Back to dr. Chows question around the two different paths of equity and workforce equity. I know you wont achieve one without the other. Yes, theyre the same. Im wondering how will we find a way to measure the effect or impact an increasingly or achievement on the workforce equity goals and its impact on Health Equity and vice versa. Thats one question. The other is so thats an intersectionalty question and cannot be measured and then with our external partnerships. So with this alliance across the government, how do we both benefit that alliance and benefit from that over time so were not just sort of following standards that are set but, obviously, this is something that will be growing and experiencing over time and San Francisco is a unique environment in which to apply a lot of the things coming out of this. How does that relationship have some neutral benefit and is that something that we are going to be able to hear about and somehow influence . The relationship between us and other city departments . Yes. Us and other cities. To ask the question appropriately, but obviously, were part of a larger experience in standardsetting and goal setting. This is a collective and we are in this collective with the i think all nine counties plus whos and there was a cohort of 20 institutings or municipalities in the Northern California cohort and there were nine state departments in the capital cohort and i think next year will be Something Like 18 and there are some in the teens in Southern California and thats just the state of california and so it is a group where we can look online and answer a question from arizona and look at somebody elses work that theyre doing in florida or other places, but also its linking the city departments through the human rights commission. So my question is what is the larger benefit well see . So its a Reference Point and it is sharing environment, but sort of from were trying to catalyze big change here. So what does the participation in that tell us . And i know its an esoteric question. Its not, were not ahead. Were ahead in some areas but this isnt one and we have lots of models to use. The third question is, were part of a larger effort now within the city. Yes. My question would be similar, how does what were doing, very particularly in the department of Public Health inform and relate to efforts that are happening in the other departments of the city . Because im sure theyll have processes there. They do and how does that all come together and again, not a question you have to answer now but something you would probably need to be able to consult with others. And the last question had to do with, because we are a department that does a lot of our work with outside contractors, nonprofits and we are also in a rich environment in health in the private sector a lot of crosssectionalty of the providers and care and their systems, how does our even with ucsf, for instance, how does what were trying to do here. That we dont get siloed and we put our heads down and do the work, which is important work and we forget that there is a larger sphere of influence both external and internal that we could have . Ill answer at length, but i will say that that is the point of centralizing. So when primary care is doing hypertension, theres virtually no way for them to really do that with an awareness of what even ph. D. Is doing, let alone what hsa is doing or what other institutions are doing. Thats my role. So thats the role of us centrally, to maintain awareness of where the other departments are doing and to bring in resources from other cities and municipalities so that were not reinventing the wheel. We took our respect policy and modeled it after one of the park and rec and were using our mta, just came to me to about some f the work were doing there. Thats the role of having a Central Office so that dph can be represented in those spaces and thats always a struggle for us, because if you send someone from the network, they represent the network and if you send someone from Behavioral Health, they represent Behavioral Health. We were not able to do that before. The point of centralizing is to do that and to be ail t able toe the department and alignment with everybody else and move it in alignment with each other and to take that whole department effort and then make sure it actually has some view of the outside world. Just in response, i would like to say you representing that central role very well. Thank you. Thank you. From my point of view, i want to acknowledge the work that you have done. I thought it way insightful and helpful in terms of our discussion today and there will be more discussion based on the questions that my colleagues have asked you. So i dont want to repeat any of their questions, but i do want you to answer in writing because i also am i ware of your time to us, the notion of hiring, recruitment, hiring, retention and disciplinary effects on black africanamericans and the question of retention is the critical cal. One. If you recruit and hire and put folks in discipline and leave here, thats not doing much for the bottom line in terms of equity. So i want to make sure we have a strategy to address that. So along with all of the other questions that were asked, i had another question, but im not going to ask it. Ill wait for the responses from the one weve given you. But again, thank you for your insightful report. Im really excited to see so much energy and interest and really thoughtful engagement with this issue because the more that you hold us to account about that were doing about it, the easier it is to move the work along. So its an inside, outside strategy and we need pressure from both sides. Pressure from staff asking for change and pressure from above and outside looking for change and i think we will benefit from both and i will get squished in the middle and im comfortable there and we need both. Your interest, i hope it continues and challenges us and challenges not just me, because equity is not just me but every other person who comes through with something to say. Thank you. The last thing, if, in fact, you run across some articles that would be helpful to understand both ger and Health Equity means for San Francisco, would you forward them to mark and he can send them to us. So were compiling that for the champions that have to do 20 hours of education and were compiling a list to choose from and ill include that with my answers. Thank you. Youre welcome. Thank you. Commissioners, thanks for that great discussion. Item 8 is the Population Health division true north and thank you, doctor, for being patient and mr. Wagner for being more patient. Good evening. Im the Health Officer of San Francisco and the director of the Health Division and today what im going to do, just because of the time, ill im gg to move quickly and do a high cover of the true north and how it fits with our Performance Improvement and ill go through a couple of examples and we wont have time to go into detail with all of the different metric areas but ill introduce you, primarily, to the framework. First, i want to point out according to our departmental annual report, the Population Health division represents about 4 of the Health Department. So we provide core Public Health services for the city of San Francisco and together with maternal child and adolescent health, we use that for accreditations. And back in 2011, when i started this position, canya and kramer published an article called collective impact. And that really had a big influence because it really helped us reframe on how to address complex social health problems. And we took that on and we went ahead and embraced results as a primary approach that were using for collective impact and in 2013, 2014, we started our lean training at San FranciscoGeneral Hospital. By 2016, we had incorporated both lean and rba into the Population Health division, first in Environmental Health and you see there in 2016 and in 2017, we received our Public Health accreditation. And so the general framework for Public Health accreditation is based on Ten Essential Services of Public Health and with a domains of the administration and governance, we have 12 domains that were upped by. Judged by. Im showing you this slide is something one of the commissioners brought up earlier, is the issue of policy. The Population Health division says r does mor does more than. We also work this the area of assessment which includes evaluation, research, epidemiology and also in the area of policy development. So later on, ill give you a couple of examples so you can see how that fits in. The lense that were going to use is a lense of Performance Improvement and thats under where it says there evaluate. So dr. Bennett talked about normalizing and one of the ways to normalize is everybody will show you a lean triangle. This is a lean triangle for the population and Health Division. Starting from the top, we have the vision of the Health Department making San Francisco the healthiest place on earth and our mission at dph is to protect and promote health and wellbeing for all in San Francisco and our logo represents the diversity of community, clients, patients and staff. The next is the true north goals, metrics. They need to be healthy, thriving and in line with our mission and vision. We have our principles and we have our values. And then humility, compassion and dignity. Ill be focusing on the true north goals. The other question that we have is, how does results heavbased accountability connect to lean . This is from rba and what you see here is four different quadrants that can be divided by quantity, quality effort and effect and lean has amazing tools for processes and eliminating waste, especially in the area of where it says how much do we do and how well do we do it. Rba is relentlessly focusing on outcomes and under that category here, you see where it says effect and the question we ask, is anyone better off . So if you dont remember anything else from this presentation, i want you to remember three questions that i want you to hold this accountable to every time, which is you want to ask us, how much did we do and how well did we do it and is anyone better off . Im going to focus on, is anyone better off . Im going to briefly touch upon those areas, but im going to dive into a couple of areas in Health Impact. You had a presentation on equity so i wont spend any time there. Under workforce development, the key metric, percentage of staff recommending ph. D. As a place to work, for service experience, increasing the percentage of our programs that collect service data and use that data to improve Services Based on what they learn . Under the area of financial stewardship, the key one to point out to you is increasing the use of priority setting and resource allocation methods. This is a tool that we use to help set priorities around budgets and try to focus investing