Jos de Blok : Keep It Small, Keep It Simple
Joel Moore - June 2019
The Rotamap Spring event 2019 was held at the Royal Society of Arts in Central London, on Friday 22 March 2019. Our main speaker was Jos de Blok, founder and CEO of the innovative home-care nursing organisation Buurtzorg. Jos received the prestigious Albert Medal from the RSA in 2014 for his role at Buurtzorg and its subsequent impact on community healthcare across the world; the RSA citation stating that "The [Buurtzorg] movement shows that craftsmanship, trust and integrating simplification offers a great deal more for society than bureaucratic and hierarchic organisations". 
Buurtzorg’s organisational structure is markedly dissimilar from that of the NHS, which has many similarities to the pyramidal organisational model made famous at General Motors (GM) between the 1920s and 1950s. GM's model, predicated on measurement and "management by objectives", functions to ensure easy auditability and efficiency, yet results in the segmentation of workