>> commissioner chow commissioner chung commissioner sanchez and commissioner pating the second item on the agenda is the approval of the minutes of october 6, 2015, and i'd like to note that commissioner pating requested on page 3 affirmative 3 underneath item 4 add the words state and federal they often don't match the needs you have a revised copy. >> i do. >> just those two words state and federal. >> what page was that correction on. >> page 3 under item 4 the third photograph the sentence is

commissioner pating noted federal and state mandates don't match local needs. >> fine i had further corrections two paragraphs further down it should say that commissioner chow commended dr. arrest going gone rather commended the other explanation on page 5 for the inspection of the third paragraph on that page has to do with with the comments on how the counties organized their emergency services and the last comment on any part was that you the minutes note that the san francisco dpw managed the services including ambulances and pharmacies i thought we should add this is transferred to the fire department many years ago

following a national trend. >> i will make that change. >> are any other corrections or additions? >> if not i'll accept those as editorial clarifying statement of a motion for acceptance. >> move for acceptance and a second any mother public comment. >> i've not received requests. >> all in favor, say i. >> i. >> opposed? and the minutes have been approved amazing. >> item 3 the director's report. >> good afternoon, commissioners i wanted to invite edwin buckle up tote pronounced edwin led our response to the valley fire i'd like him to give a quick report on our response. >> good afternoon, commissioners the main thing i really want to

start with just knowledge and give kudos to our dunst staff that really respond in overwhelming numbers on short response to the county wildfires you have in front of you the chronology a total of 4 staff during the first 40 civil certain volunteered to be advise for several days between september 17th and thirty and when they got deployed i was there for the first team they were very tuff in taking initiates for the fairgrounds they helped plan how to get the

mental health services to be provided and also played an tuff roll in the advocating of the services of note was there precedent sending of the lines of communication the needs for spanish language workers there was a significant spanish language population in the area and till when we are there the needs of spanish language survivors were not attended to not translation services at the town hall meeting every night for the survivors so we step up to the plate and our mental health transactions provided translation for the survivors to this day we have responded to a request right now we have somebody my name is of marietta hicks he wants to come back on

october 27th she currently at the local high school he signs the teachers there a violent had time off and their suffer the effects of you know the trauma of the fire he wants to come back on october 27th to provide emotional support for them we have other people lined for the two weeks to go there so the main thing i really want to say we have an excellent staff of individuals that care they want me to organize the response when i called wednesday evening on the first request by 9 o'clock the following day 19 people ready to go so i really commend the staff ready to respond. >> i wanted to commend edwin he is our connection to the state on the mutual aid at the

state level has the distinct response for mental health needs and many of the mental health is continuous need for post events so up to over a year depending on the incident from a mutual consent we have multiple languages and they're prepared they also keeps us trained in response to discharges edwin is always ready at any time of the day or night to get our staff responses. >> director are you done with that item r or are. >> there was a question if dr. sanchez. >> i was going to commend everyone in the department not only responded as a colleague through the significant

exchanges but more importantly what our core values are to recognize you know issues public health issues that effect those who don't have access to service the fact that was done in a crisis situations a significant number of families many were workers in the valley there and provided you know very critical support buses just about everything we're not getting access to anything again, it shows the training and supervision in providing the support on the requests is really a outstanding when it comes to people in the district 2. >> commend everyone on that a guarantee job well dawn i have one question you note you deployed a third request at this point doug that period of time

then do we support our workers up there in terms of then providing them housing and so forth or does the county support that. >> or the. >> the county is spotted to provide the support for lodging as well as meals sometimes in a disaster the communication lines and statistic doesn't operate for example, when i was with the first twaerm told there was lodging when i got there i asked where the lodging was i got a blanket stair so i had to scramble to find blankets from the red cross so we've since learned we're more careful for the second and third deployments to make sure that the los gatos are well arranged for i don't

blame the people in a disaster you have to be flexible so i notice the people are overwhelmed we don't expect to be treated like guests but supposed to help out. >> thank you and thank you all. >> i'll continue on my director's report the san francisco general hospital ribbon cutting as our construction san francisco general we're preparing for the contribution and pleased to announce the ribbon cutting has been set for saturday november 21st the mayor to cut the ribbon and a celebration of the new hospital building we unveil the san francisco general hospital campus in recognition by dr. and mark zuckerberg the executive director at sfgh foundation is

here and she'll be talking about this through the commission meeting. >> this year in our budget we provided for san francisco department of public health physicians that will be provided a membership to the self-medical society as you may know our san francisco medical society we're proud they're one of the most progressive in the country so is including next year our own san francisco health net will be contributing a regular column in the san francisco magazine bimonthly publication that has a print 2000 online so we proud we'll offering that if you want to opt out but san francisco employees will have automatic membership what to

talk about the primary care clinics at the at san francisco general hospital health center and the chinatown health center you mean half the commission provided a resolution for the health improvement partnering children's or health this is part of our 2 year strategic plan. >> also wanted to let all you know many of you may know johnny's now become not here today but appoint as the cfo at laguna proud of john he's played a major leader in the health center as the deputy care we're excited and i know that laguna honda is excited i'll stop there commissioners, if there is any other questions or comments i'd

like to answer questions. >> commissioners any comments if not then do you have. >> i wanted to thank the director for supporting the physician mile-per-hour and the medical society an important form for the physicians to be involved in the policymaking with regards to the communication of the public health issues the relationship relatively has been equally been beneficial i want to share i had several copies of doctor chiu's wonderful article on asian bli of 23 we'll be discussing that later on it broke in the medical society journal i had the honor of then enterprising the medicine so you'll find additional quite well spread 2 thousand members that goes

statewide in sacramento and gives san francisco a very good vehicle to share the good work we're doing in our universe and rep our public health work. >> thank you i just wanted to make a comment the alisa miller floral vicarious i'd like to commend the department in february we had noticed that chinatown has the most impact on - well, the worse record in dental health normally any experience takes a while before we go anything but the clinic is taking action so i do want to commend the speed we've respond to this so thank

you. >> thank you. >> shall i move on to item 44. >> general public comment we have currently one request. >> public comment from mr. vaughn edmond abraham; is that correct? >> yes. >> and just for everyone public comment is 3 minutes i have a timer when the buzzer goes off your time is up. >> do you have a 3 minute. >> well, thank you this is age taimentd so pardon me if i constitutional i'm not used to speaking before an audience naked i don't know about the half-naked the thing to advocate and to beg for services for an overlooked

population psych population for long survivors of aids in the two years i've been researching on my own i've found none including the ah p when above and beyond a couple years ago took aids out of their name so i feel i'm in kind of a first man on the moonwalk on this surface in many ways i know what i'm talking about and in some ways on the provider side i have no experience i've never provided a psychiatrical service it didn't have to cost a lot of money or some money it can be provided by well-trained professionals or a professional but i'm clear of

the benefits and of the what it takes for a human being to get out of bed each day when certain services are not provided i beg you at this point to please do one thing everyday and there are a thousand things to do but one would be nice everyday to forward this so that we who have survived this holocaust have a place where we can meet and discuss our unique problems we shouldn't be tloel thrown in with generally population people who are just discovering they have aids or want or looking at taking the cocktail we've done that we have a fierce ability to

stay alive to put it mildly i was diagnosed in 1985 and i'm still here it is in the pretty anymore it is very difficult some days and other days it is a complete lark but we need your help and commitment and we need our compassion more than anything to motivate you to do the right thing for us we're being overlooked in every which way thank you. >> thank you. >> that is the only public comment request. >> okay. well proceeded to the next item, please. >> item 5 is the outpatient treatment program. >> good afternoon, commissioners that is a pleasure to be here my name is angela a

psychologist with the department of public health and the director for the assistant 30ush9 program to talk about the implementation of the sawdust poushl treatment in san francisco as or as you may know the treatment is a new tool we'll have in our tool belt to support people with with millions give you a little bit of background about the assisted outpatient treatment in the passed assembly bill in 2002 and ultimate became part of institutions code in 2014 m task force recommended adaptation of the assisted poushlt treatment and ultimately paced by the board of supervisors in july of 2014 a couple of things to highlight the deposition of the outpatient is our supervisors had to make a determination that

through would not be a reduction or cut of services this is funded though the mental health services the other piece in implementing in san francisco your board of supervisors wanted to share that like all our programs within the system this is a program based on recovery and wellness tomato misses patient treatment i'll highlight those ones adopted by the board of supervisors and implementation committee was convened a different group of people including consumers mental health providers and attorneys and, of course, so on i came on board in march of this year as a director and work towards the prelims in providing this to centered and starting the programs on november 2nd of this year a week and a half

so moving on this is commonly laura's law because of laura wilcox in 2001 what is unique it has to be adopted by and i a county not a market-rate it was adopted in san francisco last year that ultimately allows for a court ordered treatment for individuals with a known millions of mentally ill the goal to get heads of crisis we have wonderful emergency psych services that is necessary how to fill the gap it we don't let people get worse before they get better a common discrepancy it allows forced treatment i want to talk about the difference of forced treatment and court ordered treatment allowed under the law forced treatment is

involuntary treatment as i mentioned involuntary psych working are an important part of system under the law for those cases a possibilities of involuntary medication and or restraint court ordered treatment ultimately is using a symbolic weight of the court to leverage someone into care arrest or someone that is likely to be compliant and that is commonly referred to as as black robe effect that is held in civil court if respond is not compliant with the treatment they'll not be held in contempt not a bench warrant issued or our involuntary hospitalization it is relying on the symbolic weight it comes with the law

