and really they've been a major referral source for the interpreters we use within the network. it's amazing how things come full circle, so i'd like to point that out. we always show the department organizational chart. again today we'll be talking about the network, which you'll see on the left-hand side of this chart. and getting a little bit in more detail, this is the network organizational chart. in addition to the major divisions that you're most familiar with, laguna honda zuckerberg, ambulatory care, including jail health, primary care, maternal health and adolescent health, and behavioral health. there are also other nut units within the network. part of our journey was to centralize key aspects of our operations. so, for example, on the far

left, at the bottom of the chart, you'll see a couple of areas that are part of the network. and those are -- >> mr. pickens, you can use the point -- you can use the thing to point to it. >> there we go. thank you. so in addition to our clinical services, the network also oversees supply chain operations for the department. that's purchasing of materials and supplies. and then also we have our rehabilitation services, including occupational therapy, physical therapy, speech therapy and our health-at-home program. then when you come over to the far other side, you'll see two other programs that are affiliated and part of a network, whole person care, which we have talked about before, which is part of the

1115 medicaid waiver. and then our telehealth and language services, which you'll be hearing more about later on in the preparation. -- in the presentation. so just to refresh your memory and where we are in terms of our strategic priorities, this is what's called our x matrix. it represents the result of our strategic planning process. as you know, we utilize the lean process. and in lean of strategic planning, it's referred to as ocean condrey. it really means a compass or a direction in terms of where the organization is going and interpreter condrey represents a method by which you deploy that. this x matrix is meant to represent kind of a one-stop shopping in terms of a balanced score card, at a high level for

the organization. by no means does this depict all that we're doing within the network. but it's really meant to show where is our major focus, both in the short-term, over the next year, and in more long-term, three to five years. so to react on that, there's what we call the north box, the east box, the south box and the west box. so the north box, up here, represents the strategic initiative, that the leadership decided upon for the network. and we've got three covering this year. e.h.r. readiness, develop our people through lean, and value-based care. when you move over to the east box, so each of those strategic

initiatives has what we call an a3, which is a document that really goes into detail describing what that initiative is about, what's the current state, what problems or areas of concern that we're addressing. and so each of those a3s has counter measures and those counter measures are listed here in this section. so, for example, e.h.r. readiness, some of the count measures for e.h.r. readiness are listed here. then as you go to the bottom, it shows which members of the team are responsible, are either as owners of that particular metric or as members of that a3 team. so those performance metrics really were meant to show how are we doing in terms of the progress of those strategic initiatives and their a3s. then we move to the south box. and here we have our true north

outcomes. and you'll remember the true north is really metropolitan to be a-- really meant to be a concise set of ideals that the organization holds it to be, continuously improving in its performance to meet. true north outcomes are meant to not change significantly in the short-term. they're meant to be more three- to five-year horizons. dr. chin will give you the specifics in terms of where we are in meeting those true north outcomes, when she gives her report. so we shared this slide last time we were here. and i'm actually going to go in reverse chronological order. so in the current fiscal year, fis -- rather preparing for the

next fiscal year '19-'20, we have the three strategic initiatives i just mentioned. the e.h.r., which we called reata, standing for right information every time anyway where. developing our people through lean, which is really deploying what we call d.m.s., the daily management system for lean, which is how we bring it down to the unit level in terms of reinforcing our true north and a3 counter measures. value-based payments, really represents our journey in terms of moving from fee-for-service to fee-for-value, based upon having reimbursement based on actual outcomes. it's good to show this, because it really shows the evolution of our thinking and our ability to prioritize and focus. when we first started our planning process, you'll see we started with nine strategic initiatives. and quickly found that that was

just too much, to realistically do given our bandwidth. we sent then -- we went back to the drawing board and we began to align both with the d.p.h. in fiscal year '17-'18 and you'll see now, preparing for next fiscal year, we are in lock-step with the strategic priorities of the department, which are a data science, developing our people and homelessness and then for the network the three initiatives we just went over. so again the three initiatives, each of them has an a3. this is just a quick snapshot of the a3. it describes a problem statement. the fact that we have i believe 67 plus electronic health systems within the department. and we are moving to one integrated platform across our delivery system and that's epic. and this also then shows what

some of the counter measures are in terms of achieving our implementation of epic. for example, setting up a governance structure and tracking milestones for epic go-live for august 3rd. a3 has to do with developing our people. as part of the process for trying to prioritize and really bring focus to our process, we decided that we needed to have our -- develop our people, lean work really focuses around the e.h.r. the countermeasures involved here involve rolling out daily management system to units that are going to be implementing epic. sorry.

