[2018 Bull’s-Eye Award Winner!] To better understand North Dakota’s decreasing immunization rates, increasing exemption rates, and the large number of students with an unknown immunization status, the North Dakota Department of Health (NDDoH) implemented quality improvement to increase rates at school entry. The NDDoH partnered with key stakeholders to identify areas of improvement and engaged the local university to study immunization policies and practices in the state. Recommendations were made for potential policy, rule, or practice/process changes to the current immunization and exemption system in North Dakota. As a result of their QI efforts, ND kindergarten entry immunization rates increased from 91% during the 2015 – 2016 school year to 94% during the 2016 – 2017 school year.