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.

>> can i just ask before we start, it might be ms. kern to respond. but how did thing get to the place they are at right now? how would you describe the situation we've gotten to in terms of the staffing levels? >> well, ron is going to talk a little bit about that, but basically before we had the structural fix, we did have a budget problem. prior to last year when it was adjusted in the budget, and so there was a slowing down of hiring and we just got behind the 8-ball. vacancy rates for many years, four or five years, below 5% in rn vacancies. so, it's just within the last year and a half where it's gone up. and once you get behind it's harder and harder to catch up. >> at the fire department there was a call for bringing in

increased overtime versus hiring new staff. here you use overtime and per diems instead of new staff because you haven't brought on new staff. is that a policy call to use per diem and ot to be able to offset benefits like we do in the fire department or is it another matter? >> in the last year and a half, as i said, we've had adequate budget. it was always our intention to fill those positions. and we just had more people leaving. we had greater turn over. a lot of people stayed on working during the economic downturn. many more people retired and left the system all at one time. that added to the backlog of hiring also. so, it was multifactorial. >> good afternoon, supervisors. my name is ron wydel. i'm the human resources director for the health department. i have been here a year.

i arrived may 1st of 2013. i came from seattle king county where i had been the director for 10 years. so, i heard the same things that you did, supervisor, regarding hiring. as soon as i got here, i started to hear, why does it take a year and a half to hire a position? and that wasn't a one-time thing. it was sort of a frequent theme. and then i would hear varying stories on the length of time to hire. so, i wanted to understand that a little bit. so, the first thing i did was look at some of the reasons and these are some of the those reasons. as sue kern mentioned, there was a budget deficit. so, they slowed down hiring last spring. there was, in my own merit section, that allowed the exam team to get down to a very few people, down to one. and if you don't do your exams -- we have 236 classifications. in order to have a referral list you have to do an exam. if you get backlogged with your exams, the hiring will come to a halt, which it did. so, i've added -- i'm

increasing that team from 1 to 6. i've got four people on board now i've hiring two more. i'm also having the city and county department of resource he, they are partnering with me and assisting with some of the exams and they are also helping us do a lean project or continuous improvement project, specifically on rn hiring. rns are our largest single classification. we have over a thousand fte so it's important if we can get that one right and use some new tools to bring -- make hiring speed up, we can use those same lessons for other classifications. >> your dhr department -- >> i'm with public health department. and then -- so, i am responsible for all public health. and then i partner with the city and county of san francisco dhr. they handle some of the exams and we're responsible for some of our own exams. so, we also had a couple of grievances and that caused some settlements that backlogged our hiring.

i'll give you a quick example. patient care assistance was one of those classifications. exams got delayed about a year and a half. we were finally able to do the exams in december 2013. we had somewhere in the area of 800 applicants. of those we said 200 weren't qualified. so, you have to notify them and then they get an appeal opportunity. then you have to do exams of the 600 you have left. so, to do that many exams we had to do 10 exam sessions because you can only fit so many people into a room. it's a paper pencil sort of an exam. so, these are some of the reasons it takes so long. we have a very open process within the city ask county because we are a government entity and, of course, we have to be very open, competitive. it's merit based. so, unlike some of our private sector partners, they don't have that same threshold. so, that's all we have to test all 600 applicants to meet the minimum qualifications and those kinds of things can slow us down. so, that's a little bit about

why we have the problem. now, the other thing about it is my staff, we have -- we had our own silos. we had a staff group at san francisco general, one at laguna honda, one downtown, and they sort of were operating somewhat independently. and that exam sanction section got down to 1 and we start today get a backlog, there wasn't a reaction, maybe transfer staff and that sort of thing. so, we have our own internal processes that we need to work on. briefly, some of the fixes, i mentioned we're increasing the size of our merit section so we can do more exams. we're going from one to six. we also have this project on the rn classification with dhr. we're well underway with that. that included meeting with stakeholders. we had about 30 rns and nursing staff. we got together and we're figuring out how to do a better hiring process there. we're also going to have two operations managers and why we need those is because i need to be able to tell managers what their vacancies are and what we're doing about it.

