to be invited. So, i happenedi happen to be there. Thats how i got. I noticed the meeting here i thought ill go to the meeting and, im not the fastest person to catch up on things and think about things. A delayed reaction sometimes and it was a lot of talk. Someone came and presented on the it situation. The servers and the whether it should be an email servers and all the upgrades were going on. He mentioned how things were in a bit of this array any mention theres even a server sitting on a desk in an office somewhere. As if that was a negative thing and i just thought about it a long time and kind of the thing i do is look at things that other people miss. It seems to me that we cant rebuild or renew our it infrastructure every single 23, four yet it is got to be a work in progress. In fact the fact there is a server sitting somewhere unused is actually a sign that were not heard back of transition which the technology were always going to be a proactive transition. Thats the ideal state it is the ideal state we can be in. Something i noticed retreat to years ago i thought i might mention two years late. They do. Thank you. Item 5 is the report that from the community and Public Health Committee Meeting from this afternoon. Who is presenting that . I have that. Commissioner pating were honored at the community and Population Health subcommittee. To have our new commissioner dr. Jimmy royce join us and commissioner chung. We are to reports. One from ms. Mary ann zell was the director of the maternal child and adolescent health division. The maternal and Child Adolescent Health division has 25,000 individual clients under care of which 82 are under medical. We reviewed the metrics for this division. Two of the tumor metrics id like to share with you were the desire to increase prenatal home visits and the desire to increase Fluoride Varnish so the department has set as its true north quality metric increasing home visits for families and mothers that are at risk for preterm or had preterm labors. This would be include africanamerican women, the first term pregnancies and particularly, those that made would be living in Public Housing and at risk for preterm labor. The department outlines three approaches that theyre using good one is visiting nurse family partnerships with user nursing thats pacific we work with highrisk moms to both before and during and after the pregnancy. Theres also a field Public Health Nursing Program and finally, a specific spell out program and were pleased to see the breath of these services as well as the focus that these National Best practice models of care brought to their disparate populations in africanamerican and latino communities. Also, we heard at this commission around Fluoride Varnish. This was elected again as another true north metric. Currently, 30 of 35yearolds of color have cavities which cavities ung youth set you up for poor dentures as adult. The department has achieved 80 of kids receiving Fluoride Varnish and so theyre making Good Progress on Fluoride Varnish. So we are going to be hearing from the Maternal Child Adolescent Health division quite broadly. We think tumor metrics which would been reviewing with that the subcommittee level and at this Commission Level, were enlightened with the departments goals and so we supported them in their efforts for these two initiatives. The second thing we heard was the rivera talked about the move from the San Francisco Health Improvement assessment which we heard two sessions ago to the development of the San Francisco Health Improvement plan. We talked about the three things that made the planned war that will tentativelywe discussed and presented to us in the plan in the following month in the fall. Im not going to go into two great detail but access to care which includes oral health, and decreasing hospitalizations for chronic diseases, Healthy Eating and physical activity which will be measured by making sure that there is food adequacy during pregnancy. Food adequacy for seniors that are on Home Deliveries and exercise and fitness programs for six and seventh graders and Behavioral Health treatment be adequate. These will be things that we emphasized in the upcoming Health Improvement plan but again this is the first draft. We were just raising questions to be able to help them focus the report. What we liked about this and what we will hope the commission will focus on is particular emphasis on disparities and inequities in the plan. This is a new approach to the Community Health planning that we did not have before. Before we look at citywide metrics for example for dental care, for return labor. And at this point what we are looking at is more of the inequities and moving in those subpopulations with regards to access, eating and physical activity and Behavioral Health. So, that ends my report and if you make questions of the glad to answer them. Questions commissioners . My only one was you mentioned that they were now at an 80 fluoride rate . I mean, thats fairly high from where it was before could probably talk about just the people that Maternal Health is taking care of or were talking about the whole city . Is mishandled here . Note . I can follow up on that commissioners and get that answer yesterday when you clarify with the 80 . The matrix we were trying to reach was to move from 73 of identified children to 78 of identified children needing fluoride treatment and they said they were at 80. So, i assumed is the population under sample and those needing and the number that was reported out recollected was 8 . So, okay does that help out . Not exactly because i was looking more since were talking about disparities that we are the biggest problems were and how they actually got to those. They were moving from 73 to 78 . Im sorry. The increase percent risk of children ages six monthssix years of multirisk for developing cavities receive fluoride punish application will go from 71. 5 to 76. 5 and a reporting at the meeting it was that 80 . So that it looked like we were meeting the target. I dont have thatthis was broken up by demographics or by disparate populations which as you and i have discussed asian population has very that was critically when i was actually looking at. Is that closing of the gap related to the some targeted interventions were not. We could probably find out. Ill work on that make sure you get that. Yes. Commissioner singer commissioner pating, i sort of a question which is kind of in contrast to some of the numbers that you just gave us where we really have defined targets for patient care. I was interested and look at the true north metrics that were presented to the committee and two in particular struck me as just sort of scratch my head on them. One was financial stewardship and one was Care Experience. The metrics that we were going after in each of those for financial stewardship among it was the percent of staff who completed medical time study. For the Care Experience it was to increase the percentage of patients who filled out a survey. It wasnt with the survey told us about the Care Experience. We actually only heard the last three of the true north metrics. The diagram on page 5 that you are referring to we heard about quality workforce and equity and we reserved for future discussions with the Maternal Child Adolescent Health division will be doing on the first three slides. We can ask the question to the staff. Commissioner i heard what you said we can pass that along to when they do the report they address those two issues. Okay. I think that would be good. So i think the commission and the subcommittee seven hearing the true north metrics presented in multiple ways and i think the department is trying them out to make sure that we are in agreement with the general direction and these will be refined over iterations. With only did three of the metrics today. Good. Further questions . If not, then we will move on to the next item. Thank you very much for the summary although theres no Public Comment for that request. The move on to item 6 which is update on the transfer of sf dph program addressing homelessness to the apartment of homelessness and Supportive Housing and commissioners, i just passed out to you a document director may prefer to an out run and open up the slide. I will be making the first presentation. Its an honor to be here with our new director jeff kazans feet of the San Francisco department of homelessness and Supportive Housing and a provide an update as well to the developers of the department. The commissioners have asked for an update on what we transferred to the new department and we gave you both things which was a financial which is 42. 5 million of services and also the fact that we are still involved with those who are homeless and well talk about that a little bit about that before introduce the new director to come up. So, 42 million, 8. 9 was 9 million, is the San Francisco was a reaching and theres only six Civil Service that are part of that. Theres over i believe almost 70 individuals who are the outreach team. Those are from a contractor so they would not be listed here under Civil Service could housing and urban health, 32 million, and that is the attachment we gave you with all of the Housing Units that housing areas that we transferred to the community departments. Under the Community Programs area, we cant conduct with homeless prenatal would almost 300,000 and many of you know what about labor projects is project homeless connect, which is a real opportunity opportunities to get involved in our own lives connect and daily connect it happens and thats 1. 1 million. As you know, the department serves Homeless Individuals every day and our job and im really proud of the fact that what the director of the new department will be doing is leveraging all of that housing route the city and we were not the only department to provide a transfer to Human Services. Did as well. They are the top two departments that did that. So, the housing component i think will be well taken care of. Also, leveraged with all the other departments. Our job will continue to be clinical and to support the individuals in those Housing Units and to work closely with the new director to ensure that the clinical needs of the clients in housing, those who are homeless, those without breach teams are continued to provide care. Mental services and primary care services. Also, at times having to be in our hospital system. So, we will continue to be partner with our new director and i want to see if theres any questions or the transfer of these funds and that we can ask the new director Jeff Kaczynski to come up and give his presentation. Commissioners, questions . The first presentation on the financial transfer. On the building where youre also talking about that these are the buildings attached to the 30 million transfer. So, the back page it looks like it mightve been cut off but it says ambassador and has little numbers. Okay. We can get that updated. It doesnt look like it came through which i think is a fairly sizable hotel. So, we can give you another update of that thank you. I will send that to you. I can print that out. Presentation is going on. Okay. That is fine. Any other questions at the moment in terms of the financials and the transverse . If not, we can proceed with the i just want to say this is done gone very smoothly. The new director can tell you exactly where they are in the process. But many of the staffers still where they are digitally in 101 as new opportunities form make space for the new department. We also are providing some of the personnel support and as the apartment ramps up its role we will be able to then go back to the role we play but right now we are trying to provide the services as much as possible to the existing services. So its a smooth transition and i think theyre going to be opt up and running very soon, though. Thank you. Salon by dr. Jeff kaczynski. Our new director of the San Francisco department of homelessness and Supportive Housing. Welcome. Thank you dir. Garcia and commissioners thank you for having me here today i has to give a brief presentation on the new departments did not just give you some topline information and be happy to answer any questions that you might have. Just a little bit about the problems that were trying to address and is currently 6700 people experiencing homelessness in San Francisco. Although that number has been relatively flat during the past five years, we have seen an increase in the number until third Homeless Individuals we currently have 3500 people approximately living on our streets. The mayor along with dir. Garcia and try and work on the Human Services agency, determined that would make sense to put all homeless pearl jams under one department in order to better coordinate the citys response to homelessness. The dph and ages they have done some very extraordinary work during the many years and providing services to the Homeless Population it i think most notable is that since 2000 2004 week of 23,000 people exit homelessness. I should also point out that some of the nationally recognized programs, actually internationally recognized programs, on how to address homelessness best practices used around the country were developed right here in San Francisco. Frankly, many of them were developed in your department. So you all should be proud of your roles in developing some model revamps including the direct access to Housing Program which is really seen as a Gold Standard for how to address the intersection between Health Issues and homelessness. Project homeless connect, the recently formed Navigation Centers in the countrys first lgbtq shelter and were all developed here in spirit San Francisco. Where we have fallen behind i think other communities is how these services are all coordinated and how clients are provided services and how we prioritize our resources. So, again denies dir. Garcia mentioned, we are funding programs and staff coming from multiple departments that you can see on this slide. Human Service Agency Public Health and weight cd, first five program, that apartment and status of women dc will wire which is not listed and the Fire Department all have resources and programs most of which are being consolidated into our department. We havent just a repeat of what i just saidlet me talk to you a bit about what our goals are in as well as our hoping to achieve them. Ultimately, the mission of our department is right coordinated and compassionate and highquality services towards the goal baking homelessness in San Francisco a rare breed and onetime events. Some of the we are currently working on developing a Strategic Plan but some of the topline goals that we have set by the middle of 2017 we will actually ended a chronic homelessness among our veterans in San Francisco. We are little bit over halfway there. Were hoping to be done by the end of december would have some challenges in with the ba ba and try to coordinate resource pools only by the summer at least a year from now will achieve this goal. We are hoping to reduce the homelessness list was away visiting our people the high users of multiple systems. Really the chronically Homeless Individuals interested were hoping to reduce that by 50 . We arewe will plan on working with private philanthropy and public resource to end family homelessness by 2019 and mayor lee has committed to helping to end homelessness for 8000 people which includes individuals and families by the end of his term in early 2020. Some of our priorities right now in how were going to achieve these goals. We are currently conducting a gap analysis and Strategic Plan can work with the nationally recognized organization that some great work in cities like houston and salt lake they may have heard of. Trying to figure out the flow through the system and really apply some sort of business sense and some Data Analysis. You some basic Operation Research skills to really figure out where the gaps are in the system and how we can best fill them. One of the other main priorities is developing this coordinated entry system for homeless folks, which right now there is 12 different databases that contain information and manage resources and services for homeless post. Were going to consolidate those into one database. Essentially, the system is going to triage people are homeless initially make sure if theyre having an emergency that theyre Getting Services immediately. Make sure they get assessed by single Assessment Tool which is an algorithm behind it which will help us essentially score people based on their acuity so we can prioritize people who are the sickest and have been homeless the longest for access to our shelter in our housing system. Which is very very different from the more firstcome first serve type system that we have in general in the city. I think the direct access to Housing Program and the Navigation Centers are kind of microcosms about things should work with a take folks who are the most acute and get them access to resources immediately. So the systems can be very critical in terms of providing Better Services to our clients, in terms of being able to have data in realtime and evil to evaluate better the successes of our nonprofits and make adjustments as necessary. Another top priority is of course addressing street homelessness particularly the tent and gammons that respondent or the city during the past year did we recently formed mcammond Response Team with some of you may have read about in the chronicle on sunday. We are currently working on a very large very old and very persistent encampment in the bayview area by islam creek that will be resolved in the next few weeks and we moving on and as that we sent out whether or not this is going to work and hopefully, our first round has been very successful. We spinning on this team and are going to actually post a list of all being gammons and our website and scheduled for resolution it we really want to be radically transparent with the public so they may not always be happy with the pace at which were working with being timid in their neighborhood is number one on the list but at least folks will note that were aware of the problem and well plan to resolve it. I really want to look in investing more homelessness prevention. Critically, working with the Public Health department. We have people coming out of Substance Abuse treatment programs that end up homeless. Weve invested tens of thousands of dollars in the recovery and then come back out on the streets again and wonder why we lapse occurs. So, really trying to figure out how to better use the prevention money we have available to sort of slowdown or shut off some of the spigots that the government really out of Government Programs theyre adding to homelessness and by that am also talking to cochairman of the medical system, folks coming out of the foster care system, folks coming out who are being evicted from our Supportive Housing system and folks in the criminal Justice System and try to figure out how can we slow down were hopefully stop, creating new homelessness to add to the folks already on the street. Lastly, were looking at expanding our double housing exits. A lot of people say theres not enough room in San Francisco and housing is really expensive. We have many many arrows in our quiver for how to help people and their homelessness. Boehmer Bound Program helps connect people to love ones and other communities. We will send them back home in follow up to make sure they are in stable housing and things are working out for them. We have master lease housing where we lease whole buildings or blocks of units from private whim words. Of course we are nonprofit developed housing. But also things like temporary rent subsidies, rapid reHousing Program. Thats been very successful with families that were looking out of single adults and also looking at housing outside of the San Francisco area. Julie got a lot of different tools available to us. When i expecting to build another 8000 units of housing for Homeless People in San Francisco. In the next few years but we are looking at improving how we use the resources that we do have in trying to be creative around positive execute very quickly, this is the investments the citys maiden homelessness. The increases you will see from 2011 to date, 35 increase in funding available around homelessness. That is why San Francisco has had a very small increase in homelessness during the past few years. Despite the increase in visibility, which is really another issue entirely, but compared to cities like la, dc, new york, seattle, denver, that ball had doubledigit increases. Some as high as 20 during that same time connected on the thing we should be cheering him for not getting much worse i think its important to note San Francisco is that a relatively good job compared to other major cities in the country. I think thats important to know our investments have gone well. Also folks often talk about the vincennes spends 241 million in homeless and i know you have heard this and we have not done a good job. Thats not quite the case. Stephen spends about 120 and about one 40 million is actually spent on keeping people in permanent housing. So to formally homeless fix. About over 50 million for medical services which will ashley stay within the department of Public Health. That leaves us with roughly 70 million the we spend trying to address street homelessness. So its not 241 million. Its quite less actually. Also should point out even if a was 241 million from its less than 3 of our citys budget that goes to the number one what many people think is the number one problem in the facing the city. So i think our investment seven used well. I think we need more investments but regardless of whether or not that happens i think we can do better with what we have. Current Department Budget is 220 million. The vast majority of that, one 75 billion going to nonprofit contracts. Lastly, the top two bit about how we envision working with an apartment of Public Health. As dir. Garcia pointed out, the hyperendemic and small contractor are what are coming over and we will be running those of the new departments. Dph will continue provide Clinical Services to people who are homeless by clinical support to the hot team as well within our Supportive Housing sites. We are currently working on coordinating the dph on whole person care program. Im sure youve heard about this. I wont go into details. We will also be working together really closely and this is really important, on access to housing and i know there are concerns that people who are high users of the medical system are getting access to who are homeless, getting access to permanent Supportive Housing. We are right with you on that and believe those are the people need to be prioritized for housing and the fact i think well be able to do this more efficiently under the new department. I think of the other more direct ways to partner that are still being considered. As a medical respite shelter that will be opening a be talked about creating Behavioral Health navigation center. Lastly, theres been a lot of administrative support from your department so thanks to you and dir. Garcia and all her staff. This transitional probably take up to a year to actually happen. Hopefully, well be picking up pieces little by little round staffing and contract support and around physically where we are locating folks. I think that we will be in a much better position around december to take on a lot of these new activities as the city is not trading a Big Department for a while and its been fairly smooth but its a lot of work. I think by next beginning of next fiscal year, we will be able to be operating on our own. Lastly, i want to just our mantra has been a longtime homelessness gets caught up in these public debates. We hear people with very an extreme views out the problems should be solved and we think that most san franciscans is one Compassionate Solutions but also the one commonsense approaches around not having tens on our street. But removing them in a way that is kind and humane and respect peoples rights. I ask all of you to to stand with me and most of the steady and calling for common sense and compassionate solution to not getting caught up in some of the debates that occur around the issue that of an unhealthy frankly, and kept us from being successful as we can be. With that ill take any questions that you have. Thank you very much. Questions, please at this point . Commissioner singer i just want to say thank you very much for coming to San Francisco and helping us with this. Thank you. Okay. Great well, no. [laughing] so, from your background how do you view because you seem to indicate that because we held the population stable people got house and we have another group of 6000, that this would be considered a avenue east, a measure of success, but the 6000 are still there. And it looks like every time we keep moving 6000 another 6000 arrived. I know youve heard that before, so you must have an expiration as to is this a given 6000 . Do they have different problems . No. A couple things. First of all we do a census of the Homeless Population every year. The last time we checked and its been pretty consistent, 71 of the people who are homeless on our streets were living in San Francisco before they came homeless does allude of a myth that all the homeless folks are coming in from other places and trying to access our services. The reason why we have house more people but we still seem relatively flat numbers and an increase in the shelter population, i think, are multiple. Essentially, it comes down to from 20072013, when the economy was in the doldrums, especially for lower income folks, we saw a big uptick in homelessness, especially among families. In fact, we start to enter percent increase in the number of humans were homeless during that period of time. We had almost 2300 students in the San Francisco Unified School District over homeless. The number has gone down significantly since that was the High Water Mark in 2014. So, as we continue to house people we are also facing an economy that has not been