PROPOSED ALTERNATIVES TO SHERIFF PRESENCE AT SFGH AND DPH CLINICS

1. Community Safety Team.

We strongly believe that the security needs at our facilities can be fulfilled by a community-based, trauma-informed safety team that does not involve law enforcement. We are advocating for a phased approach culminating in complete removal of any onsite Sheriffs. From our community survey, the most salient staff security concerns included: maintaining building safety; ensuring that potentially harmful weapons are not entering the facilities; de-escalating conflict; and restraining patients if necessary. 

We propose security personnel who are integrated members of the healthcare teams and ideally from the communities they serve. We believe that the priority should be violence prevention and that training should be centered on de-escalation and addressing the complex psychosocial needs at the root-cause of conflict.

We recommend looking into other well-established models of safety in the community. St. Anthony’s Client Safety Services (CSS) is a community-based private security team focused on de-escalation that costs approximately $500,000 annually. The St. Anthony’s CSS team has effectively been able to reduce calls for police at their facility in the Tenderloin due to skillful handling of complex situations including violent incidents, overdoses, accidents, and medical emergencies. This success stems from the fact that the team members are from the community they serve and are trained primarily in de-escalation rather than law enforcement. CSS offers safety training and consultation to other institutions, and we believe would be an excellent model for SFGH.

2. Patient Advocates.

 Instead of uniformed officers and cadets greeting patients upon entry, we propose staffing entrance areas of the hospital with Patient Advocates who are from the communities predominantly served by the hospital and who provide culturally-sensitive service to patients and visitors. A sample list of potential community organizations that could provide patient advocates can be found in Item 6. Patient Advocates would assist patients in navigating our complex health system. If needed, Patient Advocates could accompany patients to appointments, such as the accompaniment system developed by the student-run clinic Clínica Martín Baró. Currently, there are only a few Patient Advocates through the office of Patient Relations. We propose expanding those numbers and developing a robust program of advocates across the inpatient and outpatient settings with an inaugural cohort of 40 patient advocates as salaried staff. These would be additional positions within DPH and the hiring process would need to be expedited. Training would be performed in collaboration with our community partners, such as Clínica Martín Baró and organizations listed in Item 6.

3. Increase in Staff.

According to SEIU Local 1021, since May 2020, DPH has been understaffed with 1 out of every 10 full-time nurse positions vacant and 75 permanent full-time equivalent nursing positions vacant at SFGH alone (SEIU 1021, 2020). DPH has been relying on “per diem'' temporary workers to staff up to 40% of nursing hours instead of hiring more full-time staff (SEIU, 2019). The DPH budgeting for temporary nurses has been overrun for the last five years, which reflects the immediate need for increased staffing. This is particularly important in the Emergency Department where nurses have long voiced concern with current patient to staff ratios.

Staffing increases are essential to allow nurses to spend time with patients and offer them compassionate care. It allows for hired staff to build relationships of trust that are essential to navigating conflict, as opposed to relying on temporary workers who may not be as familiar with the work or the community. DPH needs to work with SEIU Local 1021 and other nursing groups to improve the working conditions, schedule, staffing, and organization in SFGH, especially the Emergency Department.  

4. Patient Support at Time of Discharge.

A significant proportion of sheriff-related incidents occur at the time of discharge, often when patients confront the uncertainty that awaits them outside the hospital. Data from the use of force incidents in fiscal year 2019-2020 revealed that 15% occurred when the patient was refusing to leave. It is important that we analyze the root cause for escalation in these situations. We propose funding for additional social work support, mental health peer support, Patient Advocates, and other resources at time of discharge in order to ensure our patients’ needs are adequately met. The increased funding to support more transition planning at discharge would ideally address patient concerns before situations de-escalate. Additionally, ensuring proper support in the community will lead to successful discharges and reduced readmission rates.

5. Expand BERT.

BERT is composed of psychiatric nurses who are experts in de-escalation and mental health response, and their presence has been shown to reduce calls to the Sheriff. BERT responds to calls regarding patient care issues, interpersonal conflicts, and mental health emergencies, which comprise at least 46% of current sheriff interactions. We propose increasing the number of BERT providers to create an interdisciplinary team of nurses, social workers, and mental health peers, from approximately 3 FTE to 23 FTE to support their presence 24/7 throughout the hospital. If non-healthcare staff are hired to support the BERT team, it is important that these individuals are unionized or have the opportunity to unionize. 

6. Funded Community Leadership Board (CLB).

 Community guidance and oversight over the process of removing law enforcement from DPH sites as well as developing and implementing alternatives is essential. We must not only include in the conversation but center the voices of those who are systematically marginalized by our health systems, including Black and Indigenous individuals, people with disabilities, trans and gender non-conforming people, undocumented individuals, formerly incarcerated individuals, those living with homelessness and people who have family members who have been victims of police violence. 

We must value the time and knowledge of the community organizations that are willing to support us in this process and propose funding their participation in meetings and development of programs. The CLB would be charged with reviewing the implementation of new security-related positions, ensuring accountability and oversight, and developing proposals for alternative services that foster a healing environment.

7. Employee-wide De-escalation Training from Community Partners.

In the Bay Area, we thankfully have access to the expertise of community organizations that have been implementing alternatives to law enforcement within their organizational models for decades. We hope that our safety strategy at DPH can draw on the wisdom of these organizations and provide contracts to them to train our new personnel and all DPH employees on community-informed, trauma-centered, and culturally sensitive de-escalation skills. For example, we recommend reaching out to organizations such as Generative Somatics, Restorative Justice of Oakland Youth, POOR Magazine, GLIDE, and Mental Health First, which are all well-versed in such training.

All DPH personnel should be required to participate in robust de-escalation skills training. For 8,000 DPH employees, at a rate of approximately $250 per person, we propose an initial $2M allocation for this, which can likely be decreased in subsequent years once current staff have been trained. 

8. Protocol Regarding Law Enforcement Presence on Campus.

Given the harms associated with law enforcement presence on campus, we want to ensure that our recommendation of removing SFSD from its role as hospital security does not result in greater presence of SF Police Department (SFPD) officers on campus with even less accountability to the hospital community. As a result, we recommend a ban on all SFPD and SFSD arrests on DPH campuses, disarming of law enforcement in clinical environments, and the development of a detailed protocol outlining SFSD and SFPD’s engagement with our hospital and clinic communities.

9. Safety Oversight and Quality Improvement.

We recommend establishment of an Oversight Committee which includes community members, patients, providers, and administrators. The Committee would review data regarding security incidents and have the power to implement change. Data on safety-related incidents should be collected and analyzed to guide quality improvement initiatives and help us take a more proactive approach to our campus safety. These initiatives should be done in collaboration with the Community Leadership Board.

10. Transformative Justice Processes after Harm.

It is essential that we not only address conflict but also engage in a process of transformative justice that prevents future harm. If harm is caused during an interaction with our staff, there needs to be appropriate follow up (eg., formal acknowledgment, debrief, quality improvement process, etc.) to ensure that the patient’s experience is validated and systemic changes are implemented. The process of filing concerns is currently limited to the Office of Patient Experience either as a Service Recovery Request or a formal Grievance Process. While the Office of Patient Experience serves as an initial avenue, the responsibilities of addressing conflict are often displaced to managers and administrators with little formalized support or community voice. We recommend consulting experts in restorative and transformative justice to advise the hospital in how to integrate this process into our care delivery. This would be useful for patients, healthcare workers, and staff who are filing grievances and desire accountability outside from punitive measures or further engagement with law enforcement.