is maggie ro-- >> ryecowski. >> i am maggie, and i'm the acting chief executive officer at laguna honda hospital with my colleague, troy williams, the chief quality officer for zuckerberg san francisco hospital and trauma centre and laguna honda hospital. we are here to talk to you about our reform plan and things that we have had in place so we can get laguna honda back on the right track. okay. and so we're going to just very briefly go over -- not briefly, but troy will be going over the regulatory compliance of where we are in the investigation, and where we are today. we'll talk to you about the leadership, quality and safety, and what we're going to do to prepare for the future. so this slide is a snapshot of the timeline of the incidents at laguna honda in february of 2019, is when leadership was made aware of the incidents -- was made aware of the incidents. at that time, all of the appropriate regulatory agencies and appropriate individuals were notified. a lot of work has been done between february and now, and i can tell you that we're very proud that on october 15th, laguna honda was

laguna honda discovered by chance rather than through standard medical reviews? according to state records, five patients were drugged with pillford medications, resulting in life-threatening overdoses and transfers to outside hospital. laguna honda doctors were aware these were not caused by illegal drugs commonly smuggled into the hospital. they were caused by medications that had not been prescribed. further, doctors at outside hospitals who treated these patients conveyed their alarm. one doctor notified laguna honda's medical director in february 2008 and was told that an internal investigation was underway. apparently that internal review wasn't fruitful. instead, the abuses were discovered 18 months later while human resources investigated an unrelated employee despite. yet, laguna honda has two medical committees that are charged are probing such adverse medical outcomes. why didn't the medical quality improvement committee or the performance improvement and patient safety committee diagnose these drugs abuses? lastly, health commissioners regularly met with doctors to review their medical quality improvement reports. didn't the commissioners notice that something was wrong? thank you very much. >> thank you

earlier, we need a lot of new clinicians and that being said, i would like to say also that laguna honda hospital, 1600 beds or 1200 beds whatever, is still empty and it's a fabulous asset to be ignored. i don't know why it's there deteriorating except for a few redecorated offices whoa need a facility where people can stay until they're stabilized and i would like to see option there. it would be really great. >> my name is june bug and i'm with the health justice academy and the san francisco heath plan advisory and aim a poor magazine and a former san francisco commissioner and because i'm someone that cares and i experienced trauma in my life and i have mental health issues. all my issues have a lot of issues that go down to my basic needs being met. and so, i'm someone who needs wrap-around services in my life. i'm at the mercy of the handout to survive and it's still not enough. we have a crisis in my city. this is my city and my home. what i see daily disturbed my heart and what i go through disturbs my mind. it's a challenge to stay focused and not give up because i live a hard life. ment

earlier, we need a lot of new clinicians and that being said, i would like to say also that laguna honda hospital, 1600 beds or 1200 beds whatever, is still empty and it's a fabulous asset to be ignored. i don't know why it's there deteriorating except for a few redecorated offices whoa need a facility where people can stay until they're stabilized and i would like to see option there. it would be really g

2012 when it started at san francisco general hospital, and then spread to primary care, population health division, environmental health, and laguna honda, and now mch. it is rapidly now being introduced to behavioral health services. so well there are several tools and documents in the lean library, the two primary drivers of an organization's implementation of lean our true north and the exmatrix which you see depicted here. true north can best be described as a precise, concise, and universal set of ideals which, when taken together, provide a compass it that describes the ideal or state perfection that a business should be continually striving towards. true north should involve both our head and our heart and considering both, the strategic hard goals and defined business targets, as well as tightly held beliefs as to our organizational purpose and values. true north pillars, would you see depicted here, safety and security, health impacts, service experience, workforce, financial stewardship and equity are meant to be consistent over time and over a multiyear period and should not change very often contrasting that to the matrix. t