personal analyst that the human resources examining and recruitment unit and suffix i started my career as a san francisco state university and got my bachelors in psyched and orientational psyche if they had we have a great relationship that the san francisco unified school district i exploded for american people interim shopping mall and become eligible for a permeate job. >> okay. perfect. >> i love working for our human resources services because of the agriculture we're laid-back with a professional mindset although human resources is a challenge we're light a hearted started as a intern guided

through the process eventually one day a a deputy director or staying with the puc is where i love it >> good afternoon everyone. the commission will trees come to order and the secretarial call to order >> pating, here. loyce peter kalb speed present chung speed present sanchez >> [pause] and cars speed present >> the second item on the agenda is the minutes >> moved to approve >> is there a second? other corrections to the minutes of january 17 queen seeing none, all those in favor please say aye the minutes have been approved before we go to the next item i like to note commissioner david singer had

resigned in mid january for personal reasons and to acknowledge publicly that thinks of the health commission and the department for the work he put in since his appointment in 2013 for the three years he served on our health commission. now our next item >> item 3 directors report. >> good afternoon commissioners. first i want to welcome all the san francisco state nursing students. why don't you raise your hands? all right. plenty of nurses in a pipeline. >>[laughing] okay. as you know we had so many issues that happen at the national and local level. i'm going to go through those and if there's any questions are mayor responded to the executive order on immigration and i would just say one

sentence he says. i commend the judge that granted the emergency state allowing immigrants a valid visa to enter the united states. then our city attorney pedal apart old lawsuit to protect her century city policy on the 31st. there was also a response to ice appearance at [inaudible] resource center and many of us met with the staff from that incident and also from many of the organizations in the mission. we are still working with the mayor's office who we have met with and listen to committee along with other immigrant communities to ensure they get access to services and support and how to continue to make-make people feel protected in san francisco. i want to commend all the leadership of the city and doing that. one of the incredible things that has happened as well, is that the board of supervisors all 11-we got all 11 votes for proving the us as a research center. on

the usmc campus today with the final reading of that ordinance and that all came through it it's 175,000 square-foot $200 million facility. we are still dealing with it parking lot of us at g and how to financially experiment garage. i will leave it at that and then if there's any questions regarding any of the other items in the directors report. questions or comments queen >> yes, commissioners, you have the report before you. i want to also note the approval of that ucsf building. it is remarkable. we have [inaudible] 11-0 to the fact that you're continuing to work on the financing for the number of parking spaces that will be needed, is there still conversations with ucsf on that

or is it be pretty >> they basically approved on hundred 30 spaces and they are providing us with dollars for mitigation of that. what we are now having to contend with oh is a future process of how to deal with transportation and ensuring that patients come first for parking and so we are working on a plan for that and then trying to look in the future, can we expand garage and we will come back to the commission once we have a little bit of time to figure that out. we still not quite got the financial package for that completed an ucsf package needed to go in a time period and we just cannot finish the package to the garage. that grade a lot of conversation at the boards but we were able to separate out those two issues and agree that ucsf and mitigate the problem of city on 130 spaces for the new building. >> now that's excellent. because several supervisors i talk to raise that question.

separating it we were able to get the used uss of the building which is wonderful >> yes. >> commissioner sanchez >> i'm just going to ask, tongue-in-cheek and yet not on this great vote for the supervisors and everybody worked on this project. there's also been some scuttlebutt going around. will be a supplemental coming into put the [inaudible] on top we >> are not heard of that commissioner. >>[laughing] >> serious discussion i know because we do have one at ucsf, mission bay. but they have to go through the-the railroad tracks go over some times that it's very congested. anyway that's [inaudible] data be the next four years spears >> yes. 40 years. i do want to acknowledge this was a three-year negotiation with us state entity city and county entity i do want to acknowledge mark primo, greg greg wagner is

long with choline charla really helped and i think we really worked good as a team with our team and also the city attorney spend hours and hours on this issue as well. >> it's an extremely important part of the continued to world-class zuckerberg san francisco general campus. so i think we are all very pleased this is now coming online. commissioners, further questions to the director on her report? if not then we will-thank you very much and thank you for all the items under the news that i guess we can all look at under the little [inaudible] >> could ask for one? >> sure. >> director garcía, with it raining so much in the past and withhold cold weather we've had housing reports about the status of our homeless housing.

since that's moved to the other departments, we may not have an opportunity to read about that but it does have health impacts. can i ask you a favor to weather the weather is turning bad and it's so inclined to put in your report you just make mention of what we are with shelters? >> yes. we do open up shelters especially during the wintertime. so we will i will make sure to note windows-we get those announcements and the expansion of the shelters have already happened almost a month ago. though we will note that and put that in our report >> i know that the housing is moved over to the homeless services, but as much as it updates the work we are doing that would be very nice. >> yes. we can definitely do that. >> okay. >> thank you any other comments to the director? if not then we move onto the next item please >> item 4 general public on and about received any request. any in the room? we can move on to

item 5 which is the report that from the finance and planning committee and those in the back standing there is plenty of seats up front. welcome to come down the aisle and six. >> commissioner chung >> good evening commissioners. the finance and planning committee met today before the commission meeting and we had like adopted a-some new contacts and also the contact reports that [inaudible] in the consent calendar for your approval. i would also like to point your attention to the february 2017 contact report. there were some errors in the last item on the contact report and so i want to give you the

correct figures. so you're proving the right amount. so, that is for the san francisco unified school district. trish and education and physical activities opportunities. and, the items that needs to be changed, the first one is the total contract amount with contingency. instead of $913,000, that number is actually $761,600. the higher annual amount without contingency, instead of $948,000, it is supposed to be $355,000. and the annual difference, instead of $676,000, it is $83,000 and the annual difference in percentage , instead of 71%, it is 24%. that would be the corrections

for the contact reports that you will be approving. >> are there any questions to commissioner chung regarding the finance committee meeting? and recommendations, which we taken up at the consent calendar? >> just want to comment on the behavioral health services occasional services report. i really like you broke down the funding between them hsa, general service, realignment, it really just pointed out to me how creative the department has been in pulling together useful and worthwhile programs. i guess it takes a whole -multiple cookie jars to make one batch of cookies. >>[laughing] >> question creep

>> i was can say they're supporting the café and did i have anything to the with the café in the report? >> omission or sanchez >> i just have a question. i know it's-i will vote for it, but in reference to our contact for our [inaudible] we are talking a three-year contracts, substantial dollars, you know and i know over the years we've always had these contracts and i guess we've always try different ways we can increase our nursing staff in different disciplines, and we are still, you know, even though we've had fantastic efforts this past year, last year and increasing the time rate for nursing programs, etc., sometimes i think maybe we could put more money into, let's say, community college there to your nursing program so they could

link with maybe ucsf or usf or sf state so they could combine the degree like them and down at uc san diego with some of the community college is there. we need them i think as we things get a little topper come i think we need to think new pathways for i know the sfgh is coming in with a new pathway without leave with uss up the duke clinical training there in their undergraduate year and that window already have the feet on the ground in for some of these difficult disciplines. i understand where we are to we made great headway but i do hope in the future again we could come up with some other new pathways so we can ensure that some of the kids starting out or coming back to the community college to retrain for these new entries especially from the military, too, we could often new pathways to go into a four-year program with clinical services both here and in laguna honda because laguna honda and others will be working even more with new gerontology programs with

schools and so again, i would just want to mention that for the record because i think it gives us a unique opportunity. we could just offer so many critical programs which would be inclusive and minimal cost to the students and the families. then provide them, because many of them will be from this area, with the sensitivity and culture that we know is you need to san francisco. anyway, and the comments. >> i do support this but i want to think about it. we been doing this for quite a while and these two new programs for three years and we've a new program at usf gf with usf and the programs especially so hopefully it'll come on with a multitude more. >> i believe commissioner chung, this was discussed at the finance committee. it was my understanding that even as we recruit, these are actually the fill in his for short-term absences over time, searches

that occur, and this does not negate the effort to continue to look for permanent nurses. is that not correct, chair? >> right. >> intact there are two different contacts for that. mission or karshmer >> i want to pass up the opportunity to applaud our colleagues at the mgh sfgh. and the good honda good for working so closely with the nursing program in the bay area to try to provide high-quality clinical experiences to educate the next generation of nurses, and i think there's always opportunities to build those partnerships stronger in the bay area. >> just to note, when they graduate this san francisco nurses, we will need these registries. >>[laughing] >> thank you. any further

questions on the finance report? if not we will proceed on to the next item please spews although there is no public comment request for that item to item 6 is the consent calendar ends commissioner chung noted the only change is the minor changes in the amounts for when the context and the contractor report which he noted. >> so you have before us the consent calendar from the finance committee and planning committee. it it is a request for the approval of the contracts report and five new contracts. these would be voted on as a block unless any of the commissioners which is to extract any of the items. seeing none, we will proceed then to vote for the entire consent calendar. all those in favor say, aye. [chorus of ayes.] opposed, say nay. the consent calendar has been adopted. thank you.

>> item 7 is the sfdph nonhospital employee recognition awards. the commissioners will be reading aloud the names and as that happens, please therefore. commissioner sanchez we handing out the word. would you like them to come enter that way? just to note, director garcía is just getting over the flu so she will not be shaking your hand but not because she does not like you. >>[laughing] >> yes, in several venues recognizes the contribution of employees to the work of the department of health. we have recognized those at san francisco general and we recognize those that laguna honda and respected meetings there. today it is our opportunity to recognize employees that are not in either of those two locations and work for the entire-and have worked in other departments of the-i should say

of the divisions of the department. so we will begin with each of the commissioners assigned to read the first-the first award will be commissioner karshmer to the field public health nursing unit >> i'm delighted to honor the field public health your nursing him. i will call your name if you would please come forward. eileen armstrong, diane deacon, harlingen, susan you, elizabeth-malaysia- michelle-linda-irma riley, lee rossi, nokia navarro, jennifer acosta, jodi stu d, tammy

thomas and alycia martin. maternal child adolescent health field public health nursing team delivers vital services to the homes of san francisco's low income mothers and children who comprise the city's most honorable population. the staff are the unsung heroes of san francisco's most at risk neighborhoods and are welcomed into the homes of women with intrapartum postpartum and pediatric lines across the country right or phone service. health assortment patient education and parent support breast-feeding consultation and support, home environment and safety evaluations, access to and coordination of health services and community resources. please, join me in thanking the staff for their dedication. thank you. >>[applause] >> >>[applause]

>> commissioner loyce will now read the recognition for the san francisco health network dental services staff. commissioner. >> it's my honor to present to san francisco health network dental services by name, his award, good i will apologize in advance for the ruination of the pronunciation of your names. because i know that i will do that. here we go. stephen ambrose, martin g, evan philip, elaine full, irene hylton, ron lee, [inaudible] joseph lange lillian kwon, marco reavis, race, dream toy marine one, [inaudible] anna solano, claire fits, heidi l mark, katrina-lorena gallo, nancy gallo, any pollen, [inaudible] terry lamb, mary

and market, jennifer caswell, cirilo perez, michelle-, shirley yang, wendy xing, anthony lynn. after complete in 2009 of >>[cough] restored medi-cal coverage for adult family services in 2014. the san francisco health network dental services staff under the leadership of dr. stephen ambrose responded immediately to meet the increased demand for services. in just two years in 2013-2015 the unit increased dental encounter from 8000 to over 12,000 which is an increase of 38%. san francisco health dental plan services also has been a key partner in san francisco children's oral health initiative with preventive dental care to children and child care centers

in the gardens of schools across the city. they also conduct community outreach afferents to adults and children in such places in project homeless connect and neighborhood health centers. individual service [inaudible] are dental team serves as the most was 20,000 san francisco's each year. thank you very much. >>[applause] >> i guess the rest of you out in the community are doing some work. >>[laughing] >>[applause] >> i have the privilege to be

able to introduce our next awardee, tracy shaw said the guard, please. is she here? please, come on up. tracy. tracy is a health worker who has been a leader, a health coach, and a crucial team member in our southeast health centers initiative to improve what pressure control for african-american patients with hypertension. she has worked with our center of leadership the primary care hypertension equity workgroup and key dph programs such as, healthy hearts, to spearhead a world hypertension day event in may 2016. that increased awareness

among the health center stations and staff. she our reach to over 300 individuals and welcome to over 70 patients to the clinic so they could experience interactive group education, blood pressure self-monitoring, cooking and dancing demonstrations. since that event, she is continued to follow-up with patients and healthcare teams to future support their efforts in controlling their blood pressure. she is also set up similar events for copd, asthma, childhood health, and geriatrics. her ability to reach out and connect with patients on a meaningful level has been invaluable. she is also served as a resource to train other health center staff in her best practices. through addressing equity issues through direct action, she has changed how the health network cares for its african-american patients. let's think tracy schaub synagogue. job well done. >>[applause]

>> >>[applause] >> commissioner pating will now read our commendation of the healthy housing and vector control program. >> we would like to recognize for the healthy housing and vector control program mario lena,-[inaudible] marisol quaver-many director, marine sanchez, roberto-caroline lamb, joanna home, patrick wood, amy

johnson, lisa garfield, jade check, [inaudible] kerry amato, kevin ing and christine there. the healthy housing and vector control program staff provide code enforcement to assure that residents of rental units and at times entire neighborhoods are in compliance with san francisco health code article 11. this code prohibits nuisances such as unsanitary conditions among mold and pest infestations including mosquitoes, bedbugs, cockroaches and rodents. i'm so glad you guys are doing that. the staff also conducts inspections for neighborhood vector control issues and institutions such as hospital jails and schools. their work requires a keen to collaborate other dph divisions and other city agencies. most significantly, the team began

the integrate behavioral health and social work staff 12 code enforcement efforts with building residents that contributed to the creation of public nuisances. this is resulted in a reduction of the evictions related to health code violations. please, join us in thanking the staff for the impactful and very important work. >>[applause] >>[cermonial recognition] >> smooshed together. >>

[photograph] >>[applause] >> commissioner chung will now recognize another individual from our department. >> we are recognizing eileen volkman. >>[applause] as manager officer of the [inaudible] program provides

oversight and technical assistance to community based programs funded by the sfdph. she maintains a strong relationships with neighborhoods and community residents when there are concerns about the programs. ms. lofgren has addressed the increase of litter during neighborhood meetings and a police precinct meetings but she is skilled at active listening and working with community members to design effective solutions. through her work the sfdph has installed 11 disposal boxes, have a rapid response team that beat of sewage in the civic area. she's also a consistent-she's also consistent presence one members of the board of supervisors in the mayor's office want to address community issues related to sewage access and disposal. so, please, join us in thanking eileen lockman for her work. >>[applause] >>[cermonial recognition] >> what eileen's team, please come and join her. eileen's team. >>[applause]

>> eileen's coworkers and her team? >>[inaudible] [off mic] the rapid response team. i apologize. >>[applause] >>[cermonial recognition] >> commissioner loyce >> i want to ignores this group and the work he does because i can remember a time this kind of program [inaudible] and the department of public health do not sign contracts were the sons of services good so we have come a long way and thank you guys for your service. >>[applause] >> the commissioners always are pleased to be able to recognize outstanding individuals in this, the

largest department in this county get so many more are deserving and we will be recognizing in the coming years let's give everyone was recognized tonight another big hand for their work. >>[applause] >> commissioner's item 8 resolution improving the san francisco to prominent public-health-actually, 2007 state and federal legislative plans. this resolution was introduced at your last meeting and today approval is requested. >> so that a permanent 20 present once more the changes that have been made regarding the plan from our last meeting. thank you. >> good afternoon commissioner. my name is cindy

comerford on from the office of planning and planted our last health commission meeting i presented on a summary of our 2016 state and federal legislative action that we took. i talked a little bit about emerging issues and key federal updates. i also presented on or 2007 state legislative and federal plan. i want to thank you for the feedback that you gave us at the last commission hearing and we were able to integrate that feedback into a revised memo. i think you should have a copy of the memo and then the feedback that we received is documented in a memo. i'm going to quickly go through the feedback that we got in the revisions at that meeting. on page 5, of the memo, we incorporated the participants from the healthy san francisco. on page 7, we added in to increase advocate

for increasing rates for medi-cal providers.. on page 11 the change some of the language suit to augment our support for the allocation of workforce, and also on page 11 we also added in work to advocate for increased support for tele-care. that were good changes to the state legislative platform. on page 13, we added in to advocate for increased funding for the nih, national institutes of health. we also added in similar language for the allocation of workforce development and tele-care. in addition, per request of director garcía the allocation of workforce moment we included psychiatrist. so those are the changes. i'm happy to take any questions on the plan but we are here to

seek your approval for the resolution today. >> commissioner was almost a resolution language do not change. it was just the memo that ms. comerford briefed you. >> thank you. commissioners, any questions to ms., for? if there's no questions, the neighbors lucian is before us and emotion would be in order. >> moved to approve >> second. spews there's a motion and a second is there further discussion on the resolution? seeing none, will proceed to the boat. all those in favor say, aye. [chorus of ayes.] opposed, say nay. the resolution has been approved. thank you. >> there's no public comment request that item. item nine is a resolution in support of implementation of the california end-of-life option act in the san francisco network. this resolution was informally introduce it to adopt at your last meeting and today approval is requested. >> good afternoon

commissioner's good i'm [inaudible] office of policy and planning. as you may remember that your last meeting on january 17 you are presentation on the california end-of-life option act. a little bit about what the process is for patients and the departments of policy regarding implementation in the san francisco health network. i just want to note that laguna honda hospital is also develops policies and procedures that are aligned with the networks policy that will be coming to the joint conference committee in a couple of months. i believe you have a draft resolution before you for your consideration. >> thank you. the draft resolution is before you could first the mother questions to the presenter? we have a very extensive presentation at the last meeting which was really excellent. so we can then move on to a consideration of the resolution. this requires a motion >> so moved

>> second >> further discussion? there were modifications of the resolution to clarify related to california 80-15. if there's no further-any people but >> no public comment request for this item >> then if there's no further comments we can proceed to vote. all those in favor say, aye. [chorus of ayes.] opposed, say nay. the resolution has been approved. thank you. >> item 10 orissa lucian authorizing the partner public-health to recommend to the board of supervisors to except and extend retroactively a gift of $80,000 to laguna honda gift fund from molly fleischer. he was before we move on with regards to the item 9 resolution, maybe we could hear airport in one year on the implementation of the end-of-life care >> shirley. our executive sec. will note that for a report on

the ada implementation. thank you. ms. harrows a spews >> good afternoon. i want to let you know, proud graduate of san francisco state university school of nursing in the mid-80s. but i am here because last year ms. molly fleischer donated $100,000 to the gift fund to start molly's fun. within the intent to provide necessary assistive technology for laguna honda residence who lacked the funding or the means to purchase assistive devices for themselves. last december ms. molly fleischer has donated an additional $80,000 to the molly's fun. i'm here to request your approval of the attached resolution to accept and expend to recommend to the board of supervisors and approval to accept and spend

ms. molly fleischer's $80,000 donation. thank you. >> commissioner sanchez >> you're just motioning? were you going to us a question or motion >>[inaudible] [off mic] you are moving the resolution, okay. let me first ask questions queen yes, commissioner pating >> what is assistive technology equipment? could you maybe expand on that >> sure. it's the ability to communicate for some of our residents, the ability to help them improve their quality of life through technology. i could give you a really great example that we are using molly's fund ms. molly fleischer astonishment we have a resident that is-syndrome and the only way that we are able to figure out how he can communicate with us, and also

monolingual chinese speaking residence, was through his left one digit of his left toe. the funding, we were it was defined in assistive technology that he can touch with his left toe and then it would speak for the residence and translate that so that we are able to communicate with him. that is one example of assistive technology that we were able to utilize. then there might be others in terms of patients that have tricky tracheostomy's that would help with voice-recognition ability to use technology and use computers for residents that multiple sclerosis. so these are adaptive technologies for residents that are disabled and

the advancement of the equipment has allowed them to either communicate, help with twoto mobilize through the hospital or even help them mobilize out in the community. >> thank you. >> okay. further questions? if not then commissioner sanchez your motion is in order. >> so moved. >> is there a second >> second. further discussion any public on >> no public comment request for this item >> all those in favor say, aye. [chorus of ayes.] opposed, say nay. the resolution passes. thank you. >> item 11 dph disco era and 17-19 budget update. mr. wagner >>good afternoon commissioner

is greg wagner chief financial officer. i'm going to give you a presentation on her upcoming two-year budget process today. we have as we have in the past brokenness into two sections. the first will be today and the second will be at february 21 carried today we are going to go over the high-level outlines of the budget outlook including mayors office five-year financial forecast and with the financial outlook looks for the city and how that translates into our guidelines the upcoming budget process. when we come back to you next time and we will talk a little bit today about some of the issues and priorities that we are focused on bouncing around them when we come back you next on, we will have the details

balancing plan and the initiative right up business plans that you approve on an annual basis. so the outlook for the city is essentially that the economy is still growing but it is growing at a slower pace than it has been for the last several years. we are beginning to see some leveling off of growth and potentially some of the city hitting the capacity for sustained continuous expansion at the rate that we've seen over the past several years. in each year , as you are familiar with from past hearings, the city has required to propose a five-year financial plan. every two years it's a full five-year plan and then on the off years as an update to the plan. the plan is introduced by the mayor's office and adopted by the board of supervisors. that includes a projection for the cities

general fund and with the projected deficits are for the city and it includes a set of proposed strategies for bringing the deficit back into balance over the term of the plan. in the financial plan adopted by the board of supervisors, there is continued growth projected in the economy in the city's revenues. however, as i said that growth is leveling off. the growth over the five-year period is projected at 11% in general fund revenues. however, that is significantly slower than the growth in expenditures. there's a number reasons were that that we will touch on briefly because of that difference in growth rates there is a projected growth in the city's deficit. for the upcoming two-year budget cycle that we are entering into, the projected deficits are $119

million in the coming fiscal year and $283.4 million in the second year. so significant deficits projected not on the scale of what we saw during the years of the economic downturn and the following recovery. but significant nonetheless on the order it does require corrective action on the cities behalf to bring things back into balance. looking a little bit further out, that deficit continues to grow and year five projected deficit is $848.4 million and that's what happens if you project out and say, we leave things unchecked if we let present trends continue, that is what the trajectory of the outlook is projected. of course, we don't leave things unchecked it would take corrective action and that's part of the purpose of the five-year financial plan and the instructions issued by the mayor's office to the departments but you can see there's an underlying trajectory that shows cities finances are not in a naturally

stable place right now and that there is-we are in a place where action is needed to adopt-adapt. this chart in front of you on slide four, shows the growth rate of general fund revenues over time, and you can kind of see what tends to happen over time and where we are in this forecast. the city >> great tends to go as the country goes through economic cycles and you can see how those economic cycles translate directly into the impact to the city's general fund revenue. so as ourselves taxes, property taxes, our hotel taxes, property transfer tax, all those things are directly try to economic activity in the city, the region and the nation. you can see the two big tips on this chart where the.com bust in the early 2000's and then the financial crisis in 2008-9 were you

actually had negative growth in revenues and then the in between you tend to see a strong recovery and robust economic growth as the city recovers and stabilizes its economy. the projection which you can see in the dotted line on the right, is really neither of those situations. the city is forecasting that we are not expecting a recession. we are not expecting a crash although there is the possibility as there is at any time that could happen, but that is not projected, nor is it projected we will continue to see the extraordinary levels of revenue growth though we been benefited from the last several years. you can see that since fiscal year 10-11 we been experiencing

growth rates that are general fund revenues is the city's economy recovered better in the high single and even double digits. that's a remarkable rate of growth good it got a little bit used to it but it is not sustainable over the long run when you look at the data on the city's economy. so the city is projecting growth rates between 2-3% for most of the years of the plan. again, looking at the high level bottom line for the general fund projection, the bolded numbers circled at the bottom are the projected deficits in the cities five-year financial plan. you can see as i've explained, there is growth in the sources at the top but there outpaced by growth in the uses in the bottom section and that results in deficit each year and deficits that are growing as the gap between revenues and expenditures increases. this is a graphical

the direction of the same data on slide six, which is shows you how the trajectory and the percentage growth rates of our expenses and a revenues is different and because of that difference by their virgins grows over time until your five if we take no action give it very significant gap between revenues and expenditures. in terms of where we are historically, this is a table that shows you with the projected deficits have been in each of the last five-year financial projections that have been adopted by the city. you can see where we were in 2011 get this when we were still emerging from the downturn and we were projecting deficits as a city of $800 million in the fifth year. that was again due to expenditures outpacing revenues. that has come down

and got much more under control to the point where you can see in the 2014 five-year financial forecast, which is the third line, they were very modest deficits in the early years of the plan and even in the outer years the projected gap between expenditures and revenues was significantly lower than it is now. so the fundamentals of the cities budget situation have changed significantly over the last two years. there are a few big reasons for those and the three there are highlighted here are the largest in terms of pure dollar values. the first, and this almost always is the case, rising employee cost. that's the cost of wage increases, granted by the city, but even more significantly increases in the cost of benefits. the city has a much higher burden on the general fund paid into the city's pension fund than was forecast even two years ago. there's several reasons for that including lawsuits, return on the investments in the pension fund, and demographic and

actuarial changes. but that is a big contribution to the deficit. baselines and set-asides. these are the initiatives that are approved from time to time by voters that dedicate city funds to a specific use but do not dedicate a new source of funds to pay for that use. so as we carve out dollars from the general fund for a specific use, it leaves a smaller pool of funds available to fund the rest of the general governmental functions including a lot of our services at the department of public health. lastly, and this has been a big part of this five-year planning cycle, increases in services and positions and other costs in the city government over the last several years. as we have had this high rate of economic growth in the city, and growth in the city's revenues, we have

collectively spent it replacing things that were lost during the recession and then growing beyond even replacing some of those cost. as we add those cost into the city budget between new positions, because of the rate of growth in benefits and salaries got those cost compound over time and when you have add them up in the outer years of the deficit they really make a big impact on the city's bottom line. on ftes this is a little cave table that shows you the size and the type of growth in ftes in particular over the last several years the cities added over 1000 ftes since fiscal year 11-12. part of that is again the recovery and replacing what was lost during the recession but a lot of it is expansions in various areas of the government. you can see the orange piece of that are

chart on the left is us, the public health sector of government in which includes us, dph only. so that is all us. we are the second largest category we've added about 1000 ftes over that period, so we are at a historic high at her number of ftes. so in response to this outlook the mayor's office has issued instructions to departments to help get the strategies and financial plan and implement it into the deficit back under control. for the upcoming of two fiscal years to address the deficit which is about again $400 million over the two years of the upcoming budget, the mayor's office has directed departments to propose a 3%

reduction to general fund supports in the first year and an additional 3% in the second year. per dph bosoms equate to $18.4 million in the first year growing to 36.9 million in the second year. i will make a note and we did noted in the memo, this is actually instructions are not reduction to our pure amount of general fund we received. prior to making this reduction the mayors already funded all the pension increases, but coders, a lot of inflation and the cost of government and they are saying to us, after we added that please, trim it back down by 3% and 6%. so we are asking-being asked to show some restraint in the budget but even with this reduction we will have both in our allocated fund support because of those growth in our baseline cost. the second important instruction from the mayor's office is that we are instructed to not grow budget and funded ftes. so they're

basically saying we've added 5000 positions over the last five years. we are not asking you to reduce your work first. were not asking for layoffs. just asking you to pause.. work with what we have added in a propose additional new ftes. so positions over added in laster's budget cycle are exempt from that. the initiatives that we approved last year will be allowed to continue going forward were asked not to oppose new ftes in the coming year. guidance from the mayor's office on priorities . these five areas they have identified as priorities for all the departments this came from the citywide claim process the director garcía participated in with with other department heads but residents of families that [inaudible]

clean safe livable committees inclusive city, excellent city services, and a city and region prepared for the future but i think those are all consistent with the priorities of the department and the work that we have been doing. things that could change. the forecast that we are working from and the cities always aware as we are at the department of uncertainties in our forecast is federal funding is obviously a big one. if the city's policy as it is the states through the governor's budget was introduced in january, that we are not guessing what might happen in the new federal environments. we are going to wait to see whether there are concrete policy proposals before us before we react to those. so we are not making an assumption here baseline budget about changes to federal funding but we are obviously

very aware that there could be changes and there has been at least a kind of conceptual discussion at the federal level at what some of those changes might be. there is always the prospect for changes in the economy and other changes including labor issues and new budget hearing commitments that could happen in the meantime by the board of supervisors. this is a graphic you've seen in the past. it's an illustration of where those risks and the fact that we do, as we saw some of the earlier slides move relatively predictably through economic cycles in the country and in the city. these bars are the length of time and months between a recession through the history of the united states. you can see that we fairly predictably have a period of growth and then a gap, a recession, followed by growth good the line at the top, the blue portion is the period of

continuous economic expansion that we currently are experiencing. so relatively long. you orange portion shows what would happen if, as is forecasted in the five-year financial plan, we go through the next five years without a recession. that would mean we have far and away the longest period of continuous economic expansion in the countries recorded financial data. so that is a possibility but i think we and the city policymakers are very aware that may not be the case and it is possible there could be, over the term of this planning horizon, a significant downturn. if that was to happen, they've kind of muddled out with the might look like using an average scenario of the.com recession in the housing driven recession in 2008, two kind of illustrate what that could mean for the city's budget. the black line at the top is the baseline projection is the dotted line

at the bottom is what it might look like based on a typical recession if we were to experience one so the projection is, based on the history something in the order of $1 billion over three years that the city would need to deal with, in addition to what it's forecasted in the deficit if we were to experience a major economic downturn. so that is on the top of our minds as we go through planning. so from the dph perspective, a lot of the things that we are working on are not going to be a surprise to any of the commissioners. but some of the areas of focus for us could strengthening core services, we have been working on for quite some time trajectory for the department which includes development of the health network, strengthening infrastructure in a public-health division and

integration of those two divisions functionally across the department. we will continue that work and work on projects such as electronic health record. our strategy there is where we need resources for those priorities to realign them from within our existing budget we have room to do so, without asking for expansions of programs or new full-time equipment positions. we are working very closely with the mayor's office in our other city departments on priorities including homelessness and public safety. so we expect to be part of a number of those initiatives that are in development in the mayor's office. we are planning on creating a department wide lean infrastructure. as you know, we rolled out lien at a number of divisions corrupted departments and those are loosely coordinated but we want take the next step and really build a centralized department

wide gpo kpl infrastructure to prioritize and manage lean efforts across the departments, corneille goes with one another and then very importantly, for a lot of reasons focus on revenue maximization. whenever big goals as with the federal uncertainty the economic uncertainty, is let's do everything we can to solve our own problems and make ourselves self sustainable by growing our revenues really can earn them and where we are not dependent on policy decisions to generate our revenues. so items that you are likely to see before you in some form or another on february 21 or by the point of the mayor's june 1 budget summation, our continued planning and budgeting for the electronic health record system. that we are close to having that program fully funded and should be able to have the

bulk of that funded at the end of this two-year budget cycle. development of a 15 bed addiction and mental health program at the dss g campus the hummingbird navigation center. implementation of the whole person care program, which is coordinating resources around the homeless population in san francisco. after a year of experience with the us that she new building and operation we are refining what it takes to operate that facility based on actual experience and so we will be making some adjustments , the budget for that facility. we have to transfer the ems program from the department of emergency management that was approved in last year's budget but it actually happens beginning on july 1 that we officially receive jurisdiction

over that agency that will require some budget adjustments. then other programs that you've heard about including harm reduction and syringe access and cleanup efforts. so at the very highest level, the challenge that we are tasked with addressing in our budget summation to the mayor's office this spring is summarized here. you can see in the first line our general fund reduction targets of 18.4 and 36.9 million. the city has also forecasted some revenue growth in the department of public health as folder that into its five-year financial forecasted that money has already been spent so we have to cover those dollars for four we can use any dollars to solve our challenges and then continuation of the electronic health records project and so you total that up over two years. we have

$88.3 million gap that we are solving through the balancing plan that we will be bringing to you at the next hearing. so the next steps coming up again another hearing on february 21 in the interim we work closely with the mayor's office and the board of supervisors on changes and additions to the budget submission approved by the commission. june 1, the mayor introduces balanced budget to the board of supervisors then the month of june is spent with the board making having hearings in making amendment to the mayor's budget before final approval by the board in mid july and signature by the mayor in late july or beginning of august. so that was a lot of talking and-sorry about that but i'm happy to take questions.

