Buurtzorg

Two nurses on a Buurtzorg team found themselves pondering the fact that elderly people, when they fall, often break their hips. Hip replacements are routine surgery, but patients don’t always recover the same autonomy. Could Buurtzorg play a role in preventing its older patients from falling down? The two nurses experimented and created a partnership with a physiotherapist and an occupational therapist from their neighborhood. They advised patients on small changes they could bring to their home interiors, and changes of habits that would minimize risks of falling down. Other teams showed interest, and the approach, now called Buurtzorg +, has spread throughout the country.

The two nurses sensed a need, and with the power of self-management acted upon it. Self-management helped the idea to spread. Any team interested in Buurtzorg + can sign up for a training event that teaches them the basics of how the concept works and how to create such a partnership in their neighborhood.^[1]

At Buurtzorg, with a 10,000 people organization only 45 people work at the head office and there is no marketing department. In fact, since the organization was started in 2007 they have not used any conventional marketing at all. From the beginning Buurtzorg focused on patients and on solving problems.

"We believed this would create a better result. We would not use any marketing, instead use free publicity when people were satisfied with our services.", says Jos de Blok. Today Buurtzorg work a lot on establishing close and genuine relationships with patients, different stakeholders and other people with a natural interest in their services. Because of the success of the organization, this also includes communication with media and newspapers in an effort to meet the interest that has been generated by many years of good word of mouth. "Buurtzorg has become associated with something “good” now, so it is easier for us nowadays.", says Jos de Blok.

At Buurtzorg, a Dutch neighbourhood nursing organization, nurses work in teams of 10 to 12, with each team serving around 50 patients in a small, well-defined neighbourhood. The team is in charge of all tasks that were previously fragmented across different departments.

Each team has a coach. The coach has no decision-making power and works with 40 to 50 teams at a time, making sure that no one team becomes overly dependent on the coach. The coach's role is to ask insightful questions that help teams find their own solutions.

The team is responsible for doing the intake, planning, vacation scheduling as well as administration. They even decide where to rent an office and how to decorate it. There is no leader within the team; important decisions are made collectively.

Because of this, a problem-solving culture thrives. Nurses can't offload difficult decisions to a boss and when things get tense, stressful, or unpleasant, there is no boss and no structure to blame The team knows they have all the power and latitude to solve their own problems.

The teams of nurses aren't simply empowered by their hierarchy. They are truly powerful because there is no hierarchy that has decision-making power over them. Each team is also responsible for their own recruitment. Because the team members make hiring decisions themselves, they are emotionally invested in making the recruit successful.

The absence of rules and procedures imposed by headquarters staff functions creates a huge sense of freedom and responsibility throughout the organization.

The results achieved by Buurtzorg speak for themselves. A 2009 Ernst & Young study found that Buurtzorg requires, on average, close to 40 percent fewer hours of care per client than other nursing organizations. This is despite the fact that nurses in Buurtzorg take time for coffee and talk with patients, their families, and neighbors, while other nursing organizations have come to tightly allocate the time allowed for almost every service. . At Buurtzorg, patients stay in care only half as long, heal faster, and become more autonomous.

At Buurtzorg, all data concerning performance of all the teams is put on the company's intranet. A team that struggles in one area can identifiy a team in the neighborhood with outstanding results (which is not a threat, but an offer) and can ask for advice and best practices. If there is an need for a decision, the request is posted on the intranet. Teams can see every month how their productivity compares to that of other teams. The data of other teams is not anonymized or averaged out. Employees are trusted to handle the positive and negative impacts of information with integrity.

#### Team decision making procedure

Buurtzorg teams use a very efficient method for problem solving and decision-making. They first choose a facilitator. The facilitator is not allowed to make any statements, suggestions, or decisions; she can only ask questions: “What is your proposal?” Or “What is the rationale for your proposal?”. All responses are listed on a flipchart.

Then all are reviewed, improved and refined.