or limited resources in those activities that we think that will have the biggest impact. The other area that i want to point out is in the area of decision quality and increasing the percentage of staff that are decision competent and use decision quality criteria in problemsolving and Performance Improvement. These are draft indicators and were still working on them. And the areas to spend more time is in the area of Health Impact. You see at the top we have maternal and child adolescent help. We take a framework with the development of children and intergenerational processes, include the social and biological transmission of the effects of trauma and toxic stress and family and Community Centric approaches and environmental stresses including social and cultural. And continuing in the area of Health Impact, im going to give an example from the middle one, which is preventing infection and preserving health. And im going to give you an example of social, emotional and Behavioral Health into o to givn idea of the complexity of the problem but to summarize where we as a city in San Francisco, weve had a big impact nationally and also around the world. Ill briefly just highlight getting to zero. I wont focus on the data youve heard but really on why getting to zero is so special. And why i think San Francisco really stands out. And then i also wanted to spend a few minutes on a Public Health crisis that were having right now with a vaping epidemic and sort of paint to you the picture of how much San Francisco has actually accomplished when you ask those questions, how much, how well and is anyone better off . So you see this from this is sort of the iconic graft that we have here and where you see the number of new hiv infections are at an historic low for San Francisco. The number of people who are surviving is high and also the mortality rate has become more stable here. Focuses othis gets them virals to the viral load and decreasing commission in the community. This requires everybody on board where we have a medical intervention with a public human Health Impact. The way we measure how well did we do, we have a framework thats called hiv care cascade, where you look at different leveled. So ivlevels. Of people hiv positive, 94 know their status and weve linked 91 of them, in terms of retention, were at 64 and virally suppressed, were at 78 . In terms of the standards that we have globally which is 909090, 90 aware, 90 to care and 90 suppressed, even though were doing tremendous, we have room to improve. The other area where we have room to improve is in the area of lati nx, especially with the intersections of Mental Illness and substance use. Those most vulnerable populations are the area were moving into next and we need to do more. So yes, the wow, we have made tremendous strides and this model of collective impact is unique, we still have areas that we need to make progress in. Thats the first example that i wanted to show because its a special example. The next example i want to show is with ecigarettes. Between 2006 and 2018, San Francisco has passed eight laws. Smokefree parks, smoke manufacturfreeentrances, cabs, outdoor seats, landlord disclosure of smoking status, smokefree outdoor events, ecigarette use regulate the jusregulated likecigarettes, toe baseball stadiums, prohibiting flavoured products, including menthol. These laws were passed in collaboration with the community and oftentimes with youth groups. So the question is is that how well do we do and is anybody better off . The answer to that is yes, no, no and yes. Yes was in the middle there is National Data. You see how the prevalence of smoking has going down dramatically and in california, we were making and in sanfrancisco, we were making tremendous progress in reducing the prevalence of smoking, especially in youth. Thats the first yes. And we were doing fantastic. But then, a San Franciscobased company figured out how to tweak nicotine into a nicotine salt and make it highly addictive, where people would have high levels of nicotine in their brain like this and get youth addicted. Were now in a new Public Health crisis and thats the National Data right there that you see the vaping, ecigarette vaping epidemic. San francisco right now has the highest rate of ecigarette use of in california for kids in high school. Among tenth and 12th grade were at 20 . Think about that, 15 in San Francisco, the highest in San Francisco. So while we were making tremendous progress, we fell behind. So what happened . In 2019, right when dr. Colfax came on, the City AttorneyDennis Herrera and mr. Walton passed prohibiting sales of ecigarettes that were not f. D. A. Approved. When that came out, nobody was expecting that. This was an example where the innovative leadership comes out where you least expect it. I heard on monday this would be announced on tuesday and dr. Colfax was talking with the City Attorney and we had to mobilize and get behind this. So dr. Colfax and myself coauthored an article for the medicine journal and we really went on the offense of really reshaping the narrative on how its really important to support this ban in terms of f. D. A. Approval. We have been so successful let me point out one thing, the next thing that happened was the epidemic of vaping lung injury. And so now we had the ordinance that just passed where San Francisco was alone. We had an epidemic. Lung injury happening in the country and all of a sudden, people are realizing