>> not sure what happened there. >> i don't know. oh! >> okay. okay. and the third a3 is value-based care. again this is outlining our path to move more from a fee-for-service to fee-for-value. it talks about the problem statement that we need to have better data and use of that data, in order to measure our outcomes and performances. again this is just a brief overview of what we're doing at the strategic level. and for each of these, there are true north metrics associated with each of the a3s.

and i'll go back to this. our goal, if you look at our x matrix in the south box, is that we've set the target of having achieved 70% of the true north outcome measures across aldi -- across all dimensions and review the true north score card, so you can see where our metrics are. okay. >> i'm going to try to do a little tech fix here. see if that works.

good afternoon, commissioners. so in the same way that director pickens showed you the evolution of our strategic thinking, this slide is really meant to show how our approach to true north has evolved over the years. remember we had the six colors. those are unchanging and that's the point of the true north pillars. but what you can't see is over the last four years, we have really narrowed our focus and created more alignment. so you can see we went from 49 metrics to 47 metrics to 33 metrics and next year likely 25. importantly what we decided for next year, is we're actually going to take the same metric for financial stewardship, that's going to be not increase reliance on the general fund.

and lastly, everything will be still working on own quality and care experience measures. you see that again the narrowing and focus and alignment going on. [ please stand by ]

>> you can see at a glance if we're at goal and the blue line, our target, and how we're doing over time.

this is a lot of information at a glance. this is what we're pushing out to divisions and sections. because i know tables and graphs can be overwhelming, i wanted to give you a peek behind the dashboard. the equity measure is around decreasing disparities and african american blood pressure control. what's amazing about the work in primary care is how they're able to use the data to push out to the leadership teams to the clinics and engage frontline staff. when you look at the piece of paper you'll see who, when, where, what, why. so the bottom always round the patient data in the vignette. this is not a real patient but mr. lee is always the grounding patient paradigm for primary care. it talks about partly sunny lee, that's the

-- mrs. lee, that's the who and controlling blood pressure in african american patients by this much. this is the who, what, when, where. where, you can see the clinics is displayed. each round bubble is a clinic. the reason some don't have a heart is they don't do adult hypertension and the ones that are purple are at goal. then why is at the top. particularly for frontline staff whether you're a medical assistant or pharmacist, it's important to know why we're doing this and why are we going out of our way to do this extra work flow in order to move the metric. what's amazing about the team is they've gone beyond the who, what, when, where and why to

how. the kind of work flows is they have them come back and use team-based care and make sure the people at home have blood pressure monitors. if your insurance doesn't cover it we have a supply and we're targeting african american patients for that clinic-based supply. the quality improvement is never a one and done. we would love for all of our clinics to be part of the mission but improvement is ongoing work and you can put a lot of work into it and a staff member leaves or there's a competing priority and you get the ups and downs. this slide was supposed to be up front to show you the standardization across the measures. in the last bit i wanted to give

you a sense how it fits in. dr. pickens told you about our matrix and it's now part of the larger cas case of the departmental strategic planning and divisional and sectional division plan. i give credit to our team we established a cadence so the planning happens at this level first and we have months to digest that and incorporate that at the ph.d. level and there's a gap where people have a chance to digest and how to apply it to the it to facilities and the smaller ambulatory care divisions haven't decided to do a formal x matrix or not. if you haven't had a chance to go out, the tenet is around

visual management. you can see our priorities. or staff work by the boards all the time because they're right in the hallway. what are our priority and how we're doing. for any organization to consistently communicate that is powerful. this is the one at primary care around the corner at van ness and this is at laguna honda and there's been cross-learning and learning from best practices and quality improvement and we say steal shamelessly because it's all fair game. lastly, i want to say this is truly a team effort. we have amazing k.p.o. staff at the levels and the laguna honda primary care and have great q.i. leads and the one who pulled

this data together is on vacation and she deserve as a big thank you. with that i'll turn it over to bruce ocenya. our director of interpretive services. >> good afternoon, commissioners. i'm pleased to talk to you about interpreter service and telehealth services today. both of which are very crucial service utilities and like all utilities they're supposed to operate in the background silently and they're not supposed to be noticed until they're not working. so that's basically both telehealth and interpretive services are crucial service utilities for our core patients.

it's really nice to have an opportunity to highlight them since we're usually working in the background. i'll start with telehealth services. the goal is to provide technology-enhanced care to increase specialty access, improve care quality and enhance patient experience. i wanted to add a little thing about our approach to telehealth which i'm pretty proud of which is telehealth gets a lot of buzz these days. it's been marketed a lot the last few years. but right from the beginning we took a systemic approach to telehealth. in other words, our concern was to make sure our approach to telehealth was systemic.

meaning we paid attention to scali scaling we tried to avoid telehealth initiate were boutique driven by a provider who's tech know savvy and has good gadgets and research money and you do something that's very effective and then basically three years later the paper's written and the innovation is set aside. so we really have intentionally not taken that approach to telehealth. so we've taken everything we look at we figure out how it will scale across our whole network. given that, i'll first and highlight two of the main projects we've been working with for years and two of the more recent ones just to give you a flavor.

we use sophisticated cameras that able to take images of the back of the retina and in terms of efficiency they can be operate technicians at the level of medical assistants and prior to that the effort was done by ophthalmologist and optometrists. not surprisingly, we didn't have the funds to put one of these specialized cameras in every clinic. we put them with clinics with a major volume and then in a van. the vendor assured us we couldn't put it in a van and we said thank you and we did and it's been operating successfully

the last two years. so if your clinic does not have a camera we send the van to your clinic every month. currently the ophthalmology clinic is three days and opt tom -- on tom try is one day. the metrics were counted and this is the average now in both the clinics. you can't separate that from the utilization of these sophisticated retinal cameras.

right now we're targeting a screening rate of diabetics were 65% and our screening was at 20% and 30%. this is again substantial practice improvement and very substantial efficiency boost. moving to jail health, this is a new nshtd we started month -- initiate we started months initiative we started months ago. i'm having a hard time talking.

in terms of the ivan, we started two months ago to send this to the jail and now it's visiting san bruno. thank you so much. the challenge is there's a lot of inmates who get custodial sheriff and ophthalmology was at the to the list and it was puzzling why ophthalmology in terms of jail visits. it turns out the reason for that was more for vision screening.

that was opposed to a more serious eye disease. we took the ivan and put in an optometrist on the ivan -- eye van and gone to the jails. the significant thing is we've screened 25 inmate. that's 25 inmates that don't have to come to the hospital. we address their eye needs on the van at the jail. we take photographs and the reports go back to the primary

care docs and only the most severe cases are then made an appointment to see the dermatology clinic. the net effect in terms of efficiency is the third next available appointment for dermatology is five days. for lump and pump four days and for procedure clinic four days. determine dermatology was count in months. in a bad year the months look like eight or nine months to get into dermatology. again this is a very dramatic practice improvement. then the last thing is palliative care. we just begun this recently. we're trying to slowly understand the potential of home video visits. we started a small pilot with

palliative care and you'll see on the right-hand side some of the materials explaining how we're trying to integrate this into palliative care. as people get registered into palliative care, they're being encouraged in their third visit to try their third visit through video. we're essentially trying to expand the menu of options so for palliative care we don't want to require home visits but that way if they're feeling ill they can opt to keep their visit so it also helps us manage no-shows and be able to transition and say today, i will not come in but i'm available through video.

the initial expansion of that has been very encouraging. those are the highlights of what we've been trying to do. in terms of the challenges looking forward, one of the main ones is we're attempting to reengineer teledermatology and teler teleretinopathy is we don't want to lows the gains from the last few years and now have to shift to a new medical record and we're figuring out how to do that and in so doing doing the quality improvements we've done so far. and the other is to steadily build telehealth applications

over the next few years and this is an important challenge because it's within the constraints of trying to do the epic build. so the cornerstone for any system of telehealth would be a universal health record. so we know that's the priority. on the other hand, we can't sit on our hands for the next three years and so we're trying to figure out given the constraint how we step by step continue to mof forward in tele -- move forward in telehealth, one epic is up and tested and the tires are kicked. the next big efficiency leap will be tied closely to telehealth. we want to make sure that we're keeping that focus in light of the constraints with the epic build. moving on to interpretive service. the mission of interpretive service is to provide trained

medical interpreters to ensure service between the patients and the san francisco health network providers. our overall need is the most recent report from the data center is 36.7% but over 35% of our patients require some level of language assistance. so again, i just want to place this in context. this is extraordinary. medical systems our size are nowhere near this rate. so said another way, it's safe to say as a network we couldn't practice medicine without interpreters. that's the importance of this utility. over the past year, we've done

just to give a sense of volume, over a 250,000 interpretations. the top three languages remain stable. for years they've been spanish, the main chinese dialects and a series of second-tier languages we use vet nam -- vietnamese and the metrics have remained stable the last few years. we spent a lot of time this last year trying to get policy clarifications on all the

bilingual language and there was confusion on what is the difference between an interpreter or bilingual staff or provider and we spent time trying to it's out the different resources and determined what's the appropriate use of each of those. the most important challenge we had was to move away as a system to move away from self-report. for years we basically if you told us you were bilingual in a language we said boy, we're glad. but that doesn't fly so we have to know can we validate that's true and we're working with other national agencies.

now providers and bilingual staff all have to be tested to validate that they have a functional level of fluency. i want to stress at this point our achievement is basically written policies. it's going to take us probably a couple years to actually do the implementation so that becomes a consistent practice in that work. the other thing i want to highlight is we expanded a new level of management. we have now a lead interpreter. we added three lead interpreters and this is day to day work. to stress we do over 500 interpretations a day. you can just imagine what it take to manage that every day and where we were very vulnerable for years is the day

to day work rested on the shoulders of one manage. we were in an extremely vulnerable position and we're now able to handle the administrative and training needs of the interpreters and things like that. we have a video phone ambition in every exam room. we started to implement this at the hospital and there's four and we're starting to see the practice improvement is extraordinary.

san francisco was a pioneer in introducing video interpretation but we basically abandoned it because the technology was clunky and we had to put it on carts and we had to find the cart and drag the cart into the room. it was kind of cute but basically it didn't work. gradually people abandoned it and degraded it down to phone. now the technology exists and it's reasonable and you can put a video in every room. so we're trying to eliminate the search and fetch function so that providers can have easy access within arm's reach. the other thing we're challenged with is we have a pretty integrated service through the two hospitals and the health centers. but behavioral health still

functions in a semi-autonomous way and we're trying to take the first steps into behavioral health for the whole network. lastly, our goal would be to establish an interpreter servie group and we need some way to have consistency in policy and practice and standards when it comes to interpreter service. thank you. >> i have not received any public comment requests. >> thank you, bruce and dr. chen. commissioners, we're happy to take questions an hopefully provide answers for you.

>> commissioners, questions? commissioner guillermo. >> first of all, i just want to congratulate you on this report. it's a lot and it's hard to know where to start questions. it looks like everything's moving up and there'll a lot of green and that's our hope. i wanted to acknowledge bruce's work as i've known him 40 years. i'm glad to know he's making

contributions in the same direction that i find myself in now. i had a question about the interpreter services. one, the two-minute i guess average time from point of request to getting an interpreter, is that system wide? is that a system wide metric? >> yes, by and large it's system wide. by the time you pick up the phone and ask for an interpreter it's about the minutes before you get one. >> that's in all languages? >> good question. basically it's in the common imagines and a rare -- common lack -- languages and maybe five minutes for rare languages. >> they're telephonic. >> as i was watching bruce present i've been in the system

