said i'm sorry to ask this, but is there any way i can go to the bath roochl. room. that's just sad. sadder still is my only option in the hallway to try to protect his privacy. our rooms are full. icu patients, trauma patients are everywhere, we've done everything we can and we've had insufficient resources. he's been waiting how long and doesn't want to ask if he can go pee. about an hour later a young man punched a hole in the wall. he was angry his girlfriend had been waiting four hours for a ct scan. after he was arrested in this hallway we got and i would like

to stress that this event should not be viewed as an

outlier with the patient population that we see in the er, situations frequently escalate and violence often results. much of this violence which is often physical is often aimed and and falls on nurses. we often see violence in the er at ourselves and other patients so this event was not an outlier. there have been violent assaults on other patients by patients and on ourselves. this fe phenomenon has only worsened in my five year tenure in the emergency room as staffing has declined. is not solely a security issue, but relates to staffing as well. managing emotionally unstable or clinically agitated patients

can be better with adequate staff. working within state mandated ratios nurses have time to recognize signs that patients are having difficulty coping. they can intervene sooner to deescalate a situation that may have escalated in adequate staff including ancillary staff helps get patients to where they need to be so patients on 5150 holds that have been medically cleared have not with waiting around to be transported to psych services. this helps keep things calm in zone one. this is not even close to happening at current staff levels. what's more concerning is that under the current budget, if we filled all the open positions in the ed, we'd still be short staffed and at risk for more violence towards ourselves and other patients. i've been asked to add that we have reviewed subcommittee

minutes that indicate there are no beds closed in the ed due to staffing issues. and this is not what we're seeing in our daily practice. closing down the emergency department in order to support the clinical decision unit has become daily practice. closing additional beds to account for a lack of nursing staff also happens daily. reducing the number of beds in these less acute zones pushes more traveng to our trauma zone, which leads to extended hours and impacts our availability to ensure patient safety. thank you. [applause] >> thank you. our last speaker is melissa pits. >> my name is melissa pits and i've been a nurse at san francisco general for nine years. i have spent most of my time in the emergency room and one year in the surgical ucu.

currently i serve as a charge nurse. i'm here to ask that you patient safety in the emergency department. i'm proud to work at san francisco general. i love what we do in the ed. our job is to care for anyone in the city no matter who they are, what they can afford or what happened to them. a homeless person we walk by on the street, the mom that gets hit by the car, person that is having a heart attack our stroke and when every second counts we are responsible for taking care of all of them and so many others. i take great pride that our hospital is the only level one trauma senter in the city. with tremendous growth in the city it is not possible to absorb the influx of patients. when fully staffed we should have 22 nurses and a charge nurse. yesterday we had ten. under those circumstances when trauma happens like the who was hit by the bart train last

night we have to stop what we're doing and react. the sluks is to pull people with other obligations. because yetd wasn't an exception, it's quickly becoming the nornl. when we're short staffed patients wait while we're dealing with the trauma. the 80-year-old with a broken hip can't go to the bathroom, the little kid with a stress trackture waits for sedation. in the ed team does not shy away from challenges. i was in charge the days the flight crashed. nurses, doctors, aids and administrative staff all came in to assist without even being asked. we know what it takes to make the emergency department function. when tragedy strikes we deliver. but we need your support to run an effective department on a day-to-day basis and that means more nurses and ancillary staff

on every shift. soon i will be moving to the new facility. i have very serious concerns about the staffing ratios. i, like many of you, have had a sick family member and we all want our loved ones to get the best care, to receive pain medication quickly and never have to wait for a bedpan. as nurses, we want all of our patients to feel safe and that they're being tepided to without distraction. i hope we never meet any of you at the hospital, but i would like for you to take a minute to think about the fact that any one of you, any one of us could be a patient in that emergency room. we are dedicated nurses who want to give every patient the time and care he or she deserves and we ask that you help us work together to make a reality in a safe, efficient environment. thank you. [applause]. a: >> thank you. as was noted by our secretary,

we will take these matters into consideration. thank you very much for coming. we appreciate your concern. we appreciate your work at san francisco general. thank you. the next item on the agenda is the report back from the committee. >> commissioner.

>> which goes into effect april 26 so that was the premise for the update. one of the things that's important about this is the e cigarette sort of trend, if you will, is moving very quickly. the marketers and the tobacco industry are pushing it very heavily. one of the things that some people who are spoking them are saying it's changed my life, but we know that there are known carcinogens, heavy metals and things that are not good for us. there have not been any long term studies on e cigarettes, but one of the dangers right now is teens and there's been sort of limited information, but an neck an anecdotal

information. that's an issue. the other thing which i find very interesting is that the marketers of e cigarettes are able to advertise on television, unlike the tobacco industry so i think we'll see quite a bit of that as we move forward. there's been a lot of advocacy. san francisco once again is leading the nation and pushing for a ban to e cigarettes and basically it's a ban that would disallow the smoking of e cigarettes for a tobacco products are also banned. that's an issue. anyway, it was a very interesting update and i think there's a great deal more to come. >> would you explain to us, or perhaps the director can, that now the ordinance has been signed, what the obligations of the department are.

