Improving the quality of health care is a central challenge for America's health care system. The mission of the End-Stage Renal Disease (ESRD) program is to promote the quality, effectiveness, and efficiency of ESRD patient care and program administration. The program provides an ideal opportunity to demonstrate the use of information to help clinicians analyze and improve the care they deliver to patients in an ambulatory setting. This is possible because the program has established regional surveillance systems, called ESRD Networks, that gather information on the occurrence and outcomes of treatment of Medicare beneficiaries with ESRD. The Health Care Financing Administration, which is responsible for the administration of the program, and the renal community have worked together since 1990 to identify ways of incorporating new methods of quality improvement into the program. These methods include statistical evaluation of the processes and outcomes of care in dialysis populations; communicating recommended practices with clinical guidelines and algorithms; regional peer review and feedback (ie, technical assistance and/or collaborations for quality improvement); interventions that focus on the provision of assistance for quality improvement efforts; continuing collection and active feedback of data to providers; and a commitment to continue to evaluate and revise quality improvement activities to reflect lessons learned and newly identified needs. These ideas have been included in the 1994-1997 scope of work for the ESRD Networks and is called the ESRD Health Care Quality Improvement Program (HCQIP). This article describes the background for the ESRD HCQIP and the program's elements.