a medical grade infrastructure but what would we be used at general in terms of the it before you actually build out your next generation it? >> so commissioner chow if i may ask are you referring to the information system or to the infrastructure itself? >> well i am asking you from a clinical standpoint what would we expect to see at the time we move into general that the patients and the clinicians would be utilize something. >> so commissioners what we will have when we open the door at general hospital for the large part of the same system we have today. okay. we do have some new systems going in that we do not have. for example mdm is one of the new systems. we don't have that today but in large part we're going to

actually take what we have we're going to modify it to meet the needs of the new hospital and for example if you change the number of beds and the location the system has to be completely changed out and redesigned in some ways to make it work and anywhere from the clinical system to the financial system so that's the work effort going on today. basically the decision was made because with the rebuild and the effort it took to do the rebuild and the reorganization of the it it wasn't possible to engage in a new emr and confident we could be successful, so it was really opted we would do it more in stage fashion because the reality is commissioners even if we opted to do the new emr and had the manpower to do it our infrastructure across dph was

not ready. the things that would help us doesn't exist today so if a doctor has a reset issue he has to call the help desk and open a ticket and wait. if you have a clinical health desk they deal directly with clinicians to expedite the requests to answer questions that are related to the work flow. it is not only about the technical infrastructure but the support infrastructure that doesn't exist today. without that we cannot possibly hope to be successful with the go live. it's our effort and hope today that by 2017 when we go live we will not only be ready but better than anybody else because we would have learned from our partners. we communicate on a regular basis with many hospitals going through these efforts so we can learn from their mistakes. i hope that helps really answer that question. this really wasn't

about money at this point. >> sure. >> even if we had the will we weren't ready. >> i think that clarification is very important and again moves us as commissioner singer said to learn from the past and those organizations that have adopted where they are now and get what we learn from them to be a better system as you're moving into your 2017-18 and i appreciate the explanation. i think it's important that we understand. there is going to be a system there. it will function but it's not going to be the final ideal but it's an opportunity then for us to then look for that final ideal. >> thank you commissioner. one other thing i might add there is a paradigm switch in the way it thinks that i am trying to help bring here. it's the idea of have continual

improvement and conditional continual improvement in the process and what we buy and it does take discipline and commitment to do that and only by then we can get a truly real perfect emr and we will never reach that perfection because we're always try to improve it and this slides show it goes beyond 2018 so i know it's not as simple as buying a big box and dropping it in, but i do believe it's anitiertive and continuous process that we have to raise if we have a system to work for us. >> thank you very much mr. kim. i had a question for greg there. in terms of the significance because i understand you have put in realignment dollars. i'm not sure the realignment dollars were less or more than we used to have so that's one question

and that is straightforward as you explain. coming from the state and as we have more sponsored patients the state feels we can have less realignment but the second one is to help us understand how you feel and at what risk we have in terms of dollars on the 1115 waiver? how are we understanding that it might come out differently for the future? and what kind of risk do we have on that that you're talking about? >> okay. thank you. those are both big issues. on the realignment what we've currently forecasted for the budget and you did see a little adjustment on the mental health realignment but on the indigent realignment we just left the forecast as it is because we have a couple of big pieces of information that we need to see before we know how that's going to shake out. in the legislation that was

adopted that was the statute that governs the realignment take back there is a complex formula that takes into account our growth and our costs and our revenues and our general fund and all of that gets factored into how much realignment is pulled back so right now we're still operating on estimates and they're still based on pre-aca data so we are going to be over the course of the spring getting some updated estimates of what those numbers look like, and we should have a little better picture since we are using actuallies instead of forecasts but it's a significant amount of uncertainty. we have right now a take back of 16.$7 million in the budget. some of our forecasts indicate that could

be significantly higher and $30 million more than that so that's a big range. the other one that you rightly point out is a risk is the 1115 waiver, and there is a lot of uncertainty about that right now. we have it, and you can see if you look in our financial statements we have over $200 million worth of revenue that come in under dish and [inaudible] district vialet programs and those programs are going to be reworked. we have a group that meets regularly to review and advise on the process in that waiver discussion, but we don't know where it is going to go. we think there are some threats to the pool of funding that's available. for example, there are some hospitals that are asking for a cut of that waiver that have not received it in the past and that could

