This story was originally published in the 100 Million Healthier Lives Change Library and is brought to you through partnership with 100 Million Healthier Lives and the Institute for Healthcare Improvement.

The Tenderloin, spread over 40 blocks, is home to nearly 35,000 residents comprised of families, children, single adults, artists, seniors, newly-arrived immigrants, and many living without a home. All are accepted in this neighborhood. Nearly 70% of residents are people of color and the richness in diversity of every resident reflects the resilience it takes to make ends meet.

San Francisco is touted as a leader in technological innovation, with a median income of $96,265. However, the median income of the Tenderloin is $30,365 and 35% of households make incomes less than $15,000 a year. There are vast health disparities affecting the neighborhood, including limited access to open space. The Tenderloin has only 9.1 acres of open space, or the equivalent of one yoga mat of open space per resident.

This is the story of how TLHIP formed a SCALE Team to address inequities in the Tenderloin neighborhood.

6,925

Total acres of Open Space in San Francisco

Getting Started, SCALE Phase 1

In April of 2015, the Tenderloin Health Improvement Partnership (TLHIP) was invited to join the 100 Million Healthier Lives movement by participating in the national Spreading Community Accelerators through Learning and Evaluation (SCALE), convened by the Institute for Healthcare Improvement (IHI). TLHIP was formed as a collective impact initiative: a model for social change with five key elements: a common agenda, shared measurement system, mutually reinforcing activities, constant communication, and a skilled backbone to support the work. How would the TLHIP initiative incorporate the concepts of improvement science, race and equity, and design-thinking? What would TLHIP learn as a result?

In response to community concerns around violence, lack of safety, drug dealing and drug use, TLHIP partners launched and supported a range of strategies. Chief among them were deep investments in neighborhood bright spots such as  local parks, ‘Safe Passage’ stewards, block safety groups, and other activities that promoted community connection and strengthened partnerships.

Spread and Scale-Up: Forming the Park Network and Leading Together

In the Fall of 2017, TLHIP was invited to join the second phase of the SCALE initiative, but this time with an emphasis on scaling-up its work. This phase of SCALE involved identifying new partners to learn about SCALE and apply the lessons and tools to the work they were already engaged in, further deepening the collaboration. TLHIP saw a big opportunity to leverage the SCALE initiative process by expanding its group of SCALE partners and focusing on scaling the park activation model across all neighborhood parks.

Early on, Philip Vitale, Senior Program Manager at The Trust for Public Land (TPL) staff joined the SCALE 2.0 project. By joining with TPL, TLHIP and community partners which had been engaged in the park design process could easily transition to a SCALE Team. With a lot of excitement headed into the initial National Community Health Improvement Leadership Academy (CHILA) in Seattle and Philadelphia, the SCALE team members were focused on defining the scope of the project and clarifying its aim. As a newcomer to the SCALE methods, Philip saw a huge overlap with his role in building stewardship of public spaces with community, and the ways in which equity, leadership, data, and sustainability could support successful parks. As the team left Seattle and Philadelphia, they felt inspired that the messages of equity and the aim of improving park safety through a Wellness Trail would catalyze a range of partners and strengthen its network.

Upon reflection, the SCALE team members realized that the Wellness Trail concept was receiving positive feedback, but was not inspiring anyone to join them in a change process. When they realized this, the SCALE team decided to refocus on the community that was consistently present for park updates and planning meetings. Finding the appropriate partners, the ones that had been consistently dedicating themselves to a specific park and working to bring them together to create a stronger network, was key to formalizing and finding their path forward together. Fortunately, that shift in thinking helped establish the appropriate partners to join the SCALE journey. It was the first local SCALE-up CHILA where momentum picked up.

On April 13, TLHIP hosted its first SCALE-up CHILA meeting, engaging a group of partners in support of activation and placemaking at parks in the neighborhood . The meeting included 9 partners, reflecting diverse organizations: Patrick Roddy from the Boys & Girls Club, Enrique Aguilar from La Voz Latina, Ana Gee and Bryant de Venecia with Central City SRO Collaborative, Philip Vitale from Trust for Public Land, Josie Behrens from Walk SF, Phoeut Tak from Tenderloin Community Benefit District, Christian Martin from Lower Polk CBD and TLHIP backbone - Will Douglas from Saint Foundation and Jennifer Varano from Saint Francis Memorial Hospital.

The first CHILA meeting focused on introducing many of the tools, theories, and ideas driving the 100 Million Healthier Lives SCALE initiative. It was an opportunity to build and strengthen relationships and create a vision for the journey ahead. While most of these partners knew about one another, many of them had never worked directly together or communicated as peers. This was really the launch of the right-fit of community partners focused on building a SCALE Team Network, representing park spaces and that reflected a Community of Solutions.

