and together the recommendations would result in savings of $2,458,052 all of which are savings to the general fund. and we are still working with the department and we will report back to the committee next week. >> thank you. barbara, i know you will be coming back to us next week. but i wanted you to walk through a little bit more in detail the process under which you arrived at the cuts for the $3.1 million in cuts because i know that you went through an expepsiive process even before the mayor's budget process to engage with nonprofit providers and the staff and budget staff worked closely on the mayor's budget process and subsequent to that meetings with nonprofit providers as well. >> on a yearly basis we meet with the community-based organizations and civil servant unions to discuss new project

program initiatives and planning for the budget. and for prior to budget being committed, we work with the community-based organizations to identify areas for potential reduction. many of the providers wanted us not to kwet areas where we would also be cutting revenue. what we did is an extensive review of where the nonmatched general fund was. from that process we then allocated across the board cuts to the programs to meet some of the targets. from there we worked with the mayor's office and working with the community-based organizations through a process of identifying and then once the mayor decided on his budget, we went back with a million dollars particularly in the outpatient area and basically looked at smaller organizations under $1 million of contracts and tried to spread the $1 million so we

did not have any organization closures. we knew we were going to have program closureses and trying to look at smaller organizations we wanted to make sure they were first providing the dollars back. we had a meeting with chu and the community-based organizations and how to restore those back to the community, the community-based organizations. at that point they had some priorities. african-american communities along with homeless services and that at the end of the day they felt that the department could fairly provide some leadership and direction if we are getting restoration for that. >> thank you. supervisor kim? >> actually, i just had some clarifying questions. i know that some of the cuts we don't necessarily see because some funding goes through the r.f.p. process and i know you

had to cut some of the dollar amounts you gave out in that process and given the cuts here. and out of curiosity in terms of the funding that you allocate for aids program, what was the amount that that was allocated last year? and what was allocated this year for the r.f.p.'s? >> i believe it is around $30 million and we do that every three years. >> every three years. >> the federal dollars are so not secure that every three years and this year we were really looking at particularly understanding the treatment and the direction for prevention. we took about a year and a half of work with the community-based organizations to explain them to the new directions and moving a little bit away from behavior prevention and more into treatment and then we had multiple meetings with community-based organizations and the r.f.p. went out and came back and reducing as much of the harm there and the r.f.p.

process and whether it is the focus there and how well they do it and working diligently with transitions. and we also delayed the implementation of the cuts or changes until september so transition could happen. and we are applying to make some of the other programs whole. and we favor doing that. >> there were no losses to that and what they were was a different direction that i will clarify that for you. >> and if you could let us know what portion of the funds in the r.f.p. went to community-based organizations as well. >> most of the majority of those are -- we did for full disclosure, we did leave some of the community d.p.h. programs

out of the r.f.p.. >> with the funds for the aids program, was there a change in the percentage allocate ed d to department? and just for the sake of the public hearing on the issue, if you could talk a little bit about the shift from behavioral to treatment and the rationale behind that. some of the argument i sometimes here is the behavioral is important because it is preventative and because we have been so successful at preventing that we don't really know what the impact would be to no longer fund preventative programs. >> we believe in both behavior component and behavior takes longer for change and also the fact as we have learned people who are getting into treatment earlier and reduced the viral load and reduce the transmissions. it is important we move into the testing area and the treatment

area not only for insuring that individuals are being cared for and we have done a lot of extensive review of the literature and throughout the country and this is the new direction as well. and it was a national strategy plan from many of the federal agencies that pushed us in this direction. >> in terms of preventative for those who are currently not h.i.v. positive or have not been diagnosed with aids, studies show it is more effective to focus on treating and testing than trying to educate folkses on how to -- >> i would say both considering the amount of money that we have, it is important to go towards the testing treatment area to have a very large

population in san francisco and if there were more dollars, we would have that and i sat with many organizations to query about the fact they knew the direction we were going and how they approached their r.f.p.'s as well. >> if there is a national movement towards treatment and testing, though, is there less dollars for preventative in general out there nationally or here on the state and local level? >> because the federal government has reduced some other dollarses, including at the state level and it will be important to target the dollars where we think we will get the best and understanding the behavior change takes a longer period of time. we believe in the behavior change and have a whole system of care and view it as definitely necessary, but also a call to action in terms of a treatment area. >> on a different area, have you done any analysis on waiting

