Background: Quality improvement principles have been applied extensively to health care organizations, but implementation of quality improvement methods in school-based health centers (SBHCs) remains in a developmental stage with demonstration projects under way in individual states and nationally. Rural areas, such as New Mexico, benefit from the use of distance education techniques to reach providers throughout the state. Methods: The Envision New Mexico (ENM) Quality Improvement Initiative involves training in quality improvement concepts and methods, identification of best practices for selected clinical services, and repeated use of data to measure changes leading to improvement. The ENM employs the Model for Improvement and the "Plan-Do-Study-Act" tool, which enables providers to self-evaluate, set goals, and assess results with their own data. Results: Providers tend to overestimate their use of best practices. Contrasting these perceptions with findings from medical record reviews can provide impetus and focus for quality improvement through changes in specific clinical practices and management systems. Preliminary findings from New Mexico suggest that quality improvement interventions can be effective, with initial improvements over baseline reviews typically in the 20-40% range. Conclusion: Systematic efforts to enhance the quality of care can help improve both the effectiveness and efficiency of SBHCs, and provide evidence of the value of the care provided. Simple, efficient quality improvement techniques, with the use of distance learning technologies, can help achieve the full promise of expanded school-based health care. (Contains 3 tables.)