right now it's just sort of a fragmented system. we don't have good metrics. we can't really -- we don't push information to managers and we need to start doing that. we are going to have a lean from shes i mentioned, a continuous improvement exercise and probably do that in july and we'll be partnering with the nursing staff. we'll be partnering with everybody who is a stakeholder in the system to come up with a better way to do hiring. we do use too many temporary staff and we do use too many provisional positions. that's an outcome of badly broken hiring system. and it's not broken in any one point. it's kind of messed up and broken from the beginning all the way to the very end. the civil service predicted a manager is willing to participate in that lean process. the county deputy director is willing to participate in that lean process. so, i think we'll get some good headway with that. yes. >> just on the operation manager, you have number 3 here.

>> yes. >> you're in the process of hiring them? >> yes. >> are they facing some of the same challenges you have in hiring nurses? >> absolutely. >> in terms of how long it takes? >> yes. i started to try to get the position on in november. and after meeting with dhr and explaining, you know, anyway, it looks like probably the first week of june i'll have those two on. but yeah, we had our own problems -- the number of problems that come up, that sort of bureaucratic -- it's bureaucratic stuff comes up and it delays the hiring. i'm going to clean that up. that's the only way to get this -- i have to clean it from the bottom on my end and with the civil service commission clean it up up there. keep it open and competitive. >> thank you. >> so, we take a lot of responsibility within hr, within public health because we've allowed old system to continue and we never really challenged how we did business. we're challenging that now. and then we're going to develop

measures and metrics for measuring performance so managers will know, when did i put my job app in and how long is it taking? we're shooting for a measurement of 90 days. if we can get a hiring done in 90 days, that's not a great average if you compare it to the private sector. but for san francisco and for the department of public health, that would be a great improvement. so, that's our initial target. >> one of the things happening is we're going to expect to get about 20,000 new patients with the -- with healthcare reform, affordable care act. >> yes. >> do you believe that in term of processes we're going to create and the hiring we'll do we'll get to that, have capacity to meet that number? >> i believe we can. we're currently fixing the problem and i think, you know, i basically will do whatever it takes to make sure they have enough people on board to do the job. sometimes they means maybe i have to use some temporary employees, which [speaker not understood] don't like, civil service commission doesn't like. but i'll work with the

hospitals and the other clients within the health department to meet their needs. i'll figure outweighs to do it but i want to do it right which means permanent positions and i'm going to fix the system so that it works. >> we have a number we know we're going to need when we open up the new general hospital? do we have a number we need when we reach the demand we're going to have for new healthcare reform? do we have a sense of what we need in terms of ftes? >> in terms of additional staffing? >> i just asked you if we're going to be ready for the new 2000 patients. what is it going to take to be ready? >> we staffed up for it. we're staffed up based on our projections of the affordable care act. if we get the staffing on hand that we have in our budget, we'll be fine. yes. okay. so, i also handed out a document that was -- i've given presentations to various unions and stakeholders about what i just described, sort of that i realized we have a problem on our hands and we're working really hard to fix it.

given them? ~ some ideas of what we're doing it if i can it. if you have any questions, i'll take it. that's essentially where we're at. i'm the director, i know it's broken, i'm working to fix t. i'm working with the union, i'm working with the county, i'm working with anybody who will help me out. >> okay. please tell us what you need and [speaker not understood]. >> all right, thank you. ~ we've got our eyes watching. >> okay, thank you. >> supervisors, that's all we have in terms of presentation. if there are any other questions, we'd be happy to answer them. >> why don't we do this. we can go to public comment. a lot of people have been waiting for a while. any questions raised in public comment, we can address that. >> that would be great. >> that would be great, okay. >> great. i have a number of cards for public comment. and please come up as your name

is called. and if you heard those your called, if you can line up along the wall right in front of the tv and we'll take you one by one. today we're doing two minutes for public comment. first up, larry [speaker not understood]. sorry if i didn't get your name pronounced correctly. heather bowlinger. [speaker not understood]. amber key log. robert ivory. and we'll do one more, meg [speaker not understood]. please come forward. you don't have to worry about the order. if i called your name, just come forward. so, the first person want to come up. i'll start doing a few more names while you're coming up. david fleming. liz hewittv. ~ hewlett. aaron cramer. and [speaker not understood] cooper.

