Department of Health Services Dedication Overcame Dysfunction

Miscommunication… DHS should develop a We will continue to contributed to the resignations of plan to maintain adequate aggressively recruit nurses experienced public health nurses. nursing levels

Poor communication between DHS should develop a Upper management has the upper DHS management and the plan to improve taken significant steps to staff …resulted in poor morale. communication improve communication • 2018-2019: “The Behavioral Health Budget-A Perfect Storm” Jury Finding Jury Recommendation DHS Response to Jury

The Department of Emergency Management’s competent leadership, well-developed policies and procedures, and trained staff have helped Sonoma County weather recent disasters.

The County has extensive preparedness and emergency management policies and procedures in place, but they were not always followed by the Department of Health Services.

Lack of adequate personnel The County should Resources, including compromised the Compliance provide adequate funding staffing have been Office’s effectiveness. and support increased

Not all County staff have received regular training in emergency protocols, including the Incident Command System.

The Department of Health Services’ Department Operations Center did not demonstrate competency in the Incident Command System, nor value its use.

Budget development process Section and program Increased and open lacked transparency and staff managers should be communication has been participation. included in decision- prioritized making

Professional communication was Procedures for effective We will continue to stifled by a culture of retribution … and professional develop innovative ideas communication should be that will foster effective implemented and respectful information sharing History of Continuing and Persistent Communication Challenges When the 2016-2017 Grand Jury report was published, the Department of Health Services responded and agreed with the Grand Jury’s finding that “Poor communication between the upper management of DHS and the staff in the trenches has resulted in poor morale.” To improve these communication deficiencies and increase employee engagement, the DHS executive team “committed to providing additional regular and timely two-way communication with staff.” DHS leadership also reported to the Grand Jury that the communication plan they requested, with an emphasis on information sharing, had been developed. Unfortunately, two years later, in the 2018-2019 report, the Grand Jury again found a pattern of poor communication. That Grand Jury reported, “…professional communication was stifled by a culture of retribution and neglect which impacted the free flow of information. This led to an egregious lack of transparency.” At that time, the Grand Jury asked that the executive team develop a more collaborative relationship with middle managers. DHS responded that they have implemented several procedures to increase regular information sharing with staff. Staffing Issues Continue In addition to communication problems, the 2016-2017 Grand Jury investigated DHS resignations, retirements, and reorganizations, specifically in the Maternal, Child, and Adolescent Health (MCAH) section. The Grand Jury reported retention, recruitment, and excess workload issues, particularly among the nursing staff. The Grand Jury asked that DHS develop a staffing plan, and DHS responded that they were already aggressively recruiting nurses. Unfortunately, staffing issues continued as the 2018-2019 Grand Jury discovered in their investigation of the Behavioral Health Division (BHD). That Grand Jury found that staffing was hampered not only by budgetary constraints, but also by the significant turnover of trained staff. DHS, in its response, agreed that there was inadequate staffing, and agreed to recruit additional personnel. Emergency Operations Center Under the Federal Emergency Managements Agency’s (FEMA) Incident Command System (ICS), the Emergency Operations Center (EOC) functions as a command and control center, gathering information, directing activities, and obtaining support in disaster or emergency situations. The EOC typically consists of a range of trained and otherwise qualified personnel, often tailored to the situation. Standard sections include Command, Operations, Planning, Logistics, and Finance/Administration. In Sonoma County, the County Administrator is the Director of the EOC. However, this authority is typically delegated to the Director of the Department of Emergency Management (DEM) or their deputy when the EOC is activated. For more limited or focused emergencies, a Department Operation Center (DOC) can be utilized. The DOC is essentially a scaled-down version of the EOC, and generally would have the same sections. The 10 Essential Public Health Services The Centers for Disease Control and Prevention (CDC) has identified 10 Essential Public Health Services that should be provided in every community. The essential services include: Assessment 1. Assess and monitor population health status, factors that influence health, and community needs and assets 2. Investigate, diagnose, and address health problems and hazards affecting the population Policy Development 3. Communicate effectively to inform and educate people about health, factors that influence it, and how to improve it 4. Strengthen, support, and mobilize communities and partnerships to improve health 5. Create, champion, and implement policies, plans, and laws that impact health 6. Utilize legal and regulatory actions designed to improve and protect the public’s health Assurance 7. Assure an effective system that enables equitable access to the individual services and care needed to be healthy 8. Build and support a diverse and skilled public health workforce 9. Improve and innovate public health functions through ongoing evaluation, research, and continuous quality improvement 10. Build and maintain a strong organizational infrastructure for public health Figure 1: CDC - Public Health Systems & Best Practices Source: Centers for Disease Control and Prevention The COVID crisis has provided a severe ‘stress test’ for local public health functions. While in many regards the response was exemplary, existing resources and structures were inadequate to meet the challenges posed by the pandemic, let alone normal public health services. Significant outside funding, new or reorganized administrative functions, and temporary staffing were needed to address the emergency. Neglect of Public Health Functions According to the National Academy of Medicine: …local execution of these programs and functions is often limited by constraints imposed by both federal agencies and state and local jurisdictions. First, funding levels have historically been inadequate to support the delivery of the Essential public health services, let alone prepare for emergency situations. Second, many funding streams for public health are “categorical”, or restricted to specific priority areas (e.g., HIV, tobacco control), which leaves little flexibility for spending to support core foundational capabilities or to support surge needs in times of crisis. Other funding streams are operated as block grants, but…such models in practice have been vulnerable to funding cuts… Overall funding for foundational capabilities has run dry in the face of long- standing neglect and deprioritization by both local and national leaders, with the expenditures of public health agencies decreasing by approximately 10% (between 2010 and 2018) and the share of health care spending attributable to public health declining by nearly 17% (between 2002 and 2014). Indeed, rather than valuing prevention, the American system has become increasingly biased in favor of reaction, with per capita spending on public health services equivalent to 1-3% of per capita expenditures on medical care. Chronically deprived of resources, the capabilities of health departments have begun to atrophy over several key domains. These factors have also operated in Sonoma County. A prime example of local public health programs that have been on the chopping block was DHS’s pre-pandemic proposal to close the County’s public health laboratory. As stated in a March 2022 Press Democrat article: “…former county staff members say the proposal reflected a pre-COVID mindset that sought a shift in the mission of county health services. In essence, community-based prevention programs would be sacrificed to pay for those the county is legally-required to provide.” This proposal was quickly scrapped when the COVID crisis hit, and the value of a local, public, health lab was decisively demonstrated. The CDC’s list of essential public health services should provide the basis for an in-depth review of Sonoma County’s public health functions. This should include an examination not only of substantive programs provided by DHS, but also administrative structure, and critically, stable long-term funding. METHODOLOGY This is an investigation initiated in response to a citizen complaint received by the 2021-2022 Sonoma County Civil Grand Jury. The Grand Jury conducted over 24 interviews with key individuals in Sonoma County who are or were involved with the Department of Health Services. They included: • Elected and appointed County officials • Past and present DHS employees • County employees assisting in the COVID response The Grand Jury reviewed and evaluated hundreds of documents obtained from both public and private sources. The most important of these are listed in the Bibliography. DISCUSSION County Health Departments, including Sonoma County’s, exist to provide essential public health services, such as environmental health, control of infectious diseases, behavioral health, and services for the underserved. They are generally chronically under-funded, under-resourced, under-appreciated, and yet continue to work diligently behind the scenes to ensure we all live in a safe and healthy environment. The COVID pandemic presented a serious and unprecedented public health threat. It required an immediate response but there was no rulebook. The pandemic required the County to find and mobilize significant resources, many of which it did not have. It also required the County to work collaboratively across departments in a new, untested way. Federal and State resources were quickly provided so the County could fund operations; but it was still exploring what kind of operations it needed. Sonoma County was in uncharted territories with sketchy maps and with leaders who had knowledge of other infectious diseases, but not of this magnitude. Experience with disasters, of any sort, strengthens the response to all types of emergencies, including pandemics. One asset that Sonoma County had was its experience in successfully responding to wildfires. Over the past five years, the County has developed a finely honed capability to deal with fire, flood, and power shutoff emergencies. This includes not only fighting fires, but in providing for displaced and traumatized communities, and working with the Federal and State departments that provide funding and technical assistance. The County’s Department of Emergency Management (DEM), which initially led the COVID response, is a recognized expert in dealing with emergencies. However, the pandemic was not a standard emergency. While the EOC did have processes and training in place to cope with significant emergencies, it had never encountered an emergency of this scale and scope. This report focuses on the way the County deals with these challenges. It has not been a smooth journey and not one without conflict. The control of the response started with the EOC using the Incident Command System (ICS). Shortly thereafter, and due in part to friction between the DHS and the EOC leadership team, it transitioned into a hybrid structure with co-directors from the EOC and DHS’s Department Operations Center (DOC). Within two months it again shifted from the hybrid structure of DHS and EOC to the DOC, with the Director of Health Services now leading the response. The emergency also exposed some of the dysfunctions in the culture, structure, and management processes of the County and the DHS. These problems are not new and in fact had existed prior to the pandemic. They have been cited by previous Grand Juries as needing immediate attention, but based on interviews little has been done to address them. The pandemic is still not over and new variants or new viruses may create future emergencies. The Grand Jury believes these issues must be addressed without delay to ensure the County is organizationally robust enough to meet future public health challenges. Failure to act may seriously affect the County’s ability to respond, putting the health of the County’s population at risk. The discussion that follows explores these issues in more depth, and we begin by first outlining the incident management system which is used nationally in disaster situations. Incident Command System National Incident Management System (NIMS) The federal government has created a standard approach to managing disasters. According to FEMA, the National Incident Management System (NIMS): …guides all levels of government, nongovernmental organizations and the private sector to work together to prevent, protect against, mitigate, respond to and recover from incidents. NIMS provides stakeholders across the whole community with the shared vocabulary, systems and processes to successfully deliver the capabilities described in the National Preparedness System. NIMS defines operational systems that guide how personnel work together during incidents… NIMS defines operational systems, including the Incident Command System (ICS), Emergency Operations Center (EOC) structures, and Multiagency Coordination Groups (MAC Groups) that guide how personnel work together during incidents. NIMS applies to all incidents, from traffic accidents to major disasters. The jurisdictions and organizations involved in managing incidents vary in their authorities, management structures, communication capabilities and protocols, and many other factors. NIMS provides a common framework to integrate these diverse capabilities and achieve common goals. The guidance contained in this document incorporates solutions developed over decades of experience by incident personnel across the Nation. The NIMS system has been proven highly effective for the management of disaster/emergency situations, and is utilized by Federal, State, regional, and local agencies. Its widespread utilization allows for ready integration of multiple agencies towards common goals. Standardized Emergency Management System (SEMS) The County also follows California’s Standardized Emergency Management System (SEMS) which integrates with NIMS. Within the NIMS system is the Incident Command System (ICS), which provides a structure for responding to specific incidents. According to NIMS: ICS consists of five major functional areas, staffed as needed. They are Command, Operations, Planning, Logistics, and Finance/Administration. The ICS organizational structure is modular, expanding to incorporate all elements necessary for the type, size, scope, and complexity of an incident. The ICS structure builds from the top down; responsibility and performance begin with incident command. If one individual can simultaneously manage all major functional areas, no further organization is needed. If one or more of the functions needs independent management, an individual is assigned responsibility for that function. The initial Incident Commander determines which Command or General Staff positions to staff in order to maintain a manageable span of control and ensure appropriate attention to the necessary incident management functions. Figure 2: US. Department of Health and Human Services Of particular note is the ICS’s directive for clear leadership, and a unified approach to disaster management. The ability to rapidly make and execute decisions in disaster situations is critical for an effective response. Another important element is ‘depth of bench’ or the concept that key positions are staffed by multiple persons who can take different shifts or substitute for each other. This is critical to avoid burnout, when many high-pressure and stressful disasters are ongoing 24 hours a day, 7 days a week, sometimes for weeks or, as in the COVID pandemic, two years and counting. Sonoma County’s Use of the ICS The Board of Supervisors (BOS) adopted resolutions in support of the nationally recognized ICS system, which has been effective in managing the response to numerous disasters. The County Department of Emergency Management has developed expertise in managing disasters, particularly in the wake of the County’s ‘baptism by fire’ in the devastating infernos of 2017. The County has a comprehensive plan for dealing with a range of disasters, including earthquakes, floods, fires, terrorism, civil unrest, extreme heat, tsunamis, chemical, biological and radiological incidents, and pandemics. The County’s plan clearly states that NIMS, SEMS, and the ICS system will be utilized in declared disasters. Under the County’s plan, the BOS has ultimate authority, providing policy direction, while the County Administrator is designated as the lead administrative officer for disaster management. Typically, the County Administrator delegates this authority to the director of the EOC. In a disaster, the County activates the Emergency Operations Center which is one of the key components of the ICS system. The County may also activate one or more Department Operations Center (DOC) within departments actively engaged in the disaster response. Pursuant to the County’s emergency operation plan, all entities involved with the disaster response are to use the ICS system. Figure 3: Sonoma County ICS Chart Example Source: Sonoma County COVID-19 EOC Activation Assessment Report, July 2021 Disaster Service Workers A Disaster Service Worker (DSW) is any County or Agency employee who may be required to work for a declared disaster assignment. California Government Code 3100 provides that all public employees are DSWs and may be assigned disaster service activities. Some of the assigned activities included: answering telephones, ordering/delivering food or supplies, managing volunteers, developing information or communications, tracking information in the EOC, helping out in a warehouse, shelter or food bank, language interpretation, etc. Emergency Operations Center to Department Operations Center Emergency Operations Center Activated On January 31, 2020, to address the growing public health threat posed by COVID, the United States Health and Human Services Secretary declared a public health emergency for the United States. On March 3, 2020, following local cases of COVID, the Public Health Officer for the County of Sonoma declared a local public health emergency and the EOC was activated. A series of follow-up actions ensued as the virus spread in the community and the County responded, including the activation of the County’s DSWs. Emergency Operations Center De-activated – What Happened? Early on in the pandemic, the County Administrator’s Office (CAO) approved a restructuring of the EOC to have ‘dual directors’ with the EOC Director and the DHS Director as co-leaders. This arrangement, which interviewees indicated lasted for about two months, conflicted with the standard Incident Command System (ICS) management structure and led to problems in decision making and implementation. According to interviews conducted by the Grand Jury, this structure had not been used previously, and was not known to be utilized elsewhere in the state. Under the direction of the EOC, a July 2021 “Sonoma County Assessment Report” was prepared by Tetra Tech consultants to evaluate the emergency pandemic response between March 1, 2020 and May 15, 2020. The report looked at various aspects during that time: • The dual director approach “…seemed to be an apparent challenge with having two EOC Directors. Even though staff focused on the tasks at hand, EOC staff members expressed confusion, discord, and tension.” • Some EOC participants, particularly from DHS, were not fully trained on the ICS system and did not understand their roles. • It also mentioned “poor or below average” communication and coordination between EOC and DOC. • “…Health staff were unfamiliar with EOC functions and had a challenging time fitting in and understanding operations.” • Several survey responses expressed concern about the Health staff not following procurement procedures and unfamiliarity with EOC functionality. • Participants observed that following coordination meetings “DHS would completely change direction”. This proved to be disruptive to process and continuity. Others commented that instead of adhering to FEMA requirements, especially in finance and purchasing, DHS staff often “just did their own thing.” Further, based on interviews conducted by the Grand Jury, the DHS Director was often absent from the Emergency Operations Center, leading to communication issues, some apparent duplication of effort, and delays in decision-making during a declared disaster. It was reported that at times, the DHS Director would be represented by other DHS staff, but the staff present did not appear to have authority to make important EOC decisions. Part of the standard disaster response is an ‘after action’ report. In addition to the Tetra Tech report mentioned above, once the declared emergency is over, an After Action Report will be completed by the DHS. Department of Health Services: Department Operations Center On May 10, 2020, the COVID EOC was deactivated and the emergency response transitioned to the DHS Department Operations Center (DOC). According to a number of interviews conducted by this Grand Jury, DOC staff received the unusual direction from their management to not utilize the resources of the Department of Emergency Services. In addition, the DOC did not follow key elements of the ICS system, such as having sufficient depth of staffing to avoid staff overload and burnout, staff not having adequate authority within the DOC to make key decisions, not consistently utilizing standard ICS forms for documentation, or meeting standard Federal Emergency Management Agency (FEMA) contract provisions. Instead of the DOC having internal authority to make and implement decisions, interviewees confirmed that important decisions were made at the Department Director level, likely resulting in some delays in the response. Given the long duration of the COVID emergency, these deficiencies were particularly concerning. Without sufficient depth of staffing, various employees were compelled to work for extraordinarily long hours for extended periods of time; this included salaried personnel who worked without being paid overtime. Salaried workers are not normally entitled to overtime, however FEMA recognizes that disasters often require long hours by all workers, and will reimburse a substantial portion of overtime