times for clients that will need to access mental health and substance abuse programs with the proposed cuts and any kind of analysis or cost e maestimat? >> we have not. but we certainly could be looking at that. we know that we've got the number of people that we know will be reduced by these cuts. and we certainly can do some analysis of that. we do know that it's an effective treatment and substance abuse treatment and mental health. we do have a process in which we have a host center at 10th and howard and anyone can walk in there at any time and get immediate treatment. that is one of the ways we try to offset this and in the last couple of years we have built new programs including an urgent care center in the mental health area and that has been very effective to try to reduce the numbers going to p.e.s. and we understand that many of the cuts

could have an impact on the overall system. >> thank you so much. i know that you have really gauged and led an extensive community process which i truly appreciates and no one wants to make any of the cuts and we are trying to do the best we can to cause the least harm and i as much as possible to make sure the cuts we're making don't actually incur more costs to the city by the more expensive emergency response that we have in the city and making sure that our cuts as best as we can are minimal in those types of impacts to the city. >> that is our goal as well. >> thank you. >> thank you, supervisor. supervisor weiner. >> two questions. one is about the hot team and the homeless outreach team and there is a reduction there and i know that that is in a very

effective program in my district and effectively communicating with street population. and so i just wanted to sort of get your thoughts about that program and it is like a $400,000 cut. >> yes, it is. i actually have a lot of involvement in the development of the h.o.t. team and over the years and i do know how effective they are. one of the area and it's about a $2 million program that's all unmatched general fund, so it did get impacted by that. and it impact is about nine positions, two of those which are unfilled and vacant, so would be about 6.7 positions. and i believe that's an effective team and if this cut went through, we would have to do some reorganizing of the team to insure that it continues to do that work the. right now it has two group. one that does case management

and one that does outreach and we would have to, if we didn't get those dollars back, we would have to do some changes to the programs or the group to make sure we are addressing that. >> this is of real concern because it is such a significant issue in the castro area and having those immediate ability to get immediate out there to talk to the homeless folk and off them services. and i think it works so well that immaterialed to express that. -- i wanted to express that. >> i appreciate those comments. >> the other question is just to talk about the prop j issue and i met with fciu and met with management and a little bit like ships passing in the night in terms of what's said in terms of the effectiveness of the deputy sheriff or not as effective or the effectiveness of private security and not as effective and it is very confusing to me

to have -- when you have the complete disconnect. can you help rectify all that for me? >> sure. first of all, we made this proposal so we wouldn't have an ebbi extra $2 million of service cuts and would be talking about a large cut to the h.o.t. team if that was the case. we looked at the issue of the chair and there are only two pentagons positions for the department. one is we believe we can r.f.p. it out to the private company who are doing in the business of security to provide a pretty intensive level of security and we are pretty confident of that from looking at all the security companies that exist. and with the sheriff' department, we have been pleased with many of the services but there is some restrictions of their ability to restrain patients. and they will only restrain patients that have some mandate

to them and that is a problem in trying to have health care team that is looking at both the need of a patient who will sometimes want to wander out of the hospital and those are the concern of some of the emergency rooms. so for us there's only two models. we have had a civil servant program. i do not want to start an on the job training program for learning how to do security as a department. the only two pentagons that we have is either we get the prop jshg to the process to get private security or go back. that is as simple as i can make that. >> in termses of some of the issues that they had and i know there is a sense because of the sheriffs don't really report to d.p.h. and there is some issues -- >> we have an aide person we

manage with and they manage the sheriff' department. >> in terms of the issues with the sheriffs and the challenges, has the department worked with the sheriff to try to iron out some of those issues? >> oh yes. we have been in constant communication and process with them to communicate and to work as much as they can with us and this is not about the sheriff doing a bad job but a limitation of what they can do for us. >> and why it that private security can do more than deputy sheriff? >> because the sheriff has some regards around their legal status, where a private company does not. and we do have some staff from the hospital and our leadership from san francisco general hospital and they are more than happy to share some of their concerns with you as well regarding that. >> thank you, supervisor. i know there is an item that is