in a recovery that is not the kind to lower income posted we summer people struggling economically and so there is a supply if you will of new folks not necessarily coming from other places to get services, but who are unable to sustain their housing here in San Francisco. I think also, again, i think we have not done as good of a job as we need to be doing around prevention. As ive said, we people come out of our jails, people get affected from housing or people coming out of our Public Health system and we need to do a better job of making sure those folks dont become homeless or the we have a plan for them so they dont end up on our streets. But that sort of our best explanation around whats been happening in the city. As far as the increase in disability, sort of two factors at play. One is a lot of land that is owned by the state by the city, were privately owned is been developed that had sat fallow for a long target where people have been camped out and hunker down and not visible. They are now displaced onto our streets. The other issue is frankly, some folks decide to give out 14,000 worth of tense last october to the Homeless Community and that frankly created a large increase the number of tense and the visibility of the problem on our streets. Commissioner pating mr. Kaczynski, thank you for coming to vinton you been longawaited and i hope that this is been i guess yesterday was your first day, right. Ashley started june 1. But that upon it became official legally on augustyesterday. That is correct yesterday you got your license before but you got the only thing that changes my email will tie points to hon from and why art. Other than that we have not notice many ripples. Im interested in the integration of our Health Department and your services. One of the levels of integration am interested is the around data. It looks like youre going to need to know who became what and whos going where. How are you energy to do that when the whole system a summary confidentiality barriers around hippa, 42cfr as well as we dont have a centralized database yet but soon coming. What are your thoughts on accessing and integrating health data into a conference of we Source Center for your so you can do the job you need to do . So, thank you for that question first i just want to point out the nurses 1989. My wife is a Public School teacher. My kids are Public School teachers i live in the city since then in Bernal Heights area and work in homelessness for a while. But i am new to the city family. This the government family but bit around the city for a while. So, the data question. A couple of things. One is part of this whole person care application, which was committed to the state that is can provide us some resources to work out some of these issues and try to figure out the create a band diagram, dph has a data set. We have a data set. Theres some information in the middle were to be able to share. But it will be able to share more readily dph them dph will be able to share with us, but thats appropriate given peoples rights to privacy and the medical records. But we will be able to know things like that somebody is at the hospital were that somebody is a patient. You will be able to know that somebody is homeless and where they are in the system, whether theyre in a shelter, whether theyre permanent Supportive Housing. Theres a lot of details that need to be worked out but i know the citys chief data officer is actually working on the density making the entire city hippa compliant so data sharing becomes easier. But we are working lockstep with director garcia and her staff as were developing this database. Its been going to be really critical. The way that we see at work at least on our end, if somebody is in general and were anywhere in your system, and we believe that person is homeless or they tell you they are homeless, you be with to look him up to see there in our system and just basically know some very basic information about whether theyre in a shelter. Whether they have a Case Management were important, theyre not in the system you be able to enter them into our system and paying us that, hey, john joe is a general. Has no place to live. Can you please send somebody over here because there to be discharged in a few days going to figure out whether going to go to next. Julie be able to facilitate realtime communication between our departments. Given frankly, given the incredible advances in technology that happens every year come a really, but really in the past five years, some of the products that are able to us are quite sophisticated and a been tested in other communities. We walk the same changes we do and were very close to selecting a vendor and excited i think this is a real be a real game changer for the city how we adjust homelessness thats really wonderful good i hope that comes sooner rather than later. Related to pinging you come i think that actually is probably be getting more pains then you realize. You can just up off your cell phone over here. We will start calling you. It is my belief that probably by conservative gas, maybe as much as 10 of our inpatient stays are related to unreimbursed housing days were bad days were people that dont have it discharge by mail because they are homeless. Unfortunately, this is not being accounted for good my belief in the to and 20 million. If you look at the slice of housing, its probably larger because its hidden unreimbursed bad days. Would your sister be able to help us capture that . I guess from our budget perspective we want to make sure that were measuring our Health System against real health metric. As opposed to a housing metric. This is going to be very important for us. On the bottom market so pinging you will be highest priority for probably about 10 of our beds. If i may, one of the things that we know already commissioner, is we know all these individuals and to our transitions eight units who have been very active with working with this new department. That is where we connect the dots. So these are individuals known to the system. We manage their un process through the hospital. So, i think its going to be an easy connection in terms of how we do that because we have a whole section of the department who is working on those transitions to housing and discharges. I dont think jeff has to recreate that. That is there already in the hospital give to recapture that this could . Absolutely, we can capture that this did in fact ive asked that in fact we have our cfo at the hospital working on that for other reasons in terms of unpromising care for individual but only acuity at the hospital. So, thats part of the role we will plate to ensure that jeffs department and understand who these individuals are and they arent captured commissioner are high utilizing multiple systems which is art coordinated Case Management system that were also using with the new department to ensure we share the data sets that we have. You will notice, one of our goals to reduce that list i have. Thats your list. So, we are certainly in this together but to make sure i understand your concern is about people who are in the hospital who can be discharged because they dont have a place to live but theyre not necessarily the needing medical services they want to fix yes. So, when you look at the length of stay and imagine them against benchmarks, would you look longer were costing more against was a comparable systems because theyre carrying a housing burden and hidden cost in the General Health budgeted to manage expectations, and we got 6700 people on the street roughly. Weve got about 6500 Supportive Housing units including direct access to Housing Units which were formally in your departments. The turnover rate we really only te about 400 new units are you get people moved out. People pass away. Get addicted. Situhange. So, with that 3500 on shelter people on the streets. 6500 people, roughly, 700 people who are homeless but only got 400 units of housing. With support services available. So, we should manage expectations around how quick changes going to come, but i think the bright light fighting for the city and Homeless People and for your department is that under this new system were gone to prioritize all of those housing relief for people needed the most. I will tell you, having run Affordable Housing for Homeless People in the city its for some these buildings are difficult to get into. Its kind of a byzantine process that you have to go through and frankly, what happens is people very high radial Mental Health challenges, dont have a case manager advocating for them. Theyre not point to find a way into that housing. So were going to make sure that our investment the 120 million others were invested in housing is being used to serve the folks who really need this housing the most. And frankly thats where our department intersected those are the people who are high users of your system, high users of our shelter system. So, but we should be realistic about the numbers could we are going to try to cope grow the pie bigger and we are extending these are the types of programs that are more i was a appropriate and less expensive but more appropriate for different population of folks maybe are not having a static physical or mental issues run separate rent subsidies the homeward Bound Program. Once we realized this i felt hope it will provide some relief we still need to place like home act at the no state right now, which is a repurposing of some prop 63 bond money for Affordable Housing that creates opportunities to build more of these units, but i was eight model we are going to use about the housing we develop that looks like is the one we developed here. Have all our new house in his quantity for services intensive for people love high needs. This year online the director talked about being a medical expanding 35 beds. We also are working on Behavioral Health navigation center. Some of those individuals who still need stabilization before we think about their health status. So, we do have some new services coming online shortly in the next except in eight months. My last question is really more global in her first chance to get the interact with you here. If this is really more around policy issue in terms of changes in policy. Im not really talking about tweaking services were even levels of integration which are a big policy change i realize but is there any last thought youd like to leave us as commissioners, about how we need to think about Something Different Going Forward in the future . Is it just a bunch of small tweaks thats going to get us there or is there a fundamental shift in any count policy were thinking that you think will will need to occur so we can make a really substantive change Going Forward . Otherwise were going to be doing the same thing 10 years from now with similar numbers, similar kinds of issues and this is been the history i think of our battle with trying to keep up with this there are many are not related to this mission. That are related to the criminal Justice System there related to our house. But some of the things that i can think of is expanding on work youre already doing which is like lets make sure if theres somebody thats homeless at the door in our system and not being discharged without at least some kind of housing plan or strategy that our department is making sure that people are not just going out onto the streets without knowing about it. I think its going to be very critical to another area i think is really important but i think kind of falls more on my shoulders than yours, is that were maybe its a jointits really a citywide problem and maybe this is a joint project, is we have some great programs related to Substance Abuse treatment in this city. Better worldclass but it helps many many people address this issue. Can what is happening, though, those folks are getting the dont have enough sober living set down the facilities ive been told. By one of your contractors, we need about 100 more which seems like a big number but i think we dont start setting goals around like an exactly what we do need around housing and around programs like this, were never going to get there if we dont ask enough we dont have a gold. So i think try to figure out how can weagain, just one of going with my gut. We are gathering data now kobe of people who are much smarter than me doing Data Analysis for us. But my gut tells me this is going to be an important place for us to invest some of our prevention work to make sure the folks who are in the excellent programs that you are funding and running, and are not essentially for not because we are having cant find housing for people that are graduated and are back on the streets it using again grading help situations for themselves potentially qualityoflife situation for our community and frankly, its gone of a waste of money. Weve invested in these folks. We should make a Real Investment and make sure that housing so trying to figure that out i think is going to be a top priority but its a resource issue that we need to figure out how we can use federal and state funding to better achieve some of these goals, but i think in the coming months more for you on the question but thats all of got for now thank you very much also i went with the thing and leave you with this homelessness is really a problem that was created by federal and i would say state policies that the local government has been left local governments around the country have been left to sort of hold the bag on the problem. Hud the hud budget is about 20 the size of what it was in 1978. Country has really stopped investing in Affordable Housing and as a result of direct result, we have is homelessness crisis. I should point out californias number 47 in the country per capita investment round homelessness. So, i would say advocating at the federal and state level so that the money that does pass through is flexible so that we can use it in the way we need to use it in our community but also growing those pies as well really are going to be critical if you want to permanently solve this problem in the bay area and around the country. Commissioner chung thank you for the presentation and welcome to the city family. So, with the transfer of the 42. 