roll. >> clerk: rrk "roll call." i put the minutes in front of you. commissioner chow requested a make a slight change on the top 6 page seven. i'll see text crossed out and other text that has been alded. >> commissioners, the revised or edited minutes are before us. for acceptance. so we need a motion. >> okay. >> i think this is minor and i can give it to you but -- >> go ahead. >> so on page 5, 5 of the ones that were in our packet. >> sure. >> up i number 7.

>> okay. >> just to add precision to the language there because i asked how the stock would be dealt with regarding taxes at the end of the year. what i actually think i said was how the stock would be valg valued for tax purpose. >> yes, i will make that change. >> okay. while we are making small corrections, page 6. previous page stated san francisco doesn't have a present coherent strategy. i would like to amend that that he would like to say -- commissioner repeat that. >> stated he would like p san francisco to have a coherent transportation strategy. >> yes. i'm happy with that. >> those are good changes that

unless there is objection, we would add to the changes for the motion. any further clarifications if not all those in favor say aye. all those opposed. they are approved. >> item three is general public comment. i see no one from the public here. we can move on to item four which is the report back to the planning committee meeting. >> so commissioner chung was unable to be with us today. did i chair the meeting and the meeting took up several items that the commission -- that the committee is recommending to commissions approval. and i'll go through that so that we can then act on the consent calendar following. first is a contract for the

comtel technology that replaces the old button that is available in most hospital beds and will become state-of-the-art in terms of being able to have immediate access to nurses if needed and does a number of other things telling the system what happening to the patient. so, it's a completely new system that is going to have a need for software maintenance and that is what this contract is for over the next five years. and that has been built into the anticipated budget for the general and so this is the contractor who will be the company that will be maintaining the software. so, that was the first item that

we took up. we took up a second item from roma consulting and they will be helping to facilitate our planning session this afternoon. but has been awarded a contract for working with the department over the next four years to create a lean process throughout all the department add you remember, it began at general. and they are now proposing that this -- it began in general in the year 2012. and there have been over 55 workshops already held under this process. and you've heard some of the work that has come out on this lean process and as i said, later this afternoon, we'll also then be getting a more throw briefing on the lean process and how it will assist our work.

but right here, this is a proposal for the entire department for over a four-year period to be involved with and be taught and be able to carry out the lean process on their own. they have proposed -- their proposal was forwarded to us at committee level in terms of the various subjects that they will take up on items and director garcia has assured us this is what they will need in order to make the department a lean department. and she will be providing updates twice a year on progress of contract and the progress of the department in terms of adopting the lean program and how it has been helpful to us. the committee does recommend approval of this contract. if we are unhappy this afternoon, i guess we could

review that later. >> hold it until after? >> well, we thought we would ask for a approval and we can always ask for reconsideration. >> i would like to add commissioner to tell president chow that the importance of this also is to try to build the capacity within the department so that we can lean our way away from our consultants as well. i think that is a goal for us then we have already an off of general tha that we'll build upon for that need to hold on to the services if it should become institutionalized into the department for the future. >> very good. in our conversations with the company, company has been involved with a number of organizations in terms of health care, not just at hospital levels but health systems and pertinent to us is that they were working with [inaudible]

health system and the hospital and the c.e.o. there who will soon be our c.e.o. at s.f. general. this is a tool that would be one in which the department would then be able to move forward if their planning processes. the committee does recommend approval at the commission level of this contract. the remaining contract actually has to deal with working to understand all of the assets that we have real estate-wise on the s.f. general and laguna honda campuses. as you have read, the contracts themselves, they actually have describe the number of buildlings if we just stick with s.f. general, it's almost inclusive of all the buildings

that have not either been studied recently or have been filled and that includes the ones that are enumerated. the buildings are being looked at for four different purposes. that is whether administratively or either biomedically or for housing as far as uses and so, the four contracts are needed for the -- with the different architects who have different expertise in particular, the two contracts that sound like they are working on the same buildings. m.e.i. architects and l.d.a. architects each have different expertise. and so, they will then be concentrating on those expertises in either housing or

in terms of looking at the clinical or biomedical use or administrative use. that report will be combined as an s.f. general report. as laguna honda wha they'll look at the back builds that are currently vacant and to whoo availability, how can they be used in these areas also that we've just spoke ton. this is in preparation for the potential of another capital bond issue in 2022. but this would then give us a reasonable inventory of what this department does have available in terms of available space that they are going to be needing in order to carry out all the duties they have and you will recall also that we're going to have to one day do

something with our building here and therefore vacate those services from here also. so this will be an important aspect of looking at how, then, and what capital needs we'll have in the future. so it gives us that background so we know where we're coming from. so the committee is also recommending the approval of these four contracts for this purpose. that ends my report. dr. [inaudible] was kind enough to join. do you have anything to add? >> no i would endorse all the contracts as prudent and reasonable. >> if anyone has any other questions regarding this, if not, we can move on to the next eye testimony. >> next item is the dleand contains all the consent challenged review. >> the calendar is before you.

