Plan after that. Were supposed to participate in citywide training and that is yet to be developed and there will be goals, achievement of our goals will be tied to budgeting and hiring approval from the board of supervisors and that has not been delineated about what that means, but that is the broad statement that was made. So what is the mission of this office . Its Health Equity, work castfoe and Workplace Equity and direct force and it will be clearly leading with race but not stopping there and leading with race for lots of reasons. We talked about racism as a key driver for health and p w we knw from our data, and in particular, ourace gives usa br. Its an original organizing principle and its baked into policies and procedures and when we go which correct those, rewere correcting inequities for other groups. Theres huge intersectioy between policies and practises that uphold racism and those that uphold the other isms that oppress people or keep them from having Health Equity. Were looking for a curbcut effect and by that i mean, thats the one intervention intended for one group and actually smooths the way for everybody else. So if we are doing our best for the people who we are showing the worst outcomes for, it will increase access, increase quality of care for everybody else. We are going to focus on systems change and im going to talk about the framework that leads us there in a few minutes but that means that we will not just be looking at transactional program development. What were looking at is changing our underlying policies and practises and the way we go about our work. Focusing on alignment and that means collaboration. Well take that into our equity work, as well. There are several reasons, social determinants of health are important. We know that the underpinnings of racism that lead to Health Outcome differences do that through changes this the conditions through which people live and so their housing, their transportation, their access to care and all of those things are not the purview of any one group. So it will take Population Health and the Health Network and also agencies outside of dph in order to actively address any of these things. Also, were doing many things right but theyre sa siloed andt spreading. We have examples of programs that are not scaled or spread because of the nature of our sigsilos and if we want to havea good effect on the department as a whole, which we have to do to have an effect on whole populations, then were going to have to have some mechanism to get passed that silo. Well focus on achieving Health Equity and thats a core part of this activity. Our mission is to improve the health of all of San Francisco and we know that if you take our average, we are doing that very well in lots of places. If you break down that average by race, were doing it some, not all. So we want that for all groups, not just some of the groups and not just an average. So that means pushing ourselves as we have been to have clear quantitative outcomes. We have been doing that with our lien work, with resultsbased accountability and accreditation and thats a principle happening across the department. We want to make sure that principle is applied to equity, as well, so were not just trying to make things feel better or sound better but looking at what is everybodys Blood Pressure pressure and what are we doing for life expectancy. That helps us by leveraging investments weve made in Quality Improvement and business improvement. We want to focus on workforce. That has been a call from our staff the entire time weve had that project, back to before baji. That staff has told us we dont have equity in our workforce. The same underpinnings of workforce is passed through to patients. So the kind of people who are here, not here, the way people treat patients with respect, the same way theyre treating each other. We know we cant do one without the other. Our intention is to have all staff giving their best and we know if we look at the average, thats true some places and if we disagregate, thats not true. So we want to be sure were doing the same for everybody. And also, because racism is Health Related and its important to health, that means that its a professional interest for everybody here. It should be a professional skill to deal with anything that is a healthrelated condition and so, just like we want people to be knowledgeable about food or poverty, we want them to be knowledgeable and versatile around racism. One thing thats not on here, because this came together a bit quickly, last minute, is that we want to focus on centering the community. We talk about being patient centered but we need to be both centered on the individual and the communities in which they come from and thats partly because racism is deeply geographic and because the impact that we want to have is beyond the individual. We know the drivers of health are things that impact at the community level, not just at the individual level and so thats why we talk about racism as interpersonal, meaning the relationship between two people, but also structural and institutional, things that affect everybody who comes through or the entire family or community. So the activities were going to do to make those things happen include developing the annual plan that were required to have. Weve done that as an a3 over the last two years. Supporting inequity infrastructure and that means having standing, ongoing bodies of people who will make decisions and keep focus on equity as we go forward. Were going to align with the office of racial equity, both were required to, and we need to build relationships with other departments if we want to make bigger changes. Well provide training. And then develop policies and practises. And both training and policies and practises are both about equity specifically, but also about things Like Community engagement, communication between staff, so not just inequity 101 but whats the body people need to do this practise . So the framework comes from the Government Alliance on race and equity and what