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tv   Government Access Programming  SFGTV  October 5, 2018 9:00am-10:01am PDT

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construction at zuckerberg as well as the clinics and joe will go over the scheduling. so this is just the chart we've been showing for several quarters showing the first bond sale that occurred in january, 2017 and the portion of the $176 million or $150 million broke joan down by program area. this is just the high-level version of the 272 portion of the bond that was $350 million bond in june 2016. this shows you we're spending just under $30 million of the $146.5 million which is a little under 17%. we should have been spending higher than that. one thing that slowed us down and teri and joe will get into it is the vast number of the enables projects to make room
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for dialysis and public health lab, there's a huge impact and occupant have to be moved around and space that has to be switched out. that's one reason our spending isn't as fast as we we projected it to be. at zuckerberg we were spending $22 million of the 29 million. you'll see the construction and mobilization is going to go way up. the project control is mostly design and permitting and those types of fees which aren't as great as the construction. then this is the financial picture at the clinics. we're spending less than $8 million there.
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i'll turn it over to teri. >> afternoon, teri salts, capital planning for zuckerberg. this is our accomplishment time line for building 5 work at zuckerberg. the first in july since we saw you last in june was development of the sight programs. we made great progress throughout this period and it's going to be a very complicated project with a lot of phasing because we'll be building it while it's occupied. it has a high risk factor but we came an agreement to the end users on what works best for them so we're happy about that. we started the mechanical core infrastructure study to figure out where we want to go with
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mechanical and got the first report back and just being digested now. there's added information we're waiting on for real-time air balance numbers. the seismic work we bid for the phase 1 work. the purpose of doing the phase 1 work is to primarily in the space of 80 unoccupied so it will give us information about desk control and noise control and out in the way of the ucsf building construction first. those are going through the procurement process now and they're work on the construction by the end of the year. we're doing fit studies.
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we are in construction. we started construction in the search space and working on the rehab construction and the i.t. infrastructure project has been submitted for 50% construction and development and we're working on the electrical corps studies. we have civic design approval for the southeast center and updates three of maxine hall. we saw approvals for craastro mission. we engage the art commission at the southeast health center and they have a short list of southern artists for the program. we submitted design documents at
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the hall and they've been approved by d.b.i. and we're doing assessment at chinatown and also for ocean parks. with that, i'm going pass the baton to joe. he'll talk about time lines and other construction progress. >> good afternoon commissioners. joe chen. my presentation is focus on the upcoming milestones for both zuckerberg building 5 component and community health centers. i'll focus on the zuckerberg building 5. we have two projects the service space it started early part of
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2018. it shows the demolition has been completed and we completed they'll hazmat and now in the framing portion. the next few months what we'll be anticipated is finishing framing and doing all the rebuild of mechanical duct work, plumbing systems to put everything back together based on the new program. and we started the program during the summer and we got this approved and we're in the midst and a lot of the projects are going to go through the same series of steps with a plan approved and start the hazmat abatement because they are existing building from the 1970s with things we know of that need
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to be department with abatement versus standard demolition. then moving on to the bidding phase. we do have one project much retrofit and the bids came in higher than expected and we repackaged them out for rebidding. it will impact it slightly but still anticipating to get the contracts on board by november and get the work ahead of the ucsf project and other projects. the next se projects i won't go through all 11 they're on the slide but they're going through plan review or in the design phase or just in the early phase of programming and planning. in a nutshell we've been
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tracking 19 core projects. if you do the quick math we're actively work on 16 to 19. a lot has been done since the bond was passed. there's also one project that's not finished urgent care and signed off but we're going through licensing right now so the space is pending licenses to be used for the intended purpose. and on the proj center we're focussed on finish design by first quarter of 2019. for the bidding phase and construction to start towards the end of 2019. i want to highlight as part of the design process is to go through the commission to seek approval. we got our civic design review phase two approved in september. we are now tracking for phase