so in our board of supervisors adopted the program they decided we should have called a care team or a mobile disciplinary mental health team that is consists of a health director a specialist or an individual that is a consumer mental health services and a family liaison someone that is a family member with mijdz those family liaison are unique to san francisco we're excited about them for many reasons this is embodied of the recovery and because we want to maximize the volunteer participation in the services and san francisco at the forefront or utilizing this services we know those position are vitality we think will help us to engage the individuals before we get to a court process this is an overview of the process for amt we'll talk about

this in detail the first a referral from a qualified requesting party by law and we try to make that is a assessable to accept some referrals be it a town hall free number a website that launches that has information about the assisted treatment as well as other resources from the community it will have a referral form that can be implemented and e-mailed to the care team so qualified party it one of the individuals an adult that lives with the individual a family member a care or sibling or spouse the director of a mental health facility treatment where the individuals lives the director of a hospital a licensed mental health provider to provide treatment to the individual or supervisor their

attempt and finally presiding officer or to who is assigned to the caseload another common misconception police officers can refer to this this is carrying a caseload our police officers don't carry caseloads they're not qualified parties moving to the session is it so overseen by myself i want to highlight this is a program signed to get ahead of crisis so we'll utilize some of the wonderful services we have in our robust system of care move on to the criteria for someone to be meeting all the criteria it includes the individual is 18 years or older a residents of san francisco has a severe effect to imagining or the

individual will unlikely survive without supervision and a lack of participation in the statement either their he imagining to two or more incarcerations they receive mental health treatment within 6 months are 3 years and attempts or acts of violence between the period of time a caveat is the hospitalization or incarceration immediately preceded the referral or was a catalyst that would go towards meeting this i actually think this is thoughtful the idea we don't want to order someone into treatment as a reaction of a crisis but as a system we had many opportunities to try to engage the individuals and we've been unsuccessful in doing so other criteria they've been offered an opportunity to

participate in the have arey services and part of responsibility we can we that's been done and offer them voluntary services on a going on base they have to be substantially deteriorating and the least restrictive option a ot to prevent relapse in great harm of extensively or others it reduced the livelihood of incarceration and finally, the individual will benefit from a ot what is a national statistic one in 20 need this we've anticipating fewer hundred people meet this criteria we accept more often than not an individual will offer them volunteer services but it is

voluntary at that point in time. >> now owner move-in on from the conditions are met we'll start the referral we'll do on in depth survey to gain the information about the persons history and i think we ask other important questions including what with be strengthens any i interests or strengthens as can way to engage with them we'll be outreaching them if anyone agitating them and similarly anything that interests them a thorough review the records for the fortunes of treatment and write a treatment plan i want to highlight this is a very preliminary treatment plan that has to take into account any directives in place and changes dramatically as we get to know the individual we want an

initial idea of who we recommend when we outreach an individual we'll be transparent why we're there and provide them with a lot of information including document about the patients rights the public defender's office who will be representing asa these and put together a document for legal services and all of those documents will be provided in a preferred language we would ask the individual content to conduct on assessment new, of course, a couple of things can happen if they consent to an assessment and regardless of whether or not they meet the criteria we'll offer them voluntary services if necessary meet the criteria and we'll connect them to care we'll restart the investigation at any time during the first six months of treatment from the individual

disgadgets if treatment i should not with other things county have few cases have a court process so solemnly swear today information from relocating they have one thousand phone calls will information about the program only 8 cases went to court so again, a small number of cases we hope we'll see something similar in san francisco engaging many people in voluntary services but as individuals refuses the assessment or the assessment of refuses any level of care we'll go through an engagement period by law we have to engage the person before we file a court petition every county is different san francisco has a thirty day we attempt to engage the person before filing a court order so if an individual continues to

refuse the volunteery services and meets the criteria and deteriorating we'll move forward with a court petition filed within 10 days of the last assessment of the individual it includes an affidavit assessed the person how they met the criteria as well as an updated treatment with all the information at that point in time part of the caregivers is to give the person a copy of the petition filed in court the public defender's office gets a copy any treatment provider gets a copy we meet with the individual and ask if there are any relevant persons in they life that needs a copy we again ask the individual to engage in individual services that is an effect that is unique in san francisco offering treatment

along the process in orange county there are 8 cases a petition was filed and 7 individuals expecting the attempt that is a settlement agreement it as court order the court monitored them but a degree of care now if an individual didn't enter into a she means to we'll get a court hearing within 5 business days an individual can enter into a settlement but the judge can he determine if wench meet the policy and this is outpatient services or decide we don't meet the threshold by law an update to the court every 60 days we anticipate more frequently based on other counties we have a hearing of non-inclines

we will continue to outreach them and engage them and monitor them closely for 5150 criteria as well again moving on along with the treatment looks like the treatment is a individualized affordability take into account the preferences and their unique needs and level of care it is flexible as a remind not involving involuntary- reducing the hospitalization and victimization and a our law is like new york there is some mixed data out of new york next year the day was reviewed so again talking about the services that will be offered services are field based people we'll meet them where their

confront and includes a full partnering an expansion the usf service partnership they'll say have an organization ot that is specialized to work with the population we have a small ratio of staff member to clients we'll be monitoring 245i calista caseload and, of course, there is a goal of linking to individual to long-term care we'll talk about the steps for the next services those are some things that services are that may include support services are diverse and common forms of ada compliance to highlight a couple of things we're lucky to be implementing this in a robust system of care it includes access to medication and helping assistance that is emergency short time or long

term housing, family support and san francisco taking that a step forward to identify people as family members and under the law the person we're outreaching has custody of a child we maintain that custody or ultimately not custody but we support them in supporting them necessary so the goal of reducing isolation and evidences based practices just to name a few an important question how do we know if this is working in san francisco we have to provide an annual report to the state department that is quantify and qualitative quantify data how many individual we outreach and are connected to services court petitions filed etc. qualify active is their support

systems their provider and again, our board of directors board of supervisors has taken it a step further to do a in depth 3 year analysis and it is required we use an external consultant to make sure that the reports are objective and, of course, we have not starred the record no data to show you up to this point in time but look forward to coming back and speaking with you, of course, i'm available to answer any questions you might have >> any public comment. >> i've not received public comment requests for this item. >> commissioners. >> i have 4 items. >> commissioner pating. >> thank you very much this wonderful presentation i'm glad after a long time the preparation and many, many meetings. >> it's happening. >> you we're all looking forward to it. >> so four questions so i'm

aware the nevada data not aware this was a best practices it is encouraging but with regards to nevada i think 80 percent of people were this is involuntary treatment they're willing to be voluntary this is encouraging is there anything about san francisco you will think that makes us unique we might have different outcomes or need to consider other unique vanishes. >> it is difficult planning san francisco is so unique to the other counties that have implemented that up to this point in time but as i mentioned in san francisco is at the forefront of consumer services and outreaching to the individuals we're implementing this in a different way this is robust so i'm very hope the array of services we'll offer

people will help us in connecting with individuals and care. >> with regards to the consumer reception across the state a lot of consumer opposition i haven't heard of opposition in our city i assume because you've done a great job how is it consumer with the experience have. >> received feedback and concerns that you're still trying to address. >> well commissioner, i appreciate the confidence in my ability we have made a very skertdz effort to do those including the customer run organization and, of course, there are concerns in how it is implemented and insuring that it is done so recovery and oriented fashion what i have consistently heard individuals think this is

an intervention and tool rather than a co-hers that's what we want to maximize participation and services, of course, ongoing conversation and an open dialogue with other organizations to insure that continues throughout the prelims i also think that having the pier prospective will sure we discuss that on a day to day basis. >> with regards to our care team what's the total budget and we have hundred clients what is your anticipated cost per person your imagining. >> right. >> so the care team is the 3 individuals and then in terms of an estimated costs bans the services that are provided we're estimating $30,000 a year per person but, of course, that is to be determined your so the services they'll receive comes out of this budget not the

general mental health. >> it is funded through the mental health services act. >> so stand alone maybe it uses others services the fund is there t sma. >> we're able to be reimbursed partially from medi-cal and other benefits but ultimate we be providing those services under h m a are s a you i know we're starting two or three years i think we've definitely wanted to see quality of life carts as your reporting and i think very much in terms of felt economic feasibility for the potential savings i guess the dollars back phil that have less bottom line impact savings as soon as possible to costs. >> that's important to consider while that more

nonprofit analysis in 3 years, of course, we'll be connecting daylight and that annual report is due may first of every year to additional data. >> so the next question this is i was on the do the emergency services sunset at all. >> okay (inaudible). >> that's great. >> so this is somewhat of a - well, not a free program but a great potential to do great services with dollars. >> again those are individuals that meets melanie it they're our clients we'll work with them throughout the program and hopefully long term and other services. >> do the clients mostly clients that have housing already or embed in the families

networks or homeless population or populations that are not reaching because their insured any thousands on the demographics. >> orange county it has implemented the program is very different than san francisco they're similar to the counties that have implement their primary refers is something that families have been very eager to have implemented throughout california so in anticipation of the rivers from the individuals that may include their living with family but the second highest referrals in orange county was the forensic setting we'll not see individuals coming out of jail that meets the criteria we'll be engaging that may require housing assistance. >> thank you very much. >> thank you. >> commissioner sanchez do you have a question. >> i thought that was an excellent report and we look forward. >> thank you very much. >> thank you.