>> commissioners, questions great commissioner pating >> thank you mr. wagner. i five little questions. first, though we heard in november you give us a plume and very status of our budget and imagine a 3% savings but since that time, other than the election is anything changed in the scenario significance since will be discussed at our dining retreat in november? >> yes. the fundamental picture looks roughly the same. i think what we will have to do is have to once we have the final rate on employee costs growth, so wages and benefits, we will use that to adjust the projection of show you earlier this year and then we will also adjust-we had forecast of roughly 3% rate of general fund revenue growth in the presentation will adjust it to what the actual numbers that

are included in the mayor's budget are and then we will update that scenario but those changes are not going to be huge. the underlying dynamics of what we talked about at our retreat a few months ago stand and so we are pursuing kind of the same path and a lot of the same strategies as we work through our budget planning as we discussed at that time. there are some changes. there have been some changes to the dollars available to the counties through the 1115 waiver. there was a pot of money at the former safetynet care pool dollars the were in question at that time as to whether those would be awarded to counties through the waiver. it looks like they will be awarded now. so that is some revenue that will be available to us to use over and above what had been projected to balance the budget so that will be one of our solutions. get a

piece of uncertainty that's out there that we won't know the time for this budget process is we are, for electronic health records project, we have put a lot of energy and effort and analysis into developing a projected budget but it is projected and will become real until we have gone through the process of selecting a vendor, developing a program, finalizing an implementation plan and at that point i could change with a projected budget is for that program. >> given some of the risks out there both federally and in terms of the economy, i think 1% savings is not too hard. 2% savings, okay, we got a be a little more focus. 3% is like him and now we have to think a little bit. given some of the risks out there i'm wondering though whether we should be looking for a worst-case scenario as well of 4-5%. whether you could plan for us or he just give us a sketch in a future meeting what a

worst-case scenario could look like >> if i may commissioner that's a great idea. we are starting to work on it but i want to be cautious that does cause a lot of panic within the department when we start doing that from a larger discussion that but i have asked staff to start looking at that but let's be cautious because i'm already getting those kinds of conversations within the departments. we just need to be very clear that is not a directed by the mayor but we are planning. so i've asked each of the divisions to also do that. but let's be very cautious in the conversation only because i want to make clear that that is not part of the mayor's directive of the mayor, of this secure, but it is something about the had conversations with staff about. >> i'm very satisfied with that. i think the 3% target then is i think we discussed that. it was reasonable and achieve those five-year goals. three other short questions.

reserves. i know we have each art reserves. we have other reserve parts that might help us with some seasonal fluctuations that block to dph? can mean lower savings from one year to the next? >> yes. we have three pots of reserves. we been building up the funding for eh are as you say in a pool of funds. those funds are to take a fund that carries over year-over-year. so we are confident that we can bill could that fund until the dollars available to spend when we need and that's been a strategy that we have cleared explicitly through the mayor and the board of supervisors and the comptroller. the second is that we are built-this is also part of the strategy even through the years we've been working on a strategy for the recession, and that is, we have a revenue reserve that is

through a special provision in the budget ordinance which has allowed us when we've surplus revenues to in conjunction with the controller's office deferred those revenues into a reserve so that they are available if we do have a shortfall. so please happen on perceived reduction in our revenue, we have a racer built up in our reserve is built up now to about $100 million could all have to get you the exact figure but we have been building that methodically over the last several years and has been one of our long-term financial strategies. the third is that each year as we accrue, as we booked revenues, from the waiver and other federal sources, we do reserve on the general ledger against potential take back from the

feds should so there some additional reserves purchased put on her books as a matter of course. so those reserves i think are a big part of our strategy. they are probably not enough if there is a fundamental change either in the economy or the policy environment to whether that but they will put us in a much better position than we have been in the past when we've had these big changes in economic environment >> really happy to hear that. when a matter parking meter i don't have change is very frustrating to find that extra quarter. >>[laughing] last two questions are more operational. i know we provided lien operational enhancements to improve our system and operations. is lien applied to our financial systems as well and as lean offer any cost savings in any particular break we've does lien also mean were going to run a leaner or just more efficient in terms of operations and quality? general question but i was wondering if there's a financial aspect agreed

>> a couple things visit the big aspect of lien to making sure you're getting the most out of every operational dollar that you spent and that's a big area focus. another big one for the coming couple of years is to apply lean tools to key areas where they can affect our revenue cycle. so the hospital has been very-general hospital has been very focused on applying lean to work on its patient flow issues and that is both a care quality but also fundamentally a revenue issue because we have lost revenue due to people occupying beds that were not being paid for and if you connect celebrate that so there's a lot of revenue upside. another pieces as were going to dhr and we talked about this at budget committee today, is we are undertaking an effort to do a lot of analysis and

standardization of our workflows on the revenue cycle all the way from the point at which we first encountered a patient to the point at which they cash is collected. so over the next two years we will be doing a real overhaul of those practices and using lean as a tool to approach a lot of those areas and that is one of the big efforts that we are focused on is how do we, number one, make sure we hit the ground running with a new eight ea charts were bringing in cash for we also use this as an opportunity to make sure we changed our operating practices so that were not leaving dollars on the table. think that's a direct tie between the lien investments that were making in our financial strategies that we outlined in our forecast. >> great. class questions we have all our physician positions posted? are we-i know one awfully staff yet but

i guess all the position to early think we go are going to need in the current budget or allocation? >> yes., we have as long as i've been around even in the darkest financial times, the core clinical operating positions have not been a subject of a hiring freeze. it was a point long ago when-well not all that long ago, but a certain point time ago that was the case but we generally have an agreement on positions with the mayor's office and hr. like rns and basic operations for the hospitals that we don't try to hold those are because of you don't hire those positions when the pain for them through per diem overtime registry anyway so i'm fairly confident that we will be able to manage a lot of those positions but that the larger point is

