Skip Navigation
Innovation Attempt

Staff Training and Support, Incentives, and Feedback Fails to Generate Sustainable Reductions in Pressure Ulcers at Nursing Home

Tab for The Profile



Guided by a university research team, a 136-bed, not-for-profit nursing home in Pennsylvania implemented a quality improvement program to reduce pressure ulcer incidence. The program included three components: education and tools to increase workers’ ability to recognize and prevent pressure ulcers; financial incentives for improved performance; and ongoing performance feedback. Although a significant reduction in pressure ulcer incidence occurred during the program’s 3-month implementation period, these gains were not sustained over time.
begin doxml

Developing Organizations

University of Pittsburgh
The University of Pittsburgh School of Medicine Department of Psychiatry served as the primary developer. Secondary developers included the University of Pittsburgh’s Katz Graduate School of Business, Department of Internal Medicine and Graduate School of Public Health, as well as the Geriatric Research, Education and Clinical Center at the VA Pittsburgh Health Care System.end do

Date First Implemented

begin pp

Patient Population

Age > Aged adult (80 + years); Vulnerable Populations > Disabled (physically); Frail elderly; Age > Senior adult (65-79 years)end pp

Problem Addressed

Pressure ulcers are common among nursing home residents and are associated with a significant clinical and economic burden. Although pressure ulcers are preventable, nursing home workers often lack actionable tools, skills, and incentives to monitor and prevent pressure ulcer development.
  • A common condition, especially in high-risk residents: Estimates of the prevalence of pressure ulcers in nursing homes range between 2.5 and 24 percent of residents, with a national average of 14 percent and an average of 1.6 to 2.5 wounds per resident. High-risk residents are particularly vulnerable. A study of high-risk residents in 95 nursing homes found that 29 percent developed pressure ulcers over a 12-week period,1 and approximately 70 percent of pressure ulcers occur in residents aged 70 and older.2 Before this program’s implementation, the pressure ulcer prevalence rate at this Pennsylvania nursing home typically averaged above 20 percent, prompting multiple department of health citations.
  • Severe clinical consequences: Without proper treatment, pressure ulcers can lead to severe complications, including bone and blood infections, infectious arthritis, holes below the wound that burrow into bone or deeper tissues, and scar carcinoma, a form of cancer that develops in scar tissue.1
  • Considerable economic burden: The average stage two pressure ulcer (defined as when the skin is broken) costs $2,700 to treat.1 Overall, pressure ulcers may cost as much as $11 billion annually, due primarily to the high costs of treatment.3,4
  • Lack of effective implementation of prevention strategies: Research shows that prevention strategies may not be effective when incorporated into nursing homes’ standard quality improvement processes.1 Nursing home workers often lack actionable tools, skills, and incentives to monitor and prevent pressure ulcer development.

What They Did

Back to Top

Description of the Innovative Activity

With the help of a university research team, nursing home management implemented a 3-month quality improvement program to train and motivate staff members to recognize and prevent pressure ulcers. The program, summarized by the acronym AIM (Ability enhancement, Incentives, and Management feedback), is described below:
  • Ability enhancement: All staff members (including management, nursing, housekeeping, dietary staff, and therapy staff) attended a training program that provided education and tools to identify and prevent pressure ulcers. The program including the following components:
    • Education: Staff members viewed a computer-based, interactive video program that provided education about pressure ulcers and skin care. Staff members also received instruction from the research team on how to use the sense of touch to detect early skin changes in residents with dark complexions.
    • Tools: Staff members involved in direct patient care received penlights to help them detect pressure-related changes in residents with dark complexions. They also received plastic “turn and position” cards that show the direction immobile residents should face during 2-hour intervals throughout the day, along with instructions about how to use these cards.
  • Incentives: Each staff member could receive two financial bonuses—one for completing the training program ($10) and one for successful reduction of pressure ulcer rates ($75 if pressure ulcer incidence fell below 3 percent by the final week of the implementation period, a goal set by the facility administrator). Staff members faced termination for failing to complete the training.
  • Management feedback: Two feedback mechanisms enabled management and staff to monitor progress:
    • Weekly reports on training completion: The facility administrator received a weekly report of the number of staff members who completed the training.
    • Feedback on pressure ulcer incidence rates: A large graphic of a thermometer showing pressure ulcer incidence was posted in a nonpublic staff lounge and updated weekly based on data provided by the research team.

Did It Work?

