Studies on healthcare quality improvement (QI) increasingly point at the importance of understanding multilevel organizational issues, especially interaction between national, hospital and clinical level. In a EU-study involving ten hospitals in five countries one hospital stood out in successful multilevel QI work, which is elaborated in this paper. It is suggested that there is a potential in using linkages and dependencies in terms of organisational development and resource support (O) and method, process and IT support (T) affecting the individual caregiver (H), to understand the nestedness and interaction between operational system levels in QI.