15 years, when i first started you had to wait a long time for an in-person interpreter and the fact that you can get one within 30 seconds or two minutes and we're impatient , we have to step back. like i have a yemeni arabic speaking patient and if it's not straight-up arabic and a variation, it take longer. i've had one instance where we couldn't find somebody. >> so different from where things were from what i remember and advocating for language accessible services 30 years ago. now i wanted to ask a question about the telehealth services. the ones you described in the report, is that the extent of the telehealth or are there

other telehealth services beyond the ones you exemplified here? >> those the main things we're working on. the challenge in front of us is how to continue to make steady progress in this next three years when we're trying to get epic in place. so all these are special additions but we're constrained now by resources. that's our main constraint. >> we also have a huge e-concert and a patient portal we've had in various languages and proxies because people aren't able to manure it on their own and limited texting. it's not just these but we are

holding off. >> i just want to agree or commend your strategy and not waiting for the full epic implementation to continue with the telehealth program and expansions and such. i would just say the technology is such or the state of the art is such that at some point when we'll be able to have the resources to bring the data in that's actually not going to be as heavy of a lift at some point in the future. >> we'll go to commissioner chung. >> it's good to see my former job presenting.

in terms of telehealth we often talk about digital divide in talking about the communities and who may not have the access to the same kind of hardware in order to do that. so are there any support given to those patients or they're just out of luck? like telehealth efforts for some but not all? >> so if you look at the palliative care, that issue comes right to the forefront. one of the requirements is you need digital service. that's where the digital divide comes in. the over arching issue is it's not as pronounced and how

ubiquitous people's access to the internet and their ability to use a number of handheld instruments and tablets. that's resolving itself but it's there and came up in the project with palliative care. >> and another question about the telehealth component is does that have barriers and for instance elderly may not hear as well if it's not a person or not speaking in the good year, for instance. >> with the home visits that's a major factor you come up against is who will facilitate and who will still have barriers because

even with the technology, the ability to hear and see, i have to say at this stage we're trying to get the projects and systems up. we event really gotten into the margins of that. what about the people now that it's functioning have additional handicaps we have to figure out how to address? >> i'm excited about the technology itself. i think in another 20 years we would be doing it with a different generation of patients who would be more trained or skilled in accessing these kinds of technologies. i think the transition is this is where the transition is wlt with the older baby boomers not part of the technology era and how do we mitigate some of those

barriers. we'd be interested to continue to find out. >> i'm one of those baby boomers. one thing that's been interesting is there was a sense the younger people would have a facility around technology the older folks might have a time with. it's noteworthy it's not totally true. like all chinese grandmothers are not afraid of video because they talk to their family every week. our assumption was the young people can do this but what about these parts of the community. we're finding as technology begins soon to transform our lives, some of those old

assumptions are starting to give way. >> i have one more question about the interpreter service. since there's so many languages we're providing services for, are there any cultural barriers in terms of like different cultures have different approaches and gender engagement. do those come up at all? the gender issues for some culture something we're confronted with where people need an interpreter but there's also another cultural considerations in terms of the gender of that interpreter.

the system is not that facile in shifting genders like that. the other interesting thing is on a more humorous side, when you give an interpreter, you give people a voice so sometimes it extends the visit. once they have an interpreter and they may have more questions and things what your sister said to use and things like that. >> i'd like to commend you on the team work and the breadth of

what you presented. it's fantastic. in particular it's very useful to see the number of patients we need to affect some of the red lines on the graph. it's such a small number of people. i think there's better work here than some of the red lines indicate. this very helpful to see. i did have a question about the telehealth. i know the program was one of the first published with the potential of telehealth. another accomplishment but i was wondering in light of a lot of legislation that's pending in the state to reimburse telehealth and higher levels of reimbursed services and whether that's being taken into consideration, apropos what you say about resource constraint and whether there's disease

states or other areas you might want to look at especially if there's potential state funding to allow to you enter the area. >> our director has been following the reimbursement changes and it will affect our medicare patients and we're capitated there. we are getting credit through our medicare waiver program for all the consults and non-traditional ways of interacting with patients. >> one of the things we stress a lot is at this stage, more work flow issues. we're watching the revenue streams. they're low in coming but we're

focussed on the work flow integration. a lot of times telehealth projects have this contradiction where there's a piece of it that's now elegant and it's very nice and then you get to the next stage and then someone goes and tries to find a fax machine. we have tried not to do that and try to figure out the minutia much the work flow issues. >> when you think strategically about revenue or cost impact of telehealth is why we're focussed on the jail. the jail program has been a wonderful collaboration between the groups and our experiment care director looking at the opportunities to decrease transportation and increase access. we spend a lot of money on

sheriffs transporting people to hospital and sometimes they don't low because the sheriffs don't show and there's a loss so those are the kinds of opportunities we're looking at not just reimbursement from a pair and medicare and medicaid. can i say one thing about the digital divide. we have researchers on this and we published around our patients and primary care and clinics. what's interesting is the age gap is real but the poverty and low function of health literacy gap is very real. people who have low functional health literacy which is about 50% of our patients and when we watch them complete tasks in a patient portal, two minutes longer, unable to find visits, real tangible gaps that our teams have been trying to fix by en caging our library staff in terms of training. we're developing training and

the other piece and this is a huge issue. patient portals are typically only in english and maybe spanish. we have been asked about chinese in san francisco and it doesn't look like it's coming. in the near future. if people can advocate in other forms, that would be great. >> commissioner bernal. >> first, i'd like to thank director pickens and we'd like to have the division spotlight because it brings it to the abstract to concrete when we see how the work is impacting the patients and the different divisions within the department. and i do have a question. you're the perfect person to

answer these questions and you mentioned the challenge the dermatology and retinalopathy, is that making them fit? >> we did years of work to have it go smoothly and all the work is behind the scenes. as any good utility it's supposed to stay invisible but it took a big effort to make it look easy.

and now the standards have been raised. we're trying to figure out all those things. for example, with retinopathy how the images can go smoothly from the camera into the system. how the specialist can get them up and a work list and they feel are fast enough and can work with. otherwise thai -- they feel it's too clunky and not much efficiency. then after the report how they just hit submit and it appears back in the right place in epic. not that you have to search and dig and stuff. that's the level that i think we're proud of. so the way we're approaching telehealth is one scaling so we don't want some clinics have neat telehealth and others don't. the other thing is we pay attention to work flow.

the minutia of the next step and how we get there and we're still in the process of making that transition to epic as smooth and unnoticeable to providers and specialists as we can make it. >> thank you. >> i have several comments. first of all, having been the guy that keeps looking at scorecards, going back to the network. this is no easy feat and the idea that even within a grant you have a large number of

managers but at least now they're in buckets and we're able to see what we're all working for and able to see how you are performing. for someone who likes trends, i'll have to get out my magnifying glass. on the other hand, with the colors and all, i think we're getting there. we're getting uniform and as we look to jail health, even as you get down to their metrics, we all learn how to be able to read the errors and colors we can focus on the next steps and we can get them all green and commend you quickly and move on to the next one. if they were all read you can expect a longer discussion why they're red but at least we're discussing outcomes and the questions of outcomes.

i think that's where all of us were going and dr. sanchez would see this as a culmination much what we've been looking for since we started clinics and perhaps even before as we were trying to understand what were the metrics that all of our different divisions were using in order to measure the work they were doing and it wasn't just certain widgets got produced but what happened? today we saw that in reading the contract. though we did ask for it, they actually came up with outcomes in terms of for example, a program for psychiatric

peer-to-peer program. and it's seeing where they're going and in the case of our delivery system, it's what the delivery system believes. goals we have all set and agreed and then we're able to track them. and i feel the department can after all the time i keep asking you, i think you are really on the road to doing it and i want to thank you for doing that. >> thank you for saying that. i will point out we're very hard on ourselves and it's either black or white. even though a lot of those were red were this close to meeting the target. we don't give ourself credit for

the attempt only men we meet it. in the next report we'll be further advanced and more green than red. >> i think we're doing our report cards. it would be interesting in half a year where we can come to the quarter and that will show we're on our way as ache network and you're making use of the data. and as you add them all into the epic system, we should be able to see that we're going to make use of this system not just put it in and then build it but as

we start the use of