5 million, that is primarily a lot of these services and the existing Supportive Housing programs that would be transferred over. Our sums that are not mentioned here like some of the federal funding like [inaudible]. An emergency hotels like through hiv care. Services. Are those going to be managed by your department as well spewing i think we do. [inaudible] yes. So it will be all centralized . Introduce yourself. [inaudible] the department of homelessness unsupportive husband good afternoon commissioners. A lot of the programs actually we are leading with the department. Theyre moving to the hiv Services Section which is actually where they came from. So were coming spero and that is because some of the problems that are actually not homeless programs. We are taking the one emergency housing for people with hiv with us and there are programs coming from the Mayors Office and community developments. Once youre thinking about around that theyre coming to the new department. So that was still be separately from the ones that are not specifically for homeless, yes. But theres quite a few that are especially on theside since originally hud programs and a lot of them are for People Living with hiv and or homeless and those are coming to the new department. So, thats warm curious about becauseis changing the subsidy formula, so with that affect how some of our other rental subsidy programs operate like more through like Substance Abuse sites. They also of some Supportive Housing. Does that make sense zero yes, it does. I dont know it is something we should take offline is now adjusted you mean like [inaudible] why we talk about that later. Im not sure what changes youre talking about in the subsidy programs. I know the Housing Authority and the city along with San Mateo County are working on doing a housing study to increase the fmr the rent subsidies, that will affect all federal programs. Other than that im not aware of any other changes to the program thats pretty much the part that im referring to. Because i see Congress Pass that about housing opportunities for people with aids that they now can provide subsidies based on market rates. For a long time is that it had a cap. Like essentially that would change the ability for people to like secure housing in the city hopefully will make it easier and were also looking into partnering with really Great Organization that can help us sort of source the real estate or helping individuals and families worse real estate is one of the problems we have is people being able to actually use private market housing vouchers. So, we are working on that now to try to make it. We dont send people out to the market as a good luck, here is your voucher. That has not proven to be very successful for a lot of people to individuals and families. Thanks. Commissioner sanchez to ask i just want to say welcome aboard. I think you really articulated the overall and the commitment and you are right, San Francisco is unique because we are unique community. I know you mentioned and i concur with some of our colleagues the jiggly, if we could get to baseline in operational baseline with data within the next year. Well have a unique opportunity to hopefully institute some longrange changes because homes equal safety. Safety and as we take a look at some of our different institutions, the schools, the Public Schools can play even more critical part using the Senior Citizens who volunteer and work in the schools. The programs going on and some of the communities especially among immigrants where the schools are open on a saturday and sunday their coming and see the family. If the clinics, and could they do the washing machines. They do the showers. I mean, the school on the week and becomes a community could the teachers volunteer the principal volunteers. Nobodys saying, hey, whatever. Its because thats the community. Thats what San Francisco is always said, too. Sometimes many of our seniors and other people are young people say weve had 1820 storytellers before but weve had our projects on potrero hill that the feds footing and others built good we taken down geneva towers. We have taken down the big towers in the mission. It did not work. What were talking about our communities and villages and neighborhoods that really good look at the totality. If the Student Living with grandparents even if the Student Living in the car spewing all these variables play an important part you really bring a unique perspective on how quickly after we take a look at all that data insert tracking both the kids, the seniors, veterans, etc. , i think will be able to make some unique longrange differences in this particular challenge that has been with us for many many years. Welcome aboard to the peggy wehrmacht commissioner karshmer thank you and welcome as well. I just want to ask one question get you started your remarks about how important it is to reframe the conversation. I think thats a really big deal. It is a topic that everybody talks about. I think you had some very good insight about how to think about that but what are your plans for how to get that message to the San Francisco community . Do you have sort of a time frames the one either going to be updates in the chronicle . Advance reports. Overly, some of you have seen what i think is been some very good press in the past month around the formation of the new department and i think the chronicle is done did a fairly good job of meeting the sf homeless project and we worked closely with them to make sure that they were accurate and fair in the reporting and i think that they were. We have sorry media plan is to get a Public Information officer on board and he will start in september and is a highly qualified individual with a really good experience working on this particular issue in other committees and also has worked with the city before as well. Once he is on board, we are clearly going to need to focus on that because i think theres a lot of myths about the problem and i think it creates space for dialogues in the media that are unhealthy which creates space for i think sometimes some misguided policy decision. If we think that all the Homeless People are coming from other places, it might affect how we might want to spend our resources. But i think the point the fax and we share the facts, i think were going to be more successful. I personal philosophies to be radically transparent with the public and to tell the public the truth and to not sometimes i get in trouble because i made the statement and its true that some of our cameras are really not Homeless People. The religious criminal enterprises that require police intervention. Prostitution and drug dealing and the people there that are there to do those things and having been in the city for very long i suddenly dont want to paint our home. The ration that way but well talk about whats actually happening that we need the police to assist with those and to let us work with the encampment were people are really in need of help, i think we dont make the decisions. So, my hope is we be honest with folks could we talk about our successes are failures to be really clear with people about what her plans are when that became and in your neighborhood is going to get addressed rather than shiny people on and telling them, yes, we will be out next week and not really going out and kicking the tires and not doing anything. So that is my hope. I dont know if it will work or bringing somebody on board will be fine that and figure out how to really bring this message to the community more effectively. I agree. Its a critical part of us being successful. Thank you. We are very appreciative of you coming to introduce the department to us. I would ask the director that other appropriate time perhaps six months, if you could then have bring a report showing the integration and some of the points of improvement or success and how we feel that we been able to continue to carry out our mission also in conjunction with the new department absolutely could also want to thank the new director for his collaboration with our department and look forward to working with them in the future. I think were off to a good start. Thank you very much. News on tuesday to get the having to come back any time and thank you for all the work you are doing to build such an incredible Public Health system for our city. Thank you very much the Public Comment . No Public Comment for this item thank you for providing a common there. Thank you again. For coming. Go go on to our next item item 7 resolution endorsing in approving the leasing and subleasing of the portions of the speed zuckerberg San Francisco General Hospital security for taxexempt and or taxable shortterm certificates not to exceed 160 million to finance a portion of phase 1 of the Transbay Transit Center project. Mr. Updike is here to present. Mr. Updike. Im sorry mr. Updike. To the file papers are presented to you, there is the presentation and the slides for this. I do not know we had a slide. Im sorry. Happy to be here john update director of real estate i come with a locate presentation for you today on this financing matter that involves property under the department of Public Health jurisdiction. So, as the resolution and accompanying men oh outlined, this is involving the bridge financing that the city desires to provide to the transbay terminal to facilitate the continued construction and to completion of the facility currently under construction. The bridge financing amount is split between two thirdparty trustees. One wells fargo, and thats the subject of the discussion here with you all my and then the other metropolitan Transportation Commission that is more straightforward. The aspect of a fencing where in the project is actually the pledge or the leverage, if you will. The train box is has a certain value to it and so that is sufficient to take care of it the debt issue that the mpc will be the trustee for. We are here to discuss that issue that wells fargo would be the trustee for. It requires a pledge of value in case there is really a Nuclear Situation which would involve nonpayment, the bondholders need to have that certainty beyond the citys excellent Credit Rating and history of never defaulting on such an issuance, but nonetheless, the backstop every one of these issuances of death with property. So, in this case we needed to find something that was of a critical nature so it needs to be a critical city service. Again, to give that Comfort Level for the bondholders. We identified areas within the zuckerberg General Hospital Trauma Center campus come and not the new building, but other building within the campus that satisfy the amount needed in terms of value for that much. So, as noted, this would involve north of 22nd st. Really everything is north of 22nd within the campus area. So, that is building 80, 90, btwo and zero Health Building and to the south recently carved out building 30 and 40 and nine to achieve the value goal we needed in our bound console needed for this. This is not unusual. It is something with respect to Public Health property we have done before. You will recall with laguna honda hospital project that required a similar certificate of participation and a pledge of a portion of that campus the campus had far greater value than the actual construction cost. So, this Commission Approved and the board of supervisors approved a similar arrangement that we are seeking here today. I think the only difference is this a project clearly is not a Public Health project thats been facilitated but its also the risk in terms of providing this pledge. Nokia joins me from the office of Public Financing can describe that this doctor in more detail and am happy to answer any particular question did i think Everything Else is in the memo that resolutions per fairly straight forward google is requested for today. Yes, anderson. Commissioners, before you is the resolution. Mr. Of date is correct that the last time it was our properties we were talking about for our services. This is one of different saying our properties for the transbay terminal. So, there is a difference here. Commissioner singer two questions. What are the risks . I guess the ultimate risk really is if there was a default situation. The risk then is this property is pledging through as additional collateral. Does that impact the potential operation of the facility . Im not sure it really necessarily wouldve but i think now they can speak better to what it takes to get the cataclysmic events that would have to occur to get to that point. Could you please identify yourselves. Good afternoon. 