Investing in Skilled Specialists to Grow Hospital Infrastructure for Quality Improvement

William V. Padula, Madhuram Nagarajan, Patricia M. Davidson, Peter J. Pronovost

Research output: Contribution to journalArticlepeer-review

3 Scopus citations


Objectives Hospitals can reduce labor costs by hiring lowest skill possible for the job, stretching clinical hours, and reducing staff not at bedside. However, these labor constraints designed to reduce costs may paradoxically increase costs. Specialty staff, such as board-certified clinicians, can redesign health systems to evaluate the needs of complex patients and prevent complications. The aim of the study was to evaluate whether investing in skilled specialists for supporting hospital quality infrastructure improves value and performance. Methods We evaluated pressure injury rates as an indicator of performance in a retrospective observational cohort of 55 U.S. academic hospitals from the Vizient clinical database between 2007 and 2012. Pressure injuries were defined by U.S. Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator 3 (PSI-03) for stage 3, 4, and unstageable pressure injuries not present on admission in hospitalized adults. We compared ratios of board-certified wound care nurses per 1000 hospital beds to hospital-acquired pressure injury rates in these hospitals using mixed-effects regression of hospital quarters. Results High-performing hospitals invested in prevention infrastructure with skilled specialists and observed performance improvements. Regression indicated that by adding one board-certified wound care nurse per 1000 hospital beds, hospitals had associated decreases in pressure injury rates by -17.7% relative to previous quarters, controlling for other interruptions. Highest performers supplied fewer skilled specialists and achieve improved outcomes. Conclusions Skilled specialists bring important value to health systems as a representation of investment in infrastructure, and the proportion of these specialists could be scaled relative to the hospital's patient capacity. Policy should support hospitals to make investments in infrastructure to drive down patient costs and improve quality.

Original languageEnglish (US)
Pages (from-to)51-55
Number of pages5
JournalJournal of patient safety
Issue number1
StatePublished - 2021


  • health system infrastructure
  • performance
  • pressure injury
  • quality improvement
  • workforce supply

ASJC Scopus subject areas

  • Leadership and Management
  • Public Health, Environmental and Occupational Health


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