everything and we have added the new staff today. and montica that i am pleased will be joining us and also thanks to the community advisory board, special thanks for commissioner chung who has been a great advocate for this project even before joining the health commission and especially to our community partners advocates and to our patient whose we learn from every day, so thank you. >> if i may before president chow, to thank dr. barry zevin he is a great advocate and one of the founders of transgender tuesday and he has done an incredible and the stake holders and i want to thank him as well. >> and i want to join garcia to give dr. zevin the accolades because we recently celebrated.

and i think that that is something that as a city and we as a health department with be proud of because we are leading the way for good and really appropriate transgender healthcare and with that i actually have a question. and it is really about the role map that that you have mentioned at the end. and the providers of the surgeries and i believe that there are some conversations happening before, and at ucsf which is teaching institute. and so, creating a center of excellence through this partnership. >> i think that is a great

question and i think that the workers working on this, and includes carlisle and the chiefs at san francisco general in plastic surgery, and urology and obgyn as well as the? >> the first words is that this should be a center of excellence for transgender care in our system. and i think that it is way essential that we are working with the high degree of medical expertise at ucsf. and i don't need to be the first one to say that a large academic medical institution like ucsf has its own processes in politics. and i don't feel like i am...

or that the one who is going to be able to navigate all of those processes but i do feel like i know who needs to be in the room to be able to navigate those processes. and i think that we have got a very good start. to be able to say that let's not setting up competing systems let's set up a system certainly, it is of the interest of administratively at san francisco general hospital. to not only be a center for or within our own network and to look at this at the opportunity to be a center of excellence because all of the counties in california are facing the same issue of patients who require these medically necessary procedures and not a whole lot of resources in those counties to be able to provide those surgeries and okay. and we have got the surgical at

san francisco general hospital to be able to train up our surgeons to be able to do this and possibly do this in a way that is helpful to our other counties and frankly helpful in a way to as a business model. >> so... that is i think it answers that. >> and also, because we when we adopt a resolutions we have brought up this is, you know, like we support this entire process because we believe that this would be help to improve. and it will help in the department of public health and i believe that you have a plan on how we can track that as well. >> we absolutely have a plan for this, and as many of you

know i can be ambition in my ideas about how are we going to evaluate how this has improved people's healthcare in the biggest sense. and but, that is the very ambition kind of evaluation is something that we continue to discuss through the divisions in dph about how are we going to look at transgender healthcare and the out comes. but we do step forward with a very practical kind of evaluation plan for each sfep of this. and how well is the referral process gone. and asking our primary care partners is not working for you and how well is the preparation program going to work. we have an evaluation and then follow up the plans with the patients and did this problem and met your expectations and then looking at over all, and

how has the health of those people continued? and so, that evaluation plan is in process. and i am more ambition i would say, as far as how much evaluation i would like to do, but i think that it requires resources and times so we are working on that. >> thank you. >> commissioner melara? >> yeah, i want to go back to this concept of of a center for excellence and the possibility that not that i want to give more work to the department, but considering that this is something that we have initiated that we might want to be the lead in developing in the center for excellence if we are going to level off the cost of these surgeries in the future. it is going to come from us growing new surgeons in the community. and it is not going to come

from god and additional general fund sources and we need to reduce the cost for the more people have access to it and the only way that we are going to do it is to insure that we have more people and there is more providers. because the less providers that you have obviously the costly it is. so i would encourage you to really think this true, and possibly under the umbrella of the department. >> and i greatly appreciate that is in the alignment on it and it is in alignment with the chiefs that i have spoken to at san francisco general great. >> commissioner taylor-mcghee? >> thank you. and clearly there was a paradigm shift in 2010 when medical cited that transgender surgery or sexual reassignment surgeries were medically

necessary. so obviously that obviously helps to pave the way particularly that it relevant you lated the insurance commissioner and the healthcare plan has been medically necessary, i am wondering is that still a challenge for you as you look at additional resources to make sure that you have it. and i asked this question because this is a great model as we look at other healthcare challenges within the healthcare system in terms of looking at looking at holistically and being necessary for the health and i am curious as to whether or not you find it to be some what of a challenge. >> that is a great question, and i will speak to that challenge in two ways and the first place of the challenge is it does not matter what would youer policies are or what anybody's policies are, people need to be educated and reeducated and we have to have a strong commitment to that. and i think that was a very

much and i very effective recognition on the part of the department of public health and that was going to be something of key importance. and julie gram, who i think is here today. has really led the way on a clearly recognizing that education at all of these levels from the community level to the level of our providers, and professionals and non-professional staff that that is what was going to change how much of a challenge this is to us. and i want to just as an example, we have been able to do a tremendous amount of education with san francisco health plan. and ye started out with good intentions but very little knowledge and now there is a lot of staff at san francisco health plan who are really on board with this and understanding it. second part of the challenge, i think is the ongoing challenge in terms of what the scope of

services. clinickly, i have very clear ideas of what is medically necessary, world guidelines have set standards for what is medically necessary, but that is always a consensus process, and that is always weighing of the various what is the medical evidence, how strong is it and what is the cost of things, and that is an ongoing challenge, and that we just need to stay evidence based, and as much as we can. when we talk about i give you an example of an area of controversy and should faloplasty be a covered procedure? we have a lot of controversy about that, the more that the discussion stays around what evidence based the more effective to get to a solution of those challenges of scope of service, yeah it is ongoing but i think that the key is staying

with the medical evidence and keeping that in mind. >> and commissioner, if i could, there is 2010 was not a magic moment because transgender law center has been really pushing this from a legal perspective to the health plan to medical for many, many years. and so they just turn it on and really, and an issue of really getting advocacy and what has happened in the past it was a medical necessary was being denied over and over again. i want to recognize the partners in the center who really assisted us. and it also took us time to develop this program.