is it okay if i stand here? >> sure. i can be heard? my name is heather bollinger. i'm one of the nurses in the san francisco general emergency department. i want to draw your attention to the efforts the staff has gone to to illustrate the growing problems we have in our hospital. for several years we've been documenting shift after schiff shift the numbers of staff that have been unsafe. nurses after working 12 hour days, 12 hour nights, going to meeting, discussing things and speaking out, we're trying to get someone that will hear us and someone that will care and someone that will ask the questions that we are asking. our trauma center serves over a million people and our emergency department has not had a nursing director for five years. our management positionses sit vacant or they get temporarily filled sharing between departments. ~ for years. why does the emergency department have sick to 14 beds closed on an almost daily basis? ~ why does the emergency -- why is our staff vacancies been allowed to rise to almost 25%?

why are we comfortable with the 43% diversion rate and how does it get this bad without anybody noticing? why are the nurse to patient ratios that we were guaranteed in our contract ignored? the ratios are designed to keep the patients safe and the staff safe. when those ratios are ignored, their patient care suffers. patients get unattended, they fall, they disappear. the pain medication is delayed. they get sicker. they get more agitated, in some cases they get assaulted. these are a direct result with poor staffing and poor leadership. we aren't budget experts and we're not high-paid executives. we're not professional negotiators and we're not politicians. we're nurses. we're san francisco general nurses and i've never worked with a group of people more proud of what they do. our job is to be there for anyone at any time to address the needs that no one else can or will address. to save the life, any life, that needs saving. that's our job and we're

trained to do it and do it well. we he captain do it when our efforts are hamstrung by staffing issues and inconsistent leadership. we can't do it when salary savings is prioritized over saving lives ~. we can't do it without your help. thank you for your time. >> thank you. thank you for your service. next speaker, please. good afternoon, supervisors. my name is pete [speaker not understood]. i've been a nurse at san francisco general hospital in the emergency department for three years now. i am incredibly proud of the work we do at the general and how we provide care to people regardless of insurance status or any other factor. like many of my coworkers i choose to work at general because it is not the best pain [speaker not understood] i believe in what we do. i usually work night shifts or saturdays. i happened to be covering the day shift when the [speaker not understood] crash occurred. three nurses from the unit [speaker not understood]. would be available for the

first wave of critical victim. because of their assistance i was able to go to the trauma area where extra staff were desperately need and had ensure these extremely sick patients were able to get to the operating room alive. that was put on display for the world, our resourcefulness and tenacity. 9 opportunity to work with people like this is what i enjoy most about my job. i recently took report from one of the nurses i worked with on that day during [speaker not understood]. she said it was horrible today. it was worse than asia [speaker not understood]. still demand more than we can sanely offer. nobody extra comes to help and we are left to make do with the people who happen to be at work that day. more often than not, that is far fewer than the number our staffing matrix calls for. we are supposed to have two acute nurses in our trauma area to help buffer these influxes. i took a report from my friend which is often the case on day shift.

no acuity nurse. [speaker not understood]. sometimes it is not possible to leave those patients. there can be long delays getting severely injured patientsv to the ct scan and other times procedures are delayed. it should be done immediately. i hope we are able to pull qe nurses from other sections but they are not staffed. staffing is so low on day shift -- >> can you wrap up, please? thank you very much. >> thank you. next speaker, please. hi, my name is amber [speaker not understood], i've been a nurse at san francisco general emergency department for over six years. as my colleagues have described, we have been working our 12-hour shifts and then we've been meeting at homes trying to figure out how to get our message out.

