Mental health respite programs perhaps looking this is an opportunity for overturning the imd exclusions as a long term goal. Lastly, at the state level, we might keep active ton safe injection issue, i guess that was a two year bill, that tha may come up in another year, so if that could be considered, those are my wishes, very excellent policies, i think you guys have always been ahead of the curve and as you know, as San Francisco goes, so goes the nation. Commissioner, was there something specific in either to have paragraphs or some area that you wanted to have consideration of asking for . No, these are justice ewes as i went through and looked, i didnt see them, they could be in there, if you feel theyre appropriate, i would add that as my suggestion, if you dont feel they meet our overall goals, ill also no, i think the federal policy on couldnt tra accepting is something we can add, the federal legislation on cannabis is something we could add, there is some language around confidentiality agreements and data sharing within haoe, but we can specify the 42cr. The imd exclusions, i dont know if theres anything specific on that but we did we could add that, there may be some federal action coming down on that soon and then yeah, we can talk about how we want to address the safe injection sites. Commissioner pating, i think tho are really right on to targets of our concerns. On the issue of imds, well probably have to travel from the federal to state because we will need to be able to get medical approval for providing for programs that have over 15, 16 beds, so that was one of the issues that we may have a problem with getting funding, but absolutely, i really i think your items are appropriate. Yes, excellent document again and then take it for consideration, if you feel they add value, feel free to add them. Put my name at the end. I think we just did. I think on the cannabis which is what commissioner chow also brought up last time in terms of the environment and so, perhaps you could go into that section too. Not so much federal but in terms of even you remember, we were talking with the Planning Commission at that point or the planning regulations and commissioner chow did bring up that the environment around potential Cannabis Factory should be considered as an issue which i believe planning said that they were open to making that one of the things that were talking about. Just when you talk about the environment, are you talking about the Natural Environment or the social demographic political environment . More ton Climate Change idea, she was concerned there could be certain factories that then would have certain odors that would be tracing and maybe offensive in a particular neighborhood type environment versus in a factory, sit ining an Industrial Area that we seem to have less of today, so i think that would be something that she also would appreciate that could be helpful as were looking at Climate Control or various cannabis regulations. Okay. Commissioner loyce . First of all, thank you for your indepth report and i look forward to reading more of it. I know that the [inaudible] bill came out today, im interested in following that because of the implications it presents to us, so its something today, it will be something tomorrow, it will be different, but as you track that legislation, please inform us of what your thinking is of the department and what reck m dashing you would like to make because it has concerns for San Francisco and california and the nation, but thank you for that report. Thank you, any other reck recommendation, if not, we will move forward on a motion for the resolution and we are assuming that those recommendations will be taken into consideration and placed into the plan. Motion is before you for adoption, i need a motion. So moved. And a second. Second. Okay, a motion and a second is received. Any further discussions on the resolution . If not, then were ready for the vote, all those in favor of the resolution, please say aye. Er aye. Inger all those opposed . The resolution has been passed. Thank you very much. Inger thank you very much. Thank you, commissioners, item 8 is the Emergency Medical Services update. Good afternoon, commissioners, my name is dr. John drowning im the medical direct door of the San Francisco ems agency and im here to give you a report, it eats a pleasure to be in front of you again after four years or so to talk about the ems system and the ems agency. Im going to be joined by our new ems agency administrator, mr. Jim duren who will introduce himself and his background and were going the share the presentation as soon as i can bring it up here. Thank you, and welcome back, dr. Brown, to the department. Thank you. Thanks for your help, mark. Sofrjts, what im going to do is to just give you a very brief overview of what Emergency Medical Services is and its role in the department of health and then were going to talk a little bit about the actual transition of the agency from the department of Emergency Management to the department of Public Health and then talk and highlight about three or four of our key issues that were dealing with currently. I want to also very strongly thank and this will come up in the presentation as well the investment the department of health has put into this transition and into the ems agency and the ems system. Why is this critical for Public Health and why is this a very Important Role in the department . Ems, Emergency Medical Services, provides the response for emergencies throughout the