90office of public finance. The risk you have is a risk of nonpayment could from the city and county. So with cop the general fund is a source of repayment. In the event the city fails to make payment there is a time of insured. Otherwise the trustee can sue for the fullus for that service payment. In that case, theres no repossession. There is no repossession requirement under the documents. It only allows for the trustee to sue or rent. So you would have use of the building but it would also hold insurance on the building general insurance which is more than the city selfinsurance, which is normal insurance and wont interrupt the day to day use of the building. So, you would not feel any difference other than the citys pledge to use the asset as security and this general fund would be responsible for the repayment of the obligation. Specifically, this is a short financing unlike the laguna honda project which was also financed by the same vehicle. It had a term of over 30 years. This one is assuming no more than 15 years and the Lease Agreement with the bank is three years. So, it means its shortterm and the minute it is paid off the lease is terminated and the property reverts back to the Public Health commission. I do want to note that the city has used other assets such as fire stations, to act as collateral. For example, for the purchase of zuckerberg sf General Hospital just to put in context the city tends to do that over the years were use additional funds to support other departments improvements or purchase of equipment. Thanks. That all makes a lot of sense. So, i appreciate that. My second question is more a procedural one because im not dealt with this before. So, i read the memo last night and it made perfect sense. Complicated to go through the abbreviations. The thing that i cannot figure out is why youre asking us to approve it . Is the board of supervisors approved it, why is it hears you and it seems kind of like and let me make the point, it seems like we dont have a choice. So why are you asking our opinion . I would say you always have a choice as commissioners when its an issue involving property under the jurisdiction of the part of Public Health. So, we felt it appropriate and right this would come to the commission for approval. Its ultimately, this is a decision that you take part in. Yes, the board has approved the debt issuance but still, this is a risk issue that attaches to property on your jurisdiction. So that was given the ability to weigh in. Mr. Update, if i may commissioners to up elaborate, minor standing correct me if im wrong the commission were to vote against this for some reason than the board maybe we consider when then take the commissions opinion into consideration and look forward . I think thats a fair statement would be advisory at nature there was dissent on the item. Is this normally the way things the board approves it and then it comes to a . Is that the way was the last time . The timing does vary based on where we are in the process. Some of these things gel very early and were able to to articulate articulate what exactly the game plan is did this as you can imagine with the transbay project seems to have a surprising [inaudible] for the team has not been in that spirit. So, think that might be why is pricing the little out of order to this commission. Is this out of order, i dont know . Yes i think would normally be commission first, the commission, board approval lusted at how we try to tear most legislative items good yes, you are right in feeling that this is a little bit out of kilter but nonetheless, it does await your approval and is pending now. Further questions . If not, a motion would be in order for the resolution. Can i askonce an object commissioner pating my understanding is the millennium [inaudible] involves the transbay terminal somehow possibly suits and countersuits and row were entering into financial risk into the project and what is the risk of spill over of unending lawsuits related to the sense of blame around the millennial tilting and blaming the transbay and we have sort of writing there is this doesnt seem like there is a sort of a bottomless sort of risk theyre attaching to our property. Could you just explain if thats a credible risk at all . As im reading the public papers. Thats a fair question. I think its a different risk for a given group. The risk here is associated with the debt issuance of 260 million. The question is whether the city repays that. With its general Obligation Bond it makes in any certificate of participation are filtered to do so is been the risk issue are you all. Theres other issues relative to the transbay project, whether that be cost overruns in developing the project, because it still ongoing. That is a risk. Were litigation for joining owners and it does look like there may be some, thats a risk to the transbay joint powers authority. Its not a risk to this particular item relative to the property thats been pledged for the debt. That is a project risk thats really different and an aside to this particular risk issue before you now. Think. I just was wondering if dir. Garcia might speak to this issue in her assessment of this bond issuance be one of the many myths dont have a lot of experience with this. This is important in terms of also the process of bonds and we have been a recipient of over 40 of the bond issuance is for the circuit so this is kind of our way to put forth a bond process and its not an unusual process. Its been done. I think our director real estate talked about the procedural process that probably shouldve come to the commission first. I do want to note our City Attorney also helped us make sure that we were part of that process and i dont think that will happen again in the process because i think it just was an oversight quite frankly i think. I think that this is important in terms of the entire bond process of the city and is a recipient of a big part of those bonds this is part of being part of the city and also only property that the city owns as a whole. So, i do believe this is an important vote to make sure we can move forward and also to ensure other projects are supported like we will be coming forward to them again in the next 45 years to seek another bond for more bond support. This part of the bond process and we are very fortunate we have a very high Credit Rating for the city and as they said, this is a low risk in terms of our ability to pay back. Now, thats considering the fact that none of us can see in a crystal ball for the financial settings of the city and the state and the country as an example, but this is part of the process of being part of the city and owning property uncomfortable with being part of the city family. Terms of your assessment one other question, mr. Garcia, any discontinuity in City Services . To see any of that spirit we heard from real estate no, i do not. No, i do not commissioner, youre ready to move the motion . I have received a motion from commissioner royster is there a second . Moved and seconded. To get the resolution is before good if there any further discussion on the resolution itself be one tickets on the theres no Public Comment for this item thank you. There is no Public Comment. There is no comment from the commission. We are prepared for the boat all those in favor say, aye [chorus of ayes] opposed . The resolution is passed. Thank you. On going to abstain on this because i think youve got actually abstention is not permitted at the commission. I dismembered that now. Unless there is a conflict of interest and the commission has agreed. So, you wish or both recorded as opposed . Did your boat is recorded as, no. Thank you. The resolution is passed 61. Thank you. Item 8, the paperwork i mentioned earlier relates to this item not the item before good presentation to the Health Commission on the status of the city and county of event and the regents of the university of california proposal and disposition and Development Agreement for a new ucsf Research Facility building and ground lease of zuckerberg sf hospital by john updike. I have a slider which i will set up for you. Director garcia i dont know if you want to make any opening remarks were all just go through the schedule and highlight as many of you know, we are very excited to look to the future of the potential of having a New Research Building by the university of california San Francisco. We have been in negotiations now four months and good negotiations, and i think we wanted to give you an update on where we are. Also, were getting to a point where were getting close toi note you see you to make these decisions before going to the regents. We wanted to let you know all the efforts weve all made both on the city side and that you see side. To get this Research Center built. As you know, the Research Center is so important to ensure retention and recruitment of the incredible positions that we have in that partnership of the university of california going to 150 years. So, having the Research Center on the campus provides the ability for our physicians to quickly move from one role they play, which is providing care for our city residents, and then also doing the responsibility around the research will. So with the comp. Process in that we as a city providing a lease for the land and also you have two entities that are Government Entities that are sovereign in many areas. I think we have come very far in our conversations and we still have more to go. We want to give you an update of where we are today. So, john, who is been part of these negotiations with the department and the City Attorney and with the you see will provide that force. Thank you. Thank you. Mr. Update thank you director garcia. John updike. Its been a very large team. You being the widow well represented both of the City Attorneys office and within dph staff and we are just honored and pleased to be a part of this process. I think the director hit it on that. Its all about sovereignty of both the city and university of california. Navigating those particular transition issues that somebody bring to the table. Which is can be done by certain organizations. We are threading the needle as best we can get out quickly highlight some of those things and im sure mark leno will fill in all the blanks that i be behind on purpose. So, first to the schedule and to catch you up on what we have done a reminder that we were here a little over a year ago gaining your blessing for the nonbinding term sheet which then the board of supervisors also approved. Now, the real driving forces the entitlement process to allow construction to begin and so, that ceqa processes under. There are eir was published as you see in this case. Its expected to be finalized in september and thats a real key milestone date that once it the process is beyond them that allows them to actually begin construction. So that forces us to wrap up our negotiations and have a ground Lease Agreement in place as soon thereafter as possible. So, toward that end, weve ramped up our negotiations of a number of items. One of the ground lease of course that was the real essence of the term sheet that you all saw back in may and then theres always disposition and Development Agreement, a companion of agreement, that facilitates certain aspects of arrangement there really are best put in that format rather than a ground lease. Then theres an easement for utilities to the Research Building. This is almost an Island Property surrounded by the department of Public Health personal, and so we had to address what we would call offsite improvements and how to deal with those. Then, as a companion unrelated but sort of related item are also negotiating the lease for Building Three which we think is important aspect that needs the result at the same time. So, we have been doing concurrent negotiations on that lease which is due for renewal. So, those are the items being discussed. The key issues, again, revolve around indemnity provisions. Certain, what if scenarios though the two if if for some reason this arrangement that has been wonderful for the last over 100 years fails to be so wonderful in the future, how do we divorce ourselves . What is the import of that to a ground lease arrangement of a Laboratory Facility while maintaining the need to have this be the current and future auxiliary piece being a Trauma Center . So we are been navigating