Are there Outcome Measures that you are going to i understand with Health Equity and what you said that theres very specific measures with the blood pressure, et, but with policy, process and practise, will there be Outcome Measures that youll be able to have in place . I think there are Outcome Measures possible in every stage. So ill give you a couple of examples. So were going to deploy a respect policy some time soon which delineates disrespectful behaviours and encourages us to move to using our standard discipline and other mechanisms to actually enforce our Workplace Culture to do something about disrespectful behaviour. And so, the outcome of that is measured in a few ways. The process of whether or not people make those complaints and how many there are and what the nature of them is. And are there an overconcentration in an area to give us a sense of where we go next but tells us about what the department is doing so thats a process measure but the outcome measure is why we ask that baseline question. Are you seeing disrespectful behaviour . Because our hope is that people who sigh i see it is see it res, over time be answering different to that question. We may see a spike as people see it responded to, which elevates the issue as it happens, but then looking longterm, were hoping that we would see people report back to us that they are seeing less of that, that they can agree or strongly agree that managers are respectful and that staff are respectful. A lot of things we dont have the baseline in order to establish where the policy has had an impact, but we are needing to put those in place. So another example ill give you, at mcah, theyre looking at why they have such discrepancies with their latinex and black american women and i think it was the nurse family partnership. So they looked at both the retention of patients and who leaves at what point so thats their outcome measure and they want people to remain in the program longer and equally across those groups but they looked at the process measure of, how are our staff interacting with patients and found there are differences and how many times theyll call you before they close their case or how long they stay on the phone. So looking at that to stay we looked at what our behaviour is and our behaviour became equal. So are people getting three calls and case is closed, still, after three years of changing the policy . So rather than having it be up to the nurse to just decide, actually deciding thats an area we need a policy and well do it the same way and set a standard so we can say when the standard is not being met. And then looking at, does that have an impact on people retained in the program and an impact on whether or not people have Health Outcomes from the children. Im always concerned with policy and practise change, that there is the outcome and the followup, because we all can create policies and wonderful emission, but whats the end product . And how are we measuring it versus our policy . And so as youre going through this, it would be just really helpful and i would be interested in the information . Well, what will help us on both fronts is that we have been marching forward as a department to increase our rigger around holding ourselves accountable for outcomes. So the a3s that people are producing that have processed measures and Outcome Measures in them and say we should be checking this at this cadence and have the display boards, having that underpinning of structure of how to go about it will help us if we can use that structure on this issue. And so, if were looking at er wait times, trying to get them to look at, is that wait time different, for different groups and is there a reason people are leaving earlier. So being able to use the increased rigger, wer were tro have in all areas apply to this issue and were trying to do that, even around policy. Thank you. No problem. Commissioner bernell. Thank you for your excellent, thoughtful presentation. I recall when you were here a little more than a year ago, we were talking about a normalization phase and there were a number of conversations, facilitated conversations happening across the department that were proven to be extremely valuele. In looking at some of the data youve shown or some of the ways at looking at this, like system change and the employee surveys and how there are some groups, of course, who have a favorable view of how things are than others, im wondering if over this period of time, when youve been having these normalizing conversations, you know, we, of course, all want to see those numbers get better. We want the perception in system change to look further along and we want higher percentage responses among the employee surveys and have you seen theres a value in, perhaps, some of the groups responding with higher favorable rates . Perhaps those rates are lowering and being more of a convergence where peoples perceptions are coming together so there may be some value in se seeing certn people changing their minds and seeing were not as far along or favorable . That is, in fact, our expectation, that somebody who thinks no disrespect is happening or seeing in the same department as someone who thinks its happening all of the time or somebody who sees us as a fix think things are worse as they become more aware of whats happening around them. So we dont expect everyone to stay the same and both sides are a problem. Its a problem if you see everything as terrible, because youre right and youre not seeing the positive changes but its a problem if youre seeing everything is great because it means youre not actively working to improve the problems because you dont see them. Theres some of that that has been seen. Mch is quite ahead of some of the other sections in the department and have been working on this for a couple of years in a concentrated way and has had feedback from their staff that they didnt see this and they started their own discussion group, a tea Time Discussion Group about what is our role in this and how do we see