Back to Top


A pre- and post-implementation comparison revealed that pressure ulcer incidence decreased significantly during the 3 months when the research team directly supervised the quality improvement program, enabling the facility to reach its short-term goal for the program. However, pressure ulcer incidence rose significantly (yet remained below baseline levels) during the 3-month post-intervention period when research support was absent. Results are as follows:
  • An initial drop, then an increase, in pressure ulcer incidence: The percentage of residents with pressure ulcers (stage one or higher) decreased from 38 percent at baseline to 10 percent during the 3-month intervention but then increased to 19 percent during the 3-month period following the intervention. The incidence rates of severe ulcers (stage two or higher) were 31 percent at baseline, 10 percent during the intervention, and 15 percent in the 3 months following the intervention. Overall, 21 residents had stage two or higher pressure ulcers at baseline, compared with 10 during the intervention and 13 during the 3 months after the intervention.
  • Pressure ulcer incidence goal met during intervention: During the final 4 weeks of the intervention period, the incidence of pressure ulcers was 2.7 percent, meaning that the facility met its goal and staff members each received the $75 performance bonus. As stated earlier, however, the overall pressure ulcer incidence rate increased after the program was over.
  • Strong program participation rates: Of the 154 staff members, 148 voluntarily completed the training during the 3-month baseline period. (Four staff members received reprimands and subsequently completed the training during a 1-week extension period, while two were fired for not completing the training after receiving reprimands.)

What They Learned

Back to Top
  • Motivation and financial support needed: Without ongoing outside support, a highly motivated internal administrator, and consistent leadership, quality improvement programs using the AIM approach are unlikely to achieve sustained success. Information provided in April 2009 indicates that factors that may have contributed to the lack of lasting results include the following:
    • Lack of motivational support: Lacking the presence of the research team, the facility administrator was no longer motivated to devote the time and energy needed to ensure the program’s continued success. The administrator stopped setting new goals for pressure ulcer incidence rates and the program was quickly abandoned.
    • Lack of consistent staffing: The nursing home faced a high turnover rate. Staff turnover was approximately 60 percent annually, and all of the administrators involved in the program (the administrator, the director of nursing, and the assistant director of nursing) were no longer employed by the facility within 9 months of program completion. This may have contributed to the failure of new staff members to complete the training program: during the 6 months after the program’s implementation period, only 3 out of 29 newly hired staff members completed the program. In general, sustaining any quality improvement process is extremely challenging in an unstable work environment; the forces that lead to staff turnover and inhibit retention are key factors that must be addressed to sustain improvement. The program developer is currently conducting a longitudinal study of factors associated with nursing home staff turnover and retention.
  • The program can work: With appropriate ongoing support, the AIM approach can be effective in reducing pressure ulcers. Each component of the program was successful while the research team was actively involved, and during this time the program worked as a whole. For example:
    • Ability: The ability enhancement components of the program (better training, use of penlights, and the plastic "turn and position" cards) gave the staff the skills and tools necessary to recognize and prevent pressure ulcers.
    • Incentives: Financial incentives appear to have been an effective motivational tool, with the potential $75 performance bonus creating a spirit of teamwork among employees.
    • Management feedback: The visual thermometer was an effective motivational tool, providing a clear and ongoing sign of the program’s success in reducing pressure ulcers (and showing workers that they were on track to receive the performance bonus).

More Information

Back to Top

Contact the Innovator

Jules Rosen, MD
University of Pittsburgh
School of Medicine
Department of Psychiatry
Western Psychiatric Institute and Clinic
3811 O’Hara St.
Pittsburgh, PA 15241
(412) 246-5900

Innovator Disclosures

Dr. Rosen has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Rosen J, Mittal V, Degenholtz H, et al. Ability, incentives, and management feedback: organizational change to reduce pressure ulcers in a nursing home. J Am Med Dir Assoc. 2006;7(3)141-6. [PubMed]


1 Rosen J, Mittal V, Degenholtz H, et al. Ability, incentives, and management feedback: organizational change to reduce pressure ulcers in a nursing home. J Am Med Dir Assoc. 2006;7(3)141-6. [PubMed]
2 Pressure Ulcers. American Association of Homes and Services for the Aging. Washington, DC. April 27, 2007.
3 Annual nursing home expenses increased by 150 percent from 1987 to 1996. Press Release, Agency for Healthcare Research and Quality, Rockville, MD; 2001b.
4 Miller H, Delozier J. Cost implications of the Pressure Ulcer Treatment Guideline. A Report to the Agency for Health Policy and Research, Panel for the Treatment of Pressure Ulcers; August 1994.
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: April 14, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: February 12, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: February 11, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

Look for Similar Items by Subject
Disease/Clinical Category:
Stage of Care:
Setting of Care:
Organizational Processes:
Funding Sources: