proposal and included in the five-year financial projections is the appropriation for the ffne as was planned so that is included in the proposed budget for the hospital. >> and can you tell us what ffne is for the general public? >> yes. >> [speaker not understood]. >> furniture, fixtures, and equipment. so, that's a wide range of equipment that we'll need, much of which is not eligible to be funded through the geo bond, but none of less is necessary to operate the hospital. >> so, mostly general funds? >> mostly general fund and some of that will be done through lease financing which will allow us to spread the cost on some of the bigger capital items and then also we're seeking external source hees of funding to help assist with that. ~ sources >> we'll see it -- this coming

year will be the 14-15 budget and the 15-16 budget that will cover it? >> absolutely. and in the two-year budget thats was adopted last year for year 14-15 which was the second year we had a significant appropriation in that budget already and then this budget will include the remainder of that appropriation in year 15-16. so, we're on track. it's a significant amount that we're on track as far as appropriations for that. >> thank you. >> so, just -- i won't go into great detail on all the initiatives, but just to get at kind of some of the themes we're getting at. as i said, improving outcomes and access, that's a capote pry "erth for us and we have a number of proposed initiatives in our budget to do that that we have expansion significantly of our primary care clinical capacity. we're trying to add capacity at

existing sites and look at where we can get additional capacity that will help us to get people in faster and allow us to retain clients and, therefore, to retain our revenue base as we go into the affordable care act. so, that's very critical. we're also doing, as part of compliance and implementation with the affordable care act we're doing expansion of dental services and [speaker not understood] which is a new benefit under medi-cal and under the aca which will allow for greater access to mental health services for, for those who need them. >> mr. wagoner? >> yes. >> can i just ask? i know that a lot of the goals are to actively plan to comply with the affordable care act. could you just explain in understandable language what you mean by integrated delivery

system plan and the delivery system reform incentive program, what do those mean? >> yeah, okay. sorry for the jargon. i'm starting to speak it fluently. so, thank you for the reminder. but integrated delivery system. so, what we mean by that and it's a term that has become widely used in health care, but what it basically means is that you're taking a lot of different elements of clinical service delivery and you're integrating and coordinating them. so, in the past, if you look at how our public health services grew up, we kind of talk about it as having grown up in silo. you had san francisco general hospital kind of on operating independently, laguna honda operating independently, behavioral health services operating independently. what we're trying to do is bring those all together and manage our health care delivery

services from the perspective of the patients who are going to access services from multiple sites and programs within the department of public health, and the term integration refers to trying to integrate those different portions of care that a person receives so that they have a seamless experience while they receive care from the department of public health rather than just san francisco general for one thing, primary care for another thing, and having to navigate between systems that are not fully coordinated. >> so, i could see how that increases efficiencies and communication. i note since the lynn spalding death and the controversy around that, a number of people might be testifying later on what is the hospital and what is our department of public health system doing about improving patient care and safety as well. but i'm just wondering if you could talk about goals from that human level, too. >> sure. we, just briefly on the department of public health as

a whole and then i'll invite our hospital ceo ross up here to respond as well. and we do have some responses to questions that supervisor avalos submitted to us which we'll also share with you that address some of those issues. but that's obviously a critical priority for us and, you know, safety is something that comes first and is a major ongoing effort for us at all of our facilities. i'll ask sue to talk a little about -- >> mr. wagoner, it could come later because supervisor avalos just mentioned that we're not even yet to that item. so, i'm sorry for jumping the gun. >> sure. so, just to continue to kind of give you some of the themes of what we're looking at, one of our major issues that we have identified through some of our

analyses that we've done over the past years is our it system. we have some significant deferred investment in our i-t systems that's really important for us for a number of reasons. the first is compliance with a lot of the new federal regulations and that includes implementation of our electronic health records and things that are clinically oriented. also includes critically for us strengthening our security efforts in terms of data and patient information, making sure that we're not vulnerable to cyber attackses from outside the department. so, those are big efforts for us that we are taking seriously in trying to get i-t foundation in place that we'll be able to use to manage patient care responsibly and build off in the future.

again, on the new san francisco general hospital, we have a significant initiative that's mostly in the second year of this two-year budget for the opening of that hospital. that is going to be a big change for us . there are a lot of moving parts that we'll be having to make changes based on the layout of that facility. we'll also have changes just in the added square footage that that facility will mean on the campus. so, we'll have to add a combination of clinical staffing. also facility staffing, environmental services. all of the support functions that go along with the hospital. so, the total proposal for that budget is about 97 ftes that we are proposing for fiscal year 15-16 at a cost of $26.9 million.

that is within the ballpark that's a little higher than what had been anticipated in our previous five-year financial plan. as we've done the analysis, we identified additional needs and we balance around that within our core budget submission. we touched on this, but we are scheduled to open in december 2015, i say '16 here, but i'll give myself a month's leeway. we are continuing with construction on schedule. we anticipate the bond program. we will be able to manage within the amount allocated by the voters to us in prop a. a little bit on our staffing. we have got a couple of graphs here to kind of show where we are. and i think the big picture is that we took a dip in our fte count during the

most difficult years of the recession and we have since recovered that. if you look at this first chart, it actually looks like we have exceeded where we were at our prior peak of fiscal year '07-'08. a lot of that is accounted by the fact that in last year's budget, the mayor and the board of supervisors approved a major, what we call our structural correction to our budget where we had been under budgeted for the ftes that we had been actually using. so, now that that is a huge thing for the department and we are greatly appreciative of it. >> this number we have, you know, the budget for efficienttion tes. what is the vacancy rate? how many vacancies are here? we've counted the va size as actual staffing positions, but the vacancies aren't filled. >> and actually i will get -- actually, right to that right now. and that is a significant issue, as you're pointing out. that's a significant challenge for us and it's something that we're very focused on. these are our budgeted ftes,

but we don't have all of our budgeted ftes filled with permanent positions to the level we would like to. so, that's been a big challenge for us and that's a big push for the department. i do have a second graph here basically showing if you take that structural correction and you kind of adjust backward in time for it to show what that looks like, basically the big picture is that we dip down during the difficult economic years and we have been building back up essentially to the staffing level proposed in this budget would be right about where we were pre-recession. and i'll answer your question. ~ in just a second. but we've got another chart in here that just shows you where those ftes are going in the proposed budget in terms of our initiatives. the two most significant, we

have about 70 ftes that are dedicated to those, that improving access to scare and quality of care. that would be primary care expansion, mental health expansion, and then 97 at san francisco general hospital. >> could you go a little bit deeper like primary care expansion would be [speaker not understood] -- >> yeah, we can give you a great amount of detail on what those exact proposals are. but a couple of initiatives that we have are to expand our staffing at the hospital-based primary care clinic. so, we are using a team-based approach which means we are using physicians and then a combination of support staff which includes patient care assistance, clerical support, all of the team that is part of providing support to the direct

providers and it helps them effectively manage their patient population. so, there's a great mixture there. on our new san francisco general hospital, i'd be happy to provide you with a list that's included in our budget initiative, but that's a wide range. it includes registered nurses. it includes patient care assistance, it includes facilities staffing. it includes all of the environmental services support staff associated with those initiatives. so, it's a wide range of different job classes. >> and the slide you have here is actually for the fiscal year starting july 1st, 2015. so, in terms of positions that are being budgeted for the next fiscal year starting july 1st of this year, it's not a significant increase in ftes

earlier, right? >> good question. and what we kind of are trying to show here is over the course of the two-year budget where we would get. but you're right, it is phased in. so, for the new sfgh positionses, a lot of those new positions are beginning in fiscal year 15-16 which is the year that the new hospital is opening he, but some of those will be phased in for the transition process. on the other initiatives, most of them are starting in the first fiscal year of the two-year budget. part of the way through the year to give us time to get through the civil service process and then annualized in the second year, i'll just ask [inaudible]. it's about half for the first year. so, if you take the 200, it's about, about half of that in the first year. so, these positions are phased in over the course of the budget. and again, just another way to

see where those positions are proposed within, within the delivery system. a couple of last things to mention before we get to the -- your question, supervisor avalos, about the vacancies. we have a couple of other things that are not included in our initiatives that are proposed by the commission, but that we wanted to make sure we remind you of our present. we have in the budget that was adopted last year for the two-year budget, reduction to our community programs. that was in last year's budget adopted in year two. halfway through the year, so, that's an $8.8 million reduction, annualizes he in the second year of the budget to $17.7 million. so, that's a previously

approved initiative that remains within the department's base budget going forward. the other two items are we have major -- >> can i ask a question? sorry. >> sure. >> i recall that from last year that there were reductions, but they weren't going to be de until this coming fiscal year. is that correct? >> that's correct. >> so, does that mean that we have a bielenson hearing this year to -- >> yes, we will have a bielenson hearing. >> we depth have one last year because it wasn't affecting last year's budget. ~ we didn't have one last year because it wasn't affecting last year's budget. i think supervisor mar [speaker not understood] he he thought he he sponsored the bielenson hearing. >> [speaker not understood]. >> trying to jog my memory. >> i think you're right. and in any case, the -- this proposal was not included in the bielenson hearing. the main reason for that is it's based on a proposal to do

an rfp that would reallocate services, but we will have a hearing for you on that proposal on this budget process. >> i remember that, too. >> so, the other big change for us is a we're going into the affordable care act, the state has come in and said to the counties essentially, you're going to be having added revenue as patients move from uninsurance to insurance. and because we have historically been giving you realignment dollars for uninsured people who are now going to be become uninsured, we are going to pull back those realignment dollars. so, it's a big loss of revenue that's included in the mayor's office deficit projection and we're very thankful that we weren't asked to balance around that last, but it's a big change for us and it means that we are now on the hook to

actually replace that revenue with, with earned revenue through our patient service dollars. ~ loss so it's a big way we're funded from the state. >> dollar for dollar replacement or we're going to see -- >> the way that we, the way that we have this budgeted right now, it's about a wash. it's about even. it's about $33.8 million of realignment being clawed back and we budgeted right around $30 million of revenue growth, a lot of which is associated with these aca related care transitions. there are a lot of moving parts to determine the formula. the state has a formula to determine the realignment claw back that's very complex and is still in the process of being negotiated. so, we have yet to see where that lands and that formula is going to move and change over time.

on the other side of the equation for the revenue that we hope is replacing it, we do have to go out and earn that revenue and we have to earn it by retaining members in our network and with the department of public health so that we can keep that balance. so, that's one of the big financial changes for us. it's really going to push us into a different way of thinking about how we bring in our revenues. >> right. and access to care and quality of care are going to be super important to that. >> absolutely, absolutely. those will be the critical determinants of how, how people l make their choice of access care. and then lastly, a we had a hearing on earlier today, we have additional proposed reductions to funding for hiv services and we are happy to hear that it sounds like that will be replaced in the budget

process earlier today. so, to get to your point and then i will -- supervisor avalos, and i will bring some of our other dph folks up to talk a little bit more about this, but critical focus for the department is on hiring of our vacant positions. this is top to bottom within the department. one of our main action goals for the immediate future for the commission all the way down through the organization, we he do have a significant vacancy rate within the department. that's for a lot of reasons which our hr director will tell you a little bit more about. but we do need to correct that because it's not a sustainable way to operate as we're providing our current services plus trying to do access expansionses and move into a new hospital. so, it really is a major focus

throughout the department to try to get our hiring pipeline accelerated and make sure that we're bringing in people to fill those positions that are budgeted and that's the distinction that, as you mentioned earlier, a budgeted position does not necessarily equate to having a full-time permanent staff in those, in those ftes. so, generally speaking, a lot of those vacant positions, we are backfilling and staffing with as-needed staffing to hit our staffing requirements. there are some cases where that's not, such as our i-t staffing, [speaker not understood], some of those other staff that are not always backfilling with overtime. but that's a constant challenge for the department. so, with that i'd like to ask sue, a lot of this discussion and the focus of this

department has been at san francisco general. i'd like to ask our ceo sue kern to come up and talk a little bit about where we are there and the human resource hees director for plans of getting that hiring pipeline going. >> thank you. and before ms. kerns talks, i'd like to just have some comments. last friday morning i visited general hospital, the er there, and was very impressed by what i saw. the nurses that were there -- there were nurses and medical evaluation assistants and i believe patient care assistants and just a number of impressions that i had, just the level of concentration that was going on with all the distractions that were still going on were pretty amazing. people are working under the

most stressful conditions and they are handling security issues, safety issues. there are nurses who are acting as clerks when they are doing their work. there are a limited number of meas there available to assist in the work that's being done. it's compounding nurse's work who are actually i think nurses and clerks and meas all at the same time. there are reports of -- often that there is a lack of personnel available to actually be there for the functions during the day. i was shown a list of texts that nurses who are on call are receiving and asking if they can come in to work. there seems to be those texts are pretty common that happen almost on a daily basis. issues of security and safety were of great concern. recently, of course, we had the lynn spalding case and

interestingly it was reported to he me the lornspalding case was not necessarily a problem -- it wasn't a problem she wasn't found but there was also a problem that she was lost. it seems like the focus in the media has been how come lynn spalding wasn't found, but why she wasn't lost was because there wasn't a coach that was available for someone in her condition who needed extra care round the caloric care, someone to be with her and that person wasn't available or was pulled away. so, it looks like the issues of staffing and care are grave, you know, issue that happens practically, if not -- seems like every day. everywhere i go and through the hospital, that section of the hospital on friday, i would be met with several nurses who would want to talk to me all at the same time. one after the other, telling me about the challenges that they face on a daily basis. we had charge nurses who were actually doing the work of

regular nurses who were pulled away as charge nurses. we have people doing, you know, going above and beyond their work. don't know when their break is going to happen. just incredible. and the level of stress that was there was remarkable. but also the level of concentration that was there was really remarkable as well, equally so. and i was very impressed with a number of people who had worked there decades. i think one person i met had been there for 32 years. there were other people who talked about being there, i guess around the same time period who were there when the aid ward was the aids ward back in the early '80s. so, it seems like you have, you know, incredible, you know, confluence of remarkable dedicated service oriented people who live in a workplace with a high level of stress, but are able to manage the work really effectively. and you also have the conditions of on the other side

just that there are so many limited resources, limited staffing to really make the quality of care that seem to be -- that is in the mission of the department of public health, you know, reachable. and i really feel based on -- we'll hear a presentation in a moment -- what the plans are. i believe that there are certainly vacancies and one of the concerns raised we have information about is that the processes he of doing the exams and bringing people in through dhr are very slow and cumbersome and i think that, you know, i'd love to hear there is a [speaker not understood] prong approach. one is dhr, one is staffing, one is looking at funding, one is making sure that we have the proper resources for peep to do their work once they're on as well that will help alleviate this problem. so, very interested in hearing what those concerns are. you know, we all -- the city faced some really major challenges with the economic

downturn that happened. [speaker not understood] 2008-2009-2010, and we had to reduce staffing. i understand the madthers made it very difficult to fulfill the staffing level that we had before to provide high quality care. it seems like the more staffing levels became the new normal for the present. and i don't think it's something that if we want to be able to live up to our aspirations as a city, the department of public health and the new world of the affordable care act and the new, you know, [speaker not understood] somewhat in competition with other health care providers is that we really need to step up our game. staffing is going to be key to it. i know we're getting prepared for general hospital and that the reconstruction and start of general hospital next year. the current year, early next fiscal year are key to be able to start the improvements and staffing and care. so, love to hear that

presentation and thank you for allowing me to go on a tie ~ tyrade right now. >> good afternoon, supervisors. i'm [speaker not understood] from san francisco general. i'm a registered nurse and i've worked at san francisco general on and off for over 30-year. so, i'm very familiar with the issues and i'm glad that you were able to come out and take a look at the extraordinary work that is done there every day by a dedicated staff who is really committed to the mission of san francisco general and providing compassionate care with respect to all of our patients. and as was reported by greg, we do have a staffing issue there. it's not that we don't have enough budget. we do have enough budget. we do have enough budgeted ftes and we've just gotten behind in

our hiring process. currently right now we have a 13.4% vacancy rate that's a little less than 90 ftes which is a large number of rn vacancies, broken them down here in the different areas. we're in the process of doing quite a bit of hiring now and it's my number one goal to provide the resources that the staff need to be able to take care of the patients. as you said, because you don't have support staff in different areas that causes nurse he he and physician and other people to do the work of other people like clerical work, or work of patient care assistants or medical assistants. right now we're working closely with hr to recruit experienced and new rns. we have -- we don't have a shortage of applicants for every position that we have vacant. so, it's really a great opportunity for us to be able to recruit experienced nurses.

all hospitals have fluctuations in staffing due to just natural turnover and because of census and acute issues. we're not undifferent than those other hospitals. we utilize registry staff and part-time or per diem staff to fill vacancies for vacations, fmla, sick calls, those kind of things, and regular vacancies. the hospital has $5.7 million budgeted for registry. we're going to be -- we were going to be over on that registry budget trying to backfill to make up for the vacancies that we have. about 16% of our staffing model is based on registry, the use of registry and part height and bulk time staff. ~ part-time staff. right now we're looking at how

we can provide better break coverage. we're actually reassessing the chief nursing officer terry [speaker not understood] is reassessing how we provide that break coverage because right now we found that we don't have a robust system to really document how the breaks are being covered. so, we recognize that that's an issue for us. i'm going to call up ron from hr to come and give you an update on what specifically is being done in hr. >> just briefly, supervisors, i'll hand you a couple of documents which are some supplemental data in responding some of supervisor avalos's questions and also a document that our new h.r. director ron [speaker not understood] will walk through that he's prepared on our hiring strategy.