They do not anticipate labor force changes. The nurse wills continue to be employed by the hospital if they are general surgery trained. The current surgeon wills continue to practice at other area hospitals. The an thesology Group Service wills continue to be provided for other surgical procedures st. Marys. And golden gate profusion wont be providing the services at st. Marys anymore, but they have contracts with other area hospitals as well. So in conclusion, despite st. Marys low surgical volume and a general trend in having min cally invasive technology, San Francisco has a growing older Adult Population and Cardiovascular Services will be increasingly more important. And, accumulation with the residual impacts like i said before of the closure and that the complexity of patients able to be seen by the remaining cardiologists at st. Marys may be impacted. And then finally, there will be an average of, as we said, at least 35 Cardiovascular Surgery patients annually who will no longer be able to choose st. Marys as a location of the complete cardiac care. So the closure of st. Marys Cardiovascular Surgery program is a reduction in services in San Francisco and for the aforementioned reasons, it will have a detrimental impact on the community. The memo that you ul a received included draft resolutions for the closure, but that concludes my comments on the issue. I will take any questions at this time. I did not receive any Public Comment requests for this item. Could we have st. Marys representatives speak to this issue . Thank you very much. And thanks to the commission. Really appreciate it, dr. Colfax and dr. Baba and appreciate secretary and claire lindsays assistance for a great presentation. We appreciate the confidence that enough st. Marys and saint francis. I am dr. David klein, the president of both. Saint francis for three years and st. Marys for three weeks, so im fairly new to the role at st. Marys, but i have been in touch with the plans for the closure through my leadership role in dignity health. I think that was a very nice outline of the pertinent fact, and i dont want to be repetitive, but i think a couple of points are worth repeating. Its been a tail of i a trigs at st. Marys. Of attrition at st. Marys. 12 years ago they were doing 1200 cases and was the leader in the market. And now we are down to this year looks like we will close the year with 15 heart surgeries. There is a number of reasons for it. One of them, of course, all the programs are seeing diminishments in the number of heart surgeries due to the new technology. Moving to a minimally invasive world, which is, in fact, better for patients in a lot of cases and the number of open procedures is decreasing. We currently only have three physicians that are practicing and doing open heart surgery at st. Marys. There has been a number of attempts to recruit more doctors in that role, and just not available as was pointed out. The number of cardiovascular surgeons are diminishing in the country as that surgery gives way to the minimally invasive techniques that are out there. And as a former surgeon, it is for such complicated surgery that required an integrated team with a lot of experience working together, the low volume as was mentioned does not support high quality. Even though the quality results have stood up with the test of time, as we see diminishment in the number of case, it is hard to maintain staff proficiency. This is a very well oiled machine and if they do one or two a nt mo, you can imagine it is hard for it to always come out the way we would like it to, so the optimal skills of our very experienced team is being challenged as our volumes drop. We plan to continue to be in the cardiac business and a robust cath lab and hybrid suite and those procedures can be done for the most part and proven nationally that you can go those procedures without an open heart program. We have arranged for an emergency transport to a number of institutions pointed out on the map including parnassis which is a few minutes down the road in the event that we need to have an emergency transferred. As was also mentioned, we anticipate no reduction in the f. T. E. S. All the employees that were working on the cardiac surgery because we had such low volume have other skills and other duties and have all been and will be reassigned to other areas in the hospital, so we see no reduction plan. And i think lastly and importantly, just the fact that we are asking for closure at this point doesnt preclude us in the feature if things change in the nature of the business changes where it makes sense, we can always adapt the technology and resume surgery in the future, but for right now we believe its in the best interest of the community and facility to terminate those procedures. Happy to answer any questions. Thank you. It is now in the hands of commissioners. Commissioners, questions . There was no Public Comment . There was no Public Comment on this item. Commissioner green. Yes. I do have a few questions. Thank you for your information. Have you seen an increase in the number of with the number of case that was dropped . What is your standoff doing to increase the uptake of the noninvasive. I cant speak to st. Marys directly as to whether they have seen a volume increase and i can speak nationally the number of minimally invasive procedures have increased. I think that probably realistically we will see a slight decrease in the Cath Lab Procedures because there are some physicians who feel they may need an open heart team to pack them up and we are anticipating some decrease in the complicated Cath Lab Procedures as we close the program. That is a great question. If i am understanding this correctly t cardiac surgeons have prifr ledges in other