Jos de Blok pleads for customization and reduction of overconsumption in home care The self-steering and care-driven teams of Buurtzorg
By Dr Jaap van Ede, editor-in-chief business-improvement.eu, 06-05-20151. Available in Dutch on procesverbeteren.nl
What can other organizations learn from Buurtzorg? This home care provider is completely self-steering. There are no managers, they even have no HR-department! Small local teams decide according to their own judgement, what care matches best with the wishes of their customers. De facto, these teams function as mini-companies.
On paper, Jos de Blok is the CEO. However, a commanding role does not fit with the concept of autonomous teams. De Blok acts more as a facilitator and guard of the self-steering principles. ‘Buurtzorg is a care-driven, instead of a problem-driven organization’, he says.
De Blok criticizes the bureaucratic control of the home care in the Netherlands, with the aim to serve nine 'standard products' as cheap as possible. The result is that as much as possible of these ‘care products' are supplied to the customer as long as possible. In other words, the outcome is overconsumption and unnessarily high costs. I addition, it is bad for the customer, who will not revalidate well and/or does not learn to remain as self-supporting as possible.
There is a better alternative: more trust should be given to the care organizations. For example a fixed quarterly budget could be alotted per customer type, in combination with a monitoring system to assess the quality of the care.
During the interview, Jos de Blok made an intrigueing remark: ‘Lean is terrible’. What makes him think that, while Buurzorg has so many characteristics of a true Lean organization, like coaching leadership, and using the talents of everyone?
The highly successful Dutch home care organization Buurtzorg (litterally: care in your neighbourhood) was founded in 2006 by Jos de Blok. Originally he was a district nurse. However, at that time he was an innovation manager, within a large home care company. It turned out to be impossible to carry out the reforms he wanted. Therefore he decided to start his own organization.
De Blok had a mission: creating an organization that would no longer 'produce' as much care as possible. He wanted to provide the care that meets the wishes of the customers (the people that need care) best, nothing more, nothing less.
Buurtzorg is entirely based on the principle of self organization. As a result, the care professionals can fully develop and use their talents. Managers, intakers and planners are not needed anymore. Small teams of nurses and other care takers, localized in the neigbourhood of their customers, decide according to their own judgement what care matches best. This is done in close cooperation with each customer and the social network around this person. In other words: context- and relationship-directed care is given. This resembles the way in which district nurses used to operate, but not everyone in a Buurtzorg team has the same role. Tasks are distributed across the team members in a natural way.
The care to be delivered is more a project than a product, because every customer has different needs. Each team consists of up to twelve persons, operates from a building they choose in the neigbourhood of their customers, and is reponsible for their own results. When a team has problems they can't solve themselves, or when they have questions, they can call the help of a regional coach. This coach does not interfere directly, but gives hints so that the team can find a solution themselves. After this, the team members have become better problem-solvers!
Only in extreme cases, for example when there is a serious internal conflict, or when a team performs substandard for years, the regional coach contacts Jos de Blok. ‘In that case, together with the coach, I will have a conversation with the team concerned’, De Blok explains. ‘Often the problem will resolve itself. It is very rare that people need to be transferred to another team, or even need to be fired.’
The teams are spared regarding administrative tasks. That way, they can give their full attention to care giving. Negotiations with the care administration offices are for example done by a small support center. This center also steps in when problems arise regarding the assesments - which care may a client recieve - by the Dutch office for care assesment (CIZ).
On the other hand, everything that touches the primary process, and that can be done by the care professionals themselves, is left to the teams. This even includes hiring new personnel, and executing performance interviews. This high degree of self-steering makes the overhead of Buurtzorg very small. ‘We dont have a human relations department, in fact we don't have any departments at all’, emphasizes De Blok.
Jos de Blok: "Internally we don't use the word customers. It gives the wrong impression that we deliver standard care products, with a matching delivery process that one could optimize"
Solution driven interaction
By way of the Buurtzorg-web, an intranet application, teams can exchange experiences. They also ask questions, and ventilate ideas. A lot of things that cause problems in traditional hierarchical organizations, are solved effortless by the self-steering teams. De Blok gives an example: ‘Other organizations always have capacity problems during the summer holiday. We don't, most of the teams already reach an agreement regarding their summer schedule in february.’