pay, including for salaried workers. Federal and State reimbursement can vary by declared disaster. Per testimony to the Grand Jury, under standard FEMA policies, and in Federally-declared disasters, FEMA reimburses up to 75% of local costs; the State then pays 18.75%, with the County responsible for the remaining 6.25%. The County paid overtime for all salaried disaster workers for approximately two months—far shorter than the duration of the COVID pandemic. While this saved the County money, what was the impact to County employees? Without the depth of staff, some worked long and stressful hours, six or seven days a week for months on end, affecting their personal lives and well-being. Once salaried worker overtime pay was terminated this resulted in a hardship for those employees who were still required to work the overtime. Notably, partway through the COVID emergency, President Biden approved 100% reimbursement of local costs for a limited time period, which was recently extended to July 2022. In spite of this assurance, the Board of Supervisors did not authorize additional overtime expenditures beyond the first two months of the emergency. As of the writing of this report, the County is considering a ‘cap’ on salaried worker disaster overtime pay. This could balance the need for appropriate compensation in emergency situations with fiscal concerns. Factors that should be considered with any salary cap include the duration of an emergency, coupled with sufficient staffing so that no one is forced to work extraordinarily long hours for an extended period of time. Organizational Culture, Communication and Morale The DHS stated principles call for an open, collaborative, and supportive work culture. The DHS Strategic Plan 2019-23 affirms that the “…plan is built on the values of equity, collaboration, and excellence which provide the foundation for how we do our work and achieve our goals.” In describing its values, the Strategic Plan states that “…we strive to create a culture of learning, innovation, and data-driven practices to guide our internal operations, improve performance, and build staff expertise.” It adds that “…we engage and work collaboratively with partners, community and staff to maximize our impact in Sonoma County.” • Goal 3 of the Strategic Plan specifies that “DHS is a highly achieving, high functioning organization.” To achieve this goal, its first objective is to “Build a highly competent and engaged workforce” through two main actions: “Promote staff well-being and engagement” and “Improve communication and collaboration.” Reinforcing the principles of the Strategic Plan, the DHS Director was quoted in The Press Democrat on March 25, 2022 as being committed to recognizing, valuing and using staff expertise throughout the organization at whatever level. The Director further added: “A top- down organization is so ineffective…The voices [sic] of everyone in our organization is so important. And there must be a focus and a communication to our staff — that every position is important…” Communication and Trust The reality, however, appears to be very different. From our interviews, a common theme emerged of a top-down leadership style characterized by what one interviewee termed a “my way or the highway” approach. Many interviewees said that top DHS leadership only wanted managers who agreed with them, and that there was a fear of retribution if they did not. As a result, there was a lack of transparency and trust. Interviewees used adjectives such as “toxic,” “hostile,” “chaotic,” “dysfunctional,” “desperate,” and “fearful” to characterize the resulting organizational climate. Furthermore, HR management systems, which should have ensured that staff were informed, supported, and felt valued, did not work effectively. Staff criticized poor supervision, irregular staff appraisals, lack of two-way communication, and an ineffective procedure for filing HR complaints. The decentralization of HR led to autonomy in the execution of HR functions within the DHS. Unfortunately, County HR lacks the authority and resources to audit and enforce HR practice in these separate HR units. With this decentralization, some essential HR processes in the DHS have been neglected over the years. This lack of attention has seriously eroded the morale and productive capacity of the DHS. Although many staff had grievances, there were no DHS HR mechanisms that they felt safe to use to make complaints. This appears to have exacerbated the on-going lack of trust. A countywide ombudsperson, independent of HR, would give employees more confidence to voice their concerns. Exit Interviews Tell a Story – Who Does Them, Where Are They Done? In addition to our interviews with current DHS staff, the Grand Jury reviewed exit interview questionnaires completed by employees who left the DHS starting in 2018. Exit interviews are often conducted when a staff member leaves County employment. They may consist of a formal conversation between the person leaving and a HR professional and/or the completion of a questionnaire. This process is designed to help the DHS and the County build a more productive workplace. An exit interview is not compulsory and not everybody leaving responds to the exit interview invitation. The Grand Jury analyzed 58 exit-interview questionnaires from staff who resigned from DHS in the 2018-2022 period. The questionnaires provide information on the reasons people left, and on the bleak picture they paint of the DHS organizational culture. The most cited reasons, in descending order were: 1. Dissatisfaction with DHS culture 2. Dissatisfaction with current position 3. Family / personal reasons 4. Other including retirement 5. Workload 6. Dissatisfaction with manager / supervisor 7. Lack of career path, seeking promotional opportunities 8. Salary and benefits Statements made by staff about why they were leaving included: • Toxic environment • Rigid top down management style • Lack of receptivity to suggestions and feedback • Humiliated, disrespected, undermined, and blamed • Negative feedback • Leadership not accessible, no regular meetings, no authority to make decisions • Unfair and unequal treatment, not recognized for the work performed, lack of cooperation and teamwork • Lack of communication regarding complaints and problems • Lack of encouragement toward career development These were not isolated comments. It is important to note that exit questionnaires and interviews also highlighted many positive attributes of working for the DHS. These included: the opportunity to serve the community; working for the mission of public health, and working with committed, talented colleagues. The employment package was also praised. People seemed to recognize that some of the non-salary benefits of working for Sonoma County were a positive aspect of their employment. Effects on Staff Retention and Recruitment The DHS has had an average staff vacancy rate of 15% over the 2019-2022 period. This is at the upper end of rates for other County departments, but not significantly so. In January 2022, the rate was 17%, the highest it has been for the past three years. Of concern, however, has been the turnover of staff in key management and leadership positions which doubled during 2018-2019 when compared with the previous three years. Some key posts have been hard to fill, such as the Director of Nursing position which has remained unfilled for nearly a year. Although there have been considerable external factors that have contributed to this, many interviewees thought that the Department’s work culture has also adversely affected recruitment. This is an important concern as the DHS needs to staff-up and scale-up for the continued presence of COVID and future public health emergencies. As we have highlighted, the 2016-2017 and the 2018-2019 Civil Grand Juries also raised concerns about similar staffing issues. In order to prepare for the future it is critical that these concerns be addressed without delay. Cultural and Racial Tensions Add to Dysfunction The COVID pandemic created additional stressors on the Department of Health Services. Political, cultural, and racial tensions may have exacerbated the situation and led to a degraded sense of trust. Emergencies engender their own sense of crisis, tension and danger which can cause some people to act in abnormal or inappropriate ways. In addition, they often force different groups of people and organizations to work together, which can create a clash of organizational cultures. Testimony to the Grand Jury indicated that there were also tensions within the Department between medical staff and administrative staff. In addition, at the higher levels of the County government, there were tensions created by the emergency situation, such as unilateral powers of the County’s Public Health Officer (PHO). In some circumstances, the PHO’s authority exceeded that of the department head, and even the Board of Supervisors. Racial tensions added to underlying emergency stressors. During the pandemic, in a Zoom meeting regarding homeless issues, there was a highly-publicized instance of ‘Zoom bombing’ where senior officials, including DHS/CDC leadership, were subjected to racist, violent and obscene online rhetoric and images. This was reported in a July 11, 2020 Press Democrat article titled: Racist Zoom bomb ends Sonoma County meeting on homeless solutions. While Zoom meetings across the nation were similarly disrupted, a County elected official’s comments were viewed as minimizing the incident. The Grand Jury also received testimony about the perceived lack of support by County leadership for persons of color in the meeting who were subjected to this assault. At several points in the pandemic, public statements made regarding the resignation of several senior County staff persons who were persons of color, and the rescission of acceptance of an appointment to a senior DHS position by a person of color, added to the perceptions of racial tensions. Testimony to the Grand Jury highlighted the tensions and distrust provoked by these incidents. The County has responded to concerns about its efforts to address these issues, including creating an Office of Equity in 2020, which is charged with working with County departments towards racial equity in the County workforce and programs. COMMENDATION Sonoma County, along with the rest of California, the United States, and the world, faced a pandemic without precedent in the last 100 years. Few governments or agencies were prepared for a health crisis of this magnitude. Public health departments across the country and in Sonoma County were not adequately funded, staffed or conceptually prepared. The legal authority possessed by California public health officers was unknown to most members of the public, and the community’s understanding of the measures necessary to combat a pandemic were at best poorly understood. That said, in many regards, our County rose to the challenge, with rapid allocation of extraordinary resources, enactment of legal measures to reduce spread of disease and expedite response, initiation of extraordinary medical efforts to understand and mitigate the effects of the disease, and the heroic contributions by countless dedicated public and private workers and managers. We want to commend all members of the County, with special thanks to the Department of Health Services, Disaster Service Workers, and Emergency Operations Center for their commitment to the community. FINDINGS The Sonoma County Civil Grand Jury determined that:

Salaried disaster service workers worked for months on end, often seven days a week, without adequate compensation.

The Brown Act requirements make it difficult for the Board of Supervisors to directly supervise County departments.

The Board of Supervisors has the ability to change the supervisory structure of all departments within the County; modifying this structure could improve oversight.

Many Department of Health Services employees are fearful to report harassment, bullying, toxic work environment, and safety issues to their executive team due to a fear of retaliation.

Many employees in the Department of Health Services do not trust their departmental Human Resources team or its processes.

A review of Department of Health Services exit interviews shows a distrust of upper management.

Exit interviews can be done by either the County Human Resources Department or by individual departments, potentially leading to a lack of effectiveness and accountability at the department level.

The practices of human resource management in the Department of Health Services is not regularly or consistently reviewed by the County Human Resources Department.

In the Department of Health Services, essential human resource processes such as performance appraisals, supervision, conflict resolution, etc. are performed irregularly, inconsistently, and are not in alignment with County standards.

In the Department of Health Services there are numerous unfilled positions due to slow recruitment efforts and other deficiencies.

The Department of Health Services’ perceived hostile work environment may be causing extra challenges in the recruitment of senior Department of Health Services staff.

The Department of Health Services has failed to execute on their commitment to a communication plan between the executive team and their employees.

The Department of Health Services’ employee internal intranet site does not include a policy and procedures section for the Public Health Division.