hospitals. They do. And is there a plan to enable the cardiologists to do the same . In other words, to be able to have the continuity of a team even in different hospital sites and there seems to be enough room to absorb the patient volume that you would have to transfer. Is that true . Also a great question. I think in the cardiac surgeon, they have privileges elsewhere and wouldnt be able to with the amount of business they do at st. Marys. I think many of the cardiologists do follow patients and have privileges, but i think there might be some gaps, and we certainly would have those discussions as to if they would like to follow the patients and need to have privileges, particularly at the centers we will be transferring patients to. I think that is important. One other question. When i was looking at the data, the last time they did the complication rates and the publication was 2016 and you have had a halving of the number of cases since 2016. Do you have any updated data . Is a surgeon knowing about volume and with the complications and with the minimal volume. I can. I will have to come back on august 6 with the actual data from st. Marys. I am not aware of a big shift of quality concerns. I think we have a good team, but i think as we persist with lower and lower volumes, i think that is a real question. I will try to get you the exact numbers when we come back. Thank you, commissioner. And first one follow up on the cardiologists. And you say the cardiologists use your hospital and use the cardiac lab and anticipate the immediate for cardiac surgery sometimes and really do have privileges at the other hospitals . We certainly can. As you look at what is left in San Francisco, there is actually only one other private hospital, and i assume that staff who made this really meant pernassis or only mission bay that is doing card i cant go surgery. It is both. Its both. They do open heart surgery. Its both. Lets clarify that in the document because otherwise it sounds like there is even less. Kazer is not available to the kaiser is open to commercial cases. Are you aware of this . I think in emergency situation, obviously if a patient is having an acute m. I. Or a heart attack, they can go to kaiser and from a transfer standpoint, that is not the case because they tend to be restricted to their patients in their but we are not at all sure and it might be an emergency and then they would need to actually be either out of network because the nonkaiser patient would be out of network. That is exactly right. Any emergency, every hospital, every general hospital, has to care for a patient in an emergency whether they are in network or out of network. Yes, i understand. An i think in the situation of st. Marys we are closest to the ucsf pernassis campus. An i think we should in terms of information and the severity of this change actually have that from our staff and in terms of what actually happens in this case. Very similar to other cases in which we have talked about out of Network Hospitals because now were limited to only, you know, facilities that certain commercial programs may not, in fact, be in network. And can we then assure that these people are not hurt . If they are, then this could be added information concerning adversity of closing the unit. I am very saddened that going from 1200 because i was part of watching and being part of participating and having our patients from our different my own affiliated plans really use st. Marys. And before you got there, i am sure you knew that a world Status Program was created, which also included actually assisting the city of shanghai in part of its cardiac work. And to watch this program then as you say decline so, it used to be the top and i am glad you brought that out. I think we should note that. That st. Marys had a premier program and that this closure is really tragic if it is going to be occurring because for whatever reason, we have lost that opportunity. I am also troubled by one of our physicians who have written in public testimony to us concerning and that goes with this cardiology problem, but he also brings up an important issue. Dr. Chan who then submitted to us a letter indicating that his letters from china town have been triaged to st. Marys because people find him as the cardiologist that they can approach and trust within their ethnicity and language capacity. And he and i certainly know that his colleagues. They have used st. Marys and at this point you see about 47 of the asians. I am concerned how the asian population will then receive that same treatment. Can our staff find out cpmc or kaiser is going to accept them . Or anyway, i think thats another negative. Sadly, for whatever reason, st. Marys has been unable to grow the volume to where its needed. I dont question your ability or i mean your data, of course, and in terms of higher volume creating Better Outcomes and is commendable that has not occurred at st. Marys, or that, in fact, you have been able to achieve the continuation of a superb program. That makes it even more difficult to say that you are closing. Yes, sir. Commissioner i think most of these are questions for staff to try to clarify. I think you would probably also and the increase of noninvasive, because even pcca is invasive, but certainly, a decrease of the use of cardiac surgely andpy pass in terms of the well, for cardiac disease that while that has occurred and may be increasing, it really according to the data has not been a decrease of morbidity but increase in quality of life that has actually brought that. That is correct. And when, in fact, we were looking or need to look at the question of quality, of trying to look at improvement in mortality, cardiac surgery is still a problem. And we point out very well we will