This thesis focuses on the connection between learning and quality improvement in health care. I explored this from the macro, meso and micro level perspectives. The central research question of this thesis is:
Which issues support and hinder the development of healthcare professionals working in hospitals in their quality improvement work?
To investigate how healthcare professionals can be supported in their quality improvement work, I employed a case study methodology. I studied three different cases over the course of five years. The first case was the national Dutch Faster Better program. The second case was a number of different improvement projects in an academic hospital. For the third case I was intensively involved for a period of 18 months in a Dutch teaching hospital. In all three cases I used different methods for data collection and data analysis, varying from quantitative analyses of questionnaires to action research. By combining different research methods I gained more insight into the complexity associated with healthcare professionals’ learning to conduct improvement work.
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My research therefore concerns the way in which we can train healthcare professionals to achieve improvements in healthcare quality. In order to research this it is necessary to define ‘learning’ in further detail. This is especially important because learning and improvement activities in the context of quality improvement are intertwined and both follow a cyclical process. In this thesis learning is understood to be: all processes which lead to a change of knowledge, skills, attitudes, opinions, and competences with the aim of applying this in activities. Learning comprises the content (what), the process (how) and the motivation (why). Learning can take place individually, in collaboration with others, and at the organizational level. Learning can involve:
• Individual internal learning processes and interaction with others
• Formal education and training and implicit learning processes
• Conscious and goal-oriented learning and subconscious and incidental learning
• Direction by trainers / teachers and self-directed
• Utilizing explicit and tacit (subconscious) knowledge
• Tapping into single and multiple learning styles
• Aiming for first, second and third order learning

To answer the central research question I carried out research for a duration of five years. In three different cases I investigated from different perspectives how we can teach healthcare professionals to improve their own activities. In the different cases I unearthed various pieces of the puzzle. In the following paragraphs these different puzzle pieces are explained.......