we have signed petitions, sent them to management. our interim management. we sent them to the cfo, we sent them to the ceo, the head of d tion h barbara garcia. we've been testifying in front of the health commission trying to get our message out ~ but it's not just hiring more nurses, it's putting more nurses and more staff on the floor. about two years ago we were -- we had our staffing cut from 21 nurses plus the charge down to about 17 nurses and a charge. they've added two extra care areas for us to cover and we were not able to do it as well as we would like. we are here because all of our attempts to get attention haven't succeeded. the things that we're asking for are for you to meet your legal obligations, to staff the hospital safely, to make title 22 patient care recommendations. not just hire more nurses, hire

the nurses that you need to, to legally run the hospital. thank you. >> thank you. next speaker, please. my name is meg [speaker not understood]. i work in the department of psychiatry at san francisco general and i've worked there for over 25 years. when i first started, san francisco was a model county and city for providing mental health care. now it's a shadow of itself. we have been cutting services, cutting every budget cycle is cut more and more and more. both inpatient and outpatient. i work specifically at inpatient now. i've worked in outpatient before. if someone cannot be stabilized on an inpatient basis, they're going to be shoved out into the outpatient world and they're going to cycle right back into the inpatient. and that's what we see happening now. we closed two acute units.

people are being discharged much quicker than they used to be. they're not being admitted in the first place. i also work in psych emergency. i'm floated down there frequently. and we have to make the decision whether to hospitalize somebody or not and 9 times out of 10 a lot of people that we would have hospitalized even a few years ago we don't any more. they go back out to the street or they go to inadequate outpatient services and then they cycle right back in. we see the same people over and over and over again. i have also been assaulted twice at the hospital and i attribute that directly to unsafe staffing levels. we are being told -- people call in sick are being told there's no replacements and they're basically told to make do with what we have. we don't get breaks. i work on the sheriff's department unit now, [speaker not understood]. we frequently don't get breaks because there's nobody to cover us. so, in closing, i would just like to say, please don't cut

any more acute care beds. the city can't take it. >> thank you very much. next speaker, please. hi, my name is bob ivory. i'm a nurse at san francisco general. i'm proud to be a nurse at san francisco general the last 33 years. you're going to hear emotional testimony. i'm not trying to give you stat-based testimony. i'm going to speak against your budget issue 1b year to date the average daily census is 34 upped the budgeted census. they proposed to cut med psychiatry and skilled nursing units for reduction of 34 beds equals 12,410 less patient days. that's the budget proposal. i don't see those empty beds. i work in the emergency department. you can ask any of these nurse he what the 10:00 a.m. bed meeting or as we refer to it no bed meeting means. that means my patients are waiting in the emergency department 4, 5, 6 hours. they don't have a bed, they're not going to get a bed and they may be waiting in the emergency

department overnight. 87 man waiting 27 hours in the emergency department for a bed. okay. where are those 34 empty beds? i don't see them. med surge, budgeted for two 10 bed. this is the report for march. presented to the health commission. they are running a census, 216. they are over census. average psych census, 39.7. you've got it realize they've already cut beds in psych so they've cut the bed and then they count them as being -- baked them against the budget. there are only 44 available psych bed. so, at a level of 39.7, they're running their max, okay. skilled nursing 24 bed, 24.1. [speaker not understood] already been closed. so, in closing here are the numbers. how are you going to close 34 beds? how are you going to make a reduction in ftes? we need the beds. we're on diversion 43% of the time. the march report to the health commission shows that because of the cuts to the psychiatric

inpatient bed that they hit a new record high for the number of hour that the pes was on code red because they can't get a bed upstairs. though patients are being held when those patients are held, they're held in the emergency department and then they go berg cirques and assault ladies, little old ladies. thank you very much. >> thank you. next speaker, please. good evening, circumstances. my name is david fleming. i've been a nurse at san francisco general for 25 years. i work in the recovery room. i just want to follow-up on what bob ivory was saying. as he's holding patients in the emergency room and cdu, if we remember a year ago the cdu was budgeted for observation of patients who had neurological or cardiac issues. it is not actually designed to hold patients who are going to be admitted but this is what the cdu does. they hold them in cdu, they also hold them in the merge sip department. the emergency department backs up and they wind up on [speaker not understood]. we hold them in the recovery room as well because these patients have no beds upstairs. so, how can we cut 44 more beds?

