PurposeTo investigate the obstacles and challenges associated with organizational monitoring and follow-up processes related to health care quality improvement (QI) and development.Design/methodology/approachA longitudinal case study of a large healthcare organization during a system-wide QI intervention. Content analysis was conducted of repeated interviews with key actors and archival data collected over a period of four years.FindingsThe demand for improved monitoring and follow-up strategies, and what and how to monitor were described by the respondents. Obstacles and challenges for achieving monitoring and follow-up (M&F) strategies that enables system-wide and coherent development were found in three areas: monitoring, processing, feed-back and communication. Also overarching challenges were found. Practical implicationsA model of important aspects of M&F systems is presented that can be used for analysis and planning and contribute to shared cognition of such systems. Approaches for systematic analysis and follow-up of identified problems have to be developed and fully incorporated in the organization’s measurement systems. A systematic M&F needs analytic and process oriented competence, and this study highlights the potential in an organizational function with capacity and mandate for such tasks.Originality/valueMost health care systems are flooded with a vast amount of registers, records, and measurements. A key issue is how such data can be processed and refined to reflect the needs and the development process of the health care system and how rich data can be used for improvement purposes. This study presents key organizational actor’s view on important factors to consider when building a coherent organizational monitoring and follow-up strategy.