To make the self-steering concept work, several tools to prevent chaos are put to the disposal of the teams. Every team is for example trained in conflict management, and meetings are done via solution driven interaction. During such a meeting everyone can make suggestions, every vote counts. That way, the intelligence of the whole group is utilized. When there are no fundamental objections against a proposal, it will be tried out. This makes it impossible to block innovation.
Within Buurtzorg, the people and the development of their skills form the basis for excellent performance. Several characteristics of a true Lean organization are recognizable.
First, the customer, the person that needs care, is put central. The teams organize the care themselves, and they both have a grip on - and are responsible for - the results. Second, coaching leadership creates a learning culture. The teams and their members increasingly become better problem-solvers, which makes it possible for them to become even more selfs-steering and self-supporting.
Third, innovation takes place in short cycles, new ways of working are tested to see if they are better. And finally, probably the most important thing: The care professionals are given full scope to develop and use their talents, and they get the respect they deserve. In other organizations there often are managers without knowledge and experience in care giving. These can make it almost impossible for the professionals to do their work. Bureaucratic rules, invented by controlling (read: distrusting) managers, can become a huge obstacle.
What many people don't know: the top-managers of Toyota, always mentioned as outstanding example regarding Lean, behave a lot like Jos de Blok. They also have a similar background. Toyota-managers often have practical experience with building cars, and they stay in close contact with the shop floor. It is unthinkable that they make decisions sitting behind a desk, based on numbers in spreadsheets. In addition, the CEO of Toyota never is someone who has that job only for a few years. Instead, it is someone who has always worked in Toyota and in the automotive sector.
To recognize the Lean-side of Buurtzorg, one has to depart from the modern definition of Lean. This definition puts man, the organization, the Gemba (Japanese for shopfloor, the place were it all happens), and the customers first. Lean is a method in which everyone continuously tries to increase the value that is created for the customer. To that end, the professionals should get all the room, the support, the possibilities and the respect to do this! Still, Lean is often disposed as a method which solely reduces waste in production processes, with reducing costs as the main aim. According to this narrow-minded definition Buurtzorg surely isn't Lean. They should be glad, I would say.
More articles and books about self-managing organizations:
‘Lean is terrible’ Despite the similarities between Buurtzorg and what I would call a 'true' Lean business, Jos de Blok dissociates himself strongly from that idea.
‘Lean is terrible’, he provokes. ‘We never aspired to work like that. If we resemble a true Lean organization in some ways, this evolved as a result of what I see as completely different points of departure. We want to highlight the importance of professional skills, remove obstructions for people to do their job, stimulate solidarity, and seek for a balance between material and spiritual things.’
‘But all those aspects are also part of Lean’, I object. ‘The art to create things, be it products or services, is the starting point. The coaching model of Lean goes back to the master-apprentice system of the Middle Ages.’
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De Blok not only has an aversion against Lean, he distrusts all methods for business process improvement. ‘You speak about adding value for customers, but we don't even use that word. If you do that, one might think that you deliver standard services, for which there is a process that can be optimized. In home care, at least in the way we perform it, this isn't the case. You need customization.’
De Blok gives an example: ‘Suppose someone has had a stroke. Usually this results in a need for care of x hours. Next, you could set up an organization which provides this care as efficient as possible. The patient could experience this as a good solution, as well as the managers of the care organization involved. So, everybody happy? No! Our professionals say it is not the essence of their job, to make someone dependent on care. They want a quick recovery, to the maximum level that is achievable. To do that, family members should for example be trained to help. Permanent loss of body functions is then prevented as much as possible. In the end, this is not only better for the person who recieves our care, it even is cheaper.
It turns out that De Blok struggles primarily with the idea to strive for optimized business processes. Those processes then easily can become a goal in itself, instead of the true mission: adding value for man and society, with the professional skills of the employees.