this and doing some selfeducation of themselves about how racism and how it plays out in their department. Spouso we have seen some element over time and i expect that is what well see in departments that really take this forward. So in some ways, seeing less favorable responses is a good thing. Right. The other question you touched on was soji data. I know the department put forward a report, i think, in july and there was a hearing at the board of supervisors in november where we had shown progress and set some, i think, pretty strong and Ambitious Goals for the future. Now that we have epic in place and everything like that, is there a good time where you think it would be good to come back to the commission to talk about some of that progress, where we are in meeting goals that have been laid out . We know epic has reset us to some degree and were right now in the process of looking at now that weve had it a few months trying to figure out where the conversion of our workflow from our many different systems into a single workflow in epic, where that happened and carried through and we have issues about how the data flowed across and right now, were in a stabilization phase with the rest of epic. Once thats done and weve done retraining, we will have to move forward to do another phase of training and engagement with patients and with staff. So were expecting that will happen sometime in the beginning of next year. So i would say about next fall at the earliest. So thats a good time to come back to the commission to do your report. Yes. Thank you. Thank you for the excellent presentation and your leadership. This is really terrific. I have three questions and theyre connect the. Connected. The first is you discussed programs you thought were excellent but they hadnt been scaled or spread because they were siloed and i wonder if you can tell us what those are . The second is, i guess i was surprised that nearly a third of the people you surveyed that didnt think it contributed and how does that respond compared to other city departments or other municipalities and organizations participating in that gar . The third was, you talked about a dashboard and i think this reflects what the commissioner brought up, sounds like some of the things we want to measure in terminterms of metrics and im wondering when we would get a sense of what would be included and those are three different things. The first is, i think there are a couple of highlighted areas. The first, i would say, the work that i described in mcah, where theyre thrilling down to look at what is happening at the individual staff level and where staff behaviour aligns with Different Community forces that make people not take up programs that we want them to be involved in. I think that work has been stellar. There is a pathway to scale that, though, because as we build infrastructure and we ha. Weve seen that happen. That happened at mch and in primary care they took that forward and looked at their hypertension goal was to make sure they had two blood pressures for every patient. Well, then, they looked at they were getting it, great success. When they disagregated that, they werent getting that. They were getting it less often. They had ok performance. But looking at that as a standard of behaviour, now we have an infrastructure to do that on. The other is, i think the hepc work in particular has taken a really Community Engagement focus that is not seen often in the department. They have real Authentic Community involvement in their decisionmaking process, getting to zeros and doing that, as well. And both of them have focused on overrecruitment and targeted recruitment of africanamericans. So that both of them overrecruit africanamericans into the program. So theyre proportion far outweighs their proportion of the disease. Hepc is seen at a higher curate and higher than that proportion are the ones getting to a prepped to a higher proportion of people and retaining them longer and being able to show outcomes because theyre showing that concentrated effort. What was the second question . The context of a third of people its not that different. That question is used across the country and so, we have had staff here who did not know what redlining was or segregation happened outside of mississippi or somewhere they saw in a movie. So that lack of knowledge is actually quite widespread. Weve had staff here. I think its partly just the taboo name of the topic. It is just not described well in much of our educational system and many of our staff are immigrants and so theyre absorbing our racial history from tv shows and we havent done a concentrated way of letting they know, actually, what happened here. And so i think thats not a bad number. I think people are overestimating naturoverestimatn detail, im not sure many could understand the depth of what that means, that it means whether there are enough bus stops or fewer parks or the scores on Peoples School grades. So all of those things, i think, are widespread and not that unusual here, actually. And then the dashboard plan. So we have not what were trying to do is correct something that happened in baji. So we imposed some measures and we had years of struggle getting thegettinguptake from the diffes of department who did not participate in that choosing process. Now every part of the department has been asked to set their own measures and their own outcome and process measures and they are in the process of doing that. For some departments who have been doing that for years, like mcah, that is easy and they have given them to me and for other departments, because its across the board, so it and finance who have issues that could be dealt with, they have not done that and i dont have them yet. Im basing on that our headline indicators for health and what people are telling me they can work on from where their effort is. Thats why i dont have it yet because i want it to come out of the staff and not just be imposed from above. But i expect we should have that in the next two or