if anyone wishes to extract any items, otherwise we're prepared for the vote. seeing no extractions, we're prepared for the vote. all those in favor of the consent and her calendar say aye, that is passed unanimously. >> item six is a resolution recommending that the board of supervisors accept a gift of 2,625,000 from the san francisco general hospital foundation for equipment, procurement, for the priscilla chan and mark zuckerberg general hospital and trauma center. >> >> mr. martin -- sorry. >> that still happens. >> boy, was that sometime ago! >> craig wagner chief financial officer. the resolution before you is the

latest request to recommend to the board of supervisors to accept and expend funds from the san francisco general hospital foundation for fixtures, equipment and high tea he new zuckerberg general. it's been engaged in fund raising campaign to bring in private philanthropy to support the effort. it's been very successful. the commission has a proofed today $58.4 million of accepted gifts as associated with that effort. this we've been doing them roughly twice a year. this is latest installment. we try to september gifts on a relatively regular calendar without coming to you constantly. the program is going very well. we're on track and spending the money and managing within the

projected budget so we're happy with how things are going, thp help us keep the dollars going out the door. and finish up with expenditures and also carry into the early months of operating the new hospital. the resolution before you, if you approve it, would be a recommendation to the board of supervisors who would actually pass a resolution accepting the gifts so we're asking for your support for this resolution today. can happy to answer any questions. >> thank you. commissioners, the resolution -- is there any public comment? >> i have not receive ned requests for this item. >> we're prepared for a resolution that is before you. if we can have a motion. >> so moved. approval of the resolution. >> a second. any further discussion? >> what are we doing to celebrate the people at the

foundation who are continually generating funds for hospital? it's unbelievable to have these kind of people in our community. >> absolutely. it's been an incredible effort. we've done a couple of things. we did have at the board of supervisors and at the health commission particularly at the first installment, we gave acknowledgment to the board that has been active in raise being the funds. there was an event at the new building. it was in november. there was a thank you and honoring of the donors at the actual ribbon cutting ceremony for the new hospital that donors were and the board of the foundation were acknowledged extensively. so we really have been trying to make a point of what -- it's not

just great for the hospital but great example of how private philanthropy with can work for public hospitals. we're trying do as much as we can. there can't be enough. >> and to let you know commissioner singer that dr. chow and i took them to lunch and presented them with awards, the exiting chair and to amanda heras the executive for the commission. anything else we can think of, we would take into consideration for that. >> we need them. >> we need them and we -- >> we'll have further projects. >> we sat with home to in their strategic plan as well and we're meeting with them on a monthly basis, greg and i. >> keep them ingrained in what we're doing. >> exactly. >> i'd like to thank our own

commissioner sanchez for representing the commission. i'm sure that's no small thing. >> i would add that again, this is separate pertaining to these materials and supplies that would not be in the budget under the city contract were picked up on the radar a couple of years ago. and as we know, many of the donors wished to be confidential at that point in time. in order to move forward on this. but as stated, there are now numerous public thank yous pertaining to the unique leadership. bear family and you name it. all have been within their own zones been honored. there was another event which was sponsored by the art

commission to thank many of the donors who had been in the arts and served and donated to this where the artist and the community were invited to look at all the different levels of arts and whatever. it was well attended and there was much thanks given to the donors and the artists and it was really extremely well done within the context of how, in fact, they wanted to be thanked in that context. so there is on going events. but in essence, the whole purpose is how do we support -- i mean how does the foundation support to provide these resources to maintain the excellence and training of san francisco general and young, old, two and three generation foundations. it's astounding to see commitment there. i just want to say i concur.

it's an on-going communication and dialogue and something that will be there and it was a safety net when many, many years ago, we were worried about if the seawall was going to collapse and they came to our aid and have continued to come to our aid. we want to make sure that that is a continuum of support for us. sfghs. >> i found the leadership extremely dedicated and was pleased to be able to work with them and we'll continue to have opportunities to work with them. > them. so at the resolution, we've had discussion. are we prepared for the vote? all in favor, say aye. all those posed, resolution has been passed unanimously. thank you very much. >> thank you commissioners. item seven is creating healing

organizations in a regional system of care. >> good afternoon. my name is lynn dolce. i'm the directer ffer for foster care mental health. one of the trauma inform care initiative which is what we're going to talk about right knew. get my glasses on. >> it's right in the middle of the screen. >> this one. thank you. >> you're welcome. >> there are my notes. can you get them. thank you. so on behalf of director garcia and our team, with the trauma

initiative system of care. i'm grateful for the opportunity to be before you today. as you know, or may not know, but i probably do know, the trauma is the number one public health concerns we face today in the county. trauma and toxic stress have been linked to many adverse health outcomes including diabetes, heart disease. lung ailments. cirrhosis of the liver and suicide. trauma impacts more than the individual. it has a ripple effect on our communities. as such, at the department of public health has steen that a need for a preventive, collective, collaborative approach was needed to address trauma. we're used to thinking of trauma as a behavioral health incident. we think about ptsd and trauma in young children.

what we know is that trauma impacts entire communities mostly disproportionately to communities of color, particular lit african-american community and latino community here in this county. and when you add racism, bigotry, poverty to the issue of trauma, you get a toxic brew. that's what our clients and patients are coping with on a daily basis when they come through our doors in the department of health. that's what our staff is coping with. i think the reason why this paradigm shift is happening now is because we realize that we can spend and we have spent lots and lots of money on evidence-based practices to address trauma on an intervention level, one o to one intervention level and even family level, until we have a system that's a healing organization, it's just a practice that we do.

i could be the best well-trained therapist in the county, as long as my patients are experiencing trauma and stress,. my hour with them isn't going to hit the mark for our patients. we're looking at organizational change in addition to practice improvement in our offices. the ideology of the project was really in conversation with director garcia. realizing that we had a lot of work do that our staff was suffering. that we weren't really hitting the outcomes we wanted to hit. as we began to take a deeper look into why that was and is. it became clear that address trauma on an organizational level was something we needed to do. so we developed the curriculum, we call it trauma 101. this is a curriculum where every employee in the department of health, all 9,000 of us will be

trained in a basic, fundamental training around what is trauma and how it impacts us. in addition we developed trauma-informed principles that we can begin to look at how to integrate organizationally throughout our department and developed competencies around the principles so we could measure weather our organizations are making the change and how is that is impacting our staff and patients and outcomes. really, our method is to teach, to sustain and support and study how this is impacting our organization. sorry. just hitting "next." thanks. okay. so relationships matter. they rule the world. big business, corporate america,

and even in the department public health. how we feel about each other makes it a difference in how we do our work. in order to become a healing organization, we needed to talk about three things in an open way. talk about the centrality of relationships and healing. the way in which trauma can destroy relationships and how intentional leadership can combat the trauma on our delivery system. the problem is when our delivery system is siloed and fractured. when our organization is reactive, when our leaders become numb, the service delivered reflects that system. relational leadership is something that in the trauma 10 is training that we deliver to all the staff is a key message we're trying to impart to our staff. so instead of having a reactive,

numb, fragmented isolated system, we teach our workforce basic information that has the potential to dhaipg change the way they think about their work and interact with each other. the shared knowledge and language of trauma within our workplace is a place to start these conversations to really lead the change. a core message of our work with our staff is unifying our system. we can't make meaningful lasting change in our silos. we have to come together and learn how to collaborate. we've developed a local approach and now we have a regional and national approach for what we use this in this county. as you know, we get hurt in relationships. it happens all time. it's the nature of relationships. but we also heal in relationships. if the symptoms of trauma live in us as individuals and i would argue as well as in our

workforce, many of our workforce have grown up and lived in san francisco and have been exposed to chronic stress and trauma throughout our lives. they're now our employees and ask them to serve the community which they grew up in. it's a wonderful thing. i think sometimes it impacts the way we can deliver our services. we understand trauma not only now from the individual level, we've got good neuroscience behind what we understand how to help people. we understand our staff is made up of people. we understand also that our job as providers in the department of public health -- our tool is ourselves. if as people, we're not in tune with ourselves and people around us, we're into the going do our job well, how we relate to each other does make a difference. our administration is really important hererc1 because witht supportive and intentional leadership as a mentioned, we can't sustain this going

forward. we have a model which we'll talk about in a little bit which includes leadership development. even as far as our funders go, when we're vying for funding many of us do the same work in this very small county. we're competing against each other. we're competing against people we should be collaborating with. so even when we talk on that level of how do you collaborate. how could you make one door "the" door rather than having our community go true different doors. our funders have something to do with that as well. we think the principles of the system can be seen as a patd into this kind of healing organization. so we know where we are, we're in this trauma-organized looking system. you can see that chart is really kind of chaotic. trauma impacts our organization in ways in which we get confused

about our roles, the hierarchy gets confused sometimes. people get isolated and fragmented. where are we going? we're going to the trauma-informed place where we can begin to have a shared conversation around what is fundamental to the shift. and i think what we know is that a trauma-informed system is the first step. whawe want do is be a healing organization because that's our job in public health. to help people heal. help families heal. we want good communication and collaboration. there is not one way to make a trauma-informed system. this is one way. if nothing else, one of the core messages of the three-hour training that we with our staff 100 people at a team is asked them to shift their perspectives. we're very, very used to asking

what is wrong with people. what is wrong with you if you're upset? what is wrong with you if you have an ailment if and you're in primary care? when you ask that question, you locate the problem inside the individual. wie teach our staff that trauma is an external event that happens. we have our reaction to it which has a physician logical reaction to our brain. if ee stick with what is wrong with you, we don't get to this idea that we can be curious with each other. really, shift the question to what has happened to you. when you shift the question to what happened, you create less judgment and create more openness. then the person can tell you their story. providing context fosters compassion and helps us see our strengths as a community. the evidence-based practices i referenced to begin with are part of this model on your left which is that our system

sometimes functions like a machine. and really, we're not a machine. we're made up of people. we're not really doing output. we're not -- it's not about output. it's about outcome and relationships. in our mission is to ultimately serve and protect people by working with people. if we know that people are unpredictable by nature, how do we account for that? slowing down to see and understand the humanity of people we work with and acknowledge that people are doing the best they can with the deck of cards they're dealt and deal with that in the department of health. we want to understand our system and department as a living organism where it gets nurtured where leadership like the soil and rain and rest of us, the branches spill out and do the work we need to do to have our