>> like to make a comment commissioner chow first i'd like to acknowledge the great director shes she has a history in forensic and worked in our jail system so a great selection and won the things you might not have caught in 4 hundred people call for services 4 hundred people will be connected to service this is an important outreach for the department and mental health for many families whether they called county give information will be the child but helps never before it is an opportunity for us to serve for clients in the community even if they dba don't meet the criteria the department is engaging with those individuals to get them health. >> i want to go on the record

thanking dr. robison i know i see you you've been instrumental in moving this issue along thank you very much. >> i have 1 or 2 questions which was certainly thank you because laura has been sufficiently a controversy with no people that need to protest what you're or even comment on the place is a credit to how you have trartd this into the needs of san francisco but so i'm kind of curious you've said if, in fact, it became a treatment plan by law and from the recipient of this plan then choose not to follow there is noting no ultimate consequence; is that

correct. >> that's correct. >> is there this a process work with the client and trying to have them feel that there is a possible oversight from someone else watching that wouldn't you rather work with us voluntary and absolutely it is the effect of the report and as i mentioned while no formally consequences this is a group or population we feel at risk for hospitalization and incarceration in order to meet the criteria for the program and we'll be monitoring them closely with the volunteery hospitalization criteria to get the services should they meet the criteria. >> so the involuntary level. >> and outreaching them at the hospital. >> so it is interesting you've pointed out the experience we went through the other

experience to so the annual report our anticipating if you're starting in october this would be next year that you would have some data. >> right we have had 6 months of data for the may report and again, we're using the external consultant went through an revenue process work with us to insure our data for the initial report and providing an item place of residence for the ongoing years. >> it seems reasonable to get an interim report that as an issue with the county to see how it is being used in our public health committee. >> and we'll have it before that goes out to sacramento to the state vice president the final report will not be sent before we go through the commission and and owe interim focusing on concerns and efforts

to address those concerns i don't think you'll have data but structural information. >> very good well again, thank you for putting together this fine program. >> well, thank you very much and as i mentioned the implementation committee was easy to slide into and work within so i appreciate all our support and being here today. >> okay. thank you. >> thank you. >> we'll look forward to you're next report. >> thank you very much. >> the next 6 is a resolution for the type 2 diabetes and asian-american adults residents this resolution will be voted on today. >> dr. argon. >> good afternoon, commissioners. >> my comments if - we've received slips for testimony if

anyone else wishes to comment following the presentation from the public please fill out a speaker form and bring to say the secretary. >> before dr. argon begins to our right a slightly revised version of the resolution with red lines language and the public has that at the front table that is clear what the represents changes. >> so thank you, dr. argon please. good afternoon, commissioners good afternoon. director garcia i'm the health officer of san francisco and also the director the populations division today i'd like give a brief overview of body mass screening for asian-americans in the u.s. and it's relevant to the resolution and then after i speak dr. ben a medical director of the chinese

health center will pub u talk about the network i want to give special knowledge to the type 2 diabetes the asian pacific islander positions and dr. chow for collecting being a champion of this important issue and bringing national attention to the criteria so thank you. >> let me actually put my presentation up. >> do you need assistance dr. >> no i'll be fine. >> thank you. >> maybe i do need assistance here. >> is that full screen mode; is that correct? >> yes. >> i'm going to run and get it

support. >> make sure of one thing here. >> there it is. >> it's working and yep. >> yeah. okay so i'm going to briefly give an overview and background and go the reliable for why bli screening should be reduced and recognized from some of the body

that support this recommendation the first one i wanted to point out we know that diabetes is a growing problem in the united states and this reminds us first of all, the vast majority of diabetes is type 2 diabetes we know that over 46 persons are downloading every year and thirty million americans have doing the best we can and thirty million will have prediabetes perms are diabetes go on to have heart attacks and kidney failure and being responsible follow disease and amputation being responsible for lower is sxreement amputation the cost of california is $7,800 every year

and medical costs are estimated to be over 27 whether they wouldn't say problems of diabetes has increased in the united states while around 1990 the previous lens was 8.8 and 12 it is now 12.12 percent an important thing to float about doing the best we can we are interested in the total burden diabetes we're interested not only in the those who are downloading but undownloading this is a critical point to pay attention to as i go through this so for example, if you looked at the 14.3 percent of deceasing 13 percent of the us is undiagnosed you'll see this is much higher for asians and based on the data 38 percent have prediabetes this is a huge

problem the next slide is from the ed haynes data to emphasize the association between weight and diabetes you see on the graph at normal weight a to over weight to obese a prevalence is increasing as you move from left to right because the obese epidemic when you look at this data an example of type 2 diabetes in california when you look at this graph you'll see asian pacific islanders are 6.2 percent so it equivalency gives the misimpression not a problem ♪ population i wanted to get to the point what matters is the

total diagonal burden of diabetes we'll show you in a second the national data if you just were to focus on this you'll be missing an important part of problem so the u.s. census independence aligns as person from china and monocombol and southeast asia and philippines and china and vietnam additional singapore and other country's the india continent in 2011 more than two-thirds were foreign-born in the u.s. when i focus on the asian-american population currently 4 millions are chinese and 3 that is 4 filipino and 3.4

asian india and 1.7 coroner and on that are japanese that population represents 5.1 percent of u.s. population by 2016 that will go up to 8.2 percent among the faster growing population in the u.s. so this next slide is an important slide when you looked at that previous slide we are that looking downloading diabetes we're looking is the difference continue the blue bar and the green bar the blue bar is total diabetes burden it is those that are diagnosed with diabetes and those are undiagnosed with diabetes so typically when you are looking at the data only the difference between the top of blue bar and the top of green bar if you only look at that the asian category would be smaller the difference is the green bar

for asians more than 50 percent of total burn of diabetes more than 50 percent of it is undiagnosed so it's a large proposition we don't know you'll see for hispanic and asians that is much larger undiagnosed pay attention to that that explains why it you only look at part of data you miss of important part of picture and when you don't pickup this you will be surprised i'll show you data in a couple of months out of the community health assessment we looked at recently, we question happened to beginning to think about is reasons for this so you if you look at this slide this is not published that will come out in the health status report look at the diabetes from 2007 to 2012

there is a dramatic increase in you'll ethic groups of diabetes and different from the other data you'll see the asians that are highest this is an example where asians you're not following the burden of deceased disease and here it is catching to us this is part of the reason changing the screening criteria is important we need to be able to cast those undiagnosed portion of persons with doing the best we can the importance of catching them is helping us in primary preservation and weight loss so what we used right now is body mass index a way of looking at adjustment for height additional heart disease and increased cholesterol and the

problem with bmi it is weight adjusted for height it includes muscle mass, bone mass as well as the amount of fat that is in the body so it turns out for asians if you take two an asian and non-asian that has the same bmi the asian will have a higher promotion of fat it is distributed around the visa are as opposed to the fat you can see we call it sub cutaneous fat around the owners is call vice rally fat that is predicted of causing diabetes a so anyone on the outside may look to have normal weight but actually have more vice rally fat than someone else that is turning ought to be true for the asian population

begins to explain why the b m index in terms of the cut off is not visible for the asian population what about changing the cut off one thing to realize the way bmi used have a category of normal over reject e weight and obese categories this screening is focused on not changing the category designations but really improving the screening of diabetes diabetes improving the screening for diabetes this is an important thing to mention so with the category that is currently this will continue to exist but the emphasis ero on changing the cut off to diagonal diabetes for example, the current cut of 25 the

sensitivity of a b any m i have 25 is 64 percent it means 36 percent of asian-american with diabetes by dropping the cut off you'll see here the arrow on overweight by dropping the cut off to if you increase the sensitivity to 80 plus it works with the different asian groups a different cut off for the asian groups and vice chair an sensitive screening is better than for this type of screening. >> so i want to acknowledge that knowledge about this is really existing i existed since the mid 1990s they published an article in 2004 recognizing the

difference in the population this is 10 years later a long time coming countries walk china and india and japan h have changed they're cut off the 2014 has a draft that is consistent with the current guidelines of screening for persons at higher risk is didn't mention the cut off of 23 will be consistent with what we're recommending the strongest establishment from 9 america diabetes association and what we say i'll read it quickly test this be considered in all deputies over weighed and this means b mississippi m i or 23 for asian-american and other reflex factors like african-american or hispanic or ailing that is consistent with what the resolution is promoting

so what i'm going to do is ichlz to dr. benefit louie to give us information about the network. >> thank you. >> hi good afternoon, commissioners and good afternoon director barbara garcia i hope i don't have difficulties technical. >> i'll try to - see if this. >> excellence and okay. >> so i'm ben lou why a a are international medicine he serve and a another china health center thank you for having me to speak about the screening at the bmi for asian-american and the impacts on the network before i do that i want to quickly recognizing the oral disparity for the children in

the community and recognizing our staff for implementing that's a lot more that needs to be done and we'll do it we realize that so first of all, talking about our health network that is primary care which is the third column this is 72 thousand patients represents the patients served in primary care this is richly diverse population evidenced by the breakdown the pie chart here the published question is our asian-american population 25 percent of our network that represents 18 thousand patient and i'm going to talk about china public health center use to those numbers to come to estimates and thees trappings

for the screening of 23 patients china public health is a primary care health center that currently serves 55 hundred active patients over 95 percent of asian-americans represent 27 percent of health network of asian-american patients given this population the 90 percent asian-american the estimates that i'll be talking about will be helpful to estimate the impacts of bmi for obese on the network we currently have 8 hundred and 72 patients are diabetes this which is 16 percent of our population 15 hundred 60 patients have prediabetes which is about 29 percent and we'll come back to our stems and the following the bmi breakdown to 59 percent of