three months, at the most. Thank you. Commissioner chow. Thank you. And thank you for the presentation. I guess initially i was the office of Health Equity title is a little confusing because not only are you talking about Health Equity as an illness or a measure of health and wellness, but then youre dealing with racial equity. So once i got that into my mind and i could see in your presentation, which was excellent, the separation that occurs. So the title is a little hard to initially grasp because first you just think initially of Health Equity and therefore, were talking about the subject being the recipients of health. And then adding the task of also addressing the issue of racial equity, which is what the city was creating, then created two paths that you have really demonstrated very well. So i think the workplace program, i would look forward to how well youll be able to help change that because you clearly now have a baseline and you know areas in which as commissioner bernell said, weve talked about before. And i think thats definitely something that your division or office certainly has a grasp on. Im a learn more concerned about backtoHealth Equity. It took a generation to even start moving the needle after focusing on one population that had enormous despairties, our africanamerican population. And even as the population got smaller, the despairty probably got worse for many reasons, but it did. And now youre showing a change. Several had been done with the communities and wasnt very successful an and even though yu didnt present the data, we got a glimpse of it in the initial handout that showed that we were beginning to make progress. Yes. And so it required a concentration to focus. Going back to Health Equity, how will we be sure to continue that focus because now it is within a Larger Office and hasnt got the spotlight on it as it has for the last several years and also, i think that the charge now is that we shouldnt just stop at that population, but that there are other populations as we know. If we begin to disagregate better, i think its clear that some of the Pacific Islander populations, although small, is still a population that needs to be considered. How do we do that within this limited resource that we have without diluting this effort that finally is seeming to begin to show outcomes in our Africanamerican Community . So i would say that our resources are not limited. They are limited in the larger sense that we as a department are limited, but i am not the resource that will cure the hypertension despairty. That remains in primary care and health. Theyve been working together on this issue for years and they continue that work. So we are not diverting focus from them. Were asking everybody who is standing in this circle watching them to turn around and do their own work so that we have more than one place. And whats really been helpful is to have more people at that table. So ten years ago, that might have been primary care and its been helpful to have Population Health there to talk about what roles some of our cbo players can have in that and how do we include Food Security and other issues that have been really important to that patient population. The fact that that project has been successful is partly based on it not done classically and it has not been about that. Having patients in the decisionmaking body so doing things differently than they have been doing is the secret sauce of that program. And then, expanding that so that laguna honda has the same focus and that the general is taken heart readmissions which is a part of the same spectrum as their focus and so that the community contracts were doing around Community Focus groups and Community Outreach are all focused on heart health and that focus has grown from the classic doctor and patient and lets see what the nurses do to include quite a lot of the department and that work will continue. And hopefully that work will sinnesinsynergize. Work in ph. D. To move all of their programs to have the same thing and patients are in families and communities. If were focused on heart health, we need soda taxes and security resources, those are all the same patients and having them be well cared for in our clinic but food insecure and not having other issues cared for will only thank our other efforts. Were getting to a point of synergism and it will accentuate the efforts rather than take focus from them. So weve identified in the Africanamerican Community many disparities already and you were describing processes identifying others that have become hidden because we didnt disagregate the data. We know that happened in diabetes and the Asian Community and so forth. So so when would it be, going back to commissioner bernells question, we might hear of other disparities were working on and giving them that spotlight to say that we would expect that you have identified, lets say, group x in this area and how are we going to be able to follow that to understand that we are actually addressing and creating within your framework that you are describing a product that then allows us to have process and then gets to the outcome. We are including other groups. So the dula program is africanamerican and Pacific Islander. Some of the food programs are the same and there is not theres a diversity of focus across the department depending on the issue, but i would say that the data shows us that the difference between the distarity of the black africanamerican patients and everybody else is one that is nearly exponential. So any standard medical and Public Health practise of triage would say that that is where our focus remains and i dont think it will change from that if we use data as our guide for 40 years. We hey do something with somebody else, we should, but the difference between our chinese or lat the difference between those groups is really a quarter or less of the difference between africanamericans and everybody else. So while we need to keep the focus nimble, so that when we find things, we address them and