that issue in almost all of these documents. I think that sort of the major theme that cuts across any of the particular issues without getting into the weeds for you. We also had a number of staff changes on the university of california side could i think that to the good. We have seen some new perspectives that they brought forward and i think that is bringing some breakthrough opportunities here in the last several weeks to get us to final resolution of the ground lease in particular where i think most of the issues are still unresolved. We have resolved many issues. You may recall in the nonbinding term sheet, we sort of put to a parking lot a few of the more contentious difficult problems in order to conceptually agree and agree to negotiate those items. There really has been what weve been spending the last year on. Are those parking lot issues that were then brought forward. That includes parking as an issue. Which, i think mark can speak to more eloquently than i could is been in far more meetings on the topic but thats another issue of concern, that cuts across all the agreements as to how we deal with the displacement of parking replacement of parking, and expansion of the garage adjacent to the hospital facility campus. The other issue that has been bandied about is first source firing process that would be engaged by you see it those discussions continue. I think were very close to resolution given the last day or so we made progress. So i think we will find a Common Ground acceptable to the city. And really that one again is sovereignty. The state claiming that only certain conditions they can accept in the city of course wanting to ensure that local higher, wherever it can be deployed is deployed. In this project. We surely dont want an event that causes any major destruction to the hospitals operations because of this construction project. So, no thats foremost in director garcias mind as we move forward. So those are the high points. Perhaps there just a few holes i left for mark to talk about. Mark maybe if you wondered if i looked at a stack of papers. So, thank you. Iq, john. Part of the reason we been involved with this this is mark primeau, part of the reason we been involved this for three years john did not mention is probably the most complex lease and certainly the longest lease the city has ever contemplated entering into. I think some of the bigger lease is up there, john, the Ferry Building that. That 66 years. The boat is mark. This is 74 with an option for 25. Its almost 100 year lease. Within the lease in the lpga theres a lot of complexity thats why its taken us on. Also, building up to both this lease in a nonbinding term sheet you guys reviewed and may it last year and a number of things have happened. Theres a crush during its corner between the city and ucsf to pay for legal services, real estate services, appraisals, other project management services. So be of that agreement in place. Ucsf has done a series of temporary seismic improvements to the buildings and green tiles, providing egress safety, etc. That has been in place. There is been soiled warnings that an exploratory site work thats also happening. Theres been a lot of things building up to this. We have actually had meetings directly with the mayor and on june 28. July 18 and we have another one coming up on 23 august. He has been actively involved with trying to close the gap on some of the sovereignty issue. Theres not seven issues, good john mentioned indemnity, negligence and how that plays out in the ground lease as opposed to affiliation agreement which is a completely separate agreement with different standards of negligence. Theres issues of remedy defaults and remedies if someone does not pay their rent, what happens. The process does the city go through to make it whole . What kind of cure period are put into place for the lease to make the payments. Accessory interest is another issue that if state law. It really is controlled by our accessor recorder who is been given constitutional powers. We need to be able to write that language in such a way so that the city is not liable for those costs. Basically, that involves ucsf is actually exempt as his educational agencies. So we need to write that language in a way where these exemption is very clear that they filed for notice on an annual basis. So that protects the city from being charged in any kind of interest in the event some sublease it is in a building that has a interest. This issues about f and we oversee this. Its an affiliation agreement terminated by oth either parties. There issues of with the city be able to operate to purchase and lease back. So what are all those terms, when do they happen, over this 99 year or not. This issue of john talked about first source hiring and local hiring, where during the construction, similar to the new acutecare hospital, where we hired more than i think 50 of local residents on the job, and exceeded the goals of the city had, we understood ucsf has a similar project the mayor has asked us to figure out a way to partner together so that we join forces. Use databases and really maximize the number of folks that are in that 411 00 area codes to work on the project and get some economic benefit from it. Those are kind of the things we are working on. We are lucky to have a new player that john mentioned. Senior vice chancellor paul jenny, whose come on board maybe a month ago, barbara, and who has actual responsibility for Capital Finance and real estate. Deposition had been vacant prior to that so we see that as a really bright light that some of these negotiations. I can stop i like to acknowledge the hard work that all of our stuff has done both on that ucsf side and the department site. I think the chancellor is very supportive of try to figure out a pathway and so is the mayor and would try to figure out how we can legally do this and try to keep sovereignty in mind for both entities. With the understanding that how important this Research Building is. Thats kind of the role i have to play the two people on the goal. We are trying to build this Research Center and we have to figure out how to do that and protect both entities did as you saw in this last conversation with real estate the competition process. Im shearing four a yes on how we do this i know the mayor is very interested in supporting the chancellor in this regard. So, we are still to go shading and we just want to give an update on that. Because the time i know ucsf has to finalize its process to go to the regions and office of the president and i feel very positive about where we are going and i want to keep that spirit up with all this as we move forward we want to give you the opportunity to get an update on where we are. Commons . Commissioner singer i want to echo arbors commons. I mean, these things weve been in the fortunate position of the year that we dont have to understand all the nuances and important tradeoffs and productions which you guys and your teams are thinking through on behalf of the city, i do think it is very exciting that we continually see more and stronger partnerships and understanding with ucsf. With a particular lens of the future of the hospital. I would say there are few things that we could accomplish that are more important in the next 50100 years for the integrity and future of that institution than this Research Building. Because if it is not there, there are other things that are going to atrophy about our incredible institution in that time or not. If you look back at what has made it such an iconic face, it has been the association with ucsf and the terrific collaboration the strength we bring as a city in our commitment to progressive healthcare and serving our population and the worldclass research and clinical practices at ucsf. In my world view, for anything that weakens that we do at our peril and anything that strengthens that is great for both institutions. So, i really applaud you guys working through this because i know there must be times where its tricky because its tricky to balance two complex cases that have sovereignty issues and their Economic Issues involved and everything. It is incredibly important. So, im glad were doing this. There been no public, and request for this item. I also wanted to commissioner sanchez i was just going to say, three years that has been the fact that the dialogue has continued has come this far is astounding. I think you both hit it dead center. It is one thing for the affiliation pertaining to graduate medical School Education and contacts with ucsf or stanford or cmpc or whatever but land is another thing. We had the Mission Bay Area looking at alameda as a possible Research Center before mission bay was built. The fact that through the department and who really faculty who are committed to our patients and research, to drop an anchor here at sf z sf g h because as we navigate continually because this is a transfer of Land Allocation etc. , are governed by the city and county our history, the university of california is governed by the regions of the universe and telephone going back to the constitution of the state of california. Going back to the treaty of [inaudible] in all these things that are still part of the navigation and challenges and their protocols and some of their requirements a totally different than ours and the fact we been able to come this far and really bring this was to closure and hopefully it will, i think billy will be a unique challenge and opportunity. Again, its astounding what has been done and i congratulate all of of all of ofyowe stopped by the mission bay some of this is the one on pertaining to land that was committed to including some of our xsenior vice chancellors negotiated that mission they contact and are now, and thats part of the other circuit so, things change over time. Thats why im so glad the mayor and everybody is involved to really make sure we walked through this and make sure that the outcomes are really in the best interest of not only california and thats fine and thats an important part negotiate with, but the city and county of San Francisco, which is unique entity in itself. That is our bottom line. So, continue on tonight its excellent and look forward to some positive outcomes. Thank you my comments were actually very similar to the previous comments and especially, i think commissioner singer expressed it well. It is clear to me that the work we are doing at sf general and the ability to use, to have our population there along with our medical staff and the University Affiliation has created so much that has brought us the accolades from the world in terms of how we care for the population and the breakthroughs that we can find in terms of not only aids but also in so many other fields good whether its hepatitis were caring for the underserved. And those who are in a despairing condition. That only can be accomplished if theyre able to continue the Research Within the confines of the campus because we will lose the contact that is so important to allow this type of research. It is really Community Participatory research at its finest that then, produces so much information about how to continue to care for these populations did so, this becomes really vital for the 90 some odd years youre talking about because will continue to have that opportunity. Otherwise, it will be atlost. Why we will continue to be a very Strong Center for care, we will not be able to then, i believe, in the same way, use the information that we are then gathering and learning from and be able to publish and let others know what can be done. It requires this geographic proximity. I kind of recall when we were looking at what are or how to build a new Inpatient Services and, of course, the ideal to a lot of people but move everything down towards mission bay. The idea being that you had to have continuity between the outpatient and Inpatient Services. Then we had the alternate plan of such as have all the inpatient service. I think the negative all came out that said those who were trying to participate in both the inpatient and outpatient side and be able to them understand the whole of how we deliver care we are really going to be stressed because you now lost proximity of being able to be able to care for people in the same settings both honored in and outpatient subject us a lot of time you lost your Research Units could so, for this type of work that we are doing is is really vital. I would hope that both parties suffered as they may be, would understand theres a greater goal here and that in this case i believe the sum of the two will be greater than the individual parts themselves. So, i would hope that the timeline i assume will continue to be available to be meet the universities on requirements. Im not being substandard spaces right after 2019, i guess correct so, all that our stuff your can do im sure they are and you are working really needs to bring about a resolution to this so that we can continue to deliver a just worldclass care, but worldclass information to assist the health of our entire