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.

Driver diagram developed by the SCALE Team

The idea of a Walk for Wellness resonated with the group and became the focus over the next few months. As the teams met, they used a model called Equity Action Labs: a focused project to improve the coordination of park partners in order to achieve improvements in sense of safety, feeling welcome in parks, and increasing park access for community residents.

At the end of 2018, the SCALE team analyzed all data collected by parks and looked at three process elements:

• Number of programs and events at each park
• Hours of positive activities and programs at each park
• Participation levels during events and activities at each park

Though the project aim was not achieved, the Safe and Active Parks Pilots did approach the desired outcomes. Primarily, the SCALE Team strengthened collaboration, improved capacity for common measurement, and gained insights for how community users interact with park spaces pre- and post-renovation.

• Attendees during the 2018 Safe and Active Parks (SAP) Pilots:
• Accessed parks frequently, and feel welcome at parks
• Reported a lower proportion who feel unsafe in community parks
• Nearly two-thirds felt a sense of belonging at the neighborhood parks
• Nearly three-quarters agreed that they feel more connected to their community after spending time at the parks during the SAP Pilot
• 64.1% felt safe during SAP
• 88% attributed a benefit to using the park during SAP

Community Transformation: Racism, Equity, and Engaging People with Lived Experience

During the initiative the SCALE Team benefitted from multiple opportunities to explore and learn together about how systemic and structural racism has led to vast inequities in resources and outcomes both nationally, and how those same elements show up in the Tenderloin neighborhood.

After National CHILAs in Seattle and Philadelphia the SCALE Team was inspired to learn more about how public spaces and parks can be racialized, and how together and individually they could increase their knowledge of the topic, experience discussing challenging topics like racism, and discern how those actions could further inspire its collective work. And it was after the National CHILA 3 in Denver, Colorado when the SCALE Team was determined to place Race, Racism, and Equity into focus.

During the exploration and research, the SCALE Team learned about some concerning racial inequities, including:

• In San Francisco, Tenderloin residents are some of the least likely to visit a park at least once a week. Furthermore, Black and Asian residents are the least likely racial groups to report visiting parks at least once a week.
• A history of racial discrimination may explain some of the inequities in park use and access by African Americans
• Areas of the country with higher proportions of residents of color had less access to green space than areas with a higher proportion of white residents, and access to green space decreased for diverse communities of color compared to white communities over a 10-year period.
• Cities like Minneapolis, Minnesota, recognized for having the best park systems, have had to figure out strategies to address racial inequities of access, spending, and staffing as the public parks are primarily geared toward rich, white residents

After examining these and other racial and ethnic disparities, the SCALE Team identified an approach to improve access for Tenderloin residents, through an Equity Action Lab model. On August 2, the SCALE Team hosted the first Walk for Wellness Event. Residents and park users participated in art activities and walked the neighborhood in solidarity, starting at Boeddeker Park with stops at La Voz Latina, Tenderloin Community Benefit District, Sgt. Macaulay Park, and ending in Turk Hyde Mini Park.

The event was a huge success in mobilizing single adults and families (35 people), engaging in group walking activities. Eight different organizational partners worked closely together to make it happen, and met with event participants to discuss improvements to the event and park experiences. Participants shared that they enjoyed walking together and enjoyed the art activities (especially the parents). Most wanted to know when the next cycle would be and asked for more events like it. The group used the PDSA cycle to assess success, and decided that an additional cycle could yield new information.

"Although Community Champions may not be experts in community development as a science, Community Champions are indeed the best experts in how the negative issues affect the physical and mental health when propose solution are being suggested or prescribed." - Ana Gee, Community Champion and neighborhood park representative

One of the outcomes of that process was bi-weekly planning meetings focused on implementing the next Walk for Wellness event. Included were renewed pushes to collect some outcome measures of the events and activities, and an expanded effort to include the park space down at Civic Center playground to see if the spaces could be connected through a procession.

On November 1, the SCALE Team and additional partners hosted the second action lab, Walk for Wellness: Dia de los Muertos celebration.

The Dia de Los Muertos celebration was activated across all four park spaces in the Tenderloin. Starting in Civic Center, TLHIP Partners Demonstration Gardens and Skywatchers began a procession recognizing the neighbors who had died over the years and arrived at Turk Hyde Park. At Turk Hyde Park, Mayan Dancers performed for the community gathered there. The processions continued to Boeddeker Park, where staff provided Dia de los Muertos festivities and dinner for families.

Participants followed the procession led by the Mayan Dancers onto Macaulay Park, where there were more celebrations, dancing face painting, Dia de los Muertos alters, and a cultural celebration tying all of the parks together. In the end, the event was another big success with more than 100 community members participating in the recognition and celebration of Latino cultural heritage in the neighborhood.

SCALE network partners also used this opportunity to collect information from event participants at all park locations and collect information to guide thinking about future events and actions and to better understand how the pilot projects and events had influenced their sense of safety, health and wellbeing.