>> there was a lot of advocacy and there was a lot that we are we were on point and we want to move on because they did help us in moving this process. and the most timely planner that we could. >> thank you. i also want to thank you for the work that have you done. and i am curious, because we are talking about the potential of centers of excellence, and that several questions, but, first i also have to commend the department that often we pass resolutions or ask for programs, and this is one that is really there. and on the table. and very viable. and i encourage that we not just continue dialogue on what you are going to use as out come criteria but begin to try

to apply some of them so that we can get a feeling about it. so, within the state, because you talked about and is now a mandate to the health plans, what other areas that may have similar centers of excellence that the plans are using in order to in your discussion with the plans because this is a very highly specialized area, and what interests has there been to do, like, we were suggesting that perhaps this is not only a center of excellence, but can we self-sustain and those are the two questions that i have. >> i am sure that i can't speak to everything that is going on in the state, in this area, and in the bay area, i think that kaiser has had a real lead, along with the ethic dph, and is both getting a lot of demand and is trying to develop the

systems to demand and they have worked very much in parallel with us in terms of having to send the surgeries out of the network including sending the patients to arizona some of the time or bringing a surgeon in from arizona some of the time. and have faced some of the same challenges that have come to many of the same conclusions in terms of model and we learned from each other in that. and i understand that there are similar efforts in los angeles, and i don't know, as much about how they are meeting this need, and at least based on the phone calls that i get from other areas, we are way ahead, of both a lot of the other counties and a lot of the private sector in this and the people are calling me sam, well how did you do that?

how did you do this? >> i tried to control the amount of time that i spend on that stuff. but, those are the kind of questions that i get. >> thank you. >> i think that on that latter point, as we are moving towards having a more integrated system, this really represents an opportunity to a market more of this program, that we have, and i think that it is not your job to do that. and i am trying to move it into the right areas that we will then actually make this one of the services that our managed care system can do. and i am pretty sure that many of the plans really are seeking areas of expertise and california is a managed care state. and that there really is an opportunity at this point to be able to make this truly one of the centers of excellence, and certainly, it sounds like, within northern california, and we could be, and certainly

along wkaiser and thes a closed system and so you have the opportunity of many plans looking for that type of service and that we not burden you with that and make that one of the business issues that our manage care office look at. >> yes, commissioner chung. >> there are a couple of other points that i want to make, the first is that whole myth about you know, like if we build it and everybody is going to flock to san francisco and request that service. you know, as a transgender woman myself, my experience is that every single surgeon has their own signature kind of procedure and so not all kind of people will feel the same

level of comfort it does not mean that all from new york city are going to move to san francisco and register as homeless and sign up for the service if we are going to look at how to sustain the system we have to look beyond just the private public partnerships between the surgeons and our own city budget to do that. and the third point that i would like to make here and we

have transgender service and i am relevant will you curious about what lessons we have learned from that and also, because we have a parallel system which is you know the health, and service, system for the city and county of san francisco and what type of procedures are being considered as metically necessary? and you know, in terms of transition related?

>> we have the people working on that too. >> thank you. >> commissioner chow i am not sure if your microphone is on. >> thank you. >> item 8 is the other business. >> so, i know that under the other business is that we had spoken of having the committee assignment that we are continuing to work on how well we are going to accommodate everybody and i am asking our commissioners to maintain our current assignments through the

month of april. and that, in the next meeting, we will then, have assignments that would become effective may one. so, it also, i think will help the staff know who they are working with in terms of the chairs and all. and i want to thank everybody for the input that they have had and we are working to see how our committee structure we will be able to accommodate additional commissionerers that may wish to sit in on certain topics and weigh in on those and that is also part of our attempt here at the same time to see if then, some of the commissioners desires to understand certain other areas, and being limited by our committee structure would be able to actually participate in topics that they would like in the committee. so we are working on that to see if that can come out and be able to be added on to our agenda, and we will have our assignments finished by and published by our next meeting. >> and is there any other items

of business that the commissioners would like to bring before us? is there any public comment that we just. >> i received no public comment on this item. >> and any other items from the commissioners, if not, then, we will go on to the next item. item 9, is the joined conference committee report back and honda and did meet in between the last commission meeting and today, and so commissioner sanchez. we have a report from commissioner sanchez? >> yes. we had a full committee and we heard an excellent report from the hospital staff and also the unique acknowledgments given to the staff ranging from the state wide to the fiscal outstanding excellence, and the city wide awards and etc.. and there was also a full report and the balance and showing it for the past few