planet if i may commissioner, our new ceo of the hospital is here today dr. Ehrlich and i wondered if she wanted to come and say just a couple of thoughts of hers . She reports we got here just now and so she has not been part of our negotiations, but i know how important it is to her. I want to give her an opportunity to dicks thank you. Good afternoon commissioners. I dont have much more to say that as eloquent and weve already expressed in support of the project. Its very its impossible to imagine our fine institution separate from ucsf and it never actually has been in all of its history the separate. What i see every single day is that our ability to attract faculty and then, it would not be the same without their ability to do research and in turn, the research they do the teaching they do when the ads to our patients wellbeing and health. So, its unimaginable to me that any of what is going on there now could be separated and so i really appreciate your support and i really appreciate all the heroic efforts that are going on now to negotiate this lease between these two partners. Im happy to answer any questions. Just thank you very much. Thank you. If there are no other comments, then i think that our team has heard we are we feel that this is really critical and we wish you the best of luck we can do this in a timely fashion. Thank you. Next item, please item 9 is a draft policy before you for your consideration. Itll be voted on at this about september 2026 me. That was communication between individual Health Commissioners and sftp h subject commissioners come i placed before you the dph policy for that i emailed out to you as well which relates. So, commissioners, this would be in addition to our policies and procedures and help to clarify some of the questions that have come up in regards to the ability for the commissioners to receive information in order to carry out our function of oversight and policy determination. Clearly, there are times and there are important issues that need to be discussed with key people within the department and this falls within the charter process so that we stay within with the charter has mandated the amount which is that the department has its plans policies and codes established by the commission, but that administrative w the director of health and is responsible for all administrative barriers. So this tries to help clarify its and your comments would be helpful in considering this draft guideline that would then come before us as a at the commission policy. So, i know some of you have already seen this earlier and was also circulated for your consideration and if theres any comments at this point in time and if there are other comments as you go along prior to our final opportunity to make changes before a vote at the next comMission Meeting that would be much appreciated in terms of submitting it to the second. If i can clarify, the meeting would vote on this would be september 20. Two meetings away because the next one is your Committee Meeting that is corrected it will be at our regular meeting thats here which would be september 20. Yes thank you. Thanks for the clarification so, you can review this and we can have further comments. These for them to mark so that then we can look at incorporating those and then have a final vote on september 20 on the policy. Commissioner singer i like to make a comment on this just for my fellow commissioners as you think about this policy. Id like to leave you with some philosophical approaches. Which is, i actually think what we deserve to do our job required to do her job as a policy which is about 180 the opposite of this. Let me explain. As a matter of principle, i think that the government is better with more transparency, not less transparency. When transparency is reduce the quality of governance suffers. While this may look benign, that it actually represents a continualcontinued setting in place of behavior which is likely to lead to much reduce transparency. I believe that that is what the vocations of this policy are. That they basically quench any ability of commissioners to have substantive thoughtful dialogue with anyone in the department. So, for example, this policy further concentrates the flow of information about the department to the commissioners. So, we have some very complex policies to deal with in the future and i think it becomes much more difficult to be thoughtful about those and to discharge our responsibilities if we receive everything in a sanitized manner. Furthermore, i dont believe that staff will be as open with us as they might be otherwise knowing that everything has to be reported through. The director good it doesnt have to do our director. This is a matter of principle but im talking about. Were, for example, our responsibilities to do Performance Reviews. I just dont see the you get to of thoughtful Performance Review of someone without the ability to talk to people in the organization about that persons performance. So, as a matter of just fundamental government governance principle, that i believe in, i find it this commission is of two employees. It is adaptable and secretary there are venues and opportunities for us to discuss and get as much information as is required. My fear is not that were closing down transparency with this policy would that impact will be less transparent if i have the opportunity to call dr. Ehrlich, as for a bunch of questions about what i think should be happening at San Francisco General Hospital and come back to this meeting, have were joint commission say this is the information i have acquired as a result of having a conversation with dr. Ehrlich. You are looking may like wedge of a conversation with dr. Ehrlich and were only hearing about the content and the subject matter now good so, i would speak in favor of this resolution. Are there some tweaks to be made soon you will figure that out because importantly i wont be here on the 20th. So, i wont be able to see what the tweaks are but as it stands right now, im not as troubled as some of my colleagues are but what happens. I think we need to go through the director. My experience was when i was in this department, people went through the director. I didnt feel like my conversation was commissioner after i knew there was support from the director was tilted in any way shape or form and those of you who know me know that as a weapon to say when i want to say it and how i want to say. So, ill leave it at that. Thank you. Commissioner karshmer so i am all about concerns he has been on make Everybody Knows whats going on. I also have been in a similar situation you just described as a in a university that has a board of trustees and get calls from board of trustees about things. I stands is often information given as well as information getting. Im not exactly sure what i needed with information that is given as well as information that theyre getting. So, from my perspective it caused me a lot of extra now i have to go to the next person say this is what was asked by the trustee but this issue in this what i said. So, great sort of eight and then i dont know if the other deans were asked the same question i need to go back. For me, it was the time it happened it caused a great deal of consternation in my role good i too, have no problems. It wasnt like that in any way i felt that i was had and pediment about answering questions. My concern is that i dont think we doim not sure what is the manifestation of why now, why this [inaudible] i do think if we are not getting the information we are getting me to be asking the information and we need to be asking it for it on a regular basis publicly so mark was of the people can get it and if it means our meetings are longer it means our meetings are longer. Means we need to feel more comfortable doing a dialogue here read our gcc meeting or our Committee Meetings because i too am worried as you are, bob, this conversation takes place and we donti was not part of the conversation i even filled out a little bit with the gcc what happens the gcc and that comes here and we do not have all the information about what happened gcc. I feel the same way about the gcc from the laguna. Why did this come up here . Perhaps we need to be more better doing that and getting those kinds of information back and forth. Thats my three sons. Commissioner sanchez any comments . No. I think the section in the charter, i mean it says the city charter rivets and eventual Health Commissioners many dictation suggestion interference on magistrate of matters. And confers the power. The commission on the body as a whole, etc. As an Sewage Commission or whether this commission, the school board whether it be vfx commission, the police commission, whatever, they have a regular protocol where every whatever the protocols be it a president , Vice President sometimes the secretary and then the secretary to the commission and ill have either the superintendent were director or chief of police of whatever. And then each Commission Decides how they want to proceed. This commission we have the gcc. Some are mandated and some are. Because the fact many times the director in the past has been very very busy depending on what director it was being whatever the crisis was were going back presenting whatever, a lot of times the director might not be at the gcc. Therefore, the gcc respective chairs and the Committee Members would be listening Weatherby Laguna Honda etc. Etc. And we come now whether we have a different style and we have an inclusion model where the director has really attended just every gcc i can think of now. And participates along with the jcc along with the commission along with our staff and director. That gives us a unique opportunity to dialogue and discuss whatever then bring it back to the full commission for whatever action. So, i just i had mixed feelings about it. I really think that again, i mean ive seen this over the years, where as an example i contacted one of the directors saying that we have some people coming from outofstate must really it do want to talk with some of our researchers and i called i called as a matter but jimmy and others came after a shared saying who would you recommend. Would you like to do it or can i do it then we would have meetings with our researchers and Foreign Countries meet with our staff here. It wasnt a policy matter per se but was an individual requested i would pick up one and called the director. To me, that was the matter of responsibility. Again everyone marches to a different drummers but again we were not dictating to you were not violating anything is written in the charter and we all go to these meetings every two years where we have the City Attorney go over all the rules and procedures. So, i do think that if something needs shoring up, i think that you be sure and clarified and we could proceed on. At times, it could put the staff member and individual member and a difficult challenging position is in fact they have to report back or feel they should report back weatherby a faculty member at the university or go back to the Department Chair or the dean were somebodywhat im saying is the commission are appointed. We serve and be Due Diligence and each Commission Body sets up its procedure on how we are going to undertake our duties. The joint Conference Committees and the various other committees and the selection body the full commission dictate how we will operate. We have it always had the City Attorney assigned here either on call now or before actually they used to be sunnier and sit up here next to the director Public Health. Anything that came up would be referred to write here. Right there, you just move on. Again chimes change. Mayors change, as such. I think we need to ensure that the quality and the dignity of that apartment and the commission is very clear and it this clarifies this, fine. But to me the core matter is was already in the charter. I think its up to us to follow that mandate that we have been given. Again, if we need to shore up certain areas, and we concern the discussed that. I think for sure, the organizational points about the deal for directors of a board were commissioners were trustees meddling is just not appropriate on so many levels could is not probably not even worth discussing. The challenge that i have found on this commission to do my job and its probably been more historic of his frustration at the jcc but it has not been entirely absent here, is that i feel like i feel like we ask questions and actually dont get answers becauseill give you an example. So, we spent dr. Chow and you and i spent a couple years at the gcc of the hospital. Asking about when the hospital would open, are we on track early on track . We got answers that we would get and im sure like me, you got indications from staff after the meetings that im not sure im comfortable with that answer. It turned out that the hospital opened that three or four months before the hospitals supposed to open was only six months great. So, that is an example that im trying to figure out in my mind that weve done a