In a third round, proposals are put up for decision. The basis for decision-making is not consensus. For a solution to be adopted it is enough that nobody has a principled objection. A person cannot veto a decision because she feels another solution (for example, hers!) would have been preferable. The perfect solution that all would embrace wholeheartedly might not exist, and its pursuit could prove exhausting. As long as there is no principled objection, a solution will be adopted, with the understanding that it can be revisited at any time when new information is available.

If, despite their training and meeting techniques, teams get stuck, they can ask for external facilitation at any time.

Limiting ‘higher level’ regional coach meetings:

In many ways it would make good sense for Jos de Blok, CEO of Buurtzorg to meet regularly with the regional coaches: they have great insight into what’s happening in the field. Collectively, they could spot issues and opportunities and determine actions to take.

But this process would now be like an executive management committee--the opposite of what they want.

To avoid this, Jos de Block limits his meetings with the coaches to quarterly.

Example for Peer coaching

A nurse that wrestles with a certain question can ask colleagues on her team to help her sort it out in a group coaching session. How should she deal with a client that refuses to take lifesaving medication? How can she help an elderly patient accept help from his children? How to say no to clients to protect herself from burnout? Often, when a nurse struggles with one of these matters, it is because the question brings up a broader personal issue she hasn’t worked through. In these cases, a peer coaching session can help. Some Buurtzorg teams allot an hour for peer coaching every month; other teams convene when a team member requests it. “Intervisie”, the process used at Buurtzorg, follows a strict format and ground rules to prevent the group from administering the all-too-common medicine of advice, admonitions, or reassurance. During most of the process, team members can ask only open-ended questions; they become fellow travelers into the mystery of the issue the person is dealing with. A safe space is created that invites deep listening, authenticity, and vulnerability - the necessary ingredients for inner truth to emerge. The goal is for the nurse to see the problem in a new light and discover her own solutions. It is at once a simple and beautiful process. Being respectfully and compassionately “held” by a group is for many people a new and unforgettable experience.

At Buurtzorg, the company’s internal social network, “BuurtzorgWeb” plays a key role in the sharing of knowledge. When there is vast knowledge spread throughout the organization - the trick can be finding it. With BuurtzorgWeb, nurses can easily locate and contact a colleague with a specific expertise. Questions can be posted online in a continuous stream, similar to Facebook. Due to the high engagement level on the platform, each question is seen by thousands of colleagues in a few hours and attracts one or several responses.

In an example of how an initiative might scale in a Teal organization, a Buurtzorg team in the countryside recently developed a new concept - a boarding house for patients, to offer the patient’s primary caregiver a break. This concept was presented to all colleagues at a company retreat. Nobody at Buurtzorg made the call that this fit or did not fit Buurtzorg’s purpose or that resources should be allocated to scale the initiative. The concept will have to run its own course. If it is meant to scale, it will attract nurses in other teams to make it happen organically.

At Buurtzorg , nurses work in teams of 10 to 12, with each team serving around 50 patients in a small, well-defined neighborhood. The team is in charge of all the tasks that, in similar organisations, are fragmented across different departments. The initial Buurtzorg training includes techniques for conflict resolution and Nonviolent Communication developed by Marshal Rosenberg. Conflicts are worked out collaboratively within the team. For instance, when one person has lost the trust of the team, the team tries to find a mutually agreeable solution. If that doesn’t work out, the group calls in its regional coach or an external facilitator to mediate. In almost all cases, the presence of a mediator brings resolution. In some cases, the person and the team decide on some mutual commitments and give it another go. In others, after some deliberation, the person comes to see that trust is irrevocably broken and understands it is time to leave. If no agreement can be found, as a last chance to try to settle the matter, the team members can ask Jos de Blok, the founder, to mediate. In the rare cases, where even this fails, they can ask him to put an end to the person’s contract (legally, he is the only one who can do so).

One example is the creation of a unit called “Buurtdienst” (“neighborhood services”), which helps people like Alzheimer’s patients to handle domestic chores. Working with the same structure of small, self-organizing teams as in the nursing division, this project has grown to 750 employees in two years.

The organization was also approached by youth workers. In 2012, the first two teams of “Buurtzorg Jong” (“Buurtzorg Young”) started working with neglected or delinquent children. Social workers, educators and nurses work together with children and their families in their homes, and in collaboration with police, schools, and family doctors. They hope to overcome the fragmented and costly way that social services are traditionally delivered ^[2]

Peer Coaching

A nurse wrestling with a question can ask her colleagues for help in a group coaching session. How should she deal with a client who refuses to take life- saving medication? How can she help an elderly patient accept help from his children? How to say "No" to clients, to protect herself from burnout?

Some Buurtzorg teams allocate an hour for peer coaching every month; others convene whenever a team member requests it.

“Intervisie,” the process used at Buurtzorg, follows a strict format with ground rules to prevent the group from administering simplistic advice, admonitions, or reassurances to each other. During the core process, members must ask only open-ended questions. This way they become fellow travelers into the mystery of the issue the person is dealing with. A safe space emerges that invites deep listening, authenticity, and vulnerability - the necessary ingredients for inner truth to emerge. The goal is for the nurse to see the problem in a new light and discover her own solutions. It is at once a simple and beautiful process.

Personal responsibility for training

The nurses that work in self-managing teams decide on their own training needs, and look for the best provider - a medical supplier, a hospital department, or sometimes simply a pharmacist or another Buurtzorg team. It's accepted practice that a team can spend up to 3% of its revenues in training without needing to use the advice process.

Jos de Blok, Buurtzorg’s founder, comments on how this freedom allows nurses to react quickly:

"A remarkably high number of colleagues get themselves trained in specific medical conditions and technical equipment so that they can assist new clients in the best possible way. From drug pumps to dialysis and breathing devices, they learn how the equipment works and must be operated so that the number of professionals that deals with any client stays low. Because colleagues don’t need to ask if they can learn about something, their motivation to do so increases immediately. “It is as if I just woke up, because I start again to think of all sorts of possibilities,” is what you often hear at Buurtzorg."

As the word spreads that the nurses can handle all sort of devices and techniques, doctors start prescribing treatment methods that improve patients’ lives - say, a drug pump for a person with chronic pain - that fall outside the limited standards handled by a traditional nursing organization.

If a nurse wants to reduce her working hours, perhaps because she has a sick parent to take care of for instance, the team will re-shuffle existing clients and temporarily take in fewer new clients. The nurse will discuss her other commitments with her team and together they will find a solution such as temporarily taking on fewer new clients or moving the care of a patient to another nurse or team if needed^[3].

A nurse at Buurtzorg whose patients suddenly require more care might ask a colleague to take over her role of team planner for instance. For a while some nurses might carry more than their fair share of management tasks for the team and less at other times.The Teams are careful to keep management tasks somewhat spread out at all times. There is a risk, as some teams have experienced that hierarchical structures creep back in when too many management roles are delegated to a single team member.

In Buurtzorg, teams are required to make yearly plans for initiatives they want to take in the areas of client care and quality, training, organization, and other issues. All mature teams have a target for billable hours of 60 -65 percent.

Each community nursing team at Buurtzorg manages its own processes and service delivery. These are shared so that others can adopt developments and good practice if they choose. Team performance is shared openly, making very apparent which teams are at the bottom of the list. Teams are motivated to improve their performance out of pride, not shame.

All the organization stipulates is that each team must hold annual appraisals based on a competency model that the team has developed. Each team chooses its own format to give feedback. One team decided, for example, to give feedback in groups of three. Everyone prepares their self-evaluation and feedback for the other two. The process allows people to gauge their self-perception against the views of their colleagues[Laloux, Frederic. Reinventing Organizations. Nelson Parker (2014), page 126].

