In 2003, the USAID-funded Quality Assurance Project (QAP), the Ministry of Health of Nicaragua, and UNICEF/Nicaragua started a Pediatric Hospital Improvement (PHI) Collaborative aimed at standardizing and improving the care of severely ill and malnourished children at secondary care hospitals. Six regional hospitals were selected to participate based on high case fatality rates and interest on the part of the staff to improve care processes: Bluefields, Chinandega, Estelí, Jinotega, Madriz, and Matagalpa. The collaborative also sought to improve the quality of emergency services for sick children.