the bmi are equal to 23 i'll measure that 90 percent asian-americans and for bmi if you take the difference the 22 percent of patient is 12 hundred representing with the patients of bmi with 23 and 25 this is impacted by the new screening guidelines and again use this percentages in the next couple of slides this slide is you give us a sense of the bmi breakdown of the diabetics and prediabetics 8 hundred 70 diabetes patients 29 have the bmi between 23 and 25 for the 15 hundred plus patients 27 percent have a bmi between 23 and 25

this is the sense of the magnitude of the patient who have the bmi profile for the diabetics and prebeefbz using those numbers the impacts the screening for the health in effect the number of asians in our need not is 18 thousand so using the t p percentage of 22 percent having a bmi between 23 and 25 it deals with over 4 thousand paternity additionally screening at the bmi 23 for diabetes and estimating the number of prediabetes dialyses we picked a number of sxreenz and using the 29 prebeacon hill at chinatown over 90 percent are asian-americans and using that we estimate about 11 hundred and

plus diagnosis so using the chinatown our experience munld by the number of patients screens we have 6 hundred and 40 additional diabetes so this really speaks to what doctor argon talked about what was undiagnosed cases really is that the blue and the dwrr and we'll be decreasing the gap and be able to diagnose is otherwise undiagnosed cases okay. and in terms of the cost analysis the benefits are many the primary care and intervention that allows us to do that and prevents costly complication and hospitalization

the complications as mentioned include heart attacks, loss of vision and limb and it will lower the loss of prosperity among our patient as for cost hair relatively small because of the simple screening blood tests and hemming global and by and far low-cost human exercise and some of the medications like the generic those are all relatively low-cost intervention so at china public health we screen the asian-american in april of 2015 and the three because the mounting evidence for the evidence based benefit of doing so we find out the benefit

already for those patient who diagnoses with prediabetes with the local ymca doing the preprogram that is implement across the country 16 session of life coach and ymca working with patients on lifestyle changes and we'll be able to do that and really taking that into a diagnosis to the intervention we talked about and having a class with the emphasis oneself any public comment it is important for the patient that live with diabetes and prediabetes every single day i'd like to make a comment on the tremendous under the circumstances that exist to publish the opportunities like this right here in front of the us to do that and we have our

electronic medical records and to be able to leverage that and to continue to develop our data airbnb lyrics and register and try to collaborate with our public colleagues there to take it from the level of the data to tell you intervention to better outpatients and we need to be able to build the strategy and i believe there is a gap in resources to be able to take the data and consecutively have the coordination to pick the data to outpatients to benefit them that exists there. >> thank you very much. >> thank you, dr. louie. >> dr. argon are you done.

>> yes. that concludes my presentation. >> thank you very much. >> we have a number of public testifiers and i'll call 3 at that point to be prepared to come forward. >> dr. dexter louie and dr. hoe tran the first 3 please. our secretary will be keeping the time. >> yes. >> thank you, commissioners for this opportunity i wish to speak in favor of the resolution 15 dash 13 enforcing the screening for type 2 diabetes i'm a physician a full physician here in san francisco. >> would you move our microphone doctor louie thank

you. >> i'm department of education take care an ems e emt information for 40 years my office in chinatown is navigate is two fwlokz from the hospital i was born that 4 blocks from mire elementary school and 6 blocks from where i live on north beach so i'm a really native here i'm also the chair of the national council of asian physicians leading the effort in make our communities and physicians aware the need to use a bmi of 23 for asian-americans the national organize of physicians was one efforts lead organizations in the asian diabetes coalition with the american diabetes and joslyn

asian clinic so that is a strong leadership there and strong movement to support that forego several years the asian coalition is focused to screen asian-american for diabetes at bmi 23 as dr. argon and dr. louie said the standard is a bmi of 25 but not holding for asian-americans the lower b mississippi example i have if a a better measure with regards to number 3 as a senior resolution this is a health care disparities that needs to be addressed and it is to raise awareness in our communities to screen asian-americans at the bmi of 23 that is consistent with the nationals constitutes of health, world health

organization and the american diabetes resolution it is data based and includes years of research by harvard and the diabetes chaplain that is forward-looking and just plain good medicine the resolution is indian with the focus on prevent care dr. louie mentioned as population health that is upstream medicine in the 21st century we need to take care of our patients and upstream not down stream when they're sick i strongly urge to you vote in favor of the resolution. >> next speaker dr. >> yeah. i'm larry i'm a pediatrician and director the chinese-american society i've

been in practice for 44 years now and the last 20 years of or so i actually have been seeing increasing number of my patients with type 2 diabetes and actually a lot of prediabetics so much so i've seen their bmi going up i'm screening all teenagers for diabetes and i would say close to 2 or 3 percent of them are prediabetic i picked up before 4 two or three diabetes patients so i definitely endorse the screening at bmi of 23 i'm sure that will benefit the adult population since it benefits even the teenager patients of mine thank

you. >> thank you. >> dr. tran. >> good afternoon, commissioners i very much appreciate our times i'm here to talk about the 323 an issue of quality about time to understand the operation and screen according to their body mass index and the second one it goes up as presented practitioners it is based on that 50 percent of our asian-american population and not been diagnosed and the first one is the cost containment it prevents complicates from the disease and touch on issues at an early stage last but not least a patient i had diabetes i was diagnosed with hundred and 35 as

my glue close level i reduced my bmi to 23 i offer came. >> thank you our next 3 is dr. roxanne, ms. jessica and dr. eric. >> hi i'm roxanne balancing tissue the director for the asian pacific islander an organization endorses and supports the campaign thank you to the commissioners listening to us i wanted to share that we know asian-americans are unrecognized as as an at risk population for diabetes it is common in our communities as 21 percent the higher - there is

among the diabetes previous lansz in india and chinese and filipinos and koreans the data that was shared it is important they to share we worked with them on an asian sample 80 so by the serving much large groups of asians we were abdominal able to provide data to the data is really amazing to share around having 51 percent that asian-american have diabetes a national status so it is important with this resolution and this campaign asian-americans that have diabetes and prediabetes needs to be tested for type 2 diabetes and needs more education about this to be tefdz for type 2

diabetes asians are at risk of they don't reach the bmi of 23 is a redirection of obesity but to get checked by the doctors by screening every 16 thousand asian-american with diabetes that will revealed and treatment and management of diabetes can begin earlier before complications arise thank you very much. >> next thank you. >> good afternoon commissioners and discharging i'm jessica representative for the medical society represent 18

hundred physicians in training here in san francisco i'd like to on behalf of our organization put in our support for this resolution obesity and the many negative health consequence it is a worsening problem among asian-americans figures and others clinicians need training tools to address this issue amongst their patient and have a smaller bmi needs to reflect the thrown we join public health experts in endorsing the bmi at 23 and we have the issue of our journal we have on your counters with the consequence a cantonese the article that commissioner

pating referenced earlier that was co-authored by edward chow on pageant 24 thank you so much for this important issue. >> thank you very much. we have two other speakers. >> good afternoon health commissioners my name is dr. ink i eric i'm the vice president of the chinese community health care association and nonprofit associations of physicians serving the chinese community in san francisco over thirty years. >> i'm speaking in support of the skwooen for bmi 23 initiative as we all know that asian-americans consist of 34

percent of the population in the city and county of san francisco morph asian-americans are thirty percent more likely to develop diabetes than our white counterparts in south asia hawaii and asian pacific islanders the percentage of the developing diabetes is even higher morph asian-americans are more likely to develop diabetes at a lower bmi as evidenced by studies by jocelyn clinic washington university and usc b the presents conference o convention recommended e recommends the screen at bmi 25 because at 25 the chances of

developing diabetes has there's, however, if one uses this recommendation it will miss approximately 35 percent of diabetes in asian-americans population and it will even miss for cases of prediabetics in this population and national institute of health says that over 50 percent of the diabetes cases in asian-americans remain undiagnosed and unrecognized this means their missed opportunities for treatment and prevention. >> as a community eye doctor i've been seeing a good number of patients who are awe

systematic the back the retina already shows damages by the diabetes and this damage is in the back the eye it correlates well with complications in kidney ♪ micro circulations in the extremities the the heart and in the brain matt haney that these stages of the diseases are high i recommend highly to screen for diabetes at bmi 23 thank you >> thank you. >> the next (calling names). >> good afternoon, commissioners and all the leaders in

attendance i'm diane with the asian health institute at ac sf i'm glad i'm here to be able to talk about this a little bit i want to thank dr. thomas excuse me. my voice is cracking up for the wonderful presentation with the strong evidence for the bmi 23 bmi is certainly within the things we get a remedy from patients although i personally because of the reserve are more in favor of raising this didn't come bill so in lieu of the bmi the certainly strongest and easy number to come by physicians and clinicians to be a potential

diabetes patients so i speak strongly in favor of the resolution and i xels especially want to echo all the previous speakers and two of the most important points are the health equality that the bmi bring and the under diagnoses problem if we stop there is still under diagnoses but hopefully with the b mississippi m i screening that will be less in the largest number of immigrants coming to san francisco are chinese immigrants and china has also a very similar rate of diabetes as we have in the united states at 12 percent but 12 percent the population has almost 1 hundred and 14 millions of people that

is a worse problem but more the people coming over here some of the problems are going back to be burdensome to the problems 90 in san francisco thank you very much. >> thank you. >> doctor i may have mispronounced our name in so, so give that you're from the american diabetes association. >> absolutely good afternoon. i'm dr. melina uncapher corin jackson the associate director for the american diabetes i'm standard here in place of my director michael that county be here we want to come and applaud san francisco and the department of public health for nicht this

resolution and adapting the screen it is our desire to prevent and cure diabetes and help those of the folks and one of the ways to it had i serve 9 counties in our office i'm the director of programs i'm out hosting and finding partners to collaborate with you and host in face and communities based organizations we conduct free to the public diabetes education and self-management with or we have looking forward to collaborating with you in this fight against diabetes we applaud you we're coming out to the national diabetes month please look at our doing the best we can website and thank you so much for having us. >> thank you. >> that will ends public

comment unless someone didn't turn in a form and wants to speak okay. good commissioners we need commissioner chung back to continue, however, we can continue our business but we will require doctor katie tang if you discuss what time commissioners we do have a proposed resolution brother you i do want to thank staff for they're very hard work in putting this together and the revision i've suggested as part of populated resolution mirrors the discussion of testing for diabetes to clarify to some who had asked why they were looking at the resolution whether this was a mandate clearly not a mandate a recommendation that endorses the standards that are from the

america diabetes association, in fact, do so as read out to us by dr. argon the testing it be considered and so to help clarify not a mandates we are asking to do you want and therefore, if you fall short some kind of punishment this is what we wanted clear in the resolution that it is accept and therefore mirror the language used but is american diabetes association so i hope that my colleagues here would feel that that would be an acceptable substitute if respond wants to move the resolution. >> i'd like to the go ahead and move the resolution. >> second. >> and a second. >> okay. good is there further discussion by the commissioners? >> i skill want to thank you,

dr. chow for bringing this forward and playing a role in the communities for making us aware certainly you made me aware of this and helped to get it both the journal and thank you all members on the asian community for speaking for the resolution. >> okay commissioner chung. >> i have a question for the director actually so as we move forward with this recommendation will there is like a screen for diabetes when an asian patient comes as we implement the new h.r. that will be able to catch them earlier on. >> well, i think as you saw with dr. ben he kind of outlined what they're doing within the chinatown health clinic and so as we precede that with this we already have an e m r they're

able to use sometimes registry this is included and assessments and the fact their murray is different will cause as we go through the body mass assessment that is a common assessment all doctors do within a department this bring attentions is that and insure we're doing a greater assessment of that. >> commissioner sanchez. >> no, i would just make a statement i think that this an outstanding recommendations it shows a real unique oust into the population of the city i want to thank you all particularly many of you come came from the practices i thought that today we've heard everything from internal medication they've coasted the

waterfront and the resources and collaboration and so forth was a really great great deal of trust and in both all of you and in the department in bringing to death a new benchmark to look at the diagnosis and treatment in a exceptional population that transcribed in the countries and overlooked this was really a great learning curve for after all us to look at how we clarify and measure and diagnose and treat in a comprehensive holistic way that is a fantastic effort thank you to the colleagues on the commission who spends a great deal of time for representing our endorsements today. >> thank you commissioner sanchez any further comment i will make one since we have been talking about personally

here and personally in bra for 40 some odd years and noted the rising numbers of diabetics both in any own practice within the plans that we were administering through the programs at the communities led to really evaluating why this was happening and then clear that we might the no have known but the rest of the world in asia we are florida were under diagnosing and got this i know that in the health plan i was working at one of the most devastating chronic diseases what renatural disease relative to the fact everyone what was diabetic so this is one of the common disease like the eye

complications in our population we don't see has much vascular but we kept words the merger diabetes association a decade ago said you don't have any greater diabetic prevalence than the rest of the communities but it seems to me to be enabling we've been watching the rise in diabetes but to then understand that we were missing the diagnoses as our study come out in regards through the bmi led to the fact we should be doing something and very important to not just this communities but to the entire country that once the recommendations came out that had been verified through the american diabetes association we take that opportunity and have the opportunities to as the

first city in the united states here to actually campaign for the identification of diabetes in our large asian population so i really thank staff here for the work they've put together but more importantly also and really thank many of whom have testified today who really worked working very hard over the last several years to get the measurements regarding what is true incidence of diabetes in the asian communities which was published in our following the convention in 2011 that n cap helped with the coalition and from there working hard to work with the diabetes association to look at the evidence again that the rest of the world was using and this shouldn't we also be

using that that in america he hope to follow my fellow commissioners b will join necessary me in voting for in the first supply city in america to recognize this on behalf of our communities are we prepared for the vote. >> if so. >> all in favor, say i. >> i. >> of resolution 15 dash 13 i > opposed? the resolution has passed unanimously thank you to the public for coming (clapping.) thank you, commissioners that he move on to item 7 a resolution recommending the board of supervisors accept a gift of $5 million it from the san francisco general hospital and approve naming of various locations of planning and mark zuckerberg and trauma building in recognition of a film profit donation

good afternoon, commissioners i'm rolland's director the san francisco health network and also the intern chief executive director of san francisco general hospital you've begun (laughter). >> united states of america the san francisco signal foundation embarked upon an ambitious capital campaign to raise few minutes as sf fixtures and furniture and equipment those essential items needed to operate the new central nervous system that was burger to be paid for by the 8 hundred and 87 general fund bonds you'll recall

that you back on march 3rd of this year approved a resolution recommending that the board of supervisors accept and an initial gift of $25 million from the self-reliance foundation for this effort we are here today and you have before you a resolution asking our approval and recommendation to the board of supervisors that they accept now a gift of $5 million and also recommend the approval of various donor naming recognize opportunities in the new buildings that are outlined in our resolution i'm joined by amanda executive director of the sfgh foundation we also have deputy city attorney julie to help answer questions we are presenting this

resolution for your consideration and approval and i object to entertain any questions you might have. >> do we have any speakers no speakers. >> ? >> i'm asking. >> yes. yep. >> i'll note commissioner sanchez i guess lemon found out are you going to be presenting future this or is this? >> perhaps the executive director could that's the extent of my presentation but if something else. >> commissioner sanchez question. >> first of all, i want to say again to the intern executive director has been a hard working of the foundation along with our new director but i do want to state this

the board of trustees has been working diligently and passionately and quietly in order to identify a cohort of philanthropists in this city many of whom didn't want to, announced because they were either the whole family or new family everything was represented this was done with a great deal of over the last couple of years it is outstanding to think here we are a public hospital where we had voter approval unbelievably in the 80 percent bracket and built with public funds in order to maintain and provided the best equipment and the best environment we had philanthropist all over the waterfront speaks for itself come into and present dollars were raised i want to mention two families in particular

besides our doctors and his wife but our san francisco giant pam bear and her husband unknowable the old san franciscans you looked at the things you see everything from the newer families to the salesforce each one say, oh and providing resources which will make san francisco general a flagship of research for another hundred and 50 years advertised an honor for me to serve on the board as a representative from the commission since 2002 and i having served on other foundations believe me i've never seen a foundation where the generations have passed the torch has passed in

families can come together and make significant and ongoing candidates to providing provide the highest quality of health care with dignity and respect for the the patient in self-reliance i san francisco general hospital this is part of community health network and laguna an integration of coordination of services and when dr. chow came board and i he in 1998 it is the leadership and the trust and commitment to the highest level of excellence for the citizens and visitors that are in san francisco general so on behalf of i know as as member of the also the foundation and i said to this

the outstanding leadership i will move we accept this gift and thank those exceptional donors for the ongoing contributions belief in san francisco general. >> there's a motion for the resolution was interest a second? >> second. >> okay. we'll be considering the resolution he didn't see my public comment. >> could we the executive director the foundation come up and say. >> i was going to ask there is more than one resolve we need to understand how each of those resolves work we have the resolution because it has been moved and seconded and certainly like to have the executive directors also talked u talk with us perhaps someone can explain not just accepting the $5 million but 3 parts the other

two parts i recognize is sort of allowing foyer circumstances that don't have significant consequence could you explain why we have the 5 resolve to this. >> well. >> i'll defer to you and greg and the city attorney here each of them are separate dr. chow in certain types of depends on. >> we can give due recognize. >> greg this is a money thing we'll let greg handle that. >> there's a lot of money who is we're really thanking and . >> let's note doctor chow you've not seen because the quiet phase and the process that the foundation is going to consider the naming we went through the

zuckerberg's and now proceed with the naming of the all the creditable donations that's a reflection we'll let greg give details. >> we should recognize what is happening and greg wagner chief financial officer we've spent times structuring this so i simple intents so basically what resolve is broke down it is clear it reflects the timing of the various gifts that have come from the san francisco general foundation and the naming recognition is associated with those gifts to when you look at the resolution starting on page 2 you have a first resolve section which says that in honor of generosity of the individuals

who transcribed a $25 million gifts that $25 million as said in march of this year, the commission accepted the gift and the board accepted the gift that constituent the first portion of the funding from pricilla chan and a mark zuckerberg and knitted $25 million from a varieties of other donors we approved the names of the pricilla chan and mark zuckerberg general hospital but not passed a resolution with the additional naming this lists the naming earned with those enlists in the $25 million then in addition to that in section on page of you have a second section of resolve

clauses and what those are doing first, it is recommending to the board to accept an additional $5 million of cash we've been ref from the foundation on top of what we received today and secondly, listing is additional naming that is associated with that second deficit to it is absence confusing how it was laid out but to make it clear we're dissipating it out to align with the gift of acceptance resolution that have come through this commission in multiple steps so i hope that helps but happy to answer any other questions. >> for me commissioners do you see that. >> could you review the reluctance on pauctance on pagr on pagee on page on pagev on pagei on pae on paw