Two nurses on a Buurtzorg team found themselves pondering the fact that elderly people, when they fall, often break their hips. Hip replacements are routine surgery, but patients don’t always recover the same autonomy. Could Buurtzorg play a role in preventing its older patients from falling down? The two nurses experimented and created a partnership with a physiotherapist and an occupational therapist from their neighborhood. They advised patients on small changes they could bring to their home interiors, and changes of habits that would minimize risks of falling down. Other teams showed interest, and the approach, now called Buurtzorg +, has spread throughout the country.^[4]

One team in the countryside had an idea: A boarding house for patients, to offer the patient's primary caregiver a break. With most patients, Buurtzorg provides medical care, but someone else - often the patient's husband or wife, sometimes a patient's child - is really the primary caretaker. It is not unusual for the husband or wife, often elderly as well, to be exhausted by the constant care of the patient, sometimes 24 hours a day. If the strain becomes too much, the caregiver can fall sick too.

Wouldn't it be wonderful, one team of nurses thought, if we could have a place where we could take in our patients for a day or two, or even a week - a sort of bed and breakfast and lunch and dinner and care - so that their primary caretaker could take a break and rest? One of the nurses had inherited a small farmhouse in the countryside. Together, the team transformed it into a Buurtzorg boarding house.

The idea of boarding houses will run its own course. If it is meant to be, if it has enough life force, it will attract nurses from other teams to make it happen and carry Buurtzorg into a new dimension of care. Otherwise, it will remain a small scale experiment^[5]

Two nurses on a Buurtzorg team found themselves pondering the fact that elderly people, when they fall, often break their hips. Hip replacements are routine surgery, but patients don’t always recover the same autonomy. Could Buurtzorg play a role in preventing its older patients from falling down? The two nurses experimented and created a partnership with a physiotherapist and an occupational therapist from their neighborhood. They advised patients on small changes they could bring to their home interiors, and changes of habits that would minimize risks of falling down. Other teams showed interest, and the approach, now called Buurtzorg+, has spread throughout the country. The two nurses sensed a need, and with the power of self-management acted upon it. Self-management helped the idea to spread. Any team interested in Buurtzorg+ can sign up for a training event that teaches them the basics of how the concept works and how to create such a partnership in their neighborhood^[6]

Buurtzorg was created not only out of frustration with the way neighborhood nursing companies in the Netherlands had fragmented a noble profession into a series of senseless tasks. It also grew out of a new, and broader perspective of neighborhood care. The purpose of care is not to inject medication or change a bandage; it is to help people have rich, meaningful, and autonomous lives, to whatever degree that is possible. Within this broad definition, Buurtzorg keeps evolving, keeps moving to where it feels called.

Not too long ago, for instance, one team in the countryside developed a new concept: a boarding house for patients, to offer the patient’s primary caregiver a break. With most patients, Buurtzorg provides medical care, but someone else — often the patient’s husband or wife, sometimes a patient’s child — is really the primary caregiver. It is not unusual for the husband or wife, often elderly as well, to be exhausted by the constant patient needs, sometimes 24 hours a day. If the strain becomes too much, the caregiver can fall sick too. Wouldn’t it be wonderful, one team of nurses thought, if we could have a place where we could take in our patients for a day or two, or even a week— a sort of bed and breakfast and lunch and dinner and care — so that their primary caretaker could take a break and rest? One of the nurses had inherited a small farmhouse in the countryside. Together, the team transformed it into a Buurtzorg boarding house.

At a subsequent company retreat, the team presented its concept to all of its colleagues. However it was left up to them to decide if they felt called to create their own boarding houses. No one at Buurtzorg, not even Jos de Blok, the founder, made the call in the name of the company to say, “Yes, this fits Buurtzorg’s purpose, so we will create dozens of boarding houses and here is the budget we will allocate,” or “No, this is not within the scope of Buurtzorg. Let’s not pursue this.” The idea of boarding houses was left to run its own course. If it was meant to be, it would attract nurses to make it happen and carry Buurtzorg into a new dimension of care. Otherwise, it would remain a small-scale experiment.^[7]

Buurtzorg faced a crisis in 2010 and mastered it using the advice process. The young company was growing at breakneck speed when Jos de Blok heard that health insurance companies had threatened to withhold €4 million in payments to Buurtzorg, citing technical reasons (the more likely reason: the insurance companies wanted to signal to Buurtzorg that it was growing too fast at the expense of established providers). A cash crunch loomed. Jos de Blok wrote an internal blog post to the nurses exposing the problem. He put forward two solutions: either Buurtzorg could temporarily stop growing (new teams cost money at first) or nurses could commit to increasing productivity (increasing client work within the contract hours). In the blog comments, nurses overwhelmingly chose to work harder because they didn’t like the alternative: slower growth would have meant saying no to clients and nurses wanting to join Buurtzorg. In a matter of a day or two, a solution to the cash problem was found (and after some time, the insurance companies eventually disbursed the withheld funds).

