||Hospitals are an essential part of our healthcare system. In hospitals we see the progress of medical science. But how content can we be with the current status of our hospitals? What are the main issues in hospital care in most developed countries? Wherever we measure, we see a huge variation in the way care is offered and organised. We harm patients by the way we deliver and organize care which results in unnecessary suffering and even death. We have compartmentalized our care between disciplines, departments and institutions. Our care is too much doctor/organisation-centred instead of patient-centred. There is a wall between public health and our cure-system. Hospital care takes almost all our healthcare money, but what is the costeffectiveness ratio? In many places we see remarkable improvements and examples of real innovations of care. But what about implementation of this knowledge and dissemination of these best practices? What we need is interventions on four different levels: 1) Patient level: patients can be the main driving force for innovation and improvement; 2) Process level: here we need the innovation and improvement; 3) Organisational level: leadership, organisational support, redesign of the support processes, HRM and IT; 4) Level of the health care system: how about the financial incentives, the healthcare insurance system, the legal issues, etc.? Let me focus on some fundamental issues for innovation and change: 1. Leadership: I have seen a shift in the mission of hospitals: from delivering specialised care to patients, to responsibility for the healthcare in our region, to responsible to improve health in our region. Leaders are responsible for the level of ambition. They translate mission and vision into strategy and operational goals, and they are able to develop and apply a strategy for implementation and spread. They make the link between quality and finance. 2. A strategy to improve quality and safety: We need a quality-system, multidisciplinary cross-functional and cross-organisational collaboration, a framework of methods and tools, training, and a strategy for implementation and spread. 3. Involvement of patients: We have not so much experience in involvement of patients in our daily care-delivery or our improvement efforts. This will bring us to a new level of performance. 4. Specialisation and stratification of care: Quality results depend on the experience of the care team. It becomes a necessity to concentrate high-tech care and the care for rare diseases in centres of excellence and to focus on high quality standardized care for the common diseases and low/medium-tech care in our regular hospitals: a vertical integrated system. At the same time it shows that we can get much better results if we stratify our care in acute, elective and chronic care. 5. Outreach to public health: The knowledge and experience of hospital workers should be applied in public health primary prevention, immunisation programs, screening for early detection of diseases, self-help of patients and patient-groups, public information, etc. There still is a big gap between health care and social care, education, welfare, living, etc.