definitely folded into our planning as how do we put the right controls over hiring without sacrificing our patient clinical quality and our financial outcomes due to inadvertently freezing the wrong hires. >> thank you learn much >> commissioner loyce >> thank you mr. wagner. on slide number four there's a note that says digestive 1% parking business, and. i'm not sure what that means. unless it's connected to what's on slide number 14 at the bottom which is a note that says some of the same things. >> let me ask the expert here. >> i would like to note mr. wagner and ms. louis for were

very sick in the past week and just commend them for the work in getting this to you for today. >> that answers my question. b so we will figure that out. this is why that's pulled directly from the comptroller's office. so i don't know what the, and, is. i think we cut it off but when the comptroller's office their revenue numbers there are a whole lot of things that they have to fold into those. so the triple flip has to do with a deal that was made to exchange various revenues between state and local governments and it affects how much you count as local general fund revenues versus state revenues. i don't know the answer we can get clarification from the comptroller's office and how they do find that and what that budget is >> is that related to slide number 14? the general fund revenue streams week because of it is that makes then that my aunt, that make some sense to me.

>> i'm sorry could use it us part again? >> on slide 14 if you look at the bottom the general fund five revenues business hotel sales and parking tax if that's the same thing that's on slide number four after the and, then i make sense. it's not been okayed >> that might well be. i think might what's on slide four is the comptroller's office putting a footnote to be clear for anybody who is in the deep weeds of state counting funding relationships to know what's included or not get on slide 14 those five general fund revenues are those our biggest general fund revenue sources and so with the comptroller's office has done in this projection where they're saying what would a recession scenario look like, is they are modeling potential drops in those five

revenue sources to project what a recession might look like. so they use the former economic data and apply to those five areas. they're not modeling a reduction in state revenues. >> thank you mr. wagner. >> any other-commissioner? >>[inaudible] [off mic] >> yes. that is correct. what were looking at as for the hold upon a public health. when you take the adopted budget from last year for fiscal year 17-18 because the total number grow or not. >>[inaudible] [off mic] >> absolutely. were doing some of that were we a priority areas that we are adding ftes over pulling from elsewhere within the department to support them so that it will remain neutral

>> i do want to comment, too, all the divisions and leadership in very very supportive of acknowledging that and looking at they can seize and reprioritizing within their own and also sharing with others. so we can continue to do the great work that we do. i do want to acknowledge hospitals as well as the other divisions in the area. >> commissioner sanchez >> i think it's an excellent first presentation given the citywide strategies rejecting his gives us [inaudible] with the strategies are and how we [inaudible] in the context of the budget. the only thought i would sure at this point as we move on, also, i really think the chart showing the years or months for recession flow tipping point and then starting up again is really very helpful

but it may be think about, you know, would last four years we really have been involved in unique partnerships. some that work and some that are not worth. some better work exceptionally well. when you look at the data which we are doing and when we share the data as we've been doing with other agencies and here in the city, i think we really need to take a look at that data again especially as we look at the question of housing, homeless, seniors, that trends. you name it. how do we maintain middle class-no question of families, schools etc. but when you look at as an example, numbers, in 1970 with 90,000 students. 95,000 students in the public schools. today we have less than 51. okay we stop school sites all over here. perhaps we need to again look at instead

of building these 18-20 story condos, whatever, why not think about can we provide different services in an integrated fashion using some of these old facilities which we made into beautiful housing for seniors, for handicap for that's, for families but in different parts of the neighborhoods all over the city instead of just concentrating on a couple of them. other cities are starting to do that because they have to rethink this whole housing problem is a real challenge. i guess what i'm saying is, i really think the way this was presented, it gives you just a unique thought pattern but as you look at the data from past and where we are in the projection for five years we have to rethink the city itself and the totality of the city. and of comments, but again i

want to thank you for an excellent document and your staff and it's very informative and look forward to the next hearing and presentation. it's a real challenge but we are right on target and am glad to see were projecting the five years ahead and having the integrated models. thank you >> thank you commissioner. >> thank you. are there any other comments? was there any public comment >> i've not received any request for this item >> okay. so if there's no further comments you look forward to the next hearing with the details of the city departments budget will be presented. >> thank you >> thank you damage >> item 12 other business >> commissioners any other business that you may wish to present to us.. we might take note of thursday's meeting with

the planning commission which will be held in room 400 at city hall. >> yes. at 10 o'clock and have remained for the russia be available to prove those who are driving. it's already for you >> all right. so there's no other business to be brought up by the commissioners, then we will move on to the next item gave him 13 is a report back on the generate 24th 2017 usg meeting >> yes the committee heard the presentation for the 2017 plan from the director from our executive director dr. relic, which included looking into the areas of the workforce care and the bauman financial stewardship care experience quality and safety as part of [inaudible] and she is compressing the targets for these down to i believe seven

that was an excellent presentation. as to the use of lien and helping and two n. will be leaning this years strategic planning. to respond to the needs that were surfaced in the past year. at the same time then the committee then proceeded to take the standard reports from the quality advancement regulatory affairs, hospital administrators reports, human resources report, showing continued vacancy but working on that of approximately 10% and the outpatient care services reports. under the chief of medical staff reports, the committee also approved the following. a new cpc service chief for a new lab service chief. it approved medicine privileging divisions. it approved also the end of life

physician opt in form and the community primary care critical services will send regulations were presented for approval. so those were all approved by the point conference committee and enclosed session it also reviewed and approved the minutes and the credentials report. i'll be happy to answer any questions that anyone may have. otherwise you all cds in a more detailed report in the minutes. if not we will proceed on for next-there's no other committee reports quick >> no., sir >> okay we will go on to the next item >> item committee agenda setting and read you review the counter so unless you've other items we can move onto consideration of adjournment >> so we are open for a motion for adjournment. all those in favor say, aye. [chorus of ayes.] opposed, say nay. this