1. News and media: the Dutch experience Anca Ansink Chief Inspector Curative Care Dutch Health care Inspectorate

2. Mission and ambition Mission: The Health Care Inspectorate promotes safe health care through supervision and monitoring adherence to the law and professional standards. Ambition: Legitimate confidence in Dutch health care by the public. Organisation: Relatively small organisation, 500 employees, supervising 1.3 million professional practitioners, 3.000 organisations, 60.000 addresses and 25 Acts of Parliament

3. The glass house we work in

4. Case: VUmc University hospital 5800 employees situated in Amsterdam

5. Case: VUmc March 2011: report of serious adverse event: death of a patient Nov 2011: inspectorate finalises report on investigation and recommendations inspectorate monitors improvement process closely May 2012:“final” interview with the board June 2012:final report

6. Case: Vumc What we did not know : -the board received a letter from 11 surgeons in March 2012 -the board received an alarming report from an external advisor on the conflict situation in May 2012 Why we did not know: -The board did not inform us in the interviews, nor in writing As a result -we heard about the documents through the press in August 2012 -We called the state of intensified supervision

7. 'Ontslag klokkenluider VUmc is geen incident' 'Gesloten cultuur zoals bij VUmc werkt uiteindelijk averechts' Rol leiding en toezicht VUmc onderzocht VUmc onder verscherpt toezicht IGZ, longchirurgie tijdelijk gestaakt

8. 8 The main questions -should we be embarrased about not being aware of facts the media revealed? -(how) can we avoid this? -what is the effect on our ‘power’ over the hospitals?