let's tie that picture together with the fact that nurses are staffed at a basic minimum staffing ratio of 5 to 1 or 3 to 1 and this is the staffing ratio that's hit on the floor when they need to get their breaks or their patients going. their patients are going to other nurses who have 5 or 3 patients. now they're outside of the state staffing ratio plus holding the patients in the emergency room, cdu or pack u. how can you possibly operate the hospital this way? it's dangerous. patients don't get the care they need. they may disappear. orders don't get carried out in a timely fashion, patients can suffer injury. we need to not only increase staffinging we need to increase and take a look at nurses like transport nurses and nurses that can actually cover for breaks as well in order to be able to reflectively do our job. how can a nurse possibly work 12 hours straight without taking a break? it's almost impossible to do. i couldn't do it. thank you. >> thank you. next speaker, please. hi, my name is [speaker not

understood]. i worked at san francisco general for 31 years, two years in the ed and in the last 2 years in the trauma icu. i've been a nurse for 36 years, so, i was there the weekend of the asiana plane crash and it was the best day of nursing in my life because i had all the resources to do my job. the very next day we still had 4 or 5 really critically injured patients from that crash. and we're scrambling for resources as we always do. on a good day we have one clerk and one patient care assistant. for instance, any kind of spinal injury patient needs three people to turn the patient. if the patient is obese we need more. if the patient has a cervical spine injury we need someone at the head to hold the head to make sure that no more injury occurs. patients need to be turned at least every two hours, but we only have one cna.

so, that means nurses have to come out of other patients' rooms to help us turn patients. effectively we need to examine the patient's skin every day. we need to clean them up. and we don't have the staffing or the help to do that. we are a closed unit so people have to call in when they want to come in and visit. and days without work -- i had one patient screaming in the afternoon, will somebody please answer that god dam phone? transports usually take-two nurses he off the unit, pushing the ctir, mri takes two nurses when we could have a patient if we had an extra cna they could help us with that. people are off the unit for transports. they could be in -- often in any of the area radiological areas and people still need their breaks, but we don't have the proper state coverage to give those breaks. we need transport nurses, break nurses and more cnas to help us do our job. so that patients can get out of the hospital safely.

>> thank you. next speaker, please. good afternoon. my name is [speaker not understood]. i'm a nurse at san francisco general hospital. i currently work in the cardiac icu. i worked at general hospital for six years and i can say i'm proud to be a nurse at general hospital. but i'm very concerned for the care that i provide for my patients on a daily basis related to issues around not having enough people to physically help me turn them, help me, help me feed someone that has gone hungry for three plus day, hasn't been able to eat but we literally don't have the staff to assist with that when we have other priorities like giving [speaker not understood] doing other kinds of treatments. it's very frustrating to me to think that things like this are

often neglected because of staffing. even just today we had a system that sends out messages when we're short. i receive text messages. i got one this morning, can someone come in. it's almost like a daily -- it's a daily phone call. [speaker not understood] they used to call us for days that started at 7:00 a.m., literally i would have to set my alarm to get up in the day because i knew i was getting a call from work. can you come into work? it really concerns me that there is a proposal to cut beds here. working in the icu we are consistently full which could pose problems for us and worry that any time that we have an emergent patient coming in, we need to have available staff and capacity, a room ready to roll that person in there and care for them because they need help now. and most times we are so full and we don't have somewhere to

put another patient because of they're waiting for bed, it become a real serious concern for their care. thank you. >> thank you very much. before the next speaker, i want to call a few more cards. jay ruth. timothy holston. bonnie kim. [speaker not understood]. lori may all bert. i'll stop there. hello, my name is [speaker not understood] cooper and i'm a registered nurse at san francisco general hospital. i'm also a member of the bargaining team. can i give my time to norlisa so she'll have additional time? no? i am here today to discuss patient staffing. contrary to what some people may have you believe, patient safety and staffing issues have been prevalent at sfgh. proposals have been submitted to the city related to patient safety and staffing and their

initial response was, we haven't received your wage proposal. just in case you don't know, our silence cannot be bought and our integrity is not for sale. the city's second response was, you have to work within the budget that was allocated. that they don't have the authority to allocate additional positions. that is why i stand before you today, because you are the reason our patients sit and urine and stool longer. you are the reason patients fall when that call light is not answered. you are the reason why nurses break california ratio laws when and if they get a break. and you will be the reason, the city is not reimbursed when patients from substandard patient satisfaction surveys. but you have the power to change all of that. i am disheart ened that i stand before you today, not asking for the latest innovation or the best technology. i'm asking for safe [speaker not understood]. i urge