Quality Rating System Research Articles

The deprofessionalization of family childcare providers: Wisconsin’s YoungStar system

This article is based on research conducted during a semester-long professional development workshop series for Spanish-speaking family childcare providers in Wisconsin aimed at creating space for dialogue regarding the ways in which care and professionalism are intertwined. We examine the historical, economic, and political forces accompanying Wisconsin’s adoption of YoungStar, a quality rating and improvement system. This model offers “choice” for parents and “support” for providers through a ranking system that turns care into a commodity, acting as a mechanism of homogenization which deprofessionalizes providers. We focus on one provider’s story, employing narrative inquiry to illustrate the complexity of being a caring professional in an era of neoliberal regulation where the borders of the personal and professional often blur.

Breastfeeding and Risk of Metabolic Syndrome in Children and Adolescents: A Systematic Review.

The beneficial effect of breastfeeding on individual components of the metabolic syndrome in children and adolescents has been reported, but it is unknown if there is an association between being breastfed and metabolic syndrome as a whole. Research aim: This systematic review was performed to assess quality and strength of evidence for the association between being breastfed and the development of metabolic syndrome in children and adolescents. Articles were obtained from searches using PubMed and Embase databases, as well as from secondary searches through reference lists. Study quality was assessed using a three-level quality rating system. Of 11 studies reviewed, 7 found a protective association between breastfeeding and metabolic syndrome and 4 found no association. There was no clear dose-response relationship between duration of breastfeeding and metabolic syndrome risk and insufficient evidence to demonstrate an added effect of being exclusively breastfed. The overall quality of the articles was moderate. In general, lower quality articles found no significant association, whereas higher quality articles found a significant association. Our review demonstrated a limited amount of high-quality research on the relationship between being breastfed and development of metabolic syndrome in children and adolescents. The evidence presented in this review suggests that being breastfed may be protective against metabolic syndrome, but further research with improvements in study design, such as improved measurement of breastfeeding and the use of prospectively collected data, will improve our understanding of this relationship.

Community pharmacists’ beliefs regarding improvement of Star Ratings scores using the Theory of Planned Behavior

ObjectivesThe Centers for Medicare and Medicaid Services (CMS) is moving toward a value-based model, which includes the Five-Star Quality Rating System (Star Ratings). Prescription Drug Plans include multiple pharmacy measures associated with adherence and patient safety that contribute to CMS Star Ratings scores. This study, using the Theory of Planned Behavior (TPB), explored factors associated with community pharmacists’ beliefs to improve Star Ratings scores. DesignExploratory, qualitative, use of focus groups, and the TPB. Setting and participantsFocus groups were performed in conference rooms at the College of Pharmacy main and satellite campuses. Participants were community retail pharmacists with an active Oklahoma license and 1 year of work experience. Main outcome measuresEach focus group was audio recorded and the recording transcribed to documents and analyzed with the use of a hybrid deductive and inductive qualitative approach rooted in a constant comparative framework. Coding of the data back to the TPB constitutes a deductive approach. The generation of themes and subthemes from other coded nodes constitutes an inductive approach. Analysts agreed on common themes, differences in findings, and saturation of the data gathered. ResultsFour focus groups were conducted with 26 participants in 2 categories: pharmacists with and without experience improving Star Ratings. Pharmacists shared and contrasted in salient, normative, and control beliefs about patient outcomes, data, financial implications, staff, technology, and other stakeholders associated with performance of improving Star Ratings. Themes regarding medication adherence, patient safety, and intention were also found. ConclusionThe TPB was used to explore beliefs of community pharmacists about improving Star Ratings scores. Themes that were identified will assist in future research for measuring intention to improve CMS Star Ratings scores and the development of training and education programs.

Reconsidering Hospital Readmission Measures.

Current hospital readmission measures are part of the Centers for Medicare & Medicaid Services Five-Star Quality Rating System but are inadequate for reporting hospital quality. We review potential biases in the readmission measures and offer policy recommendations to address these biases. Hospital readmission rates are influenced by multiple sources of variation (eg, mix of patients served, bias in the performance measure); true differences in quality of care are often a much smaller source of this variation. Thus, variation from caring for large proportions of socioeconomically disadvantaged or tertiary-care patients will bias a hospital's ratings. Ratings aside, readmission measures may indirectly harm patients because low readmission rates do not correlate with reduced mortality, yet the Five-Star Quality Rating System weighs readmission equally with mortality. We propose that hospital quality rankings not use readmission measures as currently constructed.

Quality Early Education and Child Care From Birth to Kindergarten.

High-quality early education and child care for young children improves physical and cognitive outcomes for the children and can result in enhanced school readiness. Preschool education can be viewed as an investment (especially for at-risk children), and studies show a positive return on that investment. Barriers to high-quality early childhood education include inadequate funding and staff education as well as variable regulation and enforcement. Steps that have been taken to improve the quality of early education and child care include creating multidisciplinary, evidence-based child care practice standards; establishing state quality rating and improvement systems; improving federal and state regulations; providing child care health consultation; as well as initiating other innovative partnerships. Pediatricians have a role in promoting quality early education and child care for all children not only in the medical home but also at the community, state, and national levels.

CMS Staff Tracking System Promises More Accuracy

PHOENIX — The new payroll-based journal (PBJ) system developed by the Centers for Medicare & Medicaid Services to determine the staffing component ratings in the Five-Star Quality Rating System will likely be “a huge change, [resulting in] a more comprehensive and more accurate” look at a facility’s staffing, Ashkan Javaheri, MD, CMD, said at the AMDA – the Society for Post-Acute and Long-Term Care Annual Conference. Medical directors’ hours are part and parcel of the new system, and “it’s important to understand that the hours you [record and] submit should be based on your medical directorship duties — on what the facility is paying you to do,” said Dr. Javaheri, assistant professor at the University of California–Davis School of Medicine and head of the geriatric division at Mercy Medical Group–Dignity Health Medical Foundation in Sacramento. “Hours for your patient care are not reportable in PBJ.” Dr. Javaheri created a medical director “time record/invoice” to use in his work with several facilities in the Sacramento area. The form lists duties such as clinical record reviews, educational presentations to community/staff/others, telephone consultations addressing administrative or medical issues as a medical director, in-service training, administrative duties, Professional Advisory Committee/Quality Assurance Performance Improvement/Safety/Utilization Review committee meetings, and regulatory/survey reviews. Nursing homes have been required to electronically submit staffing and census information based on payroll — at least quarterly — since July 2016, and CMS is currently working on incorporating these data into the Five-Star system. Before the PBJ — and since the Five-Star system was established in 2008 — facilities have self-reported staffing hours for a 2-week period just before the state inspection. Concerns about whether improvements in Five-Star ratings “reflect a real change in quality or a change in reporting practices and self-reported data” have loomed over the system, Dr. Javaheri said, and the new PBJ system (as well as the recent addition of several claims-based measures to the quality measure component) are a nod to such concerns. The new system also expands its look at “direct care” staffing beyond registered nurses, licensed practical nurses, and certified nursing assistants (CNAs). In addition to medical directors, it now includes activities directors, dieticians, and various other medical professionals as well as agency and contract staff. Moreover, the new system requires facilities to submit data on employee turnover and tenure — something that Dr. Javaheri said medical directors can influence. Studies have shown, he said, that lower turnover rates are associated not only with not-for-profit status but also with factors like the availability of training and supervision, opportunities for growth and teamwork, rewards for employees and a perception of being valued, positive feelings between aides and residents, and positive relationships with coworkers. “As a medical director, you can team up with your administrator and your director of nursing and help them understand how valuing all staff’s input and making them feel part of the team, for instance, can help with retention,” he said. “Try to help provide an environment that is enjoyable … try to praise nurses and CNAs who are good at what they do.”

Five-Star System Shines Light on CMDs

PHOENIX — The Five-Star Quality Rating System that is tightening networks and driving referrals and reimbursement is also giving certified medical directors the opportunity to “shine” and to meaningfully influence the quality of care in their facilities, Sabine von Preyss-Friedman, MD, CMD, said at the Annual Conference of AMDA – the Society for Post-Acute and Long-Term Care. “We’re at a happy place where quality and reimbursement are meeting each other,” she said. “All of a sudden administrators have skin in the game, and that’s where you as medical directors can really influence quality.” Dr. von Preyss-Friedman, the chief medical officer for Avalon Health Care, a provider of skilled nursing and assisted living facilities, encouraged directors who are just stepping up their quality improvement efforts to concentrate first on rehospitalization. Beginning in January of this year, five new quality measures were fully integrated into the calculation of the Five-Star Quality Rating System’s quality measure (QM) ratings. A measure of the percentage of short-stay residents who were rehospitalized after a nursing home admission is one of four new measures (out of the five) that are short-stay measures, and one of three that are based on Medicare claims rather than the Minimum Data Set (MDS). Each of the claims-based measures applies only to fee-for-service Medicare patients, which is “good news for us,” she said. The short-stay rehospitalization measure covers unplanned readmission to the hospital within 30 days of admission to the skilled nursing facility and includes discharged patients. Other new measures cover the percentage of short-stay residents who have an outpatient emergency department visit, and the percentage of residents who are successfully discharged to the community. As of last year, the national short-stay rehospitalization rate was 21%, according to data from the Centers for Medicare & Medicaid Services, and “at this point, many [hospitals and insurance networks] want it below 12%,” she said. “I think you should make this your goal.” (Avalon’s national short-stay rehospitalization rate now stands at 17%, she noted.) Dr. von Preyss-Friedman, also a clinical associate professor at the University of Washington, encouraged use of the INTERACT (Interventions to Reduce Acute Care Transfers) program. “Maybe just focus on the SBAR [Situation, Background, Assessment, Recommendation] communication form ... do something that focuses on early recognition of changes in condition,” she advised, adding that she had learned so much about the trends leading to hospital transfers in her facilities by using INTERACT’s Quality Improvement Tool for Review of Acute Care Transfers. (Dr. von Preyss-Friedman does not have any financial interest in the INTERACT program.) “If you have a high rehospitalization rate, I also really encourage you to form a rehospitalization committee,” she said. The committee should meet monthly and include the medical director, director of nursing, administrator, and charge nurse. Among other considerations, she highlighted the following: •MDS accuracy is still key. Even though the short-stay rehospitalization measure is claims-based (as are the measures for emergency department visits and successful discharge), the MDS-based covariates for functional status and conditions or diagnoses are part of a complex risk adjustment system that adjusts for facility risk. “It’s really important that your MDS coordinator is really good at what they do, because [their work] can affect your quality measures in a big way,” she said.•Hospice and end-of-life discussions should be integrated as early as necessary. This is because hospice-enrolled patients are excluded from the rehospitalization measure (as well as the other two claims-based short-stay measures). “If patients are entitled to a hospice benefit, bring up the conversation — don’t short-change them, because you’re short-changing [your facility] as well,” she said.•Time is of the essence. The data framing the new claims-based short-stay QMs are based on a rolling 12-month period, so they will not be up to date, she said. “You have to work on these things right now because it will take some time for your work to be reflected in updated measures.” Moreover, she added, only a Five-Star rating on the quality domain of the Five-Star system will affect a facility’s overall Five-Star rating. “You should fight for every single quality measure, every single point,” she emphasized. For more details on the Five-Star system and how ratings are calculated, see “The Fault in Our Stars: Does the Five-Star System Fall Short?” in the March 2017 issue of Caring. Christine Kilgore is a freelance writer in Falls Church, VA. •Start with Health Inspection rating•Add one star to the Step 1 result if staff rating is four or five stars and greater than the health inspection rating•Subtract one star if staffing is one star•Add one star to the Step 2 result if quality measure rating is five stars•Subtract one star if quality measure rating is one star

Associations between nursing home performance and hospital 30-day readmissions for acute myocardial infarction, heart failure and pneumonia at the healthcare community level in the United States.

To evaluate community-specific nursing home performance with community-specific hospital 30-day readmissions for Medicare patients discharged with acute myocardial infarction, heart failure or pneumonia. Cross-sectional study using 2009-2012 hospital risk-standardised 30-day readmission data for Medicare fee-for-service patients hospitalised for all three conditions and nursing home performance data from the Centers for Medicare & Medicaid Services Five-Star Quality Rating System. Medicare-certified nursing homes and acute care hospitals. 12,542 nursing homes and 3,039 hospitals treating 30 or more Medicare fee-for-service patients for all three conditions across 2,032 hospital service areas in the United States. Community-specific hospital 30-day risk-standardised readmission rates. Community-specific nursing home performance measures: health inspection, staffing, Registered Nurses and quality performance; and an aggregated performance score. Mixed-effects models evaluated associations between nursing home performance and hospital 30-day risk-standardised readmission rates for all three conditions. The relationship between community-specific hospital risk-standardised readmission rates and community-specific overall nursing home performance was statistically significant for all three conditions. Increasing nursing home performance by one star resulted in decreases of 0.29% point (95% CI: 0.12-0.47), 0.78% point (95% CI: 0.60-0.95) and 0.46% point (95% CI: 0.33-0.59) of risk-standardised readmission rates for AMI, HF and pneumonia, respectively. Among the specific measures, higher performance in nursing home overall staffing and Registered Nurse staffing measures was statistically significantly associated with lower hospital readmission rates for all three conditions. Notable geographic variation in the community-specific nursing home performance was observed. Community-specific nursing home performance is associated with community-specific hospital 30-day readmission rates for Medicare fee-for-service patients for acute myocardial infarction, heart failure or pneumonia. Coordinated care between hospitals and nursing homes is essential to reduce readmissions. Nursing homes can improve performance and reduce readmissions by increasing registered nursing homes. Further, communities can work together to create cross-continuum care teams comprised of hospitals, nursing homes, patients and their families, and other community-based service providers to reduce unplanned readmissions.

