Tenderloin Health Improvement Partnership:
Our SCALE Journey

In April 2015, the Tenderloin Health Improvement Partnership was selected as a Spreading Community Accelerators through Learning and Evaluation (SCALE) participant. The initiative, funded by the Robert Wood Johnson Foundation, brought 24 pace-setter communities from around the country to participate in a learning program developed and facilitated by the Institute for Healthcare Improvement. This is our story of SCALE: learning individually, as a team, and as a community.

SCALE Team

Our SCALE Team included representatives from:

- Saint Francis Memorial Hospital

- Saint Francis Foundation

- University of California, San Francisco

- Boys & Girls Club of San Francisco

Tenderloin Neighborhood and the Complex Challenges

Many city agencies and non-profit organizations have been providing critical services for Tenderloin residents for decades. However, even with all the great care provided daily, individuals return right back to the environment that sent them seeking services in the first place. 

For nearly 35,000 Tenderloin residents, lack of safety is a primary barrier to living a healthier lifestyle. Access to safe parks, availability of healthy food, exercise opportunities, and the quality and affordability of retail and housing all have direct and indirect implications on individual health. These social and institutional systems result in chronic health issues and poor health outcomes. A well-documented and cost-effective approach to improving population health is to address the factors that contribute to illness and disease.

Achieving lasting impact on health outcomes requires a focus not just on patient care, but on community-wide approaches aimed at improving population health. Interventions that address the conditions where we live, learn, work, and play have the greatest potential impact on our health.

- Center for Disease Control and Prevention

The Tenderloin neighborhood is full of complex social issues associated with a diverse, low-income, dense, urban environment: mental health issues, homeless, drug use and drug sales, poverty, linguistic barriers and more. 

Where to start?

Typical community health improvement initiatives will start with a broad assessment and winnow down the health needs with community input to get started. Rather, the TLHIP Team looked at the findings from previous assessments and used existing governing bodies to support the TLHIP initiative. 

Community Priorities: Safety, Community Connections, Opportunities for Healthy Choices

For the purposes of SCALE we decided to focus on neighborhood safety in order to provide a lens to view the complex issues within our community.

The Switch thinking model presented approaches that could be directly adopted: Find the Bright Spots and Shrink the Change.


SWITCH Thinking

As a core component of the SCALE community’s initial education, teams were encouraged to read “SWITCH: How to change things when change is hard,” by Chip Heath and Dan Heath. From the outset, strategies driving the TLHIP approach were modeled and adapted to fit a similar vein of thinking. TLHIP, as a place-based, collective impact initiative, was looking looking for community solutions to address the systems that have been in place for decades in the Tenderloin. 

With the renovation of Boeddeker Park and its reopening in December 2014, there was a huge opportunity to look at neighborhood assets and see how we could use those to improve community health and wellbeing.

The 40-block neighborhood was examined to figure out where there were existing Bright Spots in the community—organizations and initiatives that were already setup to address specific conditions in the neighborhood.  

These bright spots held important geographical locations in the neighborhood, and, working with the TLHIP collaborative, Action Zones were drawn around the areas close to each Bright Spot.

Upon completion, four action zones comprising 10 blocks were highlighted as priorities for the community. This allowed the TLHIP team to shrink the change.

Learn more by reading our Seeding Change report.

Find the Bright Spots and Shrink the Change.

Shrinking the Change and then Failing Forward

Once TLHIP was able to shrink the change, there was a notable shift from needs to a focus on tactics: what actions taken today will seed change in the Tenderloin?  This approach and resulting perspective on the neighborhood has helped us move into action more quickly. Neighborhood safety has continued to be a rather difficult barrier to overcome. 

However, for our team, a "fail forward" moment came toward our fourth and final CHILA (Community Health Leadership Academy) Conference -- when we looked at our aim and wondered how we would reach our aim to improve perception of safety to 81% by December 2016. 

The reality was that, based on our own questionnaire and measurements, we were seeing results that were even lower than the District 6 (Tenderloin's district includes parts of civic center, SOMA, and Treasure Island). The knowledge that we were still as far away from our aim as when we started made us look at where we could actually find a change.

So we refined our aim and decided to look at even smaller changes that could be measured.

Our AIM: Improve the perception of safety to 75% by 2020...

(...after we found that we wouldn't meet our initial aim of 81% by 2017)

Finding Focus

We looked more closely at Boeddeker Park, which was starting to feel like the safest place in the neighborhood.

Working within SCALE and applying our knowledge so that we could better articulate our "aim;" looking at drivers of perceived safety, and shrinking the change once more, resulted in a focus on capturing and measuring the success of Boeddeker Park. We worked with our SCALE Team to figure out if Boeddeker was 'successful' to the point of being able to measure the results. 

In our effort to see change, we realized that a key driver of neighborhood safety was that Boeddeker Park is safe. And that is a key driver to measure whether all neighborhood parks are safe. Measuring safety in Boeddeker, seeing the results, allowed us to feel that we have made an impact on safety in our community.

Boeddeker Park and the mural

What makes Boeddeker feel safe? 

How safe do visitors feel? 

How active does a space have to be to improve the perception of safety?

The Next Chapter

This same approach will allow us to focus on addressing safety issues within the remaining parks in smaller pockets within the neighborhood, rather than being overwhelmed by our inability to move the overall safety measure “today.” It provides away to break a challenge into smaller, more manageable tasks and move those more quickly.

The SCALE experience has enabled us to provide this leadership within our community, so we see additional examples of this type of thinking even within our organizational and strategic partners.

Looking forward, the city is now engaged with TLHIP and other community partners in creating new designs and activation plans for two remaining parks in the Tenderloin, Sargeant Macaulay Park and Turk-Hyde Mini Park. Because of Boeddeker, we now have a template for a successful park in the Tenderloin and the model and consistent investment that it takes to maintain such a welcoming, peaceful community space that feels safe.

Furthermore, working with the Tenderloin Community Benefit District and their Safe Passage Program and the Trust for Public Land, TLHIP is making access to parks safer through the identification and investment in a Wellness Trail, part of our SCALE Equity Action Lab project

The Wellness Trail will safely connect parks in the neighborhood

Bright spots and action zones with two new parks before 2020

We know that this process is not easy, but there is promise. The community is highly supportive of these project and knows that they influence the park amenities, design, and programming.

Though the goal ultimately is a safe community free of crime and violence, SCALE has taught us that incremental changes, when measured, can begin to shine a light on a path forward.

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Tenderloin Health Improvement Partnership (TLHIP) is a multi-sector collective impact partnership committed to improving health and well-being in the Tenderloin by aligning priorities, resources and activities to create pathways to health for residents.

Led by the Saint Francis Foundation and Saint Francis Memorial Hospital, TLHIP provides a framework to better coordinate between institutions, co-create solutions and deliver a deeper impact. Since 2014, TLHIP has organized a strong, multi-sector partnership and funded innovative, community-based solutions to create a healthy, vibrant, and safe neighborhood and end the cycle of poor health.