decrease the pool of overall funds available, but the other issue that we're trying to work on is how to at least advocate for our position with that waiver in a way we could design the pool of funds one, so that the allocation of the pools plays to areas where we have an advantage because we're further along in shaping our programs such as integration of physical and mental health, sort of the whole person care theme where we have done more, but also in advocating in formula for distribution of the dollars that is more predictable. one of the issues that we have seen for years under the current waiver there are complex formulas where all of the counties and tied together based on each other's actuals and the funds are distributed and that leads to these big fluctuations between our estimates that we get at the

beginning of the year and the estimated allocation by the end of the year and it's really outside of our control so part of this process we are advocating that we move the allocations of those pools to a formula that is a little bit more stable and a little bit more under our control, and i think that would have have a big benefit in terms of just increasing the certainty or the range of possible outcomes that we think we could get from those waive allocations. >> so those two by themselves -- there is about 230 plus million that maybe at some risk, not total risk, but that could really vary, and would we have some idea of that as you get closer to this budget submission such as our next meeting, a month from now on the budget? >> i may ask colleen to give a

little summary of the timeline. i don't think we will by that time. i think it's further than that but she can give you the latest thinking. >> good afternoon commissioners. colleen chawla. roland and i participated on a conference call this morning with the association of public hospitals and health systems who are the lead agency representing public hospitals like ours in the state negotiations. the question was asked when a package might come together from the association of public hospitals to put forward to the state, and the answer was given somewhere around the end of march but that is -- it's a little bit of a misleading question even because the process is so irtertive. it's not just the public hospitals participating in the process. it's also other hospitals that mr. wagner mentioned. it's community based organizations and clinics so it's a lot of

entities to try and coordinate together. i would say that my best guess we won't know the details until after october possibly. when the waiver was renewed last time it didn't meet the expiration deadline so it was continued until an agreement could be met so my guess we're not going to know until the fall really what the details are. >> so my understanding it's outside the state budgeting process and it involves our federal partners as well; right? >> that's correct. >> and we need approval for the waiver and the state has to digest and make their own decision. >> that's correct. >> i think that is helpful to understand and the risk is somewhat down the line but important to track. thank you very much. >> certainly. >> was there any other public comment? >> i have received no public comment requests for this item. >> commissioners any other discussion at this point? if not i know you can directly speak with mr. wagner about any

details and we will receive a more comprehensive budget a month from now. thank you. next item please. >> thank you commissioners. item 8 is the dph annual report for 2013-2014. >> good afternoon commissioners. i am sneha patil and in the office of planning at dph and today i am proposing what is the financial draft for the fiscal year report for

2013-2014. i would like to thank linda acosta from the communications department for helping with the design and layout of the report and thank dph staff who contributed their time and information which made this report possible. this year's report opens with a message from director garcia which highlights the two reorganized divisions. two foster collaboration between both divisions and also address significant disparities affecting the health status and outcomes of the african-american community this year dph launched the black african-american health initiative which will focus on health heart behavioral health, womens' health and sexual health and hospital. the marriage also recognizes central administration's role in providing support and facilitating the integration of

our two divisions. the following message from director garcia is from our health commission president, dr. chow. dr. chow recognizes the development of the health net workure our city's system of care and important step in preparing for the affordable care act. the message highlights the health commission's partnership with the planning commission for the input into the master plan and approved by the board of supervisors in fiscal year 13-14 and welcomes davidpateing to the health commission. based on some conversations that we had at the finance and planning committee we have added a about dph page to clarify the dual role of our department. our first division protects the health of san francisco residents, addressing consumer safety, health promotion and activities and monitors threats to the public health. our