communities flourish. we're working on this picture here. we think that building a healing organization is included the foundation, obviously. you need a roof and you need the structure. bear with me while he work on this. here is our foundation. we have six principles i sent to you last week -- or that mark did. thank you mark. two are trauma understanding and culture humility and responsiveness. those are foundational to any organization looking at trauma. the other four principles that you see rl the pillars that hold the walls up and the foundation stable. so a what's inside the house is all of our trauma-informed care practices, all the interventions that we spent money training

people on. if ear' training people and they're doing their job well with our complients and patients, if they go out in the haulway and have a terrible event with an assistant, people can't continue to function that way. the furniture i be side is protected. our evidence-based practices need to be protected by the overall structure which teaches each of us how to hold it so healing can take place. we think our t.i.s. curriculum aligns with other initiatives that the department is pursuing at this time. racial humility and trauma-informed system are almost mirror images of oach each other. they're both looking at who we are as human beings and what we bring to the work is valuable and how we can sometimes get in our own way and each other as way. i think that when we apply both

the lens of the frawm-informed lens and racial humility lens to collective impact and lean, we'll have an environment that is conducive to the healing and growth we're looking to achieve in the department. here is our slide on how we're doing all of this. so teaching, we've taught over 3,00 3,000 employees so far. how did we do it? we started out with two master trainers myself included and trained two other master trainers who have trained a new cohort of trainers. the idea is to build sustainability from within so we can do it within and we want this embedded in everything we do. queer' teaching each other how to do the work. we're training people who have interest in in this work.

they're not necessarily teachers or leaders. as we define them, but maybe they're clerks and maybe they're people who really have lived experience who work within our department and just want to spread this word. so, this cohort of next master trainers or trainers are a varied group of people within our department who come to this for very different reasons. we wanted the message to come from all levels of leadership and staff for this training. so, that kind of speaks to our sustainability plan. we are embedding the knowledge within. we are on goingly training people to train and we have champions in each area of the department that are looking at how to embed these principles into organizations. we have a leadership cohort that includes the director of maternal child health. our population health director.

director of c.y.f. director of laguna honda and pleaders from first five and j.p.d. these leaders get together and through a grant are creating a leadership tool box create leaders to embed these principles into their organizations. we are meeting with the people who are involved with lean racial humility and collective impact to make sure our curriculum jives with what is taught within the initiatives so staff is not confused with what they're hearing so it all fits together for people. in our evaluation at the end of each training, every person who takes the training fills out a two-page form and let us know how they think and doing and making the commitment to change. we evaluate how well people are in taking what they've learned and make the small change we've asked them to make. we tell them to tell us what the

changes they want to make and we follow up with a phone call and e-mail two months later to find out how they're doing with their change. and i think i sent you some of the outcome data. we can look at it. i won't spend too much time on that right now. this is just another way to show you how we're rolling it out and what the multilayer approach is while we val ute principles, we think it can be difficult at that transform the concepts into specific behaviors that meet the needs of the clients. self-assessments. when the staff are done with the survey, self-assessments can serve two or three purposes. they help to identify and evaluate are the program needs. but they also raise consciousness for people b about what they need to do to create growth in their own organization if they're reflecting on what they want to look at for

themselves. every component of the evaluation is about transitioning the knowledge into action. and -- i don't want to repeat that. okay. okay. so this will is a little bit of what we learned. that while most people approve and agree that this will is a really important toopic for them and think it will change their work experience and the way they work with clients and patients, they are worried it's not going to be easy to apply and they're really worried our leadership is going toe abandon this initiative that it won't get the support it needs and will be poorly implemented. we're taking the information to heart and focusing a lot on our leadership development around these concepts and how to really embed this and provide support for our workforce.

i'll end with letting you know that we've now been recognized nationally by sampsa in order to take our model and make it a regional model. we're the lead department in six county-effort to create a regional approach. why does a regional approach matter you might ask. why not just know cuss on san francisco? it matters because one out of five of our kids in child welfare are placed out of the county. placed in the sister counties. they're mostly impacted by trauma and they're the least likely to get trauma-informed care when they walk through the doors of other clinics in other counties. 65% of our kids in san francisco are placed out of the county. there are fault lines in between our counties and kids and families fall through the cracks all the time. there are so many barriers to care. by bringing all of these concepts and people together,

including funding streams and leadership development, evaluation and research, marketing by really taking this lens of a trauma-informed regional approach, we are really creating a shift in the way we can do business across county lines and the ways our families can seam leslie move. they don't stay in one place. they might live here and go to school somewhere else. we need to serve them as one. we are disseminating the trauma 101 curriculum in different counties. they're training their own trainers. they'll have their own master trainers based on our model and we'll work with them over the next few years. we're looking at all the initiatives through the trauma-inform lens with our partners and counties. if you have any questions, identify a be happy to answer. >> any public comment? >> clerk: i did not receive a

request for this item. >> commissioner singer. >> thanks for coming. >> hi commissioner singer. >> at least i'm coming to this fresh. i had two questions, one is, if we were in a training session, what would we experience? like trying to make the concepts which you live and breathe every day more tangible? >> good question. so you would experience a three-hour training with a couple of breaks. maybe some coffee. and we would go through these principles that i sent to you, the six principles and we would help you understand why this understanding of stress and trauma matters to you individually and why it matters to the patients we care for. we'd go through neurobiology. this a training for every single person in the department of public health. we worked on the curriculum to make it really user friendly so

that everybody in the department could understand what we say when we mean neurobiology, what the heck are we talking about. you'd see simple pictures of brain. we'd explain brain development and explain the stress response in human beings. we explain things in a simple way and ask people to reflect on that. we move through that in cultural humility and difficult examples, talk about racism and poverty. >> can you give us an example? one of the things you might talk about? >> yes. i'm trying to think of the one that maybe is pertinent at this point. so until the shift your perspective slield i showed you, that comes in when we talk about relationships and when we talk about how important it is to stay regulated at work by this time in the training, they understand what regulation what

it means to be self-regulated. we talk about how an example would be that will i am really, really functional in the morning. i get up, i maybe go for a run. i have an appropriate level of stress. i'm very good in the morning. i get my e-mails done. if you work with me, you'll get phone calls from me in the morning. by 12:00 or 1:00, i taper off. if you give me a deadline within 24 hours but i have two on my plate, you'll see in moo a market dedplees my ability in the afternoon. i will have gone over the peak of my stress level and i will be become slightly dysfunctional at that moment because i'm confused. i have a stress reaction physiologically happening. i can either stand in front of my computer and think it's going to happen somehow or i can take a break or i can go to a

coworker and i can say i need some help. my boss sent me an e-mail, i have a deadline, i don't know what to do, i need help can you help me. the coworker can say let's think this through together. that's how relationships matter. that's how i need to stay in tune with myself and know when to ask for help and how to get help in the context of my day at work without calling in sick the next day. we want to look at what keeps people coming to work and what keeps them productive and work no coming to work and being at work but actually working at work. another example around the cultural humility piece is we take a look at the very high instance of health outcomes in our residence in the southeast sector of the the city. we understand that for various

environmental reasons people are suffering with asthma many times more than other people in the county. in bayview and how do we understand that from a cultural -- not a cultural pe perspective but racial perspective. how do we have the discussions on whoo is contributing to this? how can we help this community. we can provide in-home visitation. asthma treatment but how do we have the conversation that racism matters. cultural responsiveness matters and when i'm stressed out, i kind of go to my cultural center versus being able to stay intuned with the person in front of me. if you say something to me that triggers something, you might not get the best response from me in the moment unless i can

see wow, i'm triggered. give me a minute, let me come back to you. you might get more of my east coast italian girl attitude versus what you're saying -- you're hurt, what can i do to repair that. we're teaching them tools of how to commune cailt. a great example is called pearls, it comes out communication excellence which came out of the american medical association created for surgeons. mostly because surge pes had a hard time connecting with patients. they were excellent in surgery but follow-up questionnaire was difficult. pearls is a communication technique we teach and what the feedback we get is that a lot of the clerks and people at the front desks have now laminated it and put it on their phone so when they get phone calls from people upset, they can refer to it way of communicating with

people that keeps them engaged and in the conversation versus triggering the person who is already upset on line. the feedback about that one piece for people who answer the phones has been phenomenal. it's been life-changing for us at work. that any now how to field a call from awn set client or patient in a way that feels professional and that they have their integrity still. >> thanks. when you're finished with the department, if you can do it for the u.s. airline industry, that would be helpful p. >> anyone in particular? the whole thing. >> it's beginning to sound like they all need it. this is -- part of your description here sounded more like within the employees a stress management process. so where does the word "trauma" fit if as versus why this wouldn't be sort of considered

more a stress management to your environment. >> because our staff experience a lot of secondary and vicarious trauma throughout the course of their day by serving the patients we serve. at sfgh, in 2005, we knew that every kid coming into our department of psychiatry by 6 had several exposurers. they're 16 now. four traumatics exposures by the age of six. those are our patients. when we treat them and when we provide services to them, there is a level of secondary trauma that we experience when we hear their stories over and over and over again. this is true for primary care. this is true for i.c.u. and true for anybody working in the department of public health that has patient interaction. that level of stress gets

translated back to the client. it may get translated back to, you know, i can't hear this any more or i can't return your phone call today, it has to wait until tomorrow. there are various ways we see secondary trauma and vi vicarious trauma showing up in staff. there is a stress-related response that not only our patients and clients experience but we experience. by teaching the staff, really teaching them about why this happens, that it actually makes stens that they're feeling the feelings and the behaviors make sense, we believe that we can just like we do with our patients when we teach them cognitive behavioral skills we believe we can help them change their behaviors by understanding the nature of them. they're not bad or wrong. they don't need to quit. this is a normal response to a stressful situation. >> so in your survey, it

appeared that one of a problems here is that they're saying it may not be easy to apply in their work. so the concept -- i think the only other patient -- i understand. we should become aware there may be trauma in their history and like we are supposed to be doing, we should be aware that there is trauma that is really important to understand how somebody is responding to us. i'm trying to understand your employee program to say and also then how do we get around it because it sounds like they agreed this is good and i need to try to do what you just said in the mid afternoon, that it sounds like it nay not be very easy to do. how do we then work on what were those problems to allow them then to get back on line so to

speak. be willing to take the phone call and so forth? >> i think part of it is the way we construct our policies and procedures from the top down. we have a top-down way of doing things which is fine, it works. biew we need a bottom-up feedback loop for people to participate. a lot of people who take the training say i love this, but i director would never let me do this. can i couldn't do this at work. how is it that some people can, you know, take time and do this and others can't? so i think if we think about -- there is a -- how do i explain this, i'll just say it. people are afraid. people are afraid to peek up, speak out, have hard conversations can they're afraid they'll have a negative performance evaluation. i think it's up to us as threersd think about how we can make people feel safe. there is a concept, the key

principle state of and stability in training which we talked about how to create a safe work environment that goes for physical safety as well as emotional and relationship safety. it means you can go to your supervisor and say, wow when you said that i got angry. is it okay for us to talk about that. we learn about this in racial humility that people in power have to make sphais for people on the downside of power to have the hard conversations. i'm not sure i'm answering your question exactly. so help me if i'm not. keep ask asking because i want to clarify it for you. >> maybe i'll ask director garcia. if that's the feedback that is needed, do we have mechanisms or is it your vision of this process that there would be that bottom-up without consequence in terms of i'm really afraid of my

boss or whatever is the impredments withi -- impediments for making it work? >> part of the work that we have to do is we trained our first 3,000 people so we have data to look at. it will be our responsibility and this is part of why we are looking at how we train trainers so we get deep into the organization. then probably we'll have to look at how -- once you have trained everybody, everybody understands they have permission to do this. then it becomes is there a policy that we can develope develop for that? is there a practice we can may go sure our executives in leadership, we have an integrated steering committee. we have to keep working at it. this a new process and i want to remind the commissioners that who we serve rl the most traumatic people in the city.

in fact, we have run the trauma center. go all the way down to outreach workers. our homeless outreach workers who went through a traumatic event. this last couple of weeks. this will is such an important tool for our staff. and for us to understand how to support them in supporting those who are traumatic. what i've watched is those that do the most trauma work become difficult employees. and i have an experience where i brought many of those employees together and quite frankly, our human resources said they're problematic employees. did we create them? or did we hire 20 problematic employees. i would say latter is true. because of the trauma they're dealing with and we're not dealing with them, this is one of the reasons in all of our work we're doing, we are rae

trying to provide people support like debriefing those who do some of our emergency response pieces. we're learning as we're doing and that's a great question because we have this set up a mechanism on how to enforce this. that's why we're doing the inspire department and not just half of the department, not just a third of the department, not just the hospital, every single employee. as they come through the employment process with us, this will be one of the required training they'll have to go through. >> we train the entire department of human resources in october as a whole. they came which was amazing. that they had an entire fle hours together to sit and hear this together. and now they can take it back into their various meeting structures and begin to imcomplemen implement some of the concepts they learned about. >> we serve a a large proportion of the african-american

community as well as the latino community in our services. if you stretch that out to our community-based organizations, we serve a lot majority of the population in the city who are facing traumatic events in their life river day. i thought ---if you can give us part of your background because we're so lucky to have you on staff. we started this in foster care. if you look at foster care children, 50% of them become homeless as they become adults. to think about how we're serving our foster care children is a reflection of how well we are doing in nie opinion as a department and how well we can help the families of them. and one of the biggest goals that we've had in our foster care system is to try to get them back to their families. if you can tell us a little bit of your background. >> i finished 16 years at san francisco general hospital in the can't of psychiatry for

children, need and families in partnership with pied tricks. and have long been committed to serving our population that we serve at the county level. from i taught -- i teach at u.c. i'm on faculty there. a few years ago i had the opportunity to become the director for foster care mental health. i came to d.p.h. prior to coming to d.p.h. i was talking to director garcia and colleagues and how hopeless i felt like as a provider because all the hours i spend with the families and they go out and report another exposure to a trauma, i really began my colleagues at the hospital to think about what was needed to help our families in this preventive approach became more and more appealing and this way

of looking at it organizationally because i knew how i was feeling wasn't because i'm not a good clinician or dpoant know my job, it's a problem with secondary time advertisation. we need a public health perspective. how do we do this? you know, director garcia and the director of children, youth and families reached out and asks my colleagues and i to take curriculum we wrote for san francisco unified school district which is called healthy environments in response to trauma in schools. and adapt it for public health. that's what we did. we had been in san francisco unified school district since 2008 doing very similar work with teachers, nurses, social workers and leaders. at that district level. we were able to take that curriculum and adapt to a public health perspective.

in foster compare mental health right now, the work with child welfare has grown to include a deep and robust partnership. it's really an example across the straight about how it's the only -- it's like a hybrid we share funding 50/50. it's 50% funded behavioral health and 50% from child welfare. there is a cla collaboration there. bringing the children home and bringing them to their family is our mission. and making their families ready for them is also our mission and those are the families those adults we serve them in all our clinics. those are the adults we serve. >> car commissioner karshmer. >> i applaud you doing everybody not just a few people. findinfinding that 2.82% are

corps yid this isn't going to happen. do you have thoughts on what contributes to that and -- because this is hopefully truly a cultural change. >> yes, definitely. >> horizontal work across the drpt department. what kind of things are you envisioning to help, you know, address that and is this indicative of the lack of trust? >> it is. i think the people who are reporting that they -- we have initiatives to teach here in this county. we see things come and go for 30 years. i've worked for 25 years in this county and so many initiatives and great ideas. creative ideas that we have invested in, worked on, train on. and they come and go. sometimes that depend on leadership. we can get a new director of public health and this could be

gone unless you think it's so important it doesn't matter who the director is next. part of it is that that things come and go an people are fatigued by that. you can see them sitting in their chairs like prove it to me. prove it this is going to stick around then maybe i'll invest in it myself. i think we have early adopters. we call them low-hanging fruit and people that are more cautious and that's fine. they have to be around it. they have to experience it and taste it and feel it themselves then we have people who are no matter what you say, it's going to feel like we are giving special attention to some people and not others because they have trauma. and we have to work on that. so we have to -- it is a horizontal approach but it's bottom-toop. i think the 2-pointal%, they're the people that have a hard time trusting that we mean what we

say. there is no funding. we're doing it from the inside out. it's not like we're going to lose funding. we're doing it. this is not costing a lot of money to the department. we're not relying on external grants or consultants or anybody coming in from different parts of the droin. we're doing it ourselves. no matter who leaders are, we want to create the change and embed it into our policy and procedure. >> this is the trauma-manufactured care 1.0, there a 2.0 ready to go? >> that's a good question. right now, let me go back to this slide here. you can see that what will is happening next and from the workforce training on it's getting the master trainers so we can train a thun people at a time. that's going to take 10 years. if we can train more people simultaneously, that's better.

we're trying to get the trainers trained. those people are not necessarily teachers and trainers. they didn't go to school to train people. they're doing their regular job and think they want do this so they need support on how to be in front of people pand how to speak. so we do that for them. the culture change is about probably a decade. we would see some real change in about next 10 years i would say. i think that embedding all of this in all these different areas is the next step. the 202 -- 102 happens at the champion's level. they take a deeper dive into the principles and concepts. they're developing within their cohort ways to feed back to leaders and directors so we can embed it in the pilots that we have all over the department. with the champions embedded in the pilot. because we understand that the culture is different in each agency.

what works for mine is not going to work for yours probably but we have to figure that out. the champions are doing the next level of understanding. >> looing forward to having that number go down. >> commissioner pating. >> first of all, i had the honor of listening to dr. alicia lieberman from the department of public health. i'm with you on the importance of traumatic-informed care and the science of frawm-informed care. i think what -- trauma-informed care so you're doing is bold, i see what you're doing that leads you in terms of strength-based probes so soon orr later maybe we can push or nudge the title of this initiative from traumatic-focused to resilient-based initiative.

then i have two small questions. >> a comment that we definitely -- i completely agree with you. throughout the training, the three-hour training, you hear a lot of hope in the curriculum. because we are really telling people, this does not dech you or your patient's tream. we end with a -- patient's trauma. we end with a module on resiliency and recovery. from there, we're bringing in science from the greater good science center around mindfulness, gratitude and how you can embed that in your own personal life and agency. i agree and really, i think the goal is to not even be a trauma-informed system but to be a healing organization. >> wellness-based. >> absolutely. >> so another organization mental health services had a similar mission. are you use anything monies for any of the activities? >> not currently. >> we use our own general fund

monies? >> we're not really -- what we're doing is i think part of what you see from leadership is this idea that as the director, i'm going to forgive your productivity while you do the champion's work. that's how we use the department's money. >> the second thing is with regards though this being so much a trauma-formed care or developing this is as a culture change, it starts with an approach to a culture of care as opposed to a culture of choice. moving to as a client to the center of decision-making. how will we know we are there? one of the aspects is you'll look to train so many people. but then after that, there is a training people to do certain acts. what will be some of the concrete things that you'll feel you have a first lel level of adoption? i have some thoughts on what

might work. >> well, the competencies that we developed that are in one of your handouts, defines the principle and then lists the competencies. at some point we'll go back and survey everybody and find out where they are. how competent are they in each of these principles. that's one way of looking at it. another way of looking at it is we recently did a whole staff survey, for the department. and i'm not -- i didn't really ever look at those results. i know we did that. i don't know how many people responded and i don't know exactly what the results were, but we'll do another one of those through a trauma-informed lens. i think continually and we'll expect to see a lot of improvements na souray. sur -- in that survey. this is about how people feel when they come to work.

that's going to impact how well they can do their job. those are two things we can look at, ex competencies, climate based on surveys and i think we're developing other tools for measurement as we go. we're learn big doing. if you have other ideas, i would love to to be able to consult with you. >> i see this as a whole climate shift. it's a climate shift for wellness grated into the workforce which impacts patient care and efficiencies. this is looking at a double whammy you get. where we try to deal can this in the mental services act well key healthcare values and it's hard to measure but measuring the adoption of values is good. patient care is dissal like 10 years maybe even 15 years before you're able to demonstrate this

person got faster service because of this. our hope is that, but i don't think we should expect it right away. if we start is to see some of the values get into individual staff members, annual improvement plans, i'm going to take this activity up in order to try to further this trauma system -- strawm pour system in our system. you'll see these individual meshes of adoption that we're transforming. i want to commend you on this. this is bold and i'm excited to see this will even though it will take some time, it's the right thing to do. >> commissioner singer. >> i'd love to come back with the discussion you had with dr. chow and pick up on comments that were made. maybe you can tell us what your challenges are with your staff, getting them to be more -- my sense is more permissive with

