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Team Improvement and Patient Safety Conferences: Culture Change and Slowing the Revolving Door Between Skilled Nursing Facility and the Hospital

Berkowitz, Randi E. MD; Schreiber, Robert MD; Paasche-Orlow, Michael K. MD, MA, MPH

doi: 10.1097/NCQ.0b013e31824623a4

To improve the safety culture of a skilled nursing facility, we conducted multidisciplinary “Team Improvement for Patient and Safety” (TIPS) case conferences biweekly to identify causes of transfers to acute care hospitals and improvement opportunities. Staff perceptions of organizational patient safety culture were assessed with the Nursing Home Survey on Patient Safety Culture. Over the course of the year, we held 22 TIPS conferences. Mean item scores increased during the study, indicating improved staff perceptions of patient safety culture (P < .005).

Hebrew SeniorLife (Drs Berkowitz and Schreiber); Division of Gerontology, Beth Israel Deaconess Medical Center, Harvard Medical School (Drs Berkowitz and Schreiber); and Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine (Dr Paasche-Orlow), Boston, Massachusetts.

Correspondence: Randi Berkowitz, MD, 1200 Centre St, Roslindale, MA 02459 (

The authors thank Eric Coleman, Kyle Allen, Richard DellaPenna, Alice Bonner, and Rich Jones for their help on this project. This study was funded by Practice Change Fellowship, Denver, Colorado.

The authors declare no conflict of interest.

Accepted for publication: January 28, 2012

Published online before print: February 22, 2012.

© 2012 Lippincott Williams & Wilkins, Inc.