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three which is towards fourth quarter 2019 and another subset of the commission involvement is the selection of the public artists from this project and there's money set aside from this facility. we short love listed to seven short-listed to seven and identified opportunities for art and going through the final selection of the artistses for the facility. -- artists nor facility. and long-term schedule finishing design by early part of next year and bidding and construction starts the latter half of 2019. then on the community health centers, we've been tracking two main projects, the commission and seton hall is ahead of katherine mission. we finished drawings and now moving to the bidding phase to start this month and that will segue to starting construction
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by spring of 2019. so maxine just to remind the commissioner of the scope it's a retrofit and renovation so it's a substantial scope and for caption commission we are working towards finishing design by end of the year. and going threw -- through bidding the first half of 2019 and construction by summer of 2019. and overall, all the other clinics. we're doing an assessment of the clinics we're not currently doing work on the 2016 program. we've done assessments at chinatown public health center and finishing up assessments at ocean park and city clinic and there's others on the wish list
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as well. moving on to the schedule summary. we've worked hard to come up with a schedule format we feel conveys information the commissioner's looking for bud simple enough and easy to read. i can spend a few minutes to walk you through the new schedule format. on the bottom of the page is two legend to highlight what the colors mean. we have three colors for the bars. the red is the baseline schedule. we have the yellow tracking what was reported at the last meeting and gre -- the green is
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tracking what we're tracking at the moment. we broke it down to three activities to simplify it. it comes to design, construction and transition. design represents on the r&d -- right hand corner there's a legend and design we rolled up what we called programming, design and award all tracked under the design line item. we have construction which is our traditional construction with contractors doing the work. we have construction duration and punch list and the last is transition activity and this is what happens after the project's been completed after it achieve substantial completion and is turned over to facilities to do the next series of activities whether it's affecting the insulation. we have light training, licensing and similar activities. so that's quickly how to read it.
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we didn't want to track every single project and we have urgent care we just completed and there's a vertical blue line it shows a snapshot as of now and the project status by graphics. right now all three bars line up. what that means is we're tracking to a schedule contractor and we're looking at baseline, previous and current.
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this is slide 15 and a lot of the programming projects are discussing what they think takes going through the programming phase or design. a lot is driven that is out of our control sometimes. and the last slide on the schedule is 16 and we're tracking maxine hall, the mission and southeast once it's completed and the health center doing the assessment. i'll turn it back to mr. primeau for the ucsf update. >> commissioners, i'm just going
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run through the escrow documents an ucsf can signed the ground wave. we'll talk about the uc project. >> michael bide the university program architect. >> we're officially moving on to item 10.
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i'll note there's no public comment request for item 9 and you can move on unless the commissioners want to -- do you have questions along the way or is it okay? >> no, we'll finish the uc presentation and then we'll ask questions of the entire project. >> this slide is to remind you where the site of the building. i'm sure you're familiar. the time line is on this slide. we are tracking to finish in the second quarter of 2022. at the moment we have procure the general contractor. we have done that at the outset of the project for large complex projects an create a team for
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the architect and engineers. we're at the moment we're working with a general contractor to procure those entities. everyone is under one contract. so the front end is complicated and somewhat slow but allows us to move briskly once the team's in place because the cost estimates by the term of our contract we end up not having to have a complicated bidding or buy-out process because we've done that along the way so we can move into construction briskly. the front end of our projects are always little slow and then we get going.
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by this time next quarter when i come back and talk to about all this we'll be in design. that will be early next year. that's our report. >> thank you. >> questions? >> questions -- commissioner green. >> i have one. first i wanted to thank you for the program schedule summary. it's really understandable and i really appreciate the modification have been made. i have one question that's probably naive, i was looking over slide 6. it appeared the finance cost proporti proportionate to the organization was higher than the community health centers than the hospital. i was wondering what explains
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that? was it timing or location and confused and wanting clarification. >> it depends on the scale of the project and the project controls are pretty much fixed so where zuckerberg because there's a larger number the same set of things, the permits, and design the percentage drops dramatically. it's often said that at public works and other agencies to get small projects done costs an arm and a leg because of that disproportionate ratio. >> thank you. >> other questions? i was wondering on slide 9 when you talked about the final report on chinatown.