have a shortage of cardiac surgery science and then cardiac surgeons and which may be one of the reasons that you are having problems and i think we need to note not that the newer techniques as replacing this and we have to put that balance back in in our document. Great. Director, does that make any sense . The emphasis i am trying to lay here, and i understand the Business Case that you are offering. It is very sad to hear that. But i think then this also calls for us to be much more vigilant about this problem. Lastly, i thought it would be important to quantify what the remaining facility do have with Services Available and the capacity to accept even 30 patients more per year. And we have heard about the o. B. Problems already throughout the city. And i think it would be good to have documentation for that because as we go into the future, this would be helpful in understanding and another one of the needs of the city. And the procedures and acute versus planned. With the presence in San Francisco, it is possible that some of the cases are going to another center of excellence in the region. And so i would be curious and as we look at how much capacity we need in San Francisco proper and i think we need to focus on those who might need the surgery acutely because that feeds into the transports to other hospitals and the whole cascade of changing teams and availability of the actual procedures. The other question i had is, have you analyzed at all its more than just the operating room and is also the Supportive Care after surgery and the postop care. You are really talking about much larger team of individuals to have positive outcomes. Have you thought about that. Ok. The second hearing today is about the closure of the spine center so, i do want to say that before i begin to note that, due to the recent alignment between the health and Catholic Health initiatives the California Attorney general is required to review and approve the closure of the spine center and so when saint marys submits the letter requesting the attorney general review, the attorney general will have 90 days to review and decide whether or not they approve of the closure. So, because of the attorney general timeline, the spine center will likely be closing after july 31st. Saint marys will keep staff and the commission abreast of any updates to that timeline about the closure. So, the spine center, like i said earlier, is a licensed clinical Outpatient Clinic and it function as a joint operation between dignity, Saint Marys Medical Center and the San Francisco spine Surgeons Group and ill probably refer to them as the group as we go on. So the group is a single physician practice that is made up of four Healthcare Providers and they specialize in the treatment of spine disorders and orthopedic surgery. The spine center is located at Saint Marys Medical Center in suite 450. The spine center averages 1800 individual patients a year and their Services Include less invasive treatments like exercise, manual manipulation, nutritional counseling to minutially treatments and spine surgery. So here is some information on patient demographics of the spine center. The majority of patients have commercial insurance followed by medicare. Medical is less than 1 of the Patient Population thats seen at the spine center. 43 of the spine Center Patients are between 41 and 65 and 38 are age 65 and above. So in late 2018, saint marys organized discussions with the San Francisco spine Surgeons Group to adjust the current staffing so that the spine center itself operated like a traditional hospital out patient clinic and prior to this, these conversations, the s. F. Spine group provided all of the Physician Services and then half of all non Physician Services so that left saint maries to utilize Hospital Administration for the other half of the clinic. And they node fight they would open a clinic. The location has moved, its a private clinic its moved from suite 450 to suite 600 at 1 shader street. Both saint maries and the San Francisco spine group dont anticipate any interruption or change in Heath Care Services provided to current or featured patients of the spine center. Specifically the group has confirmed that theyre going to be carrying over the same insurance contracts and they will continue to accept patients from their current payer mix which includes medical. They will maintain Emergency Department call coverage and the group will also provide outpatient Spine Services to their existing patients and maintain the same volume seen at the spine center. As i just mentioned, its not anticipated that this closure will have an impact on patients and there will not be an interruption in services nor the type or amount of services that are provided. The labor impact is not known yet. The spine center has not shared whether or not theyre going to be retaining all of the saint marys employees as administrative staff in the new clinic office. So, st. Johns marys said theyy mitigate and layoff. So in conclusion, should the sf spine group maintain the level of care provided through the spine center currently at their new clinic and should saint marys reassign any impacted employees in mitigate any layoffs then this closure should not have a detrimental impact on the community of San Francisco. That concludes my comments on that. Any comments . I think that was nicely summarized. This is different than the cardiac Surgery Program if that services arent going to change. Were sitting from a hospital operated to a private group. We did attempt to recruit some neuro surgeons from ucsf but as we look at it it makes sense to just leave it in the hands of the surgeons that have been carrying for these patients for years. As also, the closure date as isa little bit fussy,