Power and assessment: A genealogical analysis of the CLASS

ABSTRACTThe CLASS (classroom assessment scoring system) has become integrally linked with quality rating and improvement systems (QRIS) throughout the United States and other international locations. This relationship reinforces the neoliberal consumer-based perspectives of quality and devalues localized perspectives. This article challenges the notion of assessing quality in this manner and provides a genealogical analysis of the literature supporting the CLASS. The analysis focuses on three specific aspects of the CLASS research literature: the type of research used, how school success is defined, and the use of attachment theory in teacher–child relationships. The article also proposes further areas of study and analysis regarding the cultural appropriateness and international use of the assessment as well as questioning the line between research and marketing.

Engaging With Quality Improvement Initiatives: A Descriptive Study of Learning in the Complex and Dynamic Context of Everyday Life for Family Child Care Providers

ABSTRACTResearch Findings: This article reports on family child care providers’ views about their engagement with professional development programs, including providers who were and were not participating in Quality Rating and Improvement Systems in Los Angeles, California. Most providers participating in the study were taking active steps to improve their work with children, but only a few providers described themselves as satisfied with the programs available. First, we report on why providers chose to engage (or not) in formal professional development activities; specifically, we explore the relationship between career phase and engagement and the levels of participation reported by seasoned providers. Second, we describe the way many providers strategically self-customized their quality improvement (QI) activities by drawing flexibly on available programs or by finding a coach who would work with them on their specific needs. Practice or Policy: Our findings suggest that in order to increase engagement with formal QI systems, designers of professional development supports must better align these supports with the needs and interests of family child care providers in terms of content and modes of delivery. We propose the concept of just-in-time professional development as 1 way to make QI offerings more responsive to some family child care providers’ needs.

A Two-State Study of Family Child Care Engagement in Quality Rating and Improvement Systems: A Mixed-Methods Analysis

ABSTRACTResearch Findings. The current study is a mixed-methods investigation of family child care provider participation in voluntary Quality Rating and Improvement Systems (QRIS) in 2 states. Study 1 is an analysis of matched QRIS and child care licensing administrative data extracted from both states in May, 2014. Poverty and population density variables were added to the dataset by aligning U.S. Census data and Rural Urban Commuting Area codes (RUCA) to the matched state child care data. Participation patterns differed in the 2 states relative to provider characteristics (subsidy receipt, years licensed, and location). Study 2 consists of focus groups with participating (n = 22) and non-participating (n = 19) providers. Professionalism and financial incentives emerged as significant in attracting family child care providers to QRIS. Although family child care providers identified several clear benefits to QRIS, many more challenges emerged that negatively impact their participation. Practice or Policy. As most states are employing a QRIS framework to integrate quality improvement efforts, perspectives from this sector of early care and education are often overlooked. Study findings suggest that QRIS can be more responsive and effective with family child care providers if more consideration of their unique features are considered in systems design and implementation.

The Fault in Our Stars: Does the Five-Star System Fall Short?

The Fault in Our Stars: Does the Five-Star System Fall Short?

Exploring the Relationship Between Global Quality and Group Engagement in Toddler Child Care Classrooms

ABSTRACTToddlers’ engagement with their social and physical environment is an important aspect of their experience in early care and education programs. The purpose of this research study was to examine how global quality relates to children’s engagement in toddler child care classrooms. Additionally, this study explored how toddlers’ group engagement levels vary across classroom contexts, including free play, group activities, meals, transitions, and personal care routines. Thirty toddler child care classrooms participating in a statewide Quality Rating and Improvement System (QRIS) were observed using two observational measures. Results indicate that a strong positive relationship exists between engagement and global quality. Group engagement varied significantly by classroom context, with the highest levels of engagement documented during mealtime and free play and the lowest levels of engagement documented during transitions. The findings point to the importance of using multiple measures to understand toddler experiences in group care settings. Further, the variation of children’s engagement across classroom contexts suggests that more attention is needed in understanding and supporting teachers in increasing child engagement, especially during classroom transitions.

Correlations Among Hospital Quality Measures: What "Hospital Compare" Data Tell Us.

A number of quality rating systems to rank health care providers have been developed over the years with the intention of helping consumers make informed health care purchasing decisions. Many use sets of individual quality measures to calculate a global rating. The utility of a global rating for consumer choice hinges on the relationships among included measures and the extent to which they jointly reflect an underlying dimension of quality. Publicly reported data on 4 quality domains-complication, mortality, readmission, and patient safety-from Centers for Medicare & Medicaid Services' Hospital Compare website were used to examine correlations among individual measures within each measure group (within-group correlations) and correlations between pairs of measures across different measure groups (between-group correlations). Modest within-group correlations were found in only 2 domains (mortality and readmission), and there were no meaningful between-group associations. These findings raise questions about whether consumers can reliably depend on global quality ratings to make informed decisions.

Is the Currently Used Prescription Adjudication Date a Good Proxy for Calculating Medication Refill Adherence?

The Centers for Medicare & Medicaid Services (CMS) adopted the proportion of days covered (PDC) calculation for use in their Five-Star Quality Rating System for Medicare Advantage and Prescription Drug Plans. This calculation uses the prescription adjudication date (i.e., date the prescription is billed to the benefits manager by a pharmacy) as a proxy for medication adherence. Adherence programs, such as automatic refill programs, have become commonplace in community pharmacy and have been identified by industry leaders as interfering with the ability to accurately measure adherence using PDC. To evaluate the prescription pickup date instead of the currently used adjudication date to calculate PDC in the presence of a community pharmacy automatic refill program. This study used a post-only quasi-experimental design with patients aged 65 years or older enrolled in automatic and manual refill programs in a 29-store community pharmacy chain during 2014. PDC was calculated using the prescription adjudication date and pickup date (i.e., date the patient brought the medication home) using pharmacy dispensing data for CMS adherence metrics medications, including statins, renin angiotensin aldosterone system antagonists (RASA), and noninsulin diabetes medications. Mann-Whitney U and effect size calculations evaluated differences in PDC between automatic and manual refill prescriptions for the adjudication date and pickup date, as well as the difference in PDC between adjudication and pickup date. 10,936 prescriptions were included with 21.9% enrolled in the automatic refill program. Mean (SD) adherence was 88.6 (17.6) and 86.4 (17.1) for automatic refills and 85.8 (19.0) and 85.0 (18.9) for manual refills, using the adjudication date and pickup date PDC, respectively. Significant difference existed between automatic and manual refill prescriptions using the adjudication date (P < 0.001) but not for the pickup date. The difference between adjudication and pickup date PDC ranged from 0% to 32.0% for automatic refills and 0% to 38.7% for manual refills. The difference between adjudication and pickup date PDC was significant when comparing automatic and manual refill prescriptions (P < 0.001). The artificial inflation seen with adjudication date PDC indicates that the prescription pickup date is a more accurate reflection of patient medication taking. Automatic refills resulted in a less reliable PDC compared with manual refill prescriptions. Discussion about the continued use of the adjudication date to calculate PDC is needed. The project described was supported by the Clinical and Translational Science Award (CTSA) program through the NIH National Center for Advancing Translational Sciences (NCATS), grant UL1TR000427. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. Lester is employed as a pharmacist in the pharmacy chain that participated in this study. The authors report no other relevant conflict of interest. Study concept and design were contributed primarily by Lester, along with Look and Chui. Lester took the lead in data collection, along with Look, and data interpretation, along with Look and Chui. The manuscript was written and revised primarily by Lester, along with Look and Chui.

Correlations between quality ratings of skilled nursing facilities and multidrug-resistant urinary tract infections.

The purpose of this study was to determine risk factors for the acquisition of urinary tract infections (UTIs) and multidrug-resistant organisms (MDROs) in residents of skilled nursing facilities (SNFs). Using the informational database provided by the Centers for Medicare and Medicaid Services (CMS), a retrospective logistic regression was performed on 1,523 urine cultures from 12 SNFs located in Long Island, New York. Of the 1,142 positive urine cultures, Escherichia coli was most prevalent. Additionally, 164 (14.4%) of the UTIs were attributed to an MDRO. In multivariate logistic regression, sex and overall quality rating predicted the occurrence of UTIs, whereas identification of MDROs was dependent on the level of nursing care received. The mean predicted probability of UTIs and receipt of contaminated samples was inversely dependent on the facility's rating, where the likelihood increased as overall quality ratings decreased. The CMS's quality rating system may provide some insight into the status of infection control practices in SNFs. The results of this study suggest that potential consumers should focus on the overall star ratings and the competency of the nursing staff in these facilities rather than on individual quality measures.

Competition, information, and quality: Evidence from nursing homes

Economic theory suggests that competition and information can both be important for product quality, and yet evidence on how they may interact to affect quality is sparse. This paper estimates the impact of competition between nursing homes on their quality, and how this impact varies when consumers have better access to information. The effect of competition is identified using exogenous variation in the geographical proximity of nursing homes to their potential consumers. The change in information transparency is captured by the launch of the Five-Star Quality Rating System in 2009, which improved access to the quality information of nursing homes. We find that while the effect of competition on nursing home quality is generally rather limited, this effect becomes significantly stronger with increased information transparency. The results suggest that regulations on public quality reporting and on market structure are policy complements, and should be considered jointly to best improve quality.

I’ll See You Again in 30 Days

I’ll See You Again in 30 Days

Healthy Caregivers-Healthy Children: A Train-the-Trainer (TTT) Implemented Childcare Center-Based Obesity Prevention Program

The purpose of this project is to evaluate the effectiveness of the train-the-trainer (TTT)-implemented “Healthy Caregivers-Healthy Children” (HC2) obesity prevention toolkit on parent and teacher adoption of healthy lifestyle role modeling behaviors, and policy integration in childcare centers. A total of 24 Quality Rating and Improvement System (QRIS) childcare centers were randomized to HC2 or an attention control arm. Treatment centers (n=12) are currently receiving the HC2 program via a TTT model that includes menu modifications, a child-centered curriculum for healthy eating and physical activity, and a parent-and teacher-centered curriculum for healthy meal preparation, reinforced through an adult role-modeling curriculum. Control centers (N=12) are receiving an injury prevention (safety) intervention. Over a quarter of the sample (27%) is overweight/obese. Mean BMI percentile is 60.1% and z score is 0.33. Analysis of the Health Environment Rating Scale showed that at baseline only 59% have water available to drink throughout the day, 13% served vegetables 1xday (20% never), 40% always serve whole grain snacks, 38% spend at least 1.5 hours doing vigorous activity. Lower child BMI was significantly correlated with more daily vegetable servings (R=-.55, p=0.04). Health Environment Rating Scale baseline center-level analysis showed that most centers are not meeting HC2 policy standards (water as beverage choice, fruits/vegetables served daily, at least 120 minutes of physical activity/day, and < ½ hour of screen time per week). center level nutrition behavior, and serving more vegetables in particular, has a positive impact on child healthy weight. implementing standardized nutrition and physical activity policies in childcare centers can have a significant impact on child healthy growth and development.

South Carolina Team Nutrition 2014: Growing Healthy in Child Care

To provide training and technical assistance for the creation and maintenance of a healthier child care environment. Child care providers will be assisted in the development and implementation of wellness policies, provided culinary skills trainings, and educated on compliance to ABC Grow Healthy nutrition standards. Through interagency collaboration South Carolina has been strengthening its commitment to improving child health through nutrition and physical activity standards. These statewide standards are part of the Quality Rating and Improvement System (QRIS) or ABC Quality. The expected result is the creation of a supportive and sustainable child care environment that encourages and promotes healthy eating in children. Menu collection will document changes in local food procurement and foods served. A child care nutrition environment checklist will provide information on meals served, wellness policy, nutrition education, and other areas. Surveys will evaluate the number trained and training effectiveness. Technical assistance logs will record and document any changes within the child care environment. South Carolina has been using a collaborative approach in building an interagency team to promote healthy eating in child care. This has resulted in increased awareness of the importance in nutrition for child growth and development. Through continued training and technical assistance on changing the child care environment to support and promote healthy eating in children, ABC Quality has the potential to complement and extend the reach of the South Carolina Child and Adult Care Food Program (CACFP). Participation in CACFP can improve child nutrition, financial resources, and the quality of service.