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what happens to that report that one says phase two and the others say phase one. maybe you can differentiate. >> thank you for the question. so what we consider phase one assessment is making assumptions. this is the first crack at doing theize mick evaluation use -- seismic evaluation use condition based on previous reports and doing computer analysis and coming up with what they think is an appropriate seismic hazard rating as hhr is the terminology the city uses to assign a score to every city asset. phase two then goes into more detail where we bring onboard a
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geotechnical engineer and take sampling at the site we're doing assessment and may possibly do disruptive testing of the existing facility and take samples of the concrete or steel to validate the previous assumptions. so we always look at a two-pronged approach. the first is the quick look at it to make sure we know what the building is being evaluated at and if then do an evaluation stage on the back end. >> the final report is issued. what do we do with the final report? >> it will be provided. and there's recommendations from
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the report. we can create a new project to do whatever is recommended. >> dr. chow if i may -- as we go through this process and we've been doing this kind of consistently with each of our facilities as going through the evaluations, that information gets fed into the city's capital planning process and the capital budget process. so each year as we get better data on seismic condition and need, then that inform the prioritization of how city wide dollars will be allocated to different projects. that's the process we go through that becomes the basis for how the funds get allocated in the capital budget. >> very good. thank you. >> let me add to what mr. wagner just said.
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he's right on point. we're taking the accurate geotechnical information from chinatown and have programmed that into our request for next year so we're asking for $3 million to further go into design to understand the pressure of the soil and how the building will react and the seismic event and physical year 2021 we're asking for about $15 million. we're doing the groundwork that lays our ability to request funds for the next set of projects. >> thank you very much. in that building as , as we all know, doesn't sit on soil. it sits above a tunnel. where you go to find all the foundation, as a matter of fact,
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yeah. >> i can give a quick summary of the foundation system for chinatown public health center sits on piles or stilts. the building is way up on masson street and there's a column that bridges the gap all the way to a solid surface of soil suitable to support a building. >> okay. those of us just want to be sure the building is going to stay. >> commissioner sanchez. >> i have a question. you mentioned as we proceed on the retrofit phase. i think someone mentioned or maybe i wasn't listening closely that it seems it will be a higher figure than anticipated
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but i do know a lot of the contractors are having difficulty pertaining to their workforce goal. here we have this major effort here plus the ucsf building subject to some rules and not others i hope -- we'll probably get there's an as we always do but when you think how we built, you guys built and the old sfgh in '82, we didn't have these challenges then as far as the workforce and all the parts where construction workers come from different countries, asia, latin america and a lot are not available now as a workforce
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because of federal policies. that affects us here. i can see costs going up in critical areas and hope we scan still -- we can still maintain the training programs pertaining to workforce i think we've had good outcomes but we also heard about saint luke's and whatever that a lot of these people over time are not working in the areas because of the high cost. it's like when we recruit our health professionals and staff to take care of our patients, we have a heck of a problem because of cost of living and all these other springs and we had a problem with the state those doing the approvals their budget cut and we had to wait a year and a half in order to proceed which cost dollars.
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i wonder if any of you have thought if you feel there'll be a significant increase in reference to cost based on the variables hitting us today that weren't hitting us when we undertook other efforts especially in the retrofit. the six-unit apartments being retrofitted now will have to pay fines and the city's enforcing that now and all these things are coming at the same time and i can see headaches. >> there's no question. regulations are getting stricter. there's a different treatment of sizeman building to performance and relation to a fault line. what it's doing to the city's infrastructure is some of the clinics that used to be good buildings in terms of how they would perform. because of the changes in the regulations, now they're going very poor.
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and we're finding out they're doing seismic where 10 years before we were okay. we're building in the estimates reserves and the pool of resources you talked about that are shrinking is factored in. now when we ask money nor -- from chinatown and other clinics there'll be 40% or 50% or higher just to account for what you said. it's on the radar, thank you. >> thank you for the program schedule summary. you have written it so nicely.