second division the san francisco health network promotes health of the patient to provide services to insured and uninsured residents of san francisco. the next section of the report presents the more information on the health commission including fiscal year 13-14 resolutions. commissioner singer i understand you had a correction in this section of the report and we will make sure to make that change before the report is finalized. the next section of the report addressing dph's progress in meeting our three identified priorities of integrated delivery system, public health accreditation and financial and operational efficiency. these priorities mirror the triple aim of improving the experience of care and the health of the population and reducing the cost of care. the affordable care act has resulted in an increased reliance on integrated delivery systems to manage the care for

the patients and in prep raikz for the changes we created the san francisco health network. major milestones the met york include the ambulatory care and contains many different departments. another milestone was the office of managed care which administered healthy san francisco and we track and retain patients in our system. the business and intition unit provides support across the unit and the formulation of the transition section ensures system wide patient flow to the most appreciate and least restrictive levels of care. this year our population health division completed the final requirement for accreditation which is the our strategic plan. the plan goals align with the community health improvement plan and focus on increasing

health equity within populations that experience disparities in health outcomes. the strategic plan focuses on six areas listed on the slide where population health thought they could make an impact. on january 1 of 2014 the requirement for most individuals to carry health insurance went into effect and coverage options became available through the medicaid expansion and the launch of our online health insurance marketplaces and by the end of the year more than 73,000 san franciscans enrolled for insurance and to prepare for the increased patients enrolled in the managed care dph did an assessment to develop a strategy to strengthen the financial position over the next five years and elements are being implemented and include the development of a managed care function in the department.

targeted clinical capacity and increased managed care revenue and the creation of tools for productivity measurement and cost controls. so the next section of the report is our fiscal year highlights which are reported by dph's major divisions. i'm going just going to briefly talk about some of the highlights featured in this year's report. in february of 2014 laguna honda hospital became a tobacco and smoke free campus. when new residents are immediately they're informed of the policy and sign an agreement that they will not speak during their hospital stay. more than 60 residents have participated in ash kickers a support group. san francisco general rebuild continues to progress on schedule. in 2013 a transition planning steering committee began developing plans for the new hospital. as the building construction year substantial

completion in 2015 rebuild activities will ensure that staff is oriented and systems are installed to support patient care services. dph's network of primary care health centers serve almost 70,000 patients and many are low income and complex medical individuals. the division plans to transfer the health centers into high functioning patient homes and as this approach the medical home will include a wide range of services in addition to primary care providers. in fiscal year 13-14 dph organized a trauma systems inform group and respond to trauma with a comprehensive approach and the keys are develop an understanding and trauma and bed system leaders and champions of change and important to maintain change efforts through experts and voices in our system. more

than 900 dph employees are mandated to take this training over the next two years. 9,000 employees. >> >> each year on average 800 people are injured and 100 severely injured while walking in san francisco. we have a policy to eliminate all traffic related fatalities by 2024. we are leading the vision in many strategies and engagements and evaluation. healthy retail san francisco is san francisco's healthy retail program and adopted in october 2013 by the san francisco board of supervisors. healthy retail sf is staffed by dph's community health and equity and promotion branch and provides assistance to corner stores to improve food options and nine are currently participating and two are

planned for next year. we received grant support from the mark and lynn -- [inaudible] and bill and melinda gates initiative to reduce preterm birth locally. dph staff were involved with the plan and how partners can use strategies to reduce racial and socio-economic disparities in preterm birth. at the start of the year the city and county of san francisco implemented a people base solution for use in hiring. as a large public organization dph is bound by civil service and union rules and layers of process that has been built up over decades. dph is going through a lean process to implement solutions. as an effort to provide services to dph more efficiently and a lower cost to the city the it

collaborated with the department of technology to develop an it hardware infrastructure to host mission systems and by leveraging this technology the city will pay 10% of the cost with external systems partner. in july of 2013 mayor lee asked director garcia to engage stakeholders to examine san francisco's implementation of the ordinance and the intersection with the affordable care act. two key findings emerged during their deliberations which that the [inaudible] remains enact inside the affordable care act and due to high costs of living and doing business in san francisco certain potential affordability concerns will remain for certain groups of people. the next section of the report is our fiscal year by the numbers and

this is an area where we made changes from previous years. we've included some fiscal year 12-13 data for comparison and grouped sf health net work demographic data to offer a comparison across the different health systems and similar to information that has been provided in year's past this section covers performance measures. it also presents patient demographic data such as race, ethnicity, gender and enrollment in programs and healthy san francisco and medi-cal. i would like to note that dph serves more than the number of managed care enrollees in the system. for example this fiscal year the network was responsible to providing services to 80,000 managed care enrollees. however sf general served 106,000 unique patients. >>

>> and this provides more information on the budget and revenues and expenditures. the last section of the report provides a map of our service sites and affiliated partners as well as a list of our contractors and also a list of additional resources. i just want to thank the health commission for the feedback that they have provided. i know that they would like to ensure that the annual report remains useful and efficient document in future years so we will definitely take that into consideration going forward and i would like to note that our it department can use analytics to see how often the report is tracked and viewed this year so we will have that and lastly i will work with mark to ensure that the mayor and the board of supervisors receive a copy of this report and also be on file at the public library.

>> thank you. was there any public comment? >> i have received no public comment requestses. >> okay commissioners questions, discussion? >> congratulations. it looks great. >> thank you. >> i want to thank you for the commitment to the annual report. having coming on to the commission i read the last 10 years. they're informative. they get you to where you need to get a good orientation to the city that you can get and thank you very much. >> commissioner sanchez any comments? >> [inaudible] >> yeah i think and thank you because i think there's been also judicious use and appropriate use of color of the presentation of the information in here. >> >> we actually have in the past made sure that we had copies that were sent from the department and from us -- from

you barbara and myself to the mayor and to every member of the board of supervisors, individual copies, so e copy them. you might not receive the attention because i think this document is very attractive and one that should receive the attention of our legislative and executive branch. so again i want to thank staff and thank barbara and the report i think commissioner pating is indicating gets better every year. >> i believe so, yes. >> and we're very appreciative of all the effort put into t.d thank you. can we go on to the next item? >> item 9 is the dph human resources update.

>> all right. good afternoon commissioners and president chow. i'm going to briefly go over some of the highlights of the human resources program at this point. i provided a memorandum prior to the commission meeting today. i am hoping you found that useful. i will have two people assisting me with the presentation and they will step up in just a moment. so i wanted to begin briefly talking about the civil service commission. the commission is appointed by the mayor but the mayor doesn't have influence over the commission. they're an independent body. the department of human resources at the county level administers the policies of the commission and they enforce the rules of the charter and they have four volumes and 22 series

of rules which they implement. just to give you a brief example how the rules can affect us. in the memo i explain there are five points that an applicant can appeal the process. of the applications we hired 4% which means you have a lot of unhappy applicants which have an opportunity to appeal the process. we did a posting for a psychiatric social worker which is 29, 30 and 31. we had over 500 applicants. we had 300 people qualify to take the exam so we had to administer the exam to 300 people. we had one people appeal along with the union and two other protests. they appealed in december so they put the list that we can hire on hold and froze it and a hearing this week that we prevailed and which added 45 days to the process so those things can happen in this

system which we try to avoid in a civil service system. all right. what happened to my slide here? okay. there we go. sorry. the department of human resources -- i mentioned the civil service commission is at the top and then the department of human resources below them and between us and the civil service commission. i would say that the department of human resources has been accommodating and helping to change the system. in this photo you have ted, the deputy director. this is about a year ago and he met us and our nurse manages to streamline the hiring process which we have implemented in december and we're starting the results of that. we're using a continuous open recruitment which means can apply and we can get them quickly on the list so

we're seeing the fruit of that work. the other photo is dr. alice chin who is a leader for the first leader for lean and we have four activities and another on the week of the 23rd and leaders including [inaudible] part of the leadership and we had a lot of changes and continue to make the positive improvements. next i will talk about operations. i will turn it over. >> good afternoon commissioners. i am senior personnel analysts in the operations division at san francisco general and karen hill my boss wasn't able to be here today so i am here in her stead reporting on great things we have been doing at our department. i came on board a year ago so i am brand-new to the city with new eyes and was