city, medical emergencies and its xo esz composed of multiple components with multiple agency, City Department and is private agencies as well, the response is generated through generally a call to the 911 center which is part of the department of Emergency Management, dispatchers are tha are present at that department then query the caller to take if you will the unfiltered patient issue or chief complaint and then put it into a system that gives us a call determinant or a specific way in which to respond to that call based on lots and lots of medical evaluation, medical research into efficiency of ems systems. First responders are usually the first people on the scene, they are frequently the Fire Department, i would say thats 98 of the time, but they could also be other members of the Public Safety community such as Police Officers and sheriffs deputies and they provide a basic level of care, first aid and cpr and automatic defibrillator if thats available for cardiac arrest, this is followed by plans transport and this is shared duty with the Fire Department providing approximately 80 of the plans transport in the city and two private Ambulance Companies that back the Fire Department up, and then those ambulance personnel determine once the patient is assessed and stabilized a destination and well learn about the destination options in a minute, theyve been expanded in San Francisco to include other destinations besides the hospital. So, in general, First Responders stabilize, then they transport the patients, continuing the treatment of the patient during the transport and then the receiving facility provides ongoing care. We have two levels in San Francisco or three levels of responders, we have dispatchers, the 911 dispatchers who are the first time zero responders who will give prearrival estruses and help patients bhiel they are being assessed and the ambulance and the First Responders are dispatched. We have First Responders who are usually Emergency Medical Technicians with about 200 hours of training, they they can provide basic life support care and we have paramedics, paramedics on many of the fire engines, about 60 of our fire engines have paramedics and all of our ambulances in the 911 system have paramedics and they provide a higher level of care, 1600 to 1800 hours of training, air way interventions as well. What is this transition all about and what is the relevance of this system to the department of health . We were in the department of health up to 2009, there waser a lot of reorganization at that time due to various economic issues, we were move today the department of Emergency Management. The thought being that we would have a synchronization of our mission, 20 does touch on disaster preparation and response to things such as special events and medical surge situations. But also we were able to colocate in office space that was unutilized and been fit from economies of scale such as our i. T. Needs were transfer today the department of Emergency Management at that time. However, over the years, the Disaster Mission of the city and the department of Emergency Management became larger and larger and we became if you will a smaller and smaller portion of the department and many new challenges developed such as the Sobering Center and its role within the ems system and the development of mobile integrated health care which is also called community [inaudible] along with a lot of evolving research and specialization, ems medicine for instance since 2013 has been a new specialty within the house of medicine, so theres been a lot of new information, new research that we want to apply to the system, and at that time, our staffing had dropped from an original level of 12 down to a level of 6 personnel. So, director gar see yoo, director oregon, the department decided it was important to invest in ems system and this is a multimillion dollar investment with a lot of help, many resources devoted from outside the ems agency to help make this possible. Parlt of the reason were doing this and looking at this process to get more resource and more integration with the Health Mission is our enlarging workforce and workflow. We currently have over 2000emts in San Francisco and over 500 paramedics. I can tell you from my experience in meeting with my colleagues in other ems systems, this is a very well resourced system in terms of personnel and in terms of personnel experience in years, the number of years that the individual has worked before they come into the system is relatively large compared with other systems, we get a lot of experienced personnel who come here. We have an increasing number of ems calls in San Francisco, the graph that you see there takes us from 2010 through early 2017 with an increase of approximately 4 per year in ems calls, these are calls specifically with medical needs that are attached, and at that pace, our resourcing at the agency, our ability to keep up with these call and is the needs these calls generate in terms of training, education and Quality Improvement has not kept pace. We are a nexus, we are not if you will the king of the hill when it comes to determining how ems care and ems medicine is practiced within the city, the upper part of the slide gives you a visual representation of the state issues and the state entities that interact with us at ems, in some sense, i have many bosses and one of those bosses is the state Ems Authority medical director, dr. Howard backer, state laws around ems medicine, they translate those into regulations and