The aversion of De Blok against standardization and - after that - continuous improvement of processes, which is the usual approach to get Lean, is deeply rooted. He even dislikes the application of 5S. This is a method to create clean and organized places to work, by removing things that are superfluous and by giving all other materials a fixed place. ‘Doing that with the idea that you can grap things faster, I find this de-humanizing.’
De Blok deliberately exaggerates a bit, to make his point. ‘In health care, but also in for example education and in police departments, all too often you see a managerial approach, guided by Anglo-Saxon principles. I think it is time that the purpose of the profession concerned is placed back in the center. If you want that, you should strive for a minimum of managers, and for a high level of autonomy and self-steering. In the book Reinventing Organizations a number of companies are discussed, that work like that. We are mentioned, and for example FAVI. This is a French automotive supplier, that has almost the same organizational structure as we have. For each car brand they have formed self-managing teams.’
The organizational model of Buurtzorg is based on self management and giving life meaning. The picture shows an enthousiastic team in the city of Warnsveld, The Netherlands.
Lean has gotten a bad reputation in home care. It has become associated with time windows and clocks, with for example a reserved time of 2,5 minutes to put on support stockings, and 15 minutes to give someone a bath. Journalists pounced on that with reports like “How much time do we have for Grandma?’. Drinking a cup of coffee with someone would only be seen as waste.
Such a one-sided focus on reducing waste has very little do do with the true nature of Lean. In the case mentioned above time registration is not used as a tool to improve, but only as a means to check if the employees work hard enough!
Truck manufacturer Scania also works with fixed times to assemble parts, but here these so-called ‘takt times’ have a different aim: They are needed to gear the assembly steps to one another, and to prevent waiting times and intermediary stock.
The true goal of Lean is that as much value for the customer is created as possible, and to do that the talents of all the people should have full play. When defined this way, Buurtzorg is pretty Lean. After all, unneeded managers are just another form of waste. Those managers don't add value. On the contrary, they even impede the primary processes.
To conclude, self-organization and Lean don't have to be contradictory. This is nicely demonstrated by FAVI, already mentioned earlier as an example of a company with self-steering teams. This automotive supplier also is Lean, but the application of this method is not dictated by managers. The teams decide themselves what Lean tools or other improvement methods they want to use. For that reason, FAVI has no separate improvement office. The expertise to improve their work methods resides within the teams.
De Blok points out that an increasing number of companies is busy with a reorientation, aimed to give the life of their employees more meaning. Social themes and sustainability are more and more often put on the agenda. The prominent role of Buurtzorg as example in the book Reinventing Organizations already attracted the attention of several big companies, such as Philips and Unilever. ‘Kees Kruythoff, president of Unilever in North America, for example asked me how we organize things. Unilever also wants to move in the direction of more autonomously functioning teams. Interesting is that giving meaning, in the form of increasing vitality and health, traditionally is already part of their company mission.’
The government turns out to be a crack formulator of improper incentives, aimed to increase performance. Examples in the Netherlands are the number of graduated students, the number of traffic fines given by the police, and the percentage of trains that leave on time (be it with or without travelers in it!).
In a smilar way, they drive home care in the wrong direction. First, it is incorrectly assumed that it is possible to determine in advance what type of care is needed by someone. Second, it is assumed that you can deliver this care in parts, while each part is done by the lowest qualified (read cheapest) employee possible. ‘As a result, we have to deliver nine diferrent "products", when an assesment turns out that someone needs one or more of these’, De Blok explaines. ‘For giving one hour care we recieve for example 45 euro per hour, and for nursing we get 75 euro.’
Impersonal and inefficient
The way the government tries to influence the output not only made the care impersonal, but also inefficient and expensive. ‘They try to reduce the standard rates per care product. The result is that more care hours are delivered, and that this is done during a longer period. After all, the reward system makes it beneficial if people need more and longer care. This makes people dependent on care, which is not only more expensive but also not good for our clients. A quick recovery is best for them, and if this is not possible they should learn how to deal with their disease, in such a way that the syptoms are reduced.’
