A summary of a study of the quality rating and improvement systems (QRIS) in five early QRIS-adopting states (Colorado, North Carolina, Ohio, Oklahoma, and Pennsylvania), including descriptions of: the theory of action underlying QRISs; each state's system, including the aspects of quality included in the system; the development of each state's system; and challenges facing system designers and lessons learned from these states, all based on in-depth interviews with 4 key stakeholders in each state