In addition to the equity action labs, at the end of November, two SCALE Team members attended a two-day Race Equity Institute workshop held in Raleigh, North Carolina which provided an interactive presentation on the nature and impact of structural racism, and how it shows up across institutions and systems. These same SCALE Team members brought their knowledge and experience back to the Tenderloin community and led the group in a session during the next SCALE-Up CHILA focused on racial equity.

"Understanding and getting use to my role was a challenge because community member are usually told what to do or how to think about prioritizing needs in their communities. Through SCALE I was able to recognize and learned the value that community members bring to the table in understanding and creating possible solutions and approaches to the many negative issues that we deal with in our communities."Ana Gee, Community Champion and neighborhood park representative

Having worked together on understanding and ability to thoughtfully discuss and address racial equity, led by Community Champion, Ana Gee, the SCALE Team has helped to build the next wave of Community Champions - leaders in the community with knowledge and experience to affect change. Recently, she and Erica co-facilitated a workshop on identity and race. This group of new Community Champions is driving the agenda development, and they continue to want to understand and frame neighborhood and social challenges with an equity lens.

In addition, Ana Gee has served as the Tenderloin representative on the Parks and Recreation Open Space Advisory Committee thoughtfully working with other community representatives and Recreation and Parks Department staff on addressing equity challenges across the city. Recently, Ana was re-nominated to serve a second term as the district representative where she brings her Community Champion SCALE skills to that role.

Leading for Sustainability

As the SCALE initiative evolved, the investments made in team building, capacity building, and engaging individuals with lived experience as community champions has grown and expanded the SCALE Team. These elements are at the core of the sustainable model that continues to SCALE up and strengthen partnerships.

In January 2019, the SCALE Team attended the fourth and final National CHILA in Puerto Rico. Because some of the original SCALE Team members were unable to attend, it was a testament to the success of SCALE-up, as all SCALE Team members represented first or second-time National CHILA attendees. This next wave of SCALE-up added to the legacy of the SCALE work in the Tenderloin neighborhood.

Shortly thereafter, a key SCALE Team member bid farewell as he was inspired to bring some of the improvement science and community transformation approaches to his home in Hawaii. At the same time, with the addition of Erica Waltemade as the Arts and Placemaking Manager to the Lower Polk CBD, the SCALE Team continued to expand and grow the skills and talent pool. It was another moment to reflect on the ever shifting ways in which relationships and experiences bond people together for periods and that sustainability requires a deep team of partners.

Back in the neighborhood, SCALE Team members have been aligning with both local community champions, working on race, racism, and equity trainings and combining them with improvement science. The SCALE Team has also been working closely with the city’s Recreation and Parks Department to address concerns related to the renovation and reopening of two parks in the neighborhood.

SCALE Team members are advocating for safety stewards and additional city support for programs, events, and activities that have shown to bring people together, build connection, and provide fun and safe opportunities to use local parks.

The last local CHILA of this current phase of SCALE was held and included first-time attendees who are interested in learning and growing together into the future. A few days later, many of the same partners celebrated the groundbreaking of Sgt. Macaulay Park and Turk Hyde Mini Park with music and recognition of the dedication to addressing equity concerns in the neighborhood. In the meantime, SCALE Partners are continuing to meet regularly and will begin plotting the next local CHILA soon, with greater attendance and representation from community champions.

Lessons Learned

Spread and Scale-Up:

• Getting institutional leadership support from TLHIP partners earlier in the process would have meant less time spent trying to make the case for partner time commitment.
• The heavy lift of the project and focus on the outcome may have sidetracked the team from the deep community engagement required in a community of solutions. Next time, the community and park users should be a part of the planning and execution from the beginning, and part of Scaling-Up.
• The size and scope of the projects meant that the cycle couldn’t be as rapid as desired. In the future, it would help to start smaller and grow and scale from there.

Improvement Science and Measurement:

• The diversity of the neighborhood is a strength and celebrating culture and diversity creates a positive atmosphere at the parks and encourages inclusiveness
• The largest barriers to accessing parks are ‘feeling unsafe in the park’ and ‘the walk to the park is unsafe.’ Those who use parks less more likely to view them as unsafe, so let’s improve the safety elements and increase park use!
• All parks in the Tenderloin require a safety steward onsite, to support and proactively engage community access and provide a sense of oversight and safety

Community of Solutions Skills and Community Transformation Map:

• Time spent team-building and learning together in person at local and national CHILAs helped build team trust and strengthen working relationships, and positioned the team to work well collaboratively
• The focus on a common project sometimes came at the expense of some of the other elements of the SCALE initiative like intentional learning or team building. Next time, we would try to incorporate more team-building and learning components into the planning meetings to continue to build the Community of Solutions skills throughout.
• By having an emphasis on common projects, the group had to expand and bring in new partners and new individuals which in turn, grew the SCALE network

Racism, Equity, and Working Together with Lived Experience:

• Community members said that they want to be more involved in the planning and to help out during events. They are hoping to bring more activities and games to the park, and there is an opportunity for deeper community participation.
• Individuals participating in a SCALE initiative learn how to Lead from Within, which often means expanding responsibilities and learning to stretch and perform beyond the standard organizational role
• While adding partners midway can add complexity, including community voice and sharing power strengthens collaborative work, but also means adapting to different schedules and translating content