Minutes of the Health Commission Meeting December 5, 2000 3:00 P.M. at San Francisco General Hospital Carr Auditorium 22nd Street and Potrero Avenue San Francisco, CA 94110 1) CALL TO ORDER The regular meeting of the Health Commission was called to order by President Roma P. Guy, MSW, at 3:10 p.m. Present: Commissioner Edward A. Chow, M.D. Commissioner Roma P. Guy, M.S.W. Commissioner Lee Ann Monfredini Commissioner Harrison Parker, Sr., D.D.S. Commissioner David J. Sanchez, Jr., Ph.D. Commissioner John I. Umekubo, M.D. On behalf of the Commission, President Guy presented a special certificate of appreciation to Joanne Burik on her retirement after 20 years with the Department. Ms. Burik has had various positions, with the most recent as the head of the Office of Managed Care. Gene O’Connell, SFGH Executive Administrator; and Tony Wagner, CHN Executive Administrator, thanked Ms. Burik for her many years of dedication and commitment. 2) APPROVAL OF MINUTES OF THE REGULAR MEETING OF NOVEMBER 21, 2000 Action Taken: The Commission unanimously adopted the minutes of November 21, 2000 3) CONSENT CALENDAR OF THE BUDGET COMMITTEE (Commissioner David J. Sanchez, Jr., Ph.D.) (3.1) DPH Administration – Request for consideration of a modification to the FY 2000-01 Patient Rates Ordinance to increase selective patient rates at San Francisco General Hospital in order to maximize MediCal reimbursement. Ms. Zmuda reported that these patient rate increases will bring in $1 million to SFGH. (3.2) PHP-HIV Research – Request for approval to accept and expend retroactively $247,970 in funds from Public Health Foundation Enterprises (PHFE), for the first year of a five year project to fund the San Francisco Department of Public Health portion of "San Francisco HIV Vaccine Clinical Trials", for the period of June 1, 2000 to May 31, 2001. (3.3) PHP-Environmental Health – Request for approval to accept and expend retroactively a new two-year grant in the amount of $98,399, from the U.S. Environmental Protection Agency, to fund a project for adults and children with asthma and their families entitled "Healthy Homes for Healthy Airways", for the period of November 1, 2000 to October 31, 2002. Commissioners expressed concern on outreach to targeted low income communities (i.e., Latino and African American) and asthmatics with allergic sensitivities. (3.4) PHP-TB Control – Request for approval of a contract renewal with the Regents of the University of California at San Francisco (UCSF), in the amount of $1,450,839, to provide Model Tuberculosis (TB) Education and Control Center services to local and national TB health care providers, for the period of November 1, 2000 through June 30, 2001. (DPH contracted with UCSF for services totaling $11,454,369 during FY 1999-2000. Commissioner Sanchez abstained due to conflict of interest. (3.5) PHP-CMHS – Request for approval of a retroactive contract renewal with Instituto Familiar de la Raza, Inc. (IFR), in the total amount of $9,277,054, to provide mental health and administrative support services targeting adults, children and families, for the period of July 1, 2000 through June 30, 2002. (DPH contracted with IFR for services totaling $5,741,385 during FY 1999-2000). Commissioner Parker requested clarification on the total number of clients served under this contract. Estella Garcia, Instituto staff, reported a total of 350 adult/children are being served. Commissioner Sanchez noted this 2-year contract renewal is for past performance. He noted the Department needs to continue providing TA to non-profit contractors. Ms. Garcia reported that cultural competency is an important part of the social fabric; the diversity of the work force is also important. (3.6) PHP-CMHS – Request for approval of a retroactive sole source contract renewal with Continuum HIV Day Services, in the amount of $98,000 per year, for a four-year total contract of $392,000, to provide adult mental health services targeting HIV-positive adult residents of San Francisco with severe mental health diagnoses, for the period of July 1, 2000 through June 30, 2004. (DPH contracted with Continuum for services totaling $1,752,456 during FY 1999-2000). (3.7) PHP-CMHS & CSAS – Request for approval of a retroactive contract renewal with Bayview Hunters Point Foundation for Community Improvement, Inc. (BVHPCI), in the amount of $6,949,872, to provide substance abuse and mental health services targeting adults and children, for the period of July 1, 2000 through June 30, 2001. (DPH contracted with BVHP Foundation for services totaling $7,109,248 during FY 1999-2000). Commissioner Monfredini requested a 6-month follow-up to this contract, (June 5, 2000). Commissioner Sanchez supported the unique efforts of Bayview and the Department in order to rectify the issues. (3.8) PHP-CMHS & CSAS – Request for approval of a retroactive contract renewal with Walden House, Inc., in the amount of $6,724,326, to provide residential mental health and substance abuse services, for the period of July 1, 2000 through June 30, 2001. (DPH contracted with Walden for services totaling $8,623,924 during FY 1999-2000). Commissioner Sanchez encouraged the Department to provide technical assistance to CBO’s. For Item #3.7, Commissioner Chow requested any more data on the evaluation of acupuncture and the use of acupuncture for substance abuse. Dr. Katz will come up with more quantitative data. Dr. Katz pointed out it is difficult to quantify the impact of acupuncture on substance abuse. Action Taken: The Commission unanimously voted to accept the consent calendar of the Budget Committee. Commissioner Sanchez abstained on #3.4 4) DIRECTOR’S REPORT (Mitchell H. Katz, M.D., Director of Health) ADMINISTRATION CDC Satellite Broadcast on HIV Prevention for Men Who Have Sex With Men Last Wednesday and Thursday, I participated in a Centers for Disease Control and Prevention Satellite Conference on HIV prevention for men who have sex with men. I was invited as the sole representative of local health departments because of the work that we have done in characterizing the increases in unsafe sex among men who have sex with men and in recommending new directions for HIV prevention. The program was telecast to 400 sites in the United States and Canada and was watched by 6400 persons. Back on the SFGH Wards again Last Friday, I began my annual month as an inpatient attending on the medical wards at San Francisco General Hospital. It has been wonderful to see old friends among the medical and nursing staff some of whom I have known since 1986 when I began as an intern at the hospital. Working at the hospital full time always makes me proud of the high quality care we provide at the hospital. It also gives me insight into the pressing unmet needs of our clients, especially the housing and outpatient mental health and substance abuse treatment. I want to thank the members of the Health Commission for giving me the freedom to pursue my love of clinical medicine and also thank my dedicated staff for filling in for me in a variety of ways this month. Trial of SF ACT-UP Members Ends A week and a half ago, two members of SF ACT-UP were found guilty of disturbing the peace based on their actions at the June 9th Board of Supervisors’ Finance and Labor Committee hearing. This is to my knowledge, the first time that members of SF ACT-UP have been tried in criminal court for their actions, and the first time that they have been found guilty. I believe that this court ruling will make it less likely that SF ACT-UP members will continue to intimidate persons at public meetings. POPULATION HEALTH AND PREVENTION Immunization Last week, the State of California Department of Health Services received the final portion of its annual shipment of vaccine to distribute to local health departments for vaccination of low-income, high-risk individuals. Although DPH now has our full allotment of nearly 40,000 doses, this does not meet the demand for an estimated 250,000 doses needed to vaccinate the City’s high-risk population. Other large suppliers of vaccine in San Francisco include Kaiser, UCSF, Visiting Nurses Association (VNA), Catholic Health Centers West, and private providers. Many of these groups have received little, if any, of their vaccine. The 40,000 doses have been distributed to CHN, nursing homes, and other groups that serve high-risk clients. The Adult Immunization Clinic has given 2,000 doses of vaccine to high-risk individuals. They currently do not have vaccine and are awaiting a shipment of an addition 2,500 doses. On the West Coast, we begin to see influenza cases beginning in late December through March, with the highest number of cases between the end of December and January. Once someone has received the flu vaccine, it takes approximately 2 weeks to develop antibodies to the virus. Given the dearth of vaccine in San Francisco, as well as the time needed to respond to the vaccine, we anticipate that there will be an increase in hospitalizations and deaths in San Francisco due to influenza and its complications this year compared to previous years. In anticipation of an increase in number of infections and complications of influenza, we are planning an Influenza Prevention Press Conference with other City hospitals in the near future. Housing and Urban Health An article appeared in the Sunday Chronicle describing a DPH sponsored project that trains people in jail in rescue breathing and CPR as part of a program to reduce deaths from heroin OD. Environmental Health The Environmental Health Section recently took administrative action against a contractor who removed asbestos material improperly from a home in San Francisco creating the potential for public exposure. Notably, the contractor is licensed by the state to do asbestos abatement and advertises themselves as the "nations largest residential abatement company." We anticipate that the settlement of this action for $37,000 will have a strong deterrent effect against such negligent behavior among contractors working with hazardous materials. EHS will continue to cooperate closely with the Department of Building Inspection, the Bay Area Air Quality Management District, Cal-OSHA, and other enforcement agencies to identify violators and coordinate enforcement activities. Prop 36 On November 29, the Department of Public Health and the District Attorney's office cosponsored a one-day conference on implementation of Proposition 36. Over the course of the day