Controlling home care via the number of indicated hours per "care product", and simultaneously putting pressure on the price of these "products", thus only leads to overconsumption. Of course, the way in which these care products flow towards the customer can be optimized, just as many hospitals did for diagnosis-treatment combinations. However, this is not really Lean, since also in these hospitals the total delivered amount of care increased, sometimes unneccesarily.
Therefore, Buurtzorg works different. In consultation with each client and the social network and volunteers around it, they develop a customer-specific care plan. Buurtzorg only has relatively highly-qualified personnel. As a result these professionals can be flexible and multi-tasking. This makes it possible that they perform a broad spectrum of tasks for a client during one visit. This is efficient and it improves the social interaction, because only a few care professionals need to visit each client.
‘As a rule we can do our job in 40% less hours then was assessed, and in addition we provide care only half as long as other care organizations’, says De Blok. ‘This is not beneficial for us, since we cannot declare more hours then we actually use. And because we only have highly qualified employees, we sometimes recieve relatively little money per hour. However, we think it is our social responsability to deliver just the care that is needed.’
The translation to declarable hours is done by the support office of Buurtzorg. ‘They divide the care that was given over the nine standard care products. The professionals in our teams don't have to bother about this.’
Return of district nurse
Dutch politicians admit that the current way of working, with a lot of bureaucracy and large and distant care offices, needs improvement. They link this to a cost-cutting program, in which many controlling tasks are transferred to municipalities. This would bring "care nearer to the people", they say. Referring to the succes of Buurtzorg, some policians also say that the district nurse should return. De Blok is not impressed. It seems difficult to break the cycle of increasing bureaucratic control.
‘The new district nurses form an extra institutional layer for consultation and coördination. That is a move in the wrong direction: you get more bureaucracy, not less. If you leave the care to the professionals, than you need no coördination at all.’
Jos remembers the time he worked as a district nurse old-style. In those days coördination and execution was part of one job. ‘Per region we got a yearly health budget, in which the demographic composition was taken into account. This budget was devided between us, and we were entrusted to provide the best possible care. And so it happened. Dependent on the problems we observed, we contacted for example a family doctor or a social worker.’
Later it was thought that
it was better to organize things on a large scale, with a distinction between planning and execution. ‘Nothing is further from the truth. Take for example the city of Lochem, where I used to work. The capacity of available care givers and organizers there is now five times higher then it used to be.’
Applying Lean in healthcare has the aim to increase the health value which is added for the customer. ‘In any case I agree with this goal', says De Blok. ‘If you want to achieve that in home care, you should return to some kind of budgeting model. In the US you get a certain amount of money for a certain type of patient. For example 7000 to 8000 euro to care for someone with dementia. You get a budget per quarter, and it is monitored if the care has the desired effect.’
The question arises how this is done. ‘There is a system which does that, named Omaha’, Blok explains. ‘A home care organization already in the 70's started to develop it, in the city with the same name in Nebraska.’
Problem rating scale
From the start, Omaha was designed to be a computer-assisted system. It uses classification schemes for the care that is needed, and intervention schemes for the execution of it. The third part is a so-called problem rating scale, to monitor the efficiency. Customers and care givers together give scores for the following three things:
Knowledge: what does the patient know about his or her own illness and problems
Behavior: how capable is the patient in reducing the symtoms.
Status: how severe are the symptoms.
“We have been experimenting five years with this Omaha-system. In cooperation with the ministry of health, welfare and sport in the Netherlands, we now investigate if it can be introduced as a nation-wide standard.’
According to their own judgement, Buurtzorg teams tune the care to the wishes of each customer, in close consultation with the social network around it.
Buurtzorg is a good example of an agile organization. They distinguish themselves with customized care, while this does not lead to higher costs. This last thing is remarkable. After all, customer-specific services are as a rule more expensive than standard services. How did Buurtzorg tackle this problem, what is the secret that made them so succesful? We found several reasons:
Satisfied customers. Every client is served with as little people as possible visiting their homes. This is not only more efficient for Buurtzorg, it is also appreciated by their customers. As a result, the number of new customers increases.
