Claire Horton, MD, MPH
Acting Medical Director, General Medicine Clinic, SFGH
Course director, QI curriculum, San Francisco General Primary Care Medicine Residency
What was your career path to UCSF and San Francisco General Hospital?
I went to Duke for college and medical school – not the most primary care-friendly place, but a great education, and I managed to find good primary care mentors. I also crossed the basketball divide and went to UNC-Chapel Hill for a Master's in Public Health (in maternal and child health). When I found the SFPC residency, all the pieces started coming together – my interest in public health paired with a drive to do primary care, in such a phenomenal location with inspiring colleagues – it's been hard to leave San Francisco ever since!
I did take a break for a while from UCSF/SFGH though – after residency I worked for 6 months at a variety of community-based sites – St. Anthony's Free Clinic, Maxine Hall, San Mateo health center. Then I landed for the next 6 ½ years at a community health center in the East Bay - La Clinica de la Raza. I found this time to be incredibly valuable, both to strengthen my clinical skills in ambulatory medicine but also to experience primary care outside of an academic medical center. When I came back to work at SFGH, it was because I wanted to learn how to teach, and to be back in an atmosphere with constant learning and innovation.
You've always been committed to the care of underserved populations. Where did this passion originate and what makes SFGH such a special place to you?
In my family, giving back to the community was a very strong value. You had some latitude in how you wanted to do it, but there was no option not to do it. So I had very strong role models, particularly in my mother and my aunts and uncles, of people who crafted careers and lives around helping others. In college and medical school, I channeled most of this into housing work, and worked extensively with Habitat for Humanity and the Duke Hunger and Homelessness Coalition.
Coming to SFGH was a revelation. It's one of the most mission-driven places I've ever experienced. My favorite elements of my job continue to be meeting and working with people who have been hard-core social justice advocates their whole lives – people who made SFGH into a beacon during the early AIDS crisis, for example; others who founded San Francisco's homeless outreach services or the TB mobile van. You just can't beat their stories, their energy, and their joy in work. The old saying "As Real as it Gets" still holds true.
How did you become so engaged in quality improvement and patient safety work?
During residency, I knew I wanted a career with a dual focus – as I conceived it then, on primary care and public health. I was very motivated by the patient in front of me, but also wanted to think beyond that to a population health level. Back then, I don't think that I would have thought that a career in "QI and patient safety work" would have sounded so exciting. But I came to realize during my time at La Clinica that QI/PS really means population health. Also – although I loved primary care – I found that development of QI programs was a way to channel creative energy and balance the sometimes repetitive nature of a primary care practice. From a logistical perspective, I got on a few grants at La Clinica and was able to work on several interesting projects – a community health worker initiative, integrated behavioral health, and a childhood asthma project. I eventually became the Associate Medical Director for QI – a newly created position – so I got to think about the QI on a very big scale for the whole network of La Clinica sites.
What have you found as the keys to success in implementing successful QI projects in your practice setting?
Teamwork is essential; as well as clear roles for team members and prioritization of QI work. I'm very lucky to work in a clinic where the leadership is all on board with QI work. Alice Chen (the outgoing medical director) set a very strong leadership example in her prioritization of QI work and her improvement of our clinic's services. Our nursing leaders are avid improvement champions themselves. But really, I think the key is follow-up – QI work is 10% inspiration and 90% sweat. One of our staff members recently said "I'm tired of talking about how important this work is – now I want to talk about how to do it." I think that's where we are now – most people agree that we need to improve on our key QI metrics, we just need to keep making steady progress toward our goals. And we try to keep it fun along the way.
What's surprised you the most about how our trainees have engaged QI work? And, how can we continue to leverage their engagement to improve care delivery?
It's great to work with residents on QI initiatives. You can't find people who are more integral to the system than our residents – they live in the trenches every day. So when it comes time to talk about systems with them, they know every nuance. What I find surprising is the level of sophistication they now have about QI. Three years ago, we were still able to introduce them to the PDSA model. Now, their questions are likely to be about some nuance of NCQA Medical Home recognition - most of them have a great base of knowledge in QI, and some have gone much further.
Residents bring great energy and new ideas to QI projects, and they are much more technologically savvy than most of their attendings (!) As for leveraging their engagement - I think it's essential to align their interests and educational goals with the practice's core QI objectives. This allows them to work in teams with clinic staff, gives them some support for their projects, and keeps the whole clinic focused on the same core goals and objectives. As a side note, I think QI experience in residency is great preparation for future jobs. Many graduating residents have negotiated for "QI time" in their post-residency jobs, and have been really happy with the balance of clinical and nonclinical work this can bring.
How do you spend your time away from SFGH?
There's nothing I love better than kicking back with a beer and a good QI journal. Seriously - I have two kids (four and seven) so a lot of my time away from work is spent figuring out preschool schedules and trying to make it to school plays and swim classes. My husband works in affordable housing for San Francisco so we have fairly crazy lives from a scheduling perspective. As a family we love camping, hiking, travelling, and do as much of this as we can. We're hoping to do more backcountry camping now that the kids are getting bigger (although car camping isn't as bad as we thought it was going to be!) I love reading – especially historical fiction and women's history – and salsa dancing or dancing of any kind. And I also love returning to my roots – I'm from Southern Missouri – visiting family, hearing old-time music, and canoeing Missouri's rivers.