-- if people wanted respond to that. >> i just had a comment here because i'm the finance person and i frequently talk about savings and which is an easy topic and i can talk about the fact that no one loses a job to the process and that is also an easy thing to speak to, but the really credible question that we're asked over and over again is would a private security firm offer safety at a high level of safety for our patients and for our staff. and that's something that i can't respond to personally. i can respond but being the finance person, i don't think i have the same credibility that our san francisco general staff have, but what we do have here today on the question of safety and security, we have representatives from the emergency room and in patient psychiatry and we have our chief medical officer here and al of whom can speak very specifically to the safety issue. just to expand a little bit on

what barbara was saying before, because the focus of a sheriff or police officer is around criminal activity basically, someone has to be doing something illegal for a deputy to intervene or for a sheriff's member to intervene. there are circumstances under 5150 or 5250 if you are familiar with those, court ordered holds, that the sheriff can intervene. or if a person assaults somebody physically or has a weapon or something, they can intervene. but if they are not breaking the law, the sheriff and the deputy wills literally stand there and not intervene at all. so there have been instances where a patient perhaps suffering from dementia pulls a line out of their arm and blood everywhere and is insistent on leaving the hospital and we have been unable to get assistance in those kind of circumstances and where a nurse will physically try to prevent that and a doctor

will try to prevent that, the sheriff's deputy cannot and is not allowed to intervene. the private security person is a member of the hospital team and they follow the hospital's protocols and protocols around restraint. and they are not bound by the same legal limitation as that sheriff's deputy or police officer is bound by. again, i am not the best person the toll you this and would -- the best person the toll you this and have our chief medical officer or the chair of our emergency response team at san francisco general hospital answer your questions on this and try and put your mind to rest, but truly, we believe that this is a reasonable, smart way to manage security in a hospital setting and really is what is being done and the county that is the nearest, closest example, but in many, many hospitals that

offer trauma services around the country. >> we can ip violate the two representatives up perhaps to address the other issues that supervisor weiner has raised. >> thank you. >> good afternoon, supervisors. i am dr. todd mann, the chief medical officer at san francisco general hospital. i will be very clear i am not just an administrator. i am a practicing physician. i deal with these issues every day. and i think he explained well the difference. we have a great deal of respect for the sheriff's department and the work they do. the real issue is they are law enforcement officers. and they are focused on criminal activity. what we really need is to keep our patients safe and secure. the real scenarios that we run into is when our patients are ill and their medical illness is causing erratic behavior, confusion, delirium, agitation, things that comprise our ability

to take care of them at a time when they do not have a decision-making capacity for the short term. examples may be infections or brain injury, that type of thing, where patients really need care. their behavior precludes them from getting the care. not only that, they can be violent and combative, not their fault, but the effect of the illness, and they can harm staff and harm other patients. in that situation there is not a legal hold and a legal avenue for a law enforcement officer to intervene. it's not a legal issue. this is a health care issue. if we have our own security, which frankly, most hospitals have. if you look around the city, they don't have mrpolice office. they have security who work as part of the health care team and abide by hospital policies and uphold our goal to maintain safety for our patients and for

our staff and insure that we can treat patients who temporarily do not have capacity to care for themselves. >> is there anything that you would include? >> thankses, supervisors. i am the director of clinical operations at san francisco general. i, too, am a clinician on the front lines. i don't sit in an office all day either. i would like to say this opportunity is a great one for the hospital in order for us to build a security system at san francisco general with the needs of both staff and patients alike in a collaborative fashion rather than being dictated to what sfs are available. we have a very close relationship with the sheriff's department, but again, it doesn't meet the needs of our patients and our staff to keep them to keep everyone safe. we strongly urge you guys to please consider prop j. we think this is really the only way to go.

>> one question i have which i keep meaning to ask to you and i keep forgetting is in terms of putting aside private hospitalses but other county hospitals around california, in other words, having similar challenges to san francisco general beyond what a private hospital may have, do they -- has there been a survey done of whether they have private security or police officer security? >> currently the most comparable in the bay area is alameda county and john george psychiatric facility which have private security. and what we're hearing from our colleagues there is they are quite pleased with the services provided. alameda county has a satellite office that does house a sheriff's unit, but it is not part of their hospital

operations. it is more because they have no place to detain individuals, so that is why they have that relationship with the sheriff's department. >> how about l.a. or san diego or sacramento or other urban centers in california? what kind of security do they have? i don't know what the answer is. >> we have a survey of all the county hospitals in california and we know that denver health is a large comparable hospital and provides care to medi-calpatients in large numbers and very much like us they have had private security for many, many yearses and many, many hospitals across the country. yopg we focused on -- i don't think we focused on all the county hospitals across california and we can do a survey, but i am necessarily

certain if that is a definitive answer to a question or just a measure or a gauge of where the balance is in decision making and influence which is often times a factor, too. there is no other hospital in san francisco that has certainly sworn officers. st. francis is located near the tenderloin and they run a close relationship with the clinic and treat a large number of homeless and people who show up in the emergency rooms and st. mary's at golden gate park and another neighborhood where they certainly have issues and not as serious as san francisco general but also do not have sworn officers for any security. so it's just not the model that you see typically. you will only see that in county facilities only because county facilities often times are supported by the county sheriff, which is typical. and that is common more because

of the structure of the government organization and probably has as much to bring as any other reason. >> i would be interested to know, not every county in california but at least major urban, sacramento, l.a., san diego come to mind, and just a matter of knowing what the practice is and whether what we're doing is anomalous and that would be useful information. thank you. >> thank you. >> i would like to return back to the same discussion, so if your people could come back. what supervisor weiner was just inquiring about, then reflect for me why there's so much distress by others in the hospital about the change of security. i hear your perspective, but then explain to me the

interpretation of why others would be so concerned and remain uneasy. >> i think i can answer that. i think there are folks who are generally concerned about the whole issue of contracting out. that is not a philosophy a lot of them adhere to. we are very much a union shop at san francisco general. that said, there is a large contingent of san francisco general hospital employee who is very much favor this particular contracting out proposal. it particularly in areas such as the emergency department and psychiatric emergency services, acute psych, but in particular the med-surge unit and the i.c.u.'s are of particular concern. i have a whole list of employees in my pocket and on my blackberry who wish they could have been here today but couldn't because they were at work and i can forward you their names. this proposal actually had a

dual path coming to the point that we're at. certainly the budgetary one was primary, but there was a grass roots effort of frontline nursing, staff, and ancillary staff so concerned about safety at san francisco general and the lack of response of what the sheriff's department could do that they brought this issue to me as the director of clinical operations to see what we could do about it and that led to pretty high-level meetings with the sheriff's department including chief butler and the watch commander over san francisco general to try to work some of these things out. at that time the sheriff's department would only respond in instances for patient safety management if there was a 5150 in place and visible on the chart. we got through discussions with the sheriff's department counsel and we got them to move a little bit to include 520's and l.t. conservatorships and that's only

been in the last four months that we have been able to come that far. the sheriff's department's stance is unless they see a violent behavior enacted, they will not respond. that means that staff and patients have to demonstrate the violent behavior before they can even act. that being the case, we have had several instances of physicians -- i have two sitting right here -- who have been injured or kicked along with nurses because that is the trigger for action. so there is a large groundswell of support for this on the frontline staff. >> how would that trigger be any different for an on site nonpolice officer security guard who would then have to then call it into san francisco police department to effectuate the same response? the same law applies as it would for the deputy sheriffs. >> actually, it wouldn't. private contracted security would be guided by hospital

policy, number one, and in the r.f.p. we could actually indicate that we would want them to have powers to detain. the reason why certain facilities don't do that is because they actually don't have a place to detain individuals. we do. we had previously an m.o.u. with the san francisco police department which is what we would do again in order to detain and arrest. >> so power to detain based on what charge? >> it is not a legal issue. when we are talking about patient who is by the virtue of the medical condition do not have control over their mental faculties and able to make appropriate decisions, behaving erratically, that is not a legal issue. that is when you want to intervene. you don't want to wait until there is an assault and wait until a patient has removed catheters and lines and oxygen nay need and become more acutely ill.

you want to intervene before they strike out. we need folks to help us deliver the care they need. >> but you are saying to me that this issue was only just reconciled in part because of the enhancement of having the sheriff's respond to in the last four months. why did that take so long to do it within the last four months then? >> again, a confluence of things happened all at the same time. so because of the pullback of the sheriff's department, we had a very inconsistent response because the mix at san francisco general are partial sheriffs who come to us from 850 bryant and we also have the remnants, for lack of a better word, of institutional mrpolice officer who have been at san francisco general and many of whoem over the last, i don't know, two to three yeha