OBJECTIVES: Hospitals cut costs by reducing staff not providing bedside care. Yet, Weinstein and Skinner (2010) claim having insufficient infrastructure, such as skilled specialists not at bedside, such as board-certified nurses and therapists can evaluate and redesign health systems to address needs of complex patients, and paradoxically reduce costs. Our objective was to validate this theory by evaluating the impact of increased skilled specialists on patient outcomes by supporting infrastructure, using an example of correlation between nurses and a hospital quality indicator. METHODS: We analyzed a retrospective cohort of patients diagnosed with hospital-acquired pressure injuries defined by AHRQ PSI03 (stage 3, 4 and unstageable pressure injuries not present-on-admission). Ratios of board-certified nurses per 1,000 hospital beds were compared to pressure injury rates in 55 U.S. academic hospitals between 2007-2012 using UHC data. Productivity functions of labor efficiency versus pressure injury rate were plotted across hospital quintiles and fitted to smoothed curves. Mixed-effects negative binomial regression validated the statistical significance of pressure injury rate improvements relative to skilled specialist efficiency, controlling for case-mix and policy changes over time. RESULTS: High performing hospitals invested in prevention infrastructure with skilled specialists based on pressure injury rate reductions. By adding 1.0 board-certified nurses per 1,000 beds, a hospital decreased pressure injury rates 17.7% per quarter. The highest performers actually supplied fewer skilled specialists per 1,000 beds and sustained improved pressure injury rates. CONCLUSIONS: Skilled specialists bring important value to health systems as a representation of investment in infrastructure. The proportion of these specialists is formulaic relative to hospital capacity. The UK King’s Fund is investing £22 billion in NHS England infrastructure to improve quality – other health systems in North America and Europe should emulate this policy to support hospitals to make investments in infrastructure to drive down patient costs and improve quality.