months and began well defined. and i think that one of the major reports that we heard and we heard and the nutritional services and also the wellness update showing why the participation and our patients and our staff and our communities and the accessibility from the community to and the community itself. and we would serve 700 meals plus 300 and 1,000 meals a day, at laguna honda and the quality of the service and i requested an updated daily or not annually but not monthly or daily but to listen to the personnel who are involved in

this process it was really remarkable and commending to see the dedication and the commitment that they had to providing these excellent nutritional programs and specialized diets for our patients and these are continually monitored and updated sxets. and in closing, we also approved the comprehensive wide policy and procedures update which has been ongoing, and had a closed session in which we followed the procedures and running the medical staffing, and we adjourned and we had a very excellent meeting. and any additional comments from the colleagues. >> commissioners any further comment? >> any public comment on the... >> i have received no public comment for this item. >> other commissioners have no further questions? for our members at laguna good. we will go to the next item. >> 10 is committee agenda settings.

>> and okay, so, commissioners in understanding of the last planning meeting and what we will be trying to plan for a community meeting and we will be trying to select a... >> the planning. >> well, we are going to do both, you are right. and we have asked for your input on dates for the planning meeting, thank you. and also, we spoke about trying to have a community meeting and we are seeking out sights and a thought at the moment that we have not gone to the mission in the cycles that we have had for quite some time and with the change in the whole dem graphics and if the entire area and i think that it would be good for our commission to understand that and how we need to meet the needs of that population and so i have asked the director garcia to look into seeing how we can do a community meeting there this was you may remember part of the thoughts that came out of the planning meeting last year

to try to see if we could then have more community input. and we will see how that works. and an opportunity to interact with our community at the meeting. so, that will also be in the planning >> yes, commissioner melara? >> i also want to remind us that we have postponed the joint commission meeting with the department or with the commission on the side of the women and i am not even seeing it on the calendar any more. so, we need to move on that. >> i am waiting actually to hear back from them on dates, commissioners so even though it is not on here, it is on my list to make sure that it is on the calendar. >> good. >> we are also looking to see that as commissioner chung noted today, that as we move from our committees, and which are doing just some excellent amount of work in terms of looking at the issues being brought there in depth that we

are reminding ourselves what should then come before the full commission and also, have those presentations enhanced with the other partners and may be actually involved so that the wider discussion within the various parts of our city family which i think that we have all been talking about the people that would like to encourage and so, not only will we bring forward a report, but when appropriate, and the commission that you just mentioned is one of those. and although there is no specific item that we have at the moment and but there is, and i think that the long term care report was a good example of how that works, and the director garcia suggested that we can do the same with many of our other activities that also involve other city partners, or even other consorcium and the private sector that will help to enhance the total

understanding of the total picture and our own understanding of not just what we were doing is and how this is being leveraged for additional activities within the city family and the community. >> and but doctor, garcia, did you want to comment further? >> yes, we will be looking at these items and as an example of the pedestrian an safety, the vision zero, where we have a specific roll that we showed that at the committee and then we will show at the full commission, how we interact with other departments. as example of co-chairing some of the committees and we will have the departments representatives here so that you can see the full picture of how it all works and how we are collaborativive with the other departments, and but we play a specific role in that, that is probably going to be played out at the committee level, and then at the commission level, where we will show the whole picture of how it all works together with the other departments. and we will be looking at items like that so that we can build upon the committee work.

>> thank you. >> and is there some other further items that commissioners would like to see on our calendar? >> if not, no. >> you know, through the chair, no. i was just i was going to match the calendar and i was going to see that the doctor is going to present where was the, we do have an updated list of items. >> yes. >> and right. on the back page. >> and on our over all, and i was going to share as i, and i believe that the california rankings of our public health departments is now available through the rwj and the foundation and we had discussed this last year, and doctor and kevin and others were adding some thoughts to it and i thought that it might be a good time to update to see how we are doing it. and also, to take a look at the criteria. and maybe, you know, some of

the foundations that need to as various states are going through challenges, perhaps we need to bring up to the radar the fact that there are some unique challenges and a number of states are facing including ours. and in a particular unique county, such as ours and such as our discussion that we just had pertaining to our proposed center of excellence in what we are doing and there are so many new areas that concern would be part of the parameter, but at the same time, i think that it gives us an opportunity to sort of see, some of the old benchmarks that are being used, to sort of rank public health departments within the state and within the nation. >> and so i think that ties in very well with our community and public health that is monitoring our own efforts in the public health accreditation and i ask that be placed at that committee level first and i believe that certainly is something that the commission would like to hear.

>> i also will be setting up on the meetings with the commissioners who are chairing the committees so that we can go over the calendars and make sure that we are capturing all of the items with commissioner mcghee. >> very good. >> any other items if not, we will move on to the next item. >> which is adjournment. >> yes. >> is there a motion for adjournment? >> so moved. >> is there a second, please? >> second. >> all of those in favor of adjournment, please say aye? >> aye. >> all of those opposed? , therefore this meeting is adjourned. thank you.