on page 8. >> you have to be built or named. >> the first is for two of the gifts so the board is required to approve and accept a lot more details i'll invite julia but the board is required when conditions attached or associated with the gift and in these skies conditions associated with the gifts we've agreed is that the naming would have a length of time associated with with that we've carved that out ♪ resolution for all practical purposes the naming once approved by the board will stay in practices we've included the resolve clauses that is part of the discussion about those

particular naming opportunities the second one is essentially giving the director of health the recommending to give the director of health some administrative authority to do minor changes such as adjusting slightly the location of the actual singe it going to appear and making modifications if there are issues where instruction or renovation we have the horticulture to make those substantial adjustments administratively without having to come back to the board of supervisors every time we need

to - >> our executive director. >> thank you, commissioners fewer support i also wanted to acknowledge director garcia for they are partnership eucalyptus our foundation would not have been successful if we didn't have a great relationship with the department of public health and our team of individuals at the hospital to thank you briefly donor recognize is a major contribution our ability to understand and support this is really a key to be successful and just to echo commissioner sanchez you said is to great this the most beautiful thing about the effort it brought together philanthropists in san francisco and the greater by the way, to supporting the institutions it is san francisco

general a marriage of not only their financial resources but the endorsement and they're willingness to support ongoing and we're excited as we moving forward we know the needs of hospital continue to grow and we're commented to be robust this is a great deems of future engagement we're excited so i can take further questions about the core recognize if you have them. >> no, thank you further questions? >> from any of the commissioners. >> i'd like to thank the executive director amanda as well we began we're new in those areas in terms of working with the foundations and myself i want to thank the donors pub this is a very incredible risk we thought mark zuckerberg was remarkable we hope to have many

of those resolutions (laughter) and we look forward to working with amanda manned alcohol on a monthly basis to make sure she thinks where our capital future and they can strategize direct their efforts on behalf of the department anticipate the staff we want to thank the executive director and also the foundation for all the incredible support it is going to be an incredible beautiful building and just to note november 21st is a saturday and it is going to be an incredible party for this and the renaming and acknowledging all our donors and potentially more donors to come as we see what incredible work on the campus. >> one more thing in addition to the names on the list an amazing outpouring of the support from the provider in the faculty and doctors and nurses and front line people day to day doing the work it was a

continued community effort so thank you. >> well, thank you this is certainly be outstanding list and one in which we should all be assessing this with gratitude those organizations and people feel so dedicated to health care and a san francisco general thank you. >> thank you. >> commissioners any further comments are we prepared for the vote. >> i was looking at from the edward chow garden and saw a hot tube (laughter). >> ; is that correct. >> are they down to plants or something that i could use the salary the city gives me. >> no we're prepared for the vote.

>> all in favor, say i. >> i. >> with gratitude please vote i. >> i and opposed? the resolution has passed unanimously and we look forward to many more thank you. >> commissioners. >> i'd like to give a note of thanks to the city attorney they wanted to make sure they were doing this in the rights order so thank you to the city attorney. >> very, very well-thought-out (clapping.) commissioners we move on to item 8 a resolution greer the principles of ethical practices of public health we'll vote on next meeting in is just a discussion. >> before we begin is there principles or is this the privileges is the whereas the principles or another documents called the principles. >> those radio the principles there are 12 of them and . >> the whereas. >> 12. >> thank you for that

clarification. >> well, maybe you should explain what you do with those. >> so part of in our romans as health officials we're weighing the risk and benefits when we are making public health decisions so we take into account the ethical considerations part of public health coalition requires us to codify how we make and incorporate ethic alcala decisions making into the publicity activities so the credit dan by the public health society and as the code of ethics you see is whereas are 12

verbatim calls the ethical practice of public health we are requesting the commission to approve those principles and provides a foundation to build our decision making progress we are in the process of developing a comprehensive approach that is the foundation for that. >> a again example the one we did with the screening at bmi as information becomes available to use it is early general obligation bond do consider the information to weigh the risk and benefits and to make a decision that open missed the benefits and minimize the harm the screening been different for one group we want equitable health care? an example of

ethical decision making all to have equal assess for the screening of diabetes. >> okay. >> was there any public comment. >> i've not received public comment. >> so we'll precede to questions. >> sure. >> so it says those policies are bans the public health code of ethics so there are not the public health code how do we modify them and likewise we're going 20 going to comply this allows us to comply with national standards. >> rights we did we took the one there are - i'll show you there is a toolbox that summarizes the principles for public health and this is the one that is most commonly used adopted by the public health

association we took the principles verbatim their ethical processes that make it more specific those are broad principles. >> those principles are the principles from the public health code of ethics. >> it has several different names people do you want is and tweak it created by the public health society they call it the principles of public health so people call it a little bit differently we basically took the title and basically put it right here. >> right. >> may i make a request i'm till in support when you look at the ethical principle looking how they work together to - but

i trust in national endorsement it has to be good but you don't think i don't like the format of that resolution it is a inadequately and when we look at the public record it should be reshaped to say whereas the national practices has established principles and then you list the principles rather than the whereas i think it needs to be doing the public record differently the format and go elevate this this is adds you know credibility and stufr where this is from or who is in alignment with those principles so i have no problems with adopting them not form, you know, the final record for our actions it is kind of confusing. >> oh, i know your - the com

try on our first e.r. in the introductory paragraph are the whereas to many cases this seems those are the whereas we could state of those are the principles. >> okay. >> resolve that we accept those as principles and that i think then clarifies can be easily read if we're reading whereas for all united states wonderful thing and at the bottom say we're adopting the principles it is more a for the most part and then also values dating them we didn't sort of pick them out of thin air they're related to how you testify those are the histories this is where people are using we've found used intoxicate appropriate therefore wish to

add do you want them and resolve that the you know bar and then comes the principles so that. >> - commissioner chow would you like us to come back with a form or like to approve in principle this and then we presents to you here on behalf of the appellant that shoulders we should come back with a better foreman. >> on the agendas we'll discuss that and vote. >> we have other opportunities. >> so i think this works. >> (multiple voices). >> whatever final copy we'll come back with a final opportunity. >> exactly those were on the principles on which to half the department is operating the public should be aware we're looking at the promises /*

principles. >> any further comments. >> the only comment i thought i can't remember this came out in the last two years something on the public health mission pushing and i can't remember if, in fact, there was a chapter in under that dealt with that on or about you may want to check that i could be absolutely wrong i didn't flag that that way. >> i'll look at that. >> it might be worth looking. >> also the board is recommending this code or a code. >> my understanding it could be a coincide node specifically this one but this seems to be the one that is the most comprehensive in terms of it being able to give you lad it is the duty in specific practices. >> that's fine.

>> so i think those should be whereas. >> okay. >> any further comments. >> no. >> precede to the next item. >> thank you very much for the suggestion. >> we'll look forward to be able to see the principles. >> okay. great. thank you. >> item 9 is a dph financial report and mr. wagner and quick intervention. >> trying to figure out commissioners this report is for discussion no action you need to take. >> it's barely show up on the

screen. >> no, i, probably make it through here so long as the mouse works on the screen. >> thank you. >> okay. >> commissioners greg wagner chief financial officer we have a presentation on our year-end financial quarterly report so this is a summary of our year-end general funds financial position as recorded front seat in the controller's office this is a little bit later than the financial report because of the year-end in particular we have to go through a longer process of crossing out the books it making takes more times for the fabulous to settle we like to wait when we can bring them to you when in their fully cut our

big picture for the fiscal year 2014-2015 is very positive we had a good year we have a couple of of things going on we're ending the year with a net general fund contribution back of $11 million however, this is necessary of an additional contribution to reserve or so that will remain in place and be a cushion against future losses the operating expenditures and revenues were favorable? allowed us to meet your targets and allowed us with the controller's office to fund additional refers this helps u.s. bancorp us to have greater financial stability as we go forward into the continued changes in under the state and federal policy actions

so again as you can see how the high-level of numbers breakdown on the summary table when you take our flat operating expenses and revenues we had a fractiously surveillance of $74.2 million of that amount 63 .02 is programmed into those revenue refers so those are not directly returned from the general fund their withhold by the controller's office that is available to us if we have a shortfall in the future years. >> so i'll cbo through quickly by divisions and happy to answer questions i don't want to spend too much time san francisco general living san francisco general hospital had a net surplus as you can see a lot of things moving around and we have seen this over the last 18

months how we experience the projections are matching up to the affordable health care act and so some go significant changes we have our night patient revenues higher bin budgeted 10 we are budgeted significantly this, an increased medi-cal rate for eligibility program that allows us to enroll people into medi-cal and we get paid fee services that has been a big boob do your our fee revenues we're below budget on a number of the state and federal revenue streams as you can see here there's a addition safety net care pool and shawl we see that every year in our financial reports that's the second and thirds line on this slides are

tied together learner we budget a significant amount of excess budgetary authority in this case we need it to draw down the funds the supplemental few minutes we have a make a loophole expenditure that gets matches and comes back to us we don't want to run out of budgetary authority to risk noted drawing funds as you can see a shortfall in revenues but an expenditure savings that is equal and offsetting we didn't center to put that the dollars to get matches but not matched because not enough money to do that shortfalls in our revenue and significantly in our realignment dollars that are associated with the recoupment of the align dollars a significant on or about we're going to be continuing to watch

