UCSF quality guru believes every hospitalist can help improve the system
by Mark Leiser
Michelle Mourad, MD, says she’s always had “the doctor gene.” As a child, she spent countless hours playing with her Fisher-Price medical kit, and she gained an early appreciation for the scientific method thanks to family members who encouraged her to answer her own questions through discovery and experimentation. A youthful fascination evolved into a calling during high school, when she participated in a summer mentoring program at Santa Clara Valley Medical Center in San Jose, Calif. Paired with two neurosurgeons, she spent 12-hour days accompanying them on rounds, observing surgeries in the operating room, and attending case conferences.
“Right away, I was hooked,” says Dr. Mourad, assistant professor and director of quality for the division of hospital medicine at the University of California at San Francisco (UCSF) Medical Center and medical director of UCSF’s Congestive Heart Failure and Oncology hospitalist services, which comanage bone-marrow transplant and advanced-heart-failure patients in partnership with oncologists and cardiologists.
“I loved the community of medicine and I loved the hospital,” adds Dr. Mourad, one of the newest members of Team Hospitalist. “The interdisciplinary nature really resonated with me. That was when I realized this lifelong feeling of ‘I’m going to be a doctor’ actually had a lot of foundation to it.”
Question: Did you always intend to become a hospitalist?
Answer: I didn’t know hospitalists existed when I started medical school. I gravitated toward internal medicine and was pretty sure I would specialize. I went to internal-medicine residency thinking I wanted to be a gastroenterologist, but I found that a little limiting. I decided to be a pulmonary critical-care doctor, but realized, although I enjoy taking care of patients who are critically ill, I didn’t really want that to be my whole focus. When I started thinking about other options, I knew I was reaching.
Q: So how did you wind up in HM?
A: I enjoyed the community of the hospital—the fast pace, the ability to make treatment decisions and see your changes real-time, the ability to work with residents and interns, the intense time you spend with families during which you can really make or break their hospital experience and make a difference in the care they receive. When I realized I loved those things, the decision was easy.
Q: What does it mean to you to practice at one of the most highly respected HM programs in the country?
A: People want you to succeed. We are encouraged to get involved in the way the hospital works and make it about more than clinical care. The variety of things people do at our institution makes you realize hospitalists are not only clinicians; they are leaders, thinkers, role models, and advocates for patient safety. That’s incredibly motivating.
Q: Your career includes clinical, quality improvement, and administrative roles. Is there one aspect you enjoy most?
A: I need that variety. Allowing us to have that balance here has made the program great. My passion is quality improvement—the ability to affect patients on a personal level but to say, “How do I put systems in place to make hospitals safer and a better experience for every patient?” Figuring out how to navigate your own institution to engender change is challenging, but when you see that change manifest and you have providers and patients thank you for it, it’s probably the most rewarding thing I do.
Q: As director of quality, you strive to improve transitions of care around the time of discharge. What strategies have you implemented to improve that transition?
A: A hospitalist cannot do it alone. Discharge involves case managers and nurses and physical therapists and pharmacists. Our goal has been to create consensus and an urgency for change. … If you can show people their data and show how that is at odds with the vision of the care they are providing, that’s a really powerful force for change.
Q: What can other hospitalists do to improve transitions of care?
A: Form this group and take a good hard look at your data. Use that group to take small baby steps toward change, whether that’s always talking to primary-care physicians or having every patient who leaves have a follow-up appointment in two weeks, or calling every patient after discharge. I think people know what should be in their toolkit for a really safe transition. The problem is fighting the system and creating a group coalition that wants to do that with you.
Q: Have you noticed quantifiable improvements since you took over that role?
A: We put in place a program with residents to make it easier for them to do discharge summaries. They’re templated, they draw from the EMR, they’re concise, and they have what PCPs want. Nurses use them to provide targeted patient education and make sure patients understand their discharge instructions. That probably is my biggest tangible win. The biggest win overall is the culture change.
Q: How has the culture changed?
A: Faculty come up to you and say, “I had a readmission this month. I’m sorry. I really couldn’t prevent it. There’s nothing I could do.” Residents say, “I’ve been so good about communicating with PCPs this month. I can’t wait to see the audit data because I think my team has done really well.” We’re all thinking about what it takes to do a good discharge.
Q: What is the biggest advantage of UCSF’s comanagement service model?
A: The complexity of heart failure and oncology patients is incredible. That complexity means you need a subspecialist like a cardiologist or an oncologist, plus a hospitalist, because there are so many medicine issues along with cardiology or oncology issues. There are infections. There is renal failure. It takes a medicine head as well as a subspecialty head to take care of these patients.
Q: Do you believe that model will become popular for other programs?
A: I do, particularly on the surgical side. A lot of quality gains can be made by having a hospitalist partner with surgeons. The hospitalist can see a large number of patients and make sure everything has been thought about. When are they starting anticoagulation? When do those antibiotics need to come on or off? Those are quality measures that hospitalists are really good at, and I think that will make a fine partnership with surgical subspecialties.
Q: You strive to integrate QI initiatives into house staff education. Why is that important?
A: At an academic institution, you don’t provide care except going through the house staff. It’s important to make sure they understand this isn’t just one more box to be checked off or another thing their attending is asking of them. This is as fundamental as picking the right antibiotic to treat pneumonia or communicating with a PCP about a complicated discharge. That isn’t intuitively obvious. It became more apparent to me as I realized quality of care comes from clinical decisions as well as all of the extra effort we put into things like discharge and communication.
Mark Leiser is a freelance writer based in New Jersey.
The Hospitalist newsmagazine reports on issues and trends in hospital medicine. The Hospitalist reaches more than 25,000 hospitalists, physician assistants, nurse practitioners, residents, and medical administrators interested in the practice and business of hospital medicine.