The use of Quality Rating and Improvement Systems (QRISs) is continually expanding across the country; in 2010, there were 25 states operating or piloting QRISs and now nearly every other state is planning to or has already begun developing a QRIS or another quality improvement (QI) initiative (Tout, Starr, Soli, Moodie, Kirby, and Boller 2010; U.S. Department of Health and Human Services, 2010b).