over the next couple of years. >> laguna honda has a modest surplus because of revenues help at home a small surplus in salary and fringe that help at home is a deficit for years and they've corrected that in the black now for several quarters in a row that is a big effort sow so we're happy to see that and primary care we've got a $13.2 million surplus two convenes one capitated revenues we're underestimated and second a salary and fringe benefit savings we see at the end both of the hospitals and primary care we have salary and fringe savings we don't expect that to

continue as for ramping up on capacity and process changes to streamline and expedite our hire so we'll be looking at that closely but i think that is a with time catch up as we've involved in our h.r. systems to be able to fill vacant positions jail health services is essential around budget another one has historically had an expenditure deficit so they have gone a long way to terminate that as well in our mental health division some significant variances but most of what those are are results of changes in accounting more than they're an indication of something happening operationally within mental health a change in the way our interim payment are made starting in 2013-2014 so we're

essentially paid at a higher rate we had to go back and elevate when we're audited and have a supplement on the audits what's your liability to have to repay some of the funds back to the state we went through and experienced this year and look at it did dictated and updated our revenue model we've gone back and addressed add additional revenues for 2013-2014 to cover ourselves if we have to pay back because the live payment methodology we will be able to pay that and won't come off our bottom line there is a significant savings the bulk is a settlement of an old costs report that allowed us to release expenditure dollars

that's a one time widen fall because of the settlement in public health again, you'll see that we have a realignment loss that ab 85 recruitment is splits within the san francisco general and pushing you'll see a little bit of it in two places and some expenditures savings on the salary does the bulk of that from delays in phil newest budgeted it positions again as we get our hiring rammed up wiener we'll see that decrease as we're able to catch up on the timing and get those positions fills substance abuse a $5.1 million surplus substance abuse favorable expenditures due to a

higher cost settlement a one time savings we'll not expect to repeat so kind of in summary of where we are i'll be happy to answer any questions but we've under a new reserve policy we've talked about at the commission part of annual appropriation ordinance approves by the board of supervisors too years we have been able to build up reserves that burglary protect us against this volatility in state and federal revenues that's a big priority for us just because we're we've limited ability to manage on the margins when we have those big swings in the revenue over the two years ago we've now working with the controller's office set aside $92. million that reserve so give us a level of comfort in

terms of how we can deal with future losses issues that are driving the deposits into the reserve we'll be watching closely over the year we have a potential dislife without the possibility of parole significant disallowance of payments maids in prior years from sb 28 that reenforces on the laguna honda replacement project so we put marine corp money in reserve in case we have to pay that amount back we have a reduction in the deexpansion rates that is gone into effect over the last couple of months and again as part of the ongoing uncertainly over what the state will recoup and interacts the waiver we've estimated $27.9 million potential liabilities that is referred for in the fund as well

so again, it is a good year we've hit over key financial targets a second year in a row watt the supplemental appropriation that is always worth mentioning after a decade of supplemental appropriations and we've started to establish mechanisms foreign dealing with the uncertainly this is a beg source of financial anxiety for the department so i'll be happy to answer any questions and questions dr. >> first of all, thank you this is really a great written summary it looked at the late late night and it was clear and i guess two issues we're demonstrating great fiscal maternities with the captioners under our control wear containing costs and staying within our projected revenues

and we have mostly positive surplus on a management prospective thank you to everyone director garcia and mr. pickens and everything and, of course, yourself doing all the direction and also on the reports side i it out you emphasized the drivers so want to thank you for making any late night really pleasance and i'm glad i was helpful and i'm sorry. >> you have to change the reports this is a change in the reports and i got it it was very nice the question with regards to the drivers that are sort out of our control i think the one in our control there is services and safety we're doing great i'm worried about hundred million dollars the 5 percent of over total budget the state we might get it how do wells address that

i know you have contingency reserves at the local level but are the counties together working at the state level to make sure that captation praits rates don't fall below what is reasonable and the realignment revenues flow and promised i guess i would hope we can get a better grasp of hundred million dollars i know you guys are doing if you could reach. >> we've worked with all the hospital and other communities colleen is the policy director we have worked diligently working on many of the issues together but this is has been a historical process for the departments and having this reserve is won the abilities for us to be able

to responds to those at times revenue comes in it could be an audit from 5 years ago so it is very volatile that is why within our goals and one of my dowels to have the reserve for the department which the city has allowed us to do to insure we're not spending the same and don't have a reserve and all of a sudden the costs that come to us are revenue that comes to us we can't spend either we have to go through due process on a policy and advocacy level we worked with all the counties hand to hand trying to look at this week on those specific issues if you have questions about those specifics. >> one i'd like to follow-up this disallowance i'm not sure i understand what is disallowed we can here on behalf of the appellant and sure i can.

>> rather than less controls. >> sure and just briefly to add to our director garcia one of the big sources ever uncertainty is the funds that come through the 1115 waiver our addition and safety net pool few minutes it is because there's a formula that ties us to the financial performance of ever on the one hand, other counties that perhaps one of the things we've been pushing as we go into the negotiation of the new waiver to create a system that gives us a little bit more certainty and control predictability abilities one day get a letter the estimate for your allocation has changed by 36 millions positive or negative and we react we have a little way of knowing that is coming

this is one of the big policy and legislative concerns how can we work on the new waiver to make it a little bit more structured and predictable. >> on the disallowance of the sb 1228 that one really is more of a technical item we're in the process of working with the state and frequenting to fought what our option to appeal that but basically what it is their is a state plan amendment approved some years back to allows us to draw federal dollars to grurms us for the debt service of laguna honda we've been working closely what the state to do that we recently were notified that under federal accounting rules that the way they view those payments are sense they were maids on debt

services about patients occupied the new facility they're not an eligible experience for reimbursements that is a technical urgent care policy interpretation that came down to us we're in the process of really trying to dig through that and figure out you know what our options for appeal and build our argument we're going to make our best effort to change that but this really is one of the things where this is from fiscal year 2005 through 11 the payments were made it is many years later and all of a sudden one of those things that gets caught in the federal audit process those types of things so many years worth of times between the point you get paid and final audit is closed we

have some exposure of uncertainty about are we going to are a negative or positive audit settlement and align for those kinds of technicalth issues are really our best strategy to have a reserve in place you think about $2 million operating budget to essential be operating on no reserve which we've been up until two years ago it is not a viable place those are the two policy approaches to next the way the payments are made and kind of a financially plan in a $2 billion budget bound to be variations or various and how to create a modest and reasonable cushion so we're able to adapt to the new

items as and come. >> with the disallowance with a one time i mean we're going to get it or not not a reoccurring expense from our budget. >> correct going forward once the patients have occupied the facility the initial they've race is no longer a relevant grounsz for disallowance. >> so what it it sounds those are parts of the audits and that's correct. >> and go on i want to comment i thought again and this is in the just this year this formats we're using a steel helpful and continues to be transparent and allows us to understand even in the good years what is happening

and the good news this is second year as you say makes for a much more sounds sleep at night. >> absolutely (laughter). >> i'm sure in our case. >> absolutely. >> so any further comments on this ends of our report. >> i'll note no public comment requests for this. >> i don't know from the director wishes to comment. >> as a historian in the defendant department it is a good year despite the fact of audit extension again this was a goal we had to have a financial reserve to be able to manage unforeseen issues and the fact that state and federal government do take time to process those audits, etc. and so we never know what is going

to come we just get surprised but encouraged one day it is positive and now it is negative so this is here on behalf of the appellant will allow is a more stable prediction of our financing as you can see what we are doing well from the operational point of view the issues the federal government and the state government that interest changing their direction how we get paid. >> thank you very much. >> when the summer goes if we're on time and on budget maybe we should be our own country and states of san francisco maybe that's the solution. >> so move on commissioned to the next item is that all right. >> and, yes. >> item 10 new bus.

>> equal i said to thank everybody for having participated in the planning i know that commissioner pating has ideas of trying to hem formalize some of the thinking for the future and the public health so i hope the meeting was helpful. >> it was helpful thank you to the department of public health and decreasing doctors i felt i walked awful u away from that briefing feeling for the first time i understood all the divisions and how they work together and the importance of them as well i think that will help us in our smaller committee. >> thank you next items please. move on to the joint conference and commissioner sanchez you have summaries in front of you, you from the accepts j.c.

meeting and laguna honda meeting. >> so the september 22nd meeting we looked at the quality management report a new format and he guessed we're all trying to learn it. >> it had a very good update on the security port commission progress that is going and the discussion of 340 pharmacy update we'll expand the that is of service for our clients actually receiving the 340 b bed think an outpatient basis we're looking at and had continues to follow the transition for the new rebuilt, of course, we'll be having the ribbon cutting on november 21st

we otherwise received routine reports not routine in the sense that was not important but routine we get those regular reports from the hospital administrators the patient care from the human resources which is an issue they're on track and should be able to accommodate our new building at a little we'll needs our are personnel and during the staff report we had a revision to the rules and regulations and revised the clinic documents and revised the ed privilege list and in closed session approved the criminals and fifth street corridor from the director's report. >> any questions please. >> doctor sanchez

yeah laguna honda conference met on the 13th the majority of meeting was in closed session we were reviewing the medical improvement medical quality bids and incredible reports the votes were in closed session and voted not pertaining to the incredible report that really concluded the meeting for that day. >> note in public comment and move on on item 12 the committee agenda setting. >> so it is our my intent to have our closed session on the elevation of over director at our next meeting. >> we're looking at at planning a planning meeting hopefully, a session online sometime in the spring. >> any other items that the members would like to speak to

if not we'll go on to the next item. >> the consideration of adjournment. >> oh, a motion for adjournment is in order. >> motion to >> all in favor, say i. >> i. >> opposed? we're adjourned thank (clapping.) >> buenas dias good morning