better job at the gcc . Kudo view created an environment with those much more open dialogue bout what was going on so that we could have been much more effective stewards of our responsibilities and how did we get into a situation like that for example . Are we just kept asking and kept asking and we did not get it. So, what im trying to figure out such a complex environment and how to be thoughtful, that is the thing im struggling with. Through the chair, ill give you another example. It will be brief laguna honda, when we met another gcc and we have the full commission at that time there was a major cutback in the state of california and we were sitting up there and could even get approval by the state and not only that, other hospitals were being rebuilt going through the same difficulty. We heard that in the jcc Meeting Street we brought to the full commission. We hadthe committee, i mean, we discussed it and knew that it was going to cost the city and county more money because the state could not review the documents that we needed in 02 proceed on. It was one of the most frustrating things we ever did. But i mean again, we are on the same team. We discussed it was brought here. We were aware that the mayor was aware of it. The governor was aware of it and finally, it was approved after other hospitals in other counties had to write to the director Public Health to say, youre costing these counties millions of dollars. Because we dont have approval on these rebuilds for these units pertaining to the requirements mandated by the state. Any comment . Right. Ill take one more comments and then have a commonsense over to mark as needed and obviously, we dont have to vote on september 20 as we try to take all these thoughts into consideration and work with City Attorney also to try to bring about the ability to have the information that you need and transparency and yet also at the same time stay within the charter. Commissioner chung is the last, today this is a good example of why i actually think these discussions are healthier like to do that in the Public Meetings because i think that this way, its more than just one commissioner trying to problem solve but instead the commissioner is bringing the challenges back to the full commission so we can actually have a full conversation about what happens and it might stimulate even more questions because of that. I think and also, i think one thing that i dont always like about meetings being televised. It becomes a performance as well. Do we actually get to perform like the residence of San Francisco expect us to do is to give them the transparency that they want. That would not happen unless its done in a public meeting. His agenda is so people can come and whether they are supportive or descending they can, and give their point of view and we then either generate questions or come up with a decision. I wanted to get i think that is really the most balanced way. I think about doing this work. Because when we talk about power and privilege, if i call one of the staff and say that i hi, i am a whole commissioner. Conversation, what is the likely for the subject say, no, you cant. I dont want to talk you i think thats really important to think about. As we move forward as we consider this, i think that how to really create an environment thats not just because of us but the kind of culture we want to set up for future commissioners that, on or otherwise come i think a lot of things i think everybody [inaudible] if i call a number every day. And as cold bunch of questions. So, i dont think were doing that. I think its important to take that into considered. I think this is what i would like to see more good that we actually put on the agenda something that we as commissioners want to discuss and thats nothing preventing us from doing that. Commissioners, i think i just want to make one or two more comments. Some of the areas youve touched on, we were trying toand we is kind of an amalgam of the attorneys and mark and myself and also dialogue of people have wanted to have the ability to work with Staff Members to actually find a way in which if we were working on staff member will that information were sent back were be able to be utilized and thats the reason why my read was sort of telling tales out of school later but it was the idea of creating some sort of a ability to move to the reports so that information was not lost. That i can see where there is also some concern that sounds like its kind of a gestapo type approach where we been right what people said. I also hear that the openness of dialogue should be more added Commission Level perhaps rather than on the individual basis but i also hear that need for trying to work away in which we can get information that people may wish to give but feel they cant but on the other hand has commissioner weiss said, from the other side, there is a question that staff sometimes would feel intimidated even on a one to one level. So, although that we will work on further and try to work away the reason for this was some controversy as to how far people could or could not go and it goes all the way, not just to our current commission. It goes way back to a number of other times and even when commissioner royce was part of the establishment here. That has been going on in i could say that i think dr. Sanchez could say it has gone on and been a problem for at least the many years that we have been here and whether we can really write something to help resolve it, i think becomes the challenge right now. If i may come i do think dr. Pating question, why now, what is real and is a good one to get an answer to. From the department. I do think the challenge of this is that the extreme of both if you will, both points of view archaeological. It makes no sense to have an operating environments where commissioners are calling people all the time in that apartment. Its confusing, inefficient etc. As noted at this income, makes no logical sense to say every conversation we have on any issue im thinking of it is going to, as doing our work as commissioners, is to understand issues, to bring thought, in this form, its the same thing is the same sort of governance thinking that leads to thirtysomething propositions on a ballot. At some point, you have to ask yourself, like the spirit of it was good but the governance of makes no sense because no ones citizens can be thoughtful about 30 propositions. Some point you have to say,it doesnt really work. So, my point is the arguments about are equally powerful that the logical extremes are awful in terms of behavior could you cant have a commission run amok and you just cannot be thoughtful in the limited time we all have given our lives to just do the work here. It just doesnt not make sense. We have to find a balance where we feel like we are informed and that the public is also informed about our discussions and decisions being made, polities policy decisions made in the study if i may commissioners, the charter was written for reason. It is the ruling rules that we work from. Transparency is another issue. I think ive committed to the commission and the Commission Prior to this to the importance of transparency. I think the little unfair for commissioner singer to talk about the rebuild since really the rebuild was the dpw and a contractor issue and not the responsibility as much of that apartment and we worked on that we got to the transparence. I appreciated that because what also was frustrated with that as well. So, do think you cannot act alone the mission was. Thats in the charter very clear. As a whole, i will respect whatever you decide on this policy but the charter the rules and the way to change the charter is to a boating. How we practice as governments is a whole different matter as well. I dont think anyone in this room on the dais has ever been denied to me with any member of our team of staff. Nor will you as long as we know what the issue is. So that we can work on that and also so that staff understands what youre asking about. But im not going to allow for people to feel uncomfortable on staff about the way the questions are being asked and that associates back that could happen from that. So am i wont allow that. Is it a prominent as somebody who supervises people but i think its nazis really important is important to have and i think everyone my executive staff and i think you can go down the line of how much people really appreciate being transparent. Thats the commitment that i think we all can give you. The charter is the charter. How we manage the charter is up to the commission and up to me as the director of health. That theme, and i have. If theres a question but how were not being transparent than that have it and figure it out how we get more transparent. But i think its a little unfair around the building of the new building since was so many dynamic processes but i do know that there were questions and concerns about how executives are sharing that information that was corrected. That wasnt left on the table to continue. So, thats the commitment i know i have and i also note our executive team has. To the commissioners. Though, i dont think anyone has disrespected your role and i also think that no one has denied you access to anyone on the staff. Thats the practice. Thank you. I appreciate that. I totally appreciate that and i know some of the suggestions ive had [inaudible] but let me ask you the question since you waiting hear. Because the charter has is pretty clear about administrative matters, what is it about your policy you are proposing that is required giving we have to perform according to the charter. Why do we need this policy if we have the charter student tutor title policy to myself i can have because im the director. This is your policy. The policy actually, this policy was brought forth by mark and myself to also try with the departments so that there was a clearer understanding on the part of the commission. We dont need the policy if we dont wish it. I suggest that at this point in time we mull this over, look at the policies, take the information that weve got and see if we can also been come to a point where it might make sense as a process and not feel like it is some sort of restriction and thats will work on in the coming months. A comment Brown Sparrow but i think weve reached this conversation has been used is like everybody wants to follow the charter. No disagreement on that. And it sounds like Everyone Wants the policy or practice that is transparence and then the third is that nobody wants to place staff in a situation that is either less than comfortable or jeopardizes their ability to do their job. So, i dont know im just thinking at least we consent to agree with something and then the rest of the resolution is more about practices or more of solutions but i think we agree on some of the goals around there that might be a good start for whatever the iteration is thats very good dr. Pating. We have recorded that and see if we can structure around that. Commissioner should voice i support your voice that we are 1 2 cup are due to mold the solar over the next month. Two, that marks secretary more without does have the information in the request made by the commissioners in terms of formatting and the language. Then when we get all that we mull over again and vote up or down and its done. Thank you, sir. With your permission then there having been no Public Comment we will move on to the next item yes. Items in his other business commissioners. Other business . Any of the commissioners have other business they wish to present under this items. Otherwise we can go to item 11 is no Public Comment request on that item and item 11 is the joint Conference Committee report the laguna honda hospital gcc met on august 9. The meet was primarily a closed session with the report and credentialing report are reviewed and approved. Personal Public Comment on that item either. Okay. Item as well as Agenda Committee agendas and i were my nuance of the mistakes it will the meeting will take place on glide memorial and focus on tenderloin and on october 4, you have your session with a focus on the fiveyear budget. Thank you. Our next item please is consideration of a closed session. Theres a motion for closed session is there a second, please moved and seconded. All those in favor say, aye session and into open session moved and seconded. All those in favor say, aye [chorus of ayes] were now in open session. Are we ready for open session. So in open session, we have taken up the three items on the agenda. Is there a motion to disclose or not disclose the discussions of these three items . Ocean not to disclose the three items we discussed during closed session not to disclose about his russians. Is there a second . Any further discussion . If not, all those in favor say, aye [chorus of ayes] opposed . We will not disclosing discussion on a three items we discussed. Motion for adjournment is in order moved and seconded. All those in favor say, aye [chorus of ayes] opposed . This meeting is now adjourned third [gavel] [adjournment]