then we in the ems agency have roles and responsibilities to the state. The lower portion illustrate it is portion we have with our various providers, our communication and research, our policy and procedures, protocols and then the agreements that we have with each of our providers. We have as i mentioned the three 911 ambulance providers, we have the dispatch center, the 911 center, we have 6 private Ambulance Company that is perform interfacility transfers for us and then we have 13 receiving hospitals including two that are out of county and many of which have Specialty Center designations as well, so thats the environment in which we interact in the number of organizations and entities that we are working on. This is just a refresher chart for the department of Health Organization and it shows the specific spot where the ems agency lives and who we report to. At this point, ill turn the presentation over to the person thats in that slide which is jim duran who will bring you through the Current Initiative and is the transition there. Thank you sx, i appreciate the opportunity to address the commission and talk about the ems agency. My names james duren and just a little back grown, about 30 plus years of ems experience in king county Public Health system, ive been a system developer and a real passion for patient care advocacy, so a lot of what i do is all about patients and giving them the best opportunity possible in a very dire situation. So, ive been here six weeks and the running joke is every time i come back on monday, they say that week was a week that is record setting, so then the next week is the same thing and then the next week, and they always say, hey, thanks for coming back and it wont be like this next week, so im seeing what happens for next monday, hopefully its calm. I have to say one thing, in the snapshot and n the time ive been here and our staff that we have in the Health Department of Public Health has been amazing. Theres been so many people involved in this transition process and they are just behind the scenes making stuff happen and the support that ive been given right off the bat has been welcoming and i appreciate that and i i have to give a shoutout to the staff that was transitioned over from dem, as youre aware, any type of transition is very difficult on staff and weve inherited a small staff to do a very, very big job and theyve been holding the fort down for a number of years and i just want to let them know that we appreciate the work that theyve been doing and happy to have them for the wonderful opportunities for the future, i wanted to thank them. So, one of the things that whai came here for is that the transition from Department Emergency management to department of Public Health and i look at that as an opportunity where ems really should live and the fact that Public Health is all encompassing and its not just the response to the call itself, its the holistic approach to patient care, anywhere from prehospital instructions or even trying to create a Safer Community so they dont even utilize the system. If they have to utilize the system, we give them the best possible care and with the coordination of all of our stakeholders, it is a very seamless transition from the time of call until the time they get discharged from the hospital. So, the other part was creating a world class ems system for a world class city, and that was really what drew me in along with the Public Health so, with that is just like what do we need to make that happen, so this is just a arrow down. Arrow down, thank you, somebodys looking around for that, so what is it going to take to make that happen . , so, this is a draft organizational chart as you can see, the real main things is a couple of things we want to focus in onsinger one is medical direction and the medical director and ems fellows apply to come here and they can learn from our system, they can stay in our system or take it back, this provides direction for our ems system. The other thing is creating of an admin section, sections that look at fiscal responsibility, contracts, information, developing our i. T. Support which we dont have right now. The other one is research and Quality Assurance, so part of medicine is always research and being able to publish what you research and thats whats kind of lacking in the system currently, and then the other one is operations and the operations is anywhere from liaisons between hospitals and ems providers to training, to certification, recertification and in the worst case possible would be an investigation of poor care. So, a snapshot, my six weeks of being here, we have some strengths, the strengths is we have a very large group of dedicated ems professionals, not only in ems but Public Health professionals and i look at that as its really integrated which is a really nice thing. The other one is that we have a united 911 dispatch center where the dispatchers do police and fire and ems, so its a single source. And gnash namely accredited programs which is nice to be part of which is a really good thing because theyve met the criteria for excellence. So, some opportunities that i see is part of the thing that we had was a Strategic Plan that was developed in 2013, part of it was rationalized train, the development of rationalized training for our city as well as national trends. Some state requirements that were mandate today do as dr. Brown showed you in that chart, were part of a bigger system, some of those things have been lacking over the year sos we have to ki