spring valley school students we have such on exciting day ahead of us your picture day we kicked off walk to school day with many, many very special guests but before we do anything we'll say the pledge of allegiance please put our right hand over your heart let's pledge of the united states of america and to the republic for which it stands, one nation under god, indivisible, with liberty and justice for all thank you students so i again want to thank you for

participating in our walk to school day families honored guests i want to remind you that spring valley skies school a hundred and 62 years old wow. we look pretty good. (clapping.) >> and one of the things that we are thinkers we think about science and our academics and healthy take care of ours by running and riding and walking so how many of you would look to be a mayor when you grew up wow. look all those hands mayor ed lee wow. and how many of you have thinking about being the doctor? >> all right. and today, we have the top doctor if all the united states

here at our school we are our mayor, we have board commissioners commissioner president murase deputy superintendants and hydra mendosa and captain chief suhr so thank you to all our guests and students thank you for your best attention and teachers look at of housekeeping go please take a tally to see how many kids walked to school today, we'll do a class check and take our stickers off i'm going to turn it over to it mayor ed lee buenas dias good morning, everyone here at spring valley well (laughter) well, first of all, let me say thank you to all the kids and

our parents for letting me and supervisor christensen and our united states surgeon gentle to participate in a walk to school with you to school is it important for our city to make sure that our sidewalks and our streets are all safe for all of you to enjoy walk to school and walking our o on our streets we want to make sure not just today but every single day that you want to enjoy our streets that is safe for you so we are very excited to be here and walk to school day and look at behind me and besides me so many others that support this day and evidence for our safety we have the highway patrol we can our

police department, our public works and our transit system environment director and school district and many friends from the community organizations like walk sf and vision zero and search warrant have all of those agencies rec and park included and i'm sure i'm forgetting some others but i want you to know that you have many friends in the city that are working together because our americans doctor is also having a national caption campaign they wanted cities like san francisco to lead the way to make all our cities and areas safer so in san francisco we always want to number one and we always not to be the best and whether it is baseball, whether

it is basketball or whether public safety we want to be the number one and the only way to do that just like spring valley want to be the number one elementary school in our school district with all of you wonderful students we have to make sure that we work together to do that i want to thank the parents and the school administrations and especially our principal a great leaders she's been working in the school district for over 34 years and i know to say thank you (clapping.) to principal you know when someone works for 34 years they love the district and the school and especially the students and she wants you to is all i all succeed and, safe at the same time all our agencies are working hard we have a lot of projects in the city that make

the streets safer more signs and sometimes in different languages and more streets that are a lot closer together to cross the streets safer and a lot of projects called vision zero that is why is. agencies collaborating working together you'll have a better city when we collaborate on pedestrian safety this is why we're so enadam and a happy to welcome our united states surgeon general here to san francisco not only is even though number one doctor but has public safety is his major priority and i know he's kind of new this this position on this appointed last year but he's got experience in running many different divisions of our government our national

government here to join us ♪ strong effort let me present americans doctor surgeon general murphy (clapping.) >> thank you, everyone how is everyone doing in morning don't good how many of you had fun walking to school today lots of hands in the air of the all the boys and girls i want to say congratulation a good job on walking it is one of the most important things to do to be healthy and strong how many people want to be healthy and strong everyone; right? that's good, i want to thank mayor ed lee for having me area and the principal for her leadership and hosted us as well as the leaders that are here today, i know that walk sf is the program has been an important player thank you

but i have a message for the parents as well which is i know your kids couldn't walk to school without our support or you walking next to them every single day so thank you for doing that a couple weeks ago i made a big announcement no washington, d.c. does everyone know where it is boys and girls everyone i made a big announcement a few weeks ago i do said we need to get walking in the country that means we need more boys and girls to side what you the fourth this morning to walk to school the only way if so possible to do more and more is our neighborhoods are safe when i he was a young boy in miami florida i grew up in a house where i walked to school everyday we walked to school like you the fourth today we

moved to another school history in fourth grade in this neighborhood not sidewalks for us to walk some days we were worried about we didn't walk to school our parents drove us that's why the work is so important i saw a couple of young boys and girls this morning out murray's how fast the cars are going you're hoping helping to make sure it is safer for kids to all the parents and the leaders we have here today, i want to thank you for the incredible work you're doing to get america walking we need to claim a physical activity and walking is a great way to do that thank you for your leadership and having me and please keep on walking it is good for your and san francisco and good for the country thanks

everyone (clapping.) >> now we have another special guests someone that is working hard to work with the district and our parents to make sure that is our district leaders in district 3 julie christensen. >> how many people are wearing pink today, i we're picking up for you guys yeah. we have okay. how many people walked to school today how many a lot of people and how many people are still going to look nice when it is time to take >> picture you only have to look nice for a the longer than there are a lot of groups but every child know we're here because of you besides our

patent and besides our teachers that is our job to make sure that you have a safe and niece city to grew up here to that's why we're here today, we have a lot of people we have the mayor and mohammed nuru that built our situations and makes the crosswalks safe and ed reiskin that makes sure our streets are designed well and nicole she has a group to help to keep us safe and people from the skifth that helps to get to and from school and our mayor and surgery general we're working hard we want to marry you have nice places to walk to we're building parks from the park we made really nice for people to play and plant trees offender the

streets to the streets are pretty and make the crosswalks safe and ms. fewer to follow the rules so everyone is here for you so we want you to know we are working hard if you have ideas that could make things safer and better for i to walk to school come and talk to me we're about ready are have a new crook on brood about the the seniors said we needed to make that intersection more a safe for people to walk you guys keep our eyes open and thank you for having us at spring valley - is it okay to have missy wu do you know here, yes she's going to

talk with us you now give herog welcome. >> (speaking foreign language.) >> as a teacher and a parents at spring valley science school i know first hand how beneficial it is for health and well-being for the students and colleagues when i'm on the streetwalking sometimes, i see traffic dangers and especially, when kids take

routes that's why we're participating in the walk to school school day thank you (clapping.) >> so we have one more special guests i mentioned nicole has a group kind of a group called walk sf what this club did they try to think of ways to make the city nicer and safer to walk we'll let nicole say a few words. >> good morning students everyone thank you that was a great good morning. i'm so happy to be here and school board walk to school you got to walk to school a big hand to all of you for participating wow. (clapping.) and for those at the park and

got to play thank you to food and beverages for all his hard work and the rec and park department to make sure we have parks it is an honor to celebrate not only our students but the families and school administration and teachers and all the city leaders that make walking more enjoyable in san francisco especially gives thanks to the u.s. surgeon general it is an honor to be part of our call to action in walk to school and mayor ed lee and jieshgs for leadership making that easy and safer to walk to the parks and superintendent carranza and all the leaders like chief suhr and mohammed nuru who make walking safer evidences in san francisco

at spring valley we already have one rolling everyday that is outstanding so you guys serve as a model for the rest of the nation you're working to keep our hearts healthy everyday but for too many parents in san francisco peep choose not to walk because the top southern is traffic safety wear working with our city and our community partners like the chinatown ymca and the chinatown community development center to view the investigator program we did on the street we measure the speed of cars and understand how to redesign our streets as kids and you guys make sure you're not only practicing save walking but creating safer streets as you may know when a car is traveling

at 40 mile-per-hour for some of the speeds we included on broadway pedestrians have one in a 10 chance of surviving a crash but slower speed it impacting the health and walgreens of our community and kids actually can't measure or understand or gage the speed of a car until the age of 10 we need to make sure that speeds are slow if you guys walk into a street the cars can slow down and the families say healthy i want to ends up with something that doctor murphy said in his call to action it stuck with me pointed to social movement that started with the walk and the march an washington or the capital crawl expanding assess to the nation's

capital with people with disabilities and in san francisco we're responding to that call to action and wear engaging in our own walk around vision zero to make sure that our streets that we have the safety on our have the here in san francisco so that no families no parents have to incur the pain of 0 lost loved one thank you doctor murphy and all our city leaders that are working to make our city safer thank you (clapping.) and . >> finally everyone we know you're getting ready to go to class before i do that i want to say you know when we first started the walk today one of our department head food and beverages introduced a game mayor says we had so much fun that i'm

going to introduce it to the next department head meeting i have principal please come on up your pleasure to celebrate with i by proclaiming today being walk and role school day here at spring valley

(clapping.) >> okay >> (speaking foreign language.) >> we're going to give a small token that appreciation to our mayor and u.s. surgeon general and supervisor christensen thank you children.

>> teachers and children have a wonderful day walk to school stay smart and be respectful and responsible and be kind thank .

>> my name is jan an wong a regional paralyzing in the bureau i did not see might have as at management in the beginning which my career i have a master in civil engineering i thought i'll follow a technical career path i scombrie being able to create a comprehensive plan implement and shape it into realty love the champs of working through cost quality schedule political and environmental structuring and finding the satisfaction of seeing the project come into fruition i've also take advantage of the sfpuc training program yunt my certification i see the flow from the pipeline

into the tunnel one by one and i also had several opportunities to attend and make presentations at conferences also as a tape recording san francisco resident authenticity rewarding to know the work i do contribute to the quality of life my life and those around me

>> i'd like to call the tuesday, october 27, 2015, of the public utilities commission to order mr. secretary please call the roll. >> commissioner vice president moran commissioner caen county and . >> thank you a you have the minutes of october 13th minutes my additions, deletions, or changes can i have a motion. >> moved seeing >> all in favor, say i. >> i. >> oppo