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i can see and understand many projects you are on what you projected. but there are several that are significantly different. explain dialysis and the mental health rehab center you've got a baseline and in dialysis it doesn't occur for an entire year in terms of new projects. that's on page 14. >> thank you again thor the question, commissioner. the reason for lab is when we did the initial baseline we did not take into account the
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interdependencies. it will be in the same space as the rehabilitation department project. before we can start the dialysis the it has to be done so we were looking at a project by itself. now we understand the dialysis and public health lab -- the space of the rehab department moving in the third floor of building five that is available to start construction until it can move out fully licensed. then we can start the project for public health lab. that's the reason why there's such a huge gap for the two projects in particular. >> i can tell you also, commissioners, the nature of this one very different than some of the projects then we've done in the past where you've seen this type of schedule. the reason is what joe is saying
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we did the leg work up front to estimate the time line but until we got in the detailed programming and scheduling of different pieces, there was no way to have a schedule as realistic as you would have seen for example on building 25 or one building and we get to make choices about how things are sequenced more accurately. have you so this things dependent on a previous project to move, it took a lot of leg work and effort to get us to the point where we had a realistic schedule. so the red lines you're seeing here are kind of more reflective of what our best guess was before we were able to do that technical work and really set a schedule that's realistic and so we are watching the time line compared to the past but some of
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those that moved it was because we didn't have enough information to set a realistic time line and so we had to reset and say now that we've done the scheduling, the sequencing and technical work we have a real baseline to measure against the projects. >> thank you. >> that's why i think this is good. the ucsf building, do your time lines match -- most of you -- the department has it on our program schedule and then you have it on your ucsf schedule. are those two matching? >> we have nicer colors on ours. >> we had more money. >> we incorporated it into our framework so we're aligning
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exactly the same and i think teri said it best, we're concerned about the south side of the building that's adjacent to the parking lot because that's where they're going to be building. so michael and i worked out a pretty coordinated phased roadway where we temporarily moved things out about 75 feet from the building and then comes new construction and it creates that separation between our building and his building. so the good news is the city attorney's office looks like they'll complete the title of the mcinnerny act which allows the ground lease to be signed and escrow to be completed and then we can start the roadway work before we start the
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building, which is optimal. as mark said, getting the south side of building five done first frees that to happen without interference. so i think we're in a good state. i will add that we, like you, are affected by the lack of construction resources and we have four buildings in construction now and it's tough, it's really tough. we're all having to take these unfortunate circumstances into account. any further questions at this point? i appreciate your update. thank you for -- for all three of you coming and we'll see you in a quarter. thank you.
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>> item 11 is the epic organization change management update. >> good afternoon i'm winona mindolovich. i'll give you a three-part update on i.t. first is on i.t. itself, our accomplishments, status, some of our challenges and a look ahead. then i'll give you an update on the epic project and dr. albert yu will give you an update on organizational change management key to the success and implementation. this say -- is a visual of our network closets before and after. i hope you can see the state it was in before which was full of clutter and lots of wires
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hanging out of it and afterwards we not only cleaned up our own equipment but the extra stuff stored in that closet. so we have 77 of these network closets throughout dph. we upgraded 38 and plan to complete the rest by 2019. this provides better connectivity for the devices in that particular area and replaced the uninterrupted power source so if the power's out we'll have the connectivity. we've got our workplace and printers and have virtualization and keeping the lights on and we have lots of staff that are keeping the lights on for other systems and maintenance. in terms of other epic readiness, we have been working on the wireless networking. we have done asurvey of 100
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areas over the first wave of live. now we know what we need to do. the cables have been oornd -- ordered so we can have readiness before we go live. we have a new network between zuckerberg general to give us greater bandwidth and we had virtualized over 800 servers. we have about 75 left to go. this provides easier maintenance and more redundancy for users and less outages overall. because of the server -- we worked on virtualization of the work point and we did that at zuckerberg and hond da and to give you an example of what that means to the end user it was taking 88 seconds when you booted up your work station.
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it's now taking 31. it used to take 157 seconds to get if the first application. it now takes 71. so they've seen a faster response and they're using their badge to time in and they get multiple applications. the application has been successfully submitted for 52 metrics. we recorded performance. and dph can now look at the incentive payments for that. and network remains at 99.93%. the next slide you'll see a change from 2015 to 2018. in 2015 we did not have a tool to measure uptime and that will now so that will be the benchmark going forward what we did have is an mod event, a manager on duty so if a system
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was out or had a large outage it was escalated to the manager. that's been reduced from 2015 an average of 11 outages in one month escalated to a manager on duty to an average of 2.67. so drastic reduction. that points to the work done on the infrastructure. unresolved ticketing. we had over 5,000 tickets last month on the service desk. in 2015 we had 40% unresolved and we're continuing to work that down. we did random sampling and it's down from 38% satisfied with the service desk to 88% in 2018. so significant improvements in our customer service focussed on standardization and training for them.
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information governance is not a function but it's critical and necessary to utilize the wealth of data from h.r. systems that are going to be decommission and data to optimize patient care and further research objectives. the epic install is the actual opportunity to do the governance we didn't do before. so this governance steering committee was brought up over 18 months ago and you'll see a number that ensure data and access. -- data integrity and access. the data governance groups worked with a group to determine what data we'd migrate to epic and what we have to legally archive and score. that was time sensitive to do
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sampling of that conversion into epic and that's started. there's been a managing of aligning with the city's digital service to make sure we have the same look and feel and provide a service rather than just putting up data people may not be interested in and the first change you'll see over time is the website will be rebuilt. a welcomed change. probably the greatest challenge now is i.t. staffing. we have over 51 open positions right now. we're working closely with h.r. to close those and make sure we have a qualified applicant tool. i reported our priority was hiring a chief information security officer. we're in the process of closing that posting and we'll do an
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additional assessment and we're working with a hippa audit coming in. we're kicking that off and we have an external consultant existing us with framework setup so we're being careful about security. it's high priority for us. >> and d.t. is city wide. >> technology, sorry. and the wave one epic program director and chad is very successful and in his last install which is four hospitals in oregon using epic foundation. we're happy to have him. problem is chad does not want it stay long term. he wants to stay in oregon so we are recruiting for a long-term
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epic program director we want a transition as long as we have chad here. we've been ensuring good candidate scores. and they're doing an effic install. we have consulting companies to try to recruit them after they go live. we want to work on how to retrain those staff and looking at telecommuting and things with hr to keep them here. over the next years 17% of staff will be eligible to retire. we're working on succession planning and we have a very robust program that bill kim
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start and we're continuing that process and we're working with other colleges and university to do interim perhaps to do a path of -- programs to do a path of people coming in. not only construction is having problems but so are we in term of hiring people. in the next few months with virtualizati virtualization we have to be metric driven in how we're staffing. epic install we staffed looking at lots of implementation. input from our consultants that we are also getting feedback that we're complex and we need to relook at our model for ongoing live, sustaining effort. we'll be looking at that over the next month or so. what's head for ic.
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and in general management is hard because everything has an application. every single we have 55 systems to decommission and we're focussed on security, as mentioned. in 2014, bill kim came to you with a strategic plan. we have succeeded in that plan and we're looking ahead for the next three years and we'll be coming back to you for what it looks like and how we're professionaling with that plan. we're installing a new service management tool to handle incident and service requests an changes and that will be piloted later this month. to the project update. we're in wave one of the epic rollout. the first includes zuckerberg
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san francisco general and laguna honda hospital and phase three clinics and there's an adoption and build configuration through direct setting and the initial adoption sessions an now we have completed,000 and subject matter. the team is configuring the systems and there's over 21,000 to make and the sessions that are going on now and the decisions being made are how we make it unique to dph. they're downloading our financial classes, clinics, orders and master sets and on and on. the current efforts, the time line is short from january and now it's less than a year from august 3 when we go live. we're using epics foundation. that's a tried and true model
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and chat is -- chad is bringing experience so i'm sure we'll make the live date. right now the focus on the build has to complete by november 28. testing will be coming and we go live august 3 of 2019 with post-live august 5 through november 8. we debated a lot about what to give you. if you want more detail on the slide we're happy to change this and do that but we tried to keep it simple where we are with the time line. a little bit about epic, the
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staff went for training in january. we began the procurement of the 85 third-partee -- third-party systems and then a logistical challenge with 230 changes with subject matter experts that attended. our team as i reported in july, our of our staff 100% that went to epic to be trained and went to wisconsin and they all passed and are currently working on the project. super proud of the team. the project plan was completed and operations and orientation or the orientation happened with operations team as they got to see what epics looked like. we're currently in phase two the content build which are build buckets one through three. adoption sessions one and two happened and groups were established.
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this is our status report. green indicates we're on track and yellow is on the watch it state and there's no red which would mean we're in a critical state. the design and build is current currently green but it hovers on yellow because it's not would a lot of focussed effort we retain the green status and sure we will at the end as well. it's absolutely critical. they're in phases of the build and there's a number we have to do to have testing successfully. we have contingencies in place. the teams are working on testing scripts and we have a testing manager engaged and it looks like it will be successful.
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training is yellow because the initial site that was going to house most of our training -- we've ran into difficulties in work out how to do that. we're focussing on how to get that back on track and believe we can do that with the site and have our training rooms ready. interfaces are green. they're on track. we have 125 interfaces with epic. are teamed are prepared and have been doing testing. technology has been on track and i've talked about the success. good live is green because there's nothing to stop it and contract and budget are in a watch state. the changes were up to 72 contracts have been completed and we have a few that are in the medium to high risk. so we're still watching those. we don't have anything stopping the project now but it's been tough it get all the contracts through.
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budget review process is in -- we have the budget review in progress right now when we're assessing our initial estimates. so to make it real, we're adjusting that and will bring it back to you. next wave the maternal and a adolescent health and there's material health and lab and now to doctor yu to talk to you. >> good evening, commissioners. so i think it was you, dr. ciao who -- dr. chow, how we're engaging staff in the implementation process and i'll walk you through the structure and how we're engaging our staff and leaders in that process.
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we before we signed we knew it was an operation project not >> t project. that means planning the installation and training to make sure the user understands how to do the daily work. not so much navigating through an electronic record system. they're primarily service lines end to end the continuum of that particular service whether there's an emergency room service or patient environment. on the right side you can see they're relate to revenue cycle service lines where there's medical record, billing and chart or patient and scheduling registration. those are current domain groups. there are certain pieces because we have to have adequate input from the business. this give you a sense of the governance of how we are
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managing, planning, monitoring and tracking it. i'll start on the top and i'll walk you through the bottom. then i'll wrap around how ocm and leaders and star are part of the governance. at the top is the executive team. a handful of people including craig, wagner, roland pickins, allison chan and winona and myself around obviously our vendor consultants and next is the transition executive team. this includes the top executives of each divisional tower and hr., i.t., that teem is the ultimate authority on epic configuration, built, design, training, go-live, planning. any decision around that. there's a program management
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office administered through kpmg. the yellow boxes are important those are leaders and frontline staff we organize into four groups. patient care includes clinical operations as well as patient access and leadership team. i take that back, it includes clinical and operative administratorive folks and the council is charge, capture and h.i.m. information governance and the technical council interfaces integration, >> t infrastructure and the council charged with those types of decisions. the two parallel tracks that are vertical are important. the green is the project team. that's where we have loss of new
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hires and the project teams are designed around the modules an applications. this is the methodology whether it's the emergency service team or labor and delivery each are staffed by epic hire or technical leads and workforce analysts that have been transitioned in into the roles to support the discovery of that content that needs to be build and configured. on the left side are the domain groups i highlighted in an earlier slide. on the bottom there are clinical champions and supervisors and we'll start identifying the
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super user and they become available when we go live as well as with training. here's what we have stood up in the last year and a half or two, the office of informatics team is housed and represent and as well as the ocm organizational change manage plan. they're managers and make sure when they identify a gap how it gets tracked and input from the business to inform how we prepare staff to be ready when we go live. that's what the ocm managers and
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groups are trained to do. i'll walk you through some high level target to look at how leaders have been engaged in the process and so in the groundwork phase we we had high-level executive leaders making key organizational scoping decisions. there were 94. they also identified 12 of 30 benefit realization project indicators that epic asks customers to commit to and post live to track and we have 133 senior and executive leaders to organize around that phase to do the initial planning. in the direction setting, winona alouded to the session and we have 962 subject matter expert
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participates in those three-day events in the month of april. and we had about 1900 or 2000 or so work flow-related decisions made during the direction setting. during this phase, which we're still in. clinical system design sessions are the peptic -- epic project team work a handful or so frontline staff to tell us how you're organized, how many providers and room and those are the sessions to build it. and we had experts that are participating in the variation domain groups i highlighted two slides earlier. over 23,000 that winona referenced and as of this point,
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there may be more, this number will likely change, we've identified 115 gaps or so in the various domains meaning how we currently operate to where we need to be come august 3 next year. we anticipate 80 trainers based on our organizational size and typical recommendation is 1-10 ratio per staff. we have about 10,000 end users we have to train and estimate 9,000 plus or minus a little bit more. we have the ucf folks and dph employees. as of now, we're finalizing the training schedule and curriculum. we're anticipating an average number of hours per staff to go through training is 23. that's an average. some will have a lot more and some will have much less. we anticipate a total of 230,000
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training hours across the organization. the training is currently anticipated to be organized around learning modules an they're online. sort of completion about 300 and 165 in-person training. that gives you a high-level summary of how staff and leaders are being engaged in this planning. so right now the current state is we typically schedule patients and then we do the registration and medication at check-in. we try to do a little about that and the patient financial unit tries to do some insurance verification in advance but doesn't hit everyone who shows up. so what we did during the groundwork phases, epic