Little overhead. Buurtzorg provides as little care as possible, during a period that is as short as possible, in the interest of the customer. As a result, Buurtzorg can claim relatively few hours per client, but nevertheless they are financially very healthy. How do they do that?
‘Our secret is our low overhead’, explains De Blok. ‘Thanks to the formation of autonomous teams we need no departments, en we have a very small head office. On a turnover of 220 million euro, our overhead only is about 5 million. In a traditional care organization that would be about 50 to 60 million euro.’
Enthousiastic employees. The care providing teams are placed in the center. All other activities should help them to achieve their mission: giving the people the care they really need. There are no managers, only coaches. ICT-applications, such as the Buurtzorg intranet, serve only to ease the work. They are not used to check if the teams work hard enough. Employees of Buurtzorg often choose to work there, because they were dissatisfied with the amount of measurement and control (read: distrust) in other home care organizations. As a result, they are extra enthousiastic to make the Buurtzorg concept a succes. The combination of giving people a lot of freedom and trust generates a lot of positive energy. A lot of care professionals prefer to work a bit harder, instead of becoming frustrated because they are not allowed to give their customers the care they need.
According to De Blok you don't have to work harder in his organization, on the contrary. ‘We strive for a percentage of 60% declarable hours per team member. Other care organizations need a higher percentage, because their care professionals have to repay a huge amount of overhead.’
The Buurtzorg concept has also a number of weaknesses
Social network customers. Buurtzorg works with customer-specific care plans, developed with the family and friends around the client. These volunteers can perform certain simple care tasks, which creates space for Buurtzorg to provide special care. For this system to function, it is needed that the customer has a social network of people in their neighbourhood, which is not always the case.
Role of Jos de Blok. The role of De Blok within Buurtzorg is to some degree comparable with the role that Steve Jobs had within Apple. As described in the book reinventing organizations, the role of the CEO is crucial in a company based on the principle of self-organization. It already occurred several times that under a new CEO, such a company returned to a more hierarchical way of operation. The same might happen if the high degree of confidence that Buurtzorg gives to their teams, is violated somehow.
Copying. Other home care organizations copy parts of the organizational model of Buurtzorg. The formation of small home care teams, which are allowed to manage large parts of their work themselves, becomes more and more common.
Learn from Buurtzorg
The strong points of the model of Buurtzorg were described earlier in the Dutch book "Uit de schaduw van het zorgsysteem", written by Annemarie van Dalen. We read this book first, and then organized two interviews with Jos de Blok. These were the main sources used for this research article.
Let us return to the question in the beginning of this article: What can other organizations learn from Buurtzorg? We see a trend to give the employees on the shop floor, the place where value for the customers is created, increasingly more freedom and responsability. Buurtzorg is an extreme case, they don't have separate managers anymore, management has become an integral part of the autonomous teams. Within Buurtzorg, everthing is aimed to help the professionals to create maximum value. There are no more rules or procedures than needed. Only this is already worth following.
Short value chain
The value chain of Buurtzorg is short: de teams can overlook the complete chain until the delivery of care to the customer. Buurtzorg in fact consists of a large number of mini-companies, the autonomous teams. These are connected to each other via the Buurtzorg intranet, and via several supporting services, which are kept as small as possible.
Maybe you think that your company cannot be organized this way. However, you can also come a long way, by forming teams for different customer segments, like FAVI did. Those teams than deal with the complete process from quotation until delivery, in the way a quick responce cells function within Quick Response Manufacturing.
Is also that impossible or undesirable (for example because very high quality requirements makes working with autonomous teams too risky), than there are still a lot of aspects of the Buurtzorg model that might put an idea in your head. For example, if you ask people to think along about the mission and strategy, like Leaf did when they applied Appreciative Inquiry, this increases their enthousiuasm and involvement a lot!