Within Buurtzorg (which means “neighborhood care” in Dutch), nurses work in teams of 10 to 12, with each team serving around 50 patients in a small, well-defined neighborhood. The team is in charge of all the tasks that were previously fragmented across different departments. They are responsible not only for providing care, but for deciding how many and which patients to serve. They do the intake, the planning, the vacation and holiday scheduling, and the administration. They decide where to rent an office and how to decorate it. They determine how best to integrate with the local community, which doctors and pharmacies to reach out to, and how to best work with local hospitals. They decide when they meet and how they will distribute tasks among themselves, and they make up their individual and team training plans. They decide if they need to expand the team or split it in two if there are more patients than they can keep up with, and they monitor their own performance and decide on corrective action if productivity drops. There is no leader within the team; important decisions are made collectively.^[8]

Buurtzorg uses social media (as mentioned above) in a powerful and way to support the advice process. For example, if all 9,000 employees must be consulted, Jos de Blok, the founder, posts his suggestions on-line. He posts regularly, from the heart, without PR polish (there is no communications department at Buurtzorg), often at 10pm at night from his home.

Given the respect he enjoys, his posts are widely read. Typically, 24 hours later, a majority of nurses will have read the post. Within hours, these posts evoke dozens, sometimes hundreds, of comments.

This can make for fast decision-making. If the comments signal agreement, it is made within hours. If debate ensues, the proposal is amended and floated again. Or a workgroup is set up to refine it.

This kind of leadership by blog post requires a degree of trust, candor and vulnerability that few CEOs in would feel comfortable with. Once a post is published, there is no going back. Critical comments and rebukes are for all to see; they cannot be erased and cannot be ignored. And what the organization does with the post is beyond the CEO’s control.

What seems risky when looked at through a traditional lens is wonderfully efficient from a Teal perspective. A post made from the comfort of a sofa at home can be a decision by next afternoon, endorsed by thousands of people in the organization. An idea or concern about where the industry is going? Write a short post, and you get to know how the organization reacts. If people disagree with your thought, you have lost 15 minutes of your time … but gained a new insight into what the organization thinks. When we think of how decision-making happens in large organizations today (the PowerPoint decks that need to be written, the lengthy steering committee and executive meetings where decisions get debated, followed by top-down communications where every word is weighted), we can only marvel at the efficiency of leadership and decision making within Buurtzorg.

Buurtzorg's employees work in 750+ teams of 10-12 people. These teams are largely autonomous. Many decisions (say how the night shifts are handled, if there is room to accept more clients, etc.) affect the whole team, but no one else. Then, it makes sense for the advice process to take place within a team meeting. Buurtzorg uses a specific method for decisions called “Solution-Driven Methods of Interaction" developed by Ben Wenting and Astrid Vermeer of the Instituut voor Samenwerkingsvraagstukken in the Netherlands.

• The group chooses a facilitator for the meeting.

• The agenda of topics is put together on the spot. The facilitator can only ask questions: “What is your proposal?” or “What is the rationale for your proposal?” All proposals are listed on a flipchart.

• Topics are then addressed one by one. In the first round, proposals are reviewed, and refined.

• In a second, proposals are put to group decision based on a consent (not consensus). For a solution to be adopted, it is enough that nobody has a principled objection. If there are none, the solution will be adopted, with the understanding that it can be revisited at any time when new information is available.