youre looking at is the way in which it lays out what they think of as the trainingtransformational journe. Theres a law say you cant do this or that, theres a rule about who can do things. And then structural transformation i dont know weve seen but its where they dont exist and weve redressed or problems. So we have done a version of this with about 1500 of our staff, have done this very, very selfassessment or some part of it. And most of the time, we end up somewhere between three, which is transactional, which is that policies and practises are in place to promote Something Like multiculturalism or diversity, but they dont yield the results. So we celebrate different cultures but dont specifically talk about race and racism overtly. Our cultural shift where policies and practises call out race, theres an intentional review of policies and practises and things are starting to shift. And we get to that sort of three and a half average score somewhere around there, by staff saying that were a two and those staff tend to be black or latinex and staff saying were a four or five, very rarely a six and those staff are white or asian. So were not all sharing the same view of the department or same experience of our work here. Were not where we need to be. Were in the middle, on a journey. The framework is to help us understand where we are but also to help us understand where we are as a place in a journey, that there will be lots of activities required to move from one place to the next and our job is not to flip some switch that doesnt exist but to move everybody from 3. 5 to 4 or 4. 5 or whatever the area is to make things better. So were advancing equity, not striving to arrive at some finish line tomorrow. The next part of the framework is how do you move from 3 to 4 or 4 to 5 . And the way they recommend it and thats what were using, you go through three phasing. You normalize and that means that you set the priority. Thats the same thing as weve done with setting this as a true north, making statements about it, establishing things like an office, giving people the idea that this is a priority for the department through specific training, skills training, knowledge training and all of the things you need to get people used to and talking about this and using this as part of their daily job. The next is to organize, to actually put in infrastructure, groups, decisionmakers, set roles, established resources and that doesnt always mean a formal department, but making sure that people know whose job it is, what kind of of outcomes youre looking for. So actually get the data systems to give you the data you need to be able to monitor. So organizing around it in the last is operationallizing and actually making a policy change and making a practise change and changing the way you do things. So weve been doing all of those things all at once and they want you to do somewhat in order but weve been doing them at the same time to some degree. So training has been something that we have slowly developed. So we have been training in different ways, in different parts of the department. The general training, we all have slightly different training. Were doing an allstaff with hrc so that were in consistency with the rest of the city and we have not quite established that yet, but it is coming. That training will have foundations of racial and government policy history so that people actually understand the context in which theyre working and we have many staff who this was not something they learned in school and dont have a deep understanding of why things are the way they are. We need to catch people up so were on the same page and whats the actual status quo were asking them to work on. And then skills training. So managers working on communication, working on how to establish goals, have our epidemiologist aggregate data and how they relate to our goal achievement policy makers and how it has an unintended consequence of exacerbating racial equity. So all of that is happening over time and some has already happening. Fast facts is a way of normalizing and giving people information and then ill talk about the Champions Program in a moment but the learning a catch to that new program, well do a Fellowship Program in the spring for people who might be more intensive practitioners, epidemiologists and other people developing policy. Were working with that to set a curriculum so we can do a sixmonth program or so that at the end, they have expertise and we can see expertise across the department to move everybody along. So what do we know about where we are and whats our status in the chart youre about to see, ill orient you to, because its confusing. Our Staff Engagement survey this spring, we added six questions that are based on questions that they use to assess municipalities and those questions are here. The first is looking at whether people understand what institutional and Structural Racism is. So policies contribute to differences in health between racial groups and then several are about what work do you see happening . Im actively involved or my department is working on this. One is a question about skill. I feel comfortable talking about race and racism in the workplace and two are about respect and thats put in there based on staff feedback. So managers treat staff of all racial groups and staff in my department Treat Community departments from all en ethnic groups. The darker the colour means the higher the score and more people answer agree or strongly agree. So if we look at the top line, somewhere around 70 agree thats true. But there is difference by race in that answer and if you look at all of them, we have a few conclusions, so some staff dont have any more information about racism and what its impact is. If you dont believe that government policy has any impact, you are actually purveyors of government policy. You were actors or creators and if you dont think that has an impact, how do you envision your role . So many staff arent involved in the work and half say theyre actively involved or their department is actively involved and many staff dont have the skills to discuss this topic. You cant be working on something that you cant discuss. And so we need to have more discussions that people feel more comfortable doing that. Some amount of disrespectful behaviour is happening and people answered that three quarters of the time they agreed but we would like that to be higher and means one out of four answered that, seeing disrespectful things happening. If you look at that throughline in the middle, its lighter on most questions because our black africanamerican staff answered lower for many of the questions. And so, they were much less likely, so 7457 saying managers were respectful and saying staff were respectful to community. They are also also comfortable e talking about race and racism. Whether thats im not comfortable talking about it, because its not a topic i talk about, which is true for some people or because i dont feel safe talking about that here. So we dont fully know. These are just answers to questions, but they do mean that we have normalizing to do around the department about what people are expected to do and what we want them to know and about how we expect them to behave. So in terms of organizing, which is really an active of focusing on systems change and active alignment, we have two new groups that started earlier this year and are continuing once the equity governing council and thats an expansion of baji Steering Committee and that includes directors and from the jail and primary gear, from the laguna honda and includes different intentions. They developed their own departments and equity plans and goals and it helps to have people together, saying we want to get together around heart disease. They helped develop strategy and approved policy and that group is paired and they meet every other month and the governing Council Meets in the next month the Equity Leadership meets. So are managers, for the most part who are equity roles or focused program are the person in their area to learn something about this to get something going. Those are people who develop work and share best practises and who craft policy recommendations. So thats the group that said we dont have enough time to do this work and lots of people want to but arent given time. So we craft a policy to allow them to do that. Or that we see that theres some disrespect happening and then we add questions and then craft policy to address it. And then that policy goes to the governing council to get approved and then to the director. So the Champions Program is the first thing coming out of those two groups and its basically giving people five hours a month to work on equity work. The intention is that they would spend half that time learning and our expectation is that theres a low level of expertise around the department and people have a feeling they want to do this but in terms of how to go about it, its not as deep and people will spend half that time working on that and half of the time working on implementation that is not developing a Little Program in their area. We want people to be generating the foundational work that will keep them going longterm. Doing focus groups, observing patients with your staff and looking at the data about performance, when people have looked at it in the department and they have shown that some oe showing they dont offer the same as they do t. Our goal is to have 50 applicants in the first year to start and we got 70 or 75 and we got them from every section including it and finance and well work with those people to start generating what the new baseline for your area to understand what to do next. And operationallizing, were working on several fronts and were continuing with the baji work groups and weve extended passed that. Theres direct programming, the hope sf is under Health Equity, a new dula program in the community and those things are direct services to areas where we know we have an equity problem. But the larger goal is to have equity expectations in every area. So to have laguna honda has picked hypertension control and having each area pick something theyll focus on and devote time to and correct that. Rather than having discrete projects and thats moving from transactionional to transformational. The graph youre looking at is the hypertension run chart, the run chart from primary care from the beginning of that project. So in 2015, when it started, with that baji work group started, there were 53 of black africanamerican patients had hypertension under control and 61 of the general population did. And that was an 8 gap and today it is actually 67 point something percent of africanamerican patients actually 70 , they went over 70s. 67 of africanamerican patients and 70 of all patients and we expect this to happen, that when you raise the expectation, it actually raises it for all people. We did things that improved care, nurse visits, pharmacy visited, food pharmacy, all of those things were really thoughtfully directed at africanamerican patients but helped all patients so everybodys Blood Pressure got better. But because of that focus, the improvement was greater among black africanamerican patients and we were able to close the gap. If you look initially, that focus wasnt so exact and so, everybody got better at about the same amount and its in the last several years that its been more directed. Laguna honda had the same impact, they started later but brought hypertension control for africanamerican patients up to par. This is focused in the Youth Clinics to date and screening brought to 85 . In the first year, they had a dip when we had staff turnover and had to do retraining and theyre back up there and then baji preterm birth just starting. If you remember initially, that the idea had been to focus on Breast Cancer and then we shifted. The governing council asked us to shift, partly because thats where a lot of crossenergy across going and we wanted to harness that work to make sure its directed to our own health and different parts that werent part of that project were brough