>> i'd like to turn that over to tomas. >> one of the nice things about the ordinance is that it'll treat e cigarettes like all other cigarettes, so where cigarettes can't be smoked they can't use e cigarettes. from our perspective, it won't really change what we do, just expand from regular tobacco cigarettes to include e cigarettes. >> thank you. commissioners, any comments? >> point of clarification. so are you saying to me that right now because of what commissioner tailor mcgee said, right now the regulations pertaining to tobacco are not applicable to e cigarettes?

>> correct. that means in theory right today you could walk into a mcdonald's and the mcdonald's could be full of adults with e cigarettes in their hands and smoking in front of children and other families. that's currently the case. they're advertising on radio, newspapers and television. within san francisco they're going to have to follow the same laws that are followed for tobacco. we're not using the word ban. we're basically regulating them in the same way we're regulated other cigarettes. >> yes, commissioner -- >> i'd like to go off on that too pertaining to the utilization of e cigarette. i've heard from a couple of old-timers that i guess have lived in these apartments where before they used to smoke and now they no longer smoke and they say that the landlords have said that there's a smoking ordinance they pay to

the health department that says they can no longer be smoking in these small units and some of them are saying, well, the new cigarettes will be exempt from that. and my question is, what -- i mean, are we in fact submitting to certain units or all units in the city that we're charging a non smoking compliance fee for the health department? >> i'm going to have to follow up on that one to find out how that a mays applies to that specific area. i had not thought about that one. >> we need to follow up. and just recently in the press, actually last night, i guess i noted and you probably already know, the world health organization in terms of the smoking regulations in the world are looking at e cigarettes potentially coming under all of the same labeling

and bans, almost similar to what you're talking about in terms of the regs for use in different areas, but i thought more interestingly was the addition of the labeling and that's currently being sought out now. >> correct. >> yeah, so i think we should get a report on how this is going to be rolled out and how acceptable it has been to the public as these issues an challenges. i'm also assuming that if we're following the same regs that e cigarettes are not available in our facilities for smoking. >> correct. everything that applies to regular cigarettes. this went relatively smoothly. we have very little opposition. the major concern was people around medical marijuana, but it went very smooth. the youth were involved and i think we're going to be presenting in the near future,

we're going to bring the community organizations and youth groups that participated. >> at that time we can give the updates on the housing issue. >> okay, great. thank you. other commissioner comments? any public comment? >> there's no public comment. >> i just want to -- i want to thank the health commission because you passed a resolution in 2011 on e cigarettes and i belief believe you may have been the first in the country. >> thank you. we will take credit where we can. okay. any other reports? thank you, that was very important. >> the next item is the consent calendar, which we have no items to consider. we'll move to the next item. if you'll confirm we're going to switch the order of items 7 and 8 and take it road map

first. >> with the permission of the commission, because of how we pub lib so i have proposed without objection that we would have the it strategic vision and road map presented first so they would be within the context and we can review the budget initiatives being proposed. do i hear any objections? if not, we'll proceed with mr. kim, please. >> good afternoon commissioners. my name is dale kim, i'm the cio, i've been here about 8 months. it's my pleasure to share with you our health information system vision and strategy.

the cultural change i'm working to implement is to truly embrace all these elements to

help us move forward in supporting our mission. this slide shows the actual element at a high level, what these would be. so starting from the bottom of the triangle, in order to meet our goals we need to have the stable infrastructure, effective capabilities within it, relative technologies, invasion and excellence that leads to long term viability and the accomplishment of our mission and guiding principles. one thing to note in terms of stable infrastructure -- you may have heard this from other city it folks discuss this as a foundational infrastructure. without this none of the other aspect of the it vision could happen. in terms of the effective capabilities. , this really means not only having enough people, but more

accurately, having the ability to perform the required task needed to meet the requirements of our organization. in terms of relevant technologies, it is to implement technologies that are relevant of our mission and only that of our mission. i believe that having those three items, we will be able to help the organization innovate and excel as well as obtain long term viability as an organization. before i go into the details of our health it vision, i'd like to go over the current state of it. you note that we have red yellow and red. typically i'd like to see all green, but what we have is red at this time. i would break this down into three areas of what i'd consider the [inaudible] in it. first is infrastructure.

today it is very unstable and slow. on average we have one out per month. also, our network is extremely slow. some of our clinics are connected to a network speed that's slower than your home network using dsl. say in these clinics there are many nurses and doctors who are trying to access files they need to support the patients. now, why is this? first of all, we have significant amount of equipment that are end of life. number two, our who will it infrastructure design is outdated except for one lace. laguna honda is pretty new and they have a new technology. many projects are stalled or

delayed in terms of initiatives and all of this leads to increasing operational cost and the question i've been asked is why is this? how could we be here? the reality is, commissioners, that as throughout the years, as we have limited resources and many initiatives and compliance that we need to meet, there are priorities that's been put on the it, however the it did not have the vision and the strategy that they could focus on. a single point of place where they could say that's the hill we need to charge to so what happens is we have all these people doing different things with well meaning efforts, but having very poor results. in terms of the structure in governments it is in transition and therefore it's yellow. with the department going into a different model of care, the it is also moving towards the

new industry standard in it government, as well as support models. we are working to define very clear roles and responsibilities, where there was very little. and we are working to change the culture to one of the empowerment and ownership. when i came here eight months ago we had a security disk issue. it wasn't a problem, but it was a security risk. and i asked a question to a room full of my immediate support directors and i said who is responsible for security. everyone in the room raised their hand. however, when i looked at the findings under the security, we had -- i saw a lot of risks so how could it be that i have eight people in the room who are responsible for security, but we have so many risks? the reality not one single person owned and felt empowered to act on it. everything was done in a

consensus manner. that's great if you have a lot of time, but when you have risk somebody has to own it and take action. more importantly people didn't feel empowered because the actual responsibility was spread out across so many people. the next bull let point is supporting capabilities. we have a lot of capabilities here. problem is, some of them we're not very good at and there's a reason behind this. first of all it organizational structure, leadership and technical skill training was supported and funding provided, it was the actual program itself wasn't thought out from an it leadership perspective. let me explain. if you send a person to a training and spend several thousand dollars and you train them and they come back, but they are unable to use that

skill for a year, maybe two years, maybe three, how effective would that skill be? how relevant would that skill really be? the reason why that is is because the roles and responsibilities were so separated, many of the skills they learned were rarely used. on top of that, it was not their responsibility. the other areas where we have support and capabilities gap is clinical staff training and system operations. we are lacking a team within the healthcare organization called clinical team. the core function is to train our clinical staff, provide support, work with the clinical staff and optimize the work flow as well as the information

technology behind it. and it is a formal program that is taken with extreme dedication and focus. what we have today is we don't -- we do not have the clinical team. what we have in the organization are, in a very good way, the nurses assigned to those roles, but it is not a formal structure. needless to say, the team and having right leadership skill will be critical to the success out of it in terms of success of dph. i'll bring a point of example. if you purchase any hr system for -- let's say $250 million, you do not make an investment to support that system, to train the nurses and doctors,

to fully utilize that system or keep it optimized, to keep it tuned up, would you really get a full value out of that $250 million? reality is many organizations, many almost -- actually i'd say all the healthcare organizations i've worked at put significant emphasis on the functioning of that team for that sole reason. because of the capability gaps, it is unable to meet the task and projects. therefore in the current it assessment, we are red in infrastructure, yellow in governanec. we're going to build one that fits for purpose. it's all about knowing what our

purpose is and creating an infrastructure, support structure, creating the solution that's fit for us. we're going to create an infrastructure, but it's stable fast and available. good news, we have already started on it several months ago. we've actually -- just to let you know, we took our core network infrastructure and did something that was told was not possible and we did it in less than a month. we're going to tie all of our network in fiber. it's well on its way and it's going to be fast and available. available means when a network goes down, the end user will never notice. it needs to be that type of network where fiber could disconnect because somebody was trenching, does not disrupt our patient care. organization structure will also be green. we're going to be nimble. we're going to do what's right

instead of waiting for having a long consensus discussion. in a world where everybody needs to be nimble, we can fit in trying to make a decision for several years, trying to decide what is right. we're going to be accountable and accountable is really about giving credit where it's due. if someone has clear rules and responsibility and someone does a great job, we should hold them accountable, thank them, recognize the great work, but should also use accountability to find where they need help so we'll know where they're filling. in today's current situation, this accountability doesn't exist because there's so many people owning different roles or so many people in the same roles. the next item is ability capabilities in unified health

systems capabilities. this is really important to note because i would like for this organization to move away from vendor specific solutions. when we say we want to buy this because we heard it's great, it's really not about buying that chevy volt, but about buying that car. that's fit for purpose. so like wise, we want to buy the systems, build the systems, implement systems that will fit our need and not be hung up on specific vendors. we want to create a coordinated kard and continued care. if that's going to be single platform or multiple integrated systems, that really is up to many different factors, namely our needs and money. we have a unique in dph where

we have more diverse services than any other health care system i've seen which means it's very difficult to buy a single platform that will meet all our needs. in the future it could be that a single platform could do everything we need it to do. maybe they can't. but whatever it is, we're going to put in the capabilities that will meet our needs. having done all that, we will be green. the question is how long will it take to get here. in the previous slide everything was too much red. okay, here are the dates. the next two years we're going to work on building a strong infrastructure foundation. we are going to build effective it. that means our team, not only hiring more people, which the department of health has been very great in providing support and a lieuing allowing us to hire more staff, but more importantly training them so our