their organizations to allow this to stick and flourish because it sounded like this was not just for this to flourish, it wasn't just an issue of people going through training and adopting it, but it was more how we work as a department and sort of what sort of changes are you putting in place so that we can learn from this and it can be a durable part of our culture? >> i think it's middle changment that i get the most concerned about in terms of the fact that i feel that that is reflective of the racial humility component of it. iand it has do with how and who we hire for the department. part of the -- i feel like we have a good leadership component. as we get into middle management and we have people here for 20 or 30 years that watched five

directors go and come. i think i counted a hundred great practices that we accepted and let go of, it's this collective impact that you take a few things and drive it and drive it. where we need to focus is with middle management and that needs to reflect who we serve. that's the component -- we're going to be having probably a good 20% of our employees who are going to retire. in the next five, 10 years, probably five years i would expect a large portion of some individuals will retire so we'll bring new leadership in as well. there are several components to your question, it isn't just how do you fix it, it is how do you continue to improve it in terms of the process. that's why it's so important in the next couple of hours you're

going to learn about le lean and how it involves in our improvement of quality and leadership development. cultural humility is another area, we're a government agency. and commissioner singer, you have tried to champion this thing about -- issue about lyring and how we do that. that's also a struggle that we have within the civil service system. so -- and then the other area, the responsibility in the community because as i think this training also helps the providers serve our clients better. it's not just to make them feel better about the trauma, but how to thenar help our clients not asking what is wrong but tell me your story. that is a completely different paradigm. so we're trying to not just do one, but several of these issues and we have a five-year plan to see how we are ago go to move the system as a whole.

it's a complicated answer. but it's also one that i believe that we can, by moving more new succession and new development and knew leadership in the department and ensure that those who want to work with us have a real focus of the communities we serve, know how to serve them welcome well and are trained appropriately to do it and have the tools from h.r. csm from performance or the leadership to ensure is that we're driving those possibilities and those improvements down. and i think having a frontline worker as a champion and lean is in that direction as well. how do we involve our workers into the betterment of our services. i kind of see a multiple process but it has to do with watching an institution as it grows and changes because it's never the same due to the fact we change

as people. our communities have also continued to suffer in our inability to serve them well and that's the major focus we have to keep our eye on. >> i think the fundamental problem is for persons who have suffered chronic trauma, it's not everyone, but for many people because there is an inherent resilient factor, it's constructive to relationships. when you scrupt relationships, it disrupts the whole system in help seeking and service seeking. one of the things you'll hear about in our homeless community, you could have the best clinic in the tenderloin but people will wander back and forth because of apprehension of entering the clinic and all that entailed. this is where if you focus in on relationship, hopefully services can fall and we need to be

relationship-oriented both in "cultural diversity perspective and in a socio-economic or developmental perspective because of the impact on a relationship. i think that's my understanding of our focus. but it's people are coming with what they come with, their strengths and struggles. both staff and patients and helping people be self-aware of those struggles is one of the aspects where you can move people to their strengths. that's what i see you doing. >> i would add going back to commissioner ca karshmer's question to me, 2.8, they're not sure. trauma creates helplessness and hope unlessness. and we can't do anything to change this situation for myself. i think we hear that. we see that reflected in our staff quite a bit where there might be a good idea that they

have but feel like they can't make an impact because they're not a leader. a lot of what we do in trauma 101 is give the power back to people and say this is a learned response you had as a result of stress and trauma in your life and you can unlearn it and ask you for your ideas and say you doesn't wait for this person over here do it. do it yourself or do it in relationship with other people but you can actually do it, you can make the change. >> this is where you empower staff and they can empower patients. >> exactly. >> with trauma, you have more avoidance coping. >> thank you. and srml certainly this is a new process and i believe that we would like to be able to have a follow-up on how the initiative is coming. so i would assume in the coming year, we will have the director

bring this back as an item when she feels that she can then show the further development that they are moving on this. i want to thank commissioner pating for adding the elements that you have and bringing the experience that you've awe brought from your state background. >> one last question, is the issue of cultural humility separate or a part of this? >> it comes together. ken haring is our trainer in that area. those are the four areas that lynn mea be can show. >> right. and we were going to bring that also today, but the trainer was away today. so we'll bring that to the commission also. >> because we're serving racial and cultural communities in order for us, you know, to be able to do our job better, i believe having conversations we

should not be afraid of that. that has a great impact on care and especially if you are not african-american and trying to serve an african-american community, it's tools you'd need to know and understand how best to surve that community. having those four areas and this is what we're looked at for workforce development priorities and something that dr. otagon and ourselves are working on for our leadership program is looking at how we can impact our care and workforce for this training together. usually you see this separate, we want to bring it together so people understood the connectiveness. >> and dr. hardy provided a lot of that around that principle. we've integrated his work into the principle. thank you so much. >> thank you. and we'll bring the racial humility initiative along with cultural competency report to

the commission to fill out this development initiative. thank you. our next item, please. >> commissioners, i believe you may consider recess at this point. move to another room. and president chow might want to say something about that. >> we're going to be recession so that we'll have a different environment public of course is invited and they can continue to join us in room 220 and we'll reconvene at five minutes. 3:30..