Theory of Change for the Community Of Solutions Mode

Quickly thereafter, and with the momentum that was building from the initial meetings, partners joined in Denver, Colorado for National CHILA 3. During the conference, partners were introduced to how integral the Race, Racism, and Equity work was to address the health outcomes of the Tenderloin and neighborhoods like it across the country. It was during the National CHILA that the team’s relationship strengthened further and the group got to work on creating a driver diagram, focusing on a common aim across parks, and discussing how to integrate a racial equity focus into the park network projects.

With the Network established and strengthened by in-person meetings, the group met again in June to discuss how to approach the initiative and what projects to work on together. Out of that session, the idea of neighborhood Walks for Wellness came up as a way to work together and link the parks. This turned out to be a huge help to support the strengthening of the Network over the next several months. Other important factors included the quarterly in-person SCALE-Up CHILA and National CHILA’s which allowed for deep relationship-building, inspiring the team and providing new tools and skills for executing work together.

"SCALE has grounded us in approaching the work that we do in the public realm, particularly at Sergeant Macaulay Park, through the lens of race, racism, and equity. While aware of these systemic problems before SCALE, the initiative has given us the language and background to understand its effects and how it is perpetuated within the context of our own communities." - Erica Waltemade, Community Champion and Placemaking Manager for Sergeant Macaulay Park

Improvement Science and Measurement: Leading for Outcomes and Leading Together

During SCALE 1.0, the TLHIP team integrated and adapted the  into all kinds of neighborhood projects, both explicitly and implicitly. After building context but excited to scale-up, TLHIP began sharing SCALE knowledge and improvement science tools with community through workshops and meetings. During these sessions, TLHIP explored the application of improvement science and trained partners on how to utilize the model for improvement by developing driver diagrams, crafting clear aims and identifying measures, as well as introducing the Plan Do Study Act (PDSA) cycle.

While Sgt. Macaulay Park and Turk Hyde Mini Park are small in size, TLHIP and its partners recognize the importance of these open spaces in the neighborhood. The collective goals focused on how to support community park use by ensuring a sense of belonging and safety, and that programs and activities encourage park use maximizing every foot of park space.

After facilitating workshops with groups associated with Boeddeker Park and Sgt. Macaulay Park, TLHIP also shared improvement science tools on March 28 with an event themed “Data Day,” which showcased the Central Market Tenderloin Data Portal in partnership with Department of Public Health. The event was attended by 65 individuals representing more than 25 neighborhood and city organizations. In addition to data discovery, meeting participants learned how to develop driver diagrams and apply them to address neighborhood data points.

In early 2018, the Tenderloin Community Benefit District and Demonstration Gardens launched the Safe and Active Parks (SAP) Pilot, providing a daily activation of the Turk Hyde Mini Park.

Each day, Safe Passage Corner Captains set up a canopy outside of the park to signal a welcoming and safe presence. Demonstration Gardens provided a range of activities from gardening, poetry performance, and other activities to bridge people together and strengthen community connections. This was an opportunity to quickly advance learning through PDSA cycles. As summer ramped up, Lower Polk CBD and La Voz Latina, and Central City SRO Collaborative began working closely together to implement some of the change ideas that came out of their joint driver diagram, resulting in the launch of a second version of the SAP Pilot at Sgt. Macaulay Park.

SCALE Team members formed a Tenderloin Park Collaborative, which looked at a range of programs, events, and activities that offered new opportunities for people of all ages to engage in at Sergeant Macaulay Park and Turk Hyde Mini Park. Activities included gentle movement and yoga programs, self defense classes, art and performance, entertainment, as well as health, art, and cultural events.

In addition, partners utilized Tenderloin Community Benefit District (TLCBD) Safe Passage Corner Captains (at Turk and Hyde) and Lower Polk Community Benefit District (LPCBD) Pit Stop Program to provide onsite staffing at parks to ensure safety during specific hours and interact with community members during Tenderloin Park Collaborative activities.

At the same time, Boys & Girls Club staff had utilized their driver diagram to re-examine how they were working jointly with staff at the park, and where they could improve their community engagement in processes to support the positive, inclusive activities at the park. Boeddeker Park staff also began experimenting with family nights - nights when the park would stay open late and permit families to use the space longer as the days were longer. Boeddeker Park staff also experimented with a range of activities to promote family bonding, facilitate homework, and staff worked specifically with supporting parents while kids were being looked after.

"The Driver Diagram has been a great help for Boeddeker Park as it has given us a way to focus our efforts on achievable goals. It gives us the tools to really break down the larger goals of the park into something that is manageable and digestible not only to staff but to the community." Patrick Roddy, Local Improvement Advisor and Boeddeker Park Site Director

On June 6, the park network and SCALE Team met again for another local CHILA, this time to focus on how to move the work forward and chart a path together addressing neighborhood inequities around safety and park use. The group also revisited the development of a driver diagram, and reviewed how the PDSA cycles could be part of the collective work. It was during that meeting that the group decided that it wanted to work together on piloting park activations together and ensure that:

1. each park had a safety and program pilot in place, and
2. that parks could provide events and activities that bridged the park spaces and got the team to work together.