Leading Wisely

Listen to Ricardo Semler's Podcast

Jos de Blok is the co-founder of Buurtzorg - a Dutch health care company with over 9,000 nurses who work with homebound clients or people who need assistance. The company has seen tremendous growth in the last 10 years and, of course, the nurses are all self-managed. Perhaps this level of trust is due to the fact that Jos got his start as a nurse. Jos' story is fascinating and it provides us with a lot to think about in terms of how we organize our own companies.

Ricardo Semler (RS):

Can you talk to us a little about how Buurtzorg started?

Jos de Blok (JDB):

I worked as a nurse between 1980 and 1994 and, in that time, I was a community health nurse and there was a big freedom in how to organize your work for yourself. After that, in the beginning of the ‘90s, based on the new public management organization, I started to work with professional management. Between 1994 and 2005, I had several management roles in these organizations and I just thought that the work of the nurses changed rapidly into a more solution-driven way of doing things - based on craftsmanship and on the intrinsic motivation of the nurses towards more task-oriented and production-driven outcomes. And I can summarize that the quality of the care went down, the dissatisfaction of the nurses was dramatic, and the costs went up.

For me, the idea grew that I could start something myself with some friends based on the old principles of self-organization, but with the new insights of all the IT we could use to support it. We started with four nurses at the end of 2006 as a bit of an experiment and, in 2007, there were nurses from all over the country who phoned us and mailed us and said, "Can we also join?" We created a foundation called Buurtzorg and we said, "Everybody who wants to work this way is very welcome. We won't have any management. We want to keep it as simple as possible and everybody's responsible for what they're doing." Since then, we have created a horizontal network of teams all over the country.

RS:

How do you deal with the fact that these nurses are interpreting information based on their own protocol of what they should be doing in a given instance and which can create drastic consequences for the organization?

JDB:

A lot of people are concerned about risk. No matter where I am in the world, people ask me questions about what to do when things go wrong. Usually I answer, "Why are you not interested when so many things go right?" We are celebrating our 10th anniversary this year and there hasn't been one calamity. We work with 600,000 patients and what you see is that the system is very preventative. These teams work like ecosystems. The nurses are peer groups so they are constantly asking each other what they think about different, difficult cases. First, it's looking at a person and, second, it's following the protocol and not the other way around. We say, "Use your common sense and use your team members to prevent problems." My assumption in the beginning was that teams would think about the risks themselves and how to avoid risks. So they have those small systems in their teams which avoid risk. Also, when something happens, they are the ones who feel responsible to deal with it. This means that it doesn't go any further in the organization because the nurses feel that they're responsible to deal with what's happening.

On our web-based learning environments, the nurses can find all the materials and all the protocols that they need and everything goes directly to tablets that they keep with them. They also have their colleagues who are also watching which is important because things can get complicated.

RS:

Let's talk about the commercial aspect of what you're doing. You have an enormous volume of almost 300 million Euros that flows through the organization and you have a flat self-managed organization of teams. How do salaries and bonuses work?

JDB:

If you look at what nurses values are, then you’ll see that they want to have a good job and they want to have a good salary. So, we pay more than most organizations are paying in Holland. And, our nurses can spend their time following their own insights - they make a lot of the decisions in their daily work. It's also about developing themselves, so if they want to follow certain educational programs or study, then we say there is enough money to support education for everybody. Every team spends three percent of their budget on education and, if it's not enough, they can ask for more.

We don't have big issues related to salaries. We have a regulated system here in Holland and nurses earn what they get based on the agreements with the unions. So, there aren't a lot of discussions about how productivity levels correlate to compensation. It's a team effort. We are one of the most profitable health care organizations in Holland. Every year, we take a few million Euros of our profit and give bonuses to our nurses. Those bonuses are based on how long they have been working with us. Also, we have meetings in every region where we invite nurses to put forward ideas new ideas. Last year, for example, they said they wanted to do more projects on prevention and on e-health. So, we spend three million on e-health and three million on prevention projects.

RS:

Buurtzorg has had such an amazing 10 years. After all of this success, is there anything that you worries you about what’s ahead?

JDB:

I don't have many worries about the organization. The health care system here adopted our way of working. I had a lot of meetings with the Dutch Minister of Health and now the payment system is following our way of working. I think that's a big success. In terms of some more innovative next steps, we can try to figure out how to develop an infrastructure in the community which gives new possibilities for people who are disabled or who have diseases. We can also put more energy towards prevention.

Problems will come and we will discuss them when that happens. And then we will see how to deal with it. We try to focus on what extra steps that we can make. We will keep on developing and keep on experimenting with new ideas. But, we see sometimes that the motivation of people who joined us in the last few years is a bit less than the people who joined us in the first five years. So it's also trying to find new ways to inspire the new nurses.

RS:

With the way that technology is changing, is it possible that 5-10 years from now that we’ll find ourselves in a situation where patients can go directly to a nurse without having to go through a company like yours? How are these changes going to impact health care in the future?

JDB:

I think that there will be some changes that will impact the current infrastructure. I think we’ll move towards having our patients do more self-management. But if I look back on the last 35 years of working in healthcare: 10 years ago we had some assumptions about how things would look now. And if I look back 35 years, the essence of how to deal with problems hasn’t changed too much. So, while I think things will change, I also think that the human part of health care will stay the same. We have to learn how to deal with new technologies and we have to think about if this current structure we have is still effective. We are discussing like-corporative systems on a small scale - just give groups of nurses the tools and say, "These are things you need and you don't need a company anymore." I think that will be interesting for the coming years to experiment with that and just see where it leads. I believe in a certain kind of continuity of things which are very basic - and that's the relationship between people.

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