Hospital acquired pressure ulcers (HAPU) impose a significant burden that affects the physical health and psychosocial functioning of patients. This may be evidenced by increased pain, prolonged treatments, an interruption to activities of daily living, depression and isolation, a longer hospital stay, unnecessary readmission, and death. In addition to the personal toll on patients, hospitals are faced with longer lengths of stay and higher medical and legal costs. The purpose of this program evaluation is to improve and standardize regional PH&S best practice for pressure ulcer prevention in the acute care setting. The clinical inquiry question is: What pressure ulcer program interventions need to be understood, modified and spread to system-wide adoption to achieve and consistently maintain the 50th percentile in their quarterly prevalence studies?