panelists addressed the implications of Proposition 36 on the criminal justice system and the treatment system. The day was extremely well attended and received attention in the media. District Attorney Hallinan and Barbara Garcia will spearhead the process of turning the recommendations into action. HIV Prevention Section On November 29th the HIV Section was host to Zhao Wang, the Director of Disease Control for the Ministry of Health in the Peoples Republic of China. Prevention staff and Drs. Willi McFarland and Grant Colfax provided Dr. Wang and 10 members of her staff with information on HIV prevention and research here at DPH. As testimony to the level of interest and quality of information, the delegation stayed two hours over the planned visit. COMMUNITY HEALTH NETWORK DOJ Revisits LHH – A team of Federal Department of Justice representatives revisited Laguna Honda Hospital from November 28 through December 1st. The DOJ team was comprised of two attorneys, one paralegal, two nursing experts and one expert administrator. The DOJ team did not provide a formal debriefing. We expect to hear from the DOJ within the next few weeks. I will keep the Commission informed. LHH Annual Holiday Show The Laguna Honda Hospital volunteers are sponsoring the Annual Holiday Show for all Residents on Friday, December 15th at 2:00 PM in Simon Auditorium. All Commissioners are invited to attend. LHH Institutional Police Annual Toy Drive The Institutional Police at Laguna Honda Hospital have kicked off their annual toy drive. This annual program is always a success and your support will guarantee that 2000 will be our best year yet. For more information, contact Lt. Gary Kong 759-2319. Director of Nursing, Emergency Department I am pleased to announce that Mary Jo Webb, RN has returned back to San Francisco General Hospital to continue serving as the Emergency Department's Director of Nursing. She returned to SFGH on Monday, December 4th. SFGH Discharge Lounge On December 11th, new SFGH discharge lounge will be opened to provide a safe environment for patients that are medically stable and have been discharged. Hours of operation are Monday-Friday 11 am - 5 pm (closed on holidays and weekends). The discharge lounge will serve patients waiting for transportation and/or social service assistance. These patients must be independent or require minimal assistance with transfers. Many thanks to Gillian Otway, RN, Nurse Manager of 5A, for all of her hard work in developing the SFGH discharge lounge program. Commissioner Monfredini asked for clarification of how information is communicated to families of patients in the Discharge Lounge. She also encouraged flu shots be prioritized for bedside staff at SFGH and LHH. Discussions with private hospitals are also taking place. Commissioner Chow advocated for enforcement of the message for flu vaccine availability. Public Speaker: Michael Petrelis asked what happened to the $1 million from Dupont in 1999 for HIV prevention? Yolanda Chavez, Local 250, asked about the use of all levels of nursing in the Discharge Lounge. 5) PRESENTATION OF THE SAN FRANCISCO GENERAL HOSPITAL ANNUAL UPDATE A. Gene O’Connell, Executive Administrator, acknowledged her senior management and medical staff. The following areas were presented for Commission approval: Hospital Plan for Provision of Patient Care by Sue Currin Quality Improvement Plan by Hiro Tokubo Utilization Management Plan by John Luce, M.D. Competency Plan by Rod Auyang Environment of Care Update by Terry Salz These reports are available in the Commission Office. The Commission is required by JCAHO to approve all of the above plans. Commissioners commented on the following: Clarification needed in the two different Executive Administrators for SFGH and the CHN on page 5A.6. Need for correction on C1 on page 5A.24 Need for follow-up to the 0.2% unacceptable for patient care performance evaluations; what actions were taken and what were consequences; goal is to have 0% in the unacceptable category and should be in writing Question of when will these be 100% of performance evaluation completed? Requested assurance that the higher level of standard is the goal for environment of care B. The following reports, which are available in the Commission Office, were presented for discussion: Medical Staff Report by Alan Gelb, M.D. Dr. Gelb emphasized the importance of the Commission advocacy at the Federal level. Commissioner Chow expressed his appreciation for the recitation of information everyone knows; but, aside from increasing or adding more revenues, what are the urgent issues; he encouraged the physicians to come forth with innovative answers and a long term view of SFGH for the next 10 to 20 years. Commissioner Sanchez pointed out he is here to listen and assured staff that SFGH will not be on the back burner. He advocated to look at the infrastructure, how to sustain services, what kind of facility should we have, and how the public would pass a bond measure. Capital Planning Process at SFGH by Carlos Villavel Mr. Villavel presented the five options for SFGH facility planning: New conforming hospital at SFGH by 2013 Interim fix of existing hospital by 2008 Retrofit in place to SPC-5 by 2013 Phase out acute care at SFGH by 2008 New conforming hospital by 2013 and build somewhere else in San Francisco. A timetable was presented Annual Update on SFGH Medical Center by Gene O’Connell Areas covered included facts and figures, preparation for the 2001 Master Plan, descriptions of any given day at SFGH, the Level 1 Trauma Service, the U.C. Affiliation, the Public Health role, staffing levels, and future planning. Ken Jensen, CHN Chief Financial Officer, presented the Analysis of Revenues and Expenditures and the City/County Subsidies to SFGH, the October SFGH Statement of Revenue and Expenses, and the October SFGH Summary Statistical Information. Review of the Partnership Between UCSF and SFGH by Phil Hopewell, M.D. Dr. Hopewell reviewed the UCSF/SFGH Affiliation Agreement. The full report is available in the Commission Office. The $66 million budget for the U.C. Affiliation was provided to the Commission. Public Speakers: Kevin Grumbach, M.D., knows that the City leadership supports SFGH but it is important politically for the Department, the Commission, and the Mayor, to advocate for the uninsured and needy; makes sense for the City to sustain the level of care. Nora Roman, R.N., Emergency Coalition to Save Public Health, indicated DPH is in crisis; patients, workers and community are being hurt; addressed issues around the pharmacy privatization plan, inadequate staffing, crisis in emergency and urgent care services, rejection of the Strategic Plan, and Commission to play an active role in Sacramento and Washington advocating for universal health care. Eric Isaacs, M.D., encouraged Commission to talk to the Mayor about ER; gave patient examples; barely avoiding malpractice suits; not getting single standard of care; encouraged Commission to stand up to the Mayor. Howard Graves, M.D., gave overview of patients, diversion rates, overloaded ER; political courage is needed. Lynn Bui, M.D., described conditions in ER Department; advocated for help to medical staff. Chris Barton, M.D., SFGH ED, described realities in the ER, diversion rates, and census at SFGH. Teresa Palmer, M.D., LHH, represented physicians at LHH; submitted letters from Dr. Maria Rivero, Dr. Charles Stinson, Dr. Monica Banchero-Hasson, Dr. Derek Kerr, Dr. Christopher Hinnant, Dr. Brenda Ansher, Dr. Laura Duskin, Dr. Rene Thomas, Dr. C. Lee, Dr. Lisa Hoo, Dr. Vicky Young, and Dr. James Budke; expressed concerns on staffing in medicine, nursing, activity therapy, rehab, social work, dietary and housekeeping. Letters are available in the Commission Office. Brad Shapiro, M.D., Family Practice Residency Program, alarmed at Dr. Katz’s statement on seeing improvements at SFGH; described examples of patients not receiving care. Mark Jacobson, M.D., SFGH, expressed importance of SFGH physicians who believe in public health, research, and respected colleagues at SFGH; best and brightest house staff; SFGH is becoming unattractive to bring in new physicians; suggested to change the Strategic Plan. Richard Haber, M.D., SFGH Department of Medicine, has been on faculty for 25 years; was a patient at SFGH; real crisis now; funding gap has not been made up by the City; gave examples of clinic patients. Joel Ernst, M.D., Department of Medicine, gave examples of having academic researchers at SFGH (i.e., TB, AIDS). Michael Lyon, former SFGH employee, is concerned about the Strategic Plan; health care is being taken away from the working class; if nothing is done, DPH has to scale back. Jim Kahn, M.D., SFGH, single standard of care should not be below the standard of care; morale is at an all time low; Commission is inadequately informed. Meg Newman, M.D., SFGH, quoted Dr. Katz; San Francisco is in a position to remedy the problem; City should take the lead in public health; do not further erode public health system. Rick Hecht, M.D., SFGH, says it is demoralizing for faculty; described how he spends his physician time; he essentially volunteers his clinical time. Courtney Broaddus, M.D., SFGH, wants to maintain excellence of physicians; recruitment and retention of top faculty at SFGH/UCSF; faculty largely pay their own way; law morale; the Strategic Plan will not allow a full functional hospital. Robert Jasmer, M.D., SFGH, talked about a major meltdown in ICU; not enough beds for critical care patients; inadequate number of respiratory therapists; level of denial by the Mayor. Todd May, M.D., Family Medicine Department, says things are not better this year; not humanistic care; do not deny what is happening. Sue Carlisle, M.D., SFGH, gave her own history; described problems in area of anesthesiology with recruitment and retention. Guy Paiement, M.D., SFGH, described specialized services and difficulty in providing specialty services; only one kind of health – not public vs. private; poor people are being stigmatized. Stephanie Tashay, Committee of Interns and Residents, urged high quality health care to indigents; health care is a right; doesn’t support a Strategic Plan that limits care. Teresita C. Gatan, Local 250, stated the care for patients is being decreased by budget cuts; need for adequate oversight or health care and need to work with community organizations; private hospitals are dumping patients to SFGH. Lynn Carman (submitted written testimony) given by Nora Roman; restore level of care in ER; expressed objections to the Department’s Strategic Plan; gave notice of potential lawsuit on behalf of a client. Margaret Wheeler, M.D., SFGH, commented on Strategic Plan; fears the emperor has no clothes; focus on primary prevention is difficult to measure. Richard Price, M.D., SFGH, would like to deliver first class care; need to maintain a critical mass of patients and providers in order to serve indigent; reverse downsizing of SFGH. Dean Shepherd, M.D., SFGH, described a large community of scientist physicians who give many hours of patient care; these physicians want to be here. Chip Chambers, M.D., described a disconnect in the Strategic Plan regarding the trauma unit and infectious disease clinic; looks forward to fixing the situation. Bob Lull, M.D., incoming President of S.F. Medical Society, is proud to be with the physicians in the CHN/SFGH; CHN is vital to the health system of the City; maintain all services at SFGH; willing to be part of future planning in the City. Action Taken: The Commission unanimously approved the following documents with the Commissioners comments: Hospital Plan for Provision of Patient Care Quality Improvement Plan Utilization Management Plan Competency Plan Environment of Care Update President Guy stated decisions regarding capital planning for SFGH will be made at a future date. More public discussions will occur in January 2001. Commissioner Monfredini requested an access pass to SFGH so that she can make visits to SFGH. She needs to know more. Commissioner Sanchez stated the testimony heard today is historical because two years ago a similar message was delivered; the SFGH model is at risk and we need to move forward with a bond initiative. He is touched by the dedication of staff. Commissioner Chow offered to meet with any of the speakers; what are alternatives to deliver care in a different mode; what should the size of SFGH be in order to allow for academic and a university presence? He is not sure of the issues of reduction at SFGH in the Strategic Plan. He thanked the speakers. Commissioner Umekubo thanked the speakers and expressed his commitment to maintain SFGH as a crucial role in the health care system in the City. He advocated for a collaborative strategy with all parties, including the S.F. Medical Society. He expressed that Option 4 if not an option (i.e., phasing out SFGH). Commissioner Parker advocated to come together and decide what to do. There are too many turf issues and in fighting. He feels everyone will survive and SFGH will not fade away; but we cannot continue to find blame. Dr. Katz thanked the speakers and expressed his appreciation to the Commission for its understanding of the hard realities. He and the Commission believe that health care is a right for all, but our country does not believe this. The Federal government does not support this. Everyone, other than the City, has abandoned SFGH. To some degree, UCSF has abandoned SFGH (i.e., residents). The University funding is less due to its own funding decreases and its own hard times. Dr. Katz reiterated the housing crisis in the City, the increase is homelessness, all hospitals having recruitment/retention problems, and the nursing shortage. However, the City has increased support for SFGH, but the amounts removed by the Federal and State levels cause a huge problem. He qualified his comments on improvements at SFGH in that he is referring to improvements in moving patients from SFGH to LHH. He also believes that the affect on morale has to do with increasing needs and decreasing State and Federal support. The City and County are committed and are supporting SFGH. The facts and figures do not support that the City/County is not supportive. The City and County is not the enemy. President Guy expressed appreciation to the speakers for their input and commitment. She believes there is deterioration in public health. Primary care is important; and we cannot say no to the African American Health Initiative. Housing is a health issue; prevention, primary and tertiary care do work. She encouraged problem-solving not to be competitive and will go anywhere to talk to people. She is willingly a Commissioner and as the President. She expressed appreciation for the U.C. Affiliation Agreement and the fact that a formal presentation and crucial information on the Affiliation Agreement was provided to the Commission. She appreciates the UCSF leadership. She also encouraged the Department to work on improving payment methodologies. Additionally, she encouraged staff to prepare information for the Commission in the direction of building a new SFGH by 2013. All of the Commissioners indicated their support for a new conforming SFGH by 2013. Commissioner Chow cautioned that the Commission needs to have logic and support for a specific direction and size of SFGH with support from the public. Dr. Katz will bring back to the Commission sometime in January with a potential policy direction. There may be a need for a special Commission meeting in January. 6) OTHER BUSINESS/PUBLIC COMMENTS None. The meeting was adjourned at 7:50 p.m. Sandy Ouye Mori, Executive Secretary to the Health Commission