For Buurtzorg, its purpose— to help sick and elderly patients live a more autonomous and meaningful life— is paramount, so much so that Jos de Blok, its founder, has documented and published Buurtzorg’s revolutionary ways of operating in great detail, to invite competition to imitate him. He accepts all invitations from competitors to explain his methods. He and a colleague are deeply involved as advisors to ZorgAccent, a direct competitor, and don’t ask to be compensated for it. From an Orange perspective, this attitude makes no sense. Buurtzorg’s breakthrough organizational innovations are its equivalent to Coca-Cola’s secret formula: a competitive advantage that should be locked up in a vault. But from an Evolutionary-Teal perspective, the defining purpose is not Buurtzorg’s market share or Jos de Blok’s personal success. What matters is patients living a healthy, autonomous and meaningful life. De Blok says, “In my perspective, the whole notion of competition is idiotic. It really makes no sense. You try to figure out how you can best organize things to provide the best care. If you then share the knowledge and the information, things will change more quickly”.^[9]

At Buurtzorg's founding, Jos de Blok chose members of the board based on their expertise—for example, a family doctor, a banker, a lawyer, etc. Some were not comfortable with self-managing practices. Others wanted financial projections and budgets, and similar, traditional ‘tools’. Over time, de Blok persuaded several to resign and replaced them with others more comfortable with Buurtzorg's novel principles and practices. In practice, the Buurtzorg board serves as a sounding board for Jos de Blok and his colleagues.

The Buurtzorg by-laws state that the board is not responsible for CEO appointment. This comes from within the organization itself. ^[10]

Dismissals are self-managed, using a mediated conflict resolution process.

At Buurtzorg, if someone has lost the trust of the team, they try to find a mutually agreeable solution. If that doesn’t work out, the group calls in the regional coach or external facilitator to mediate. In almost all cases, the presence of a mediator brings resolution. In some cases, the person and the team decide on some mutual commitments and give it another go.

In others, after some deliberation, the person comes to see that trust is irrevocably broken and understands it is time to leave. If no agreement can be found, and as a last attempt to settle the matter, team members can ask Jos de Blok, the founder, to mediate. In the rare case where even that fails, they can ask him to put an end to the person’s contract (legally, he is the only one who can do so)^[11].

Buurtzorg has 9,000 employees, with a headquarters of only 40. There are no typical staff roles (no CFO, head of HR, etc.). Most headquarters employees are involved in administrative tasks (social security administration, for instance).

How is it possible to manage a 9,000-person-strong organization with such a bare bones headquarters? Many of the typical staff tasks are simply devolved back to the teams. Take recruitment for example: when a team feels the need to expand, it does its own recruiting (the regional coach might give advice when asked, but is not involved in the decision). Chances are that the team will co-opt somebody who fits in well. Because the team members make the decision themselves, they are emotionally invested in making the recruit successful.

How about expertise? At Buurtzorg, it doesn’t make sense for every one of the roughly 600 Buurtzorg teams to develop expertise in every arcane medical condition they might encounter. But rather than create staff roles, Buurtzorg has developed a number of effective alternatives to deal with a need for expertise, both medical and non-medical:

• Nurses on the teams are encouraged to build up expertise and become contact points beyond their team. Through Buurtzorg’s intranet, nurses can easily identify and access colleagues with relevant expertise in a specific subject area.
• Occasionally, volunteer task forces of nurses are set up to, in addition to their work with patients, investigate a new topic and build up expertise (for instance, how Buurtzorg should adapt in response to new legislation).
• When needed, an expert can be hired as a consultant , rather than brought into a staff role.
• If a staff person is hired, they have no decision-making authority over teams.

As an illustration, in a meeting of Buurtzorg’s regional coaches, a suggestion was made to hire a specialist in labor law, a topic many teams occasionally need assistance with. The suggestion made sense. And yet, other avenues were explored After closer examination, it appeared that most questions were recurring, and so the group decided to create a self-help section of “frequently asked questions on labor law” on Buurtzorg’s intranet. This took care of most questions, but a year later, the group realized that some questions still popped up for which the FAQ provided no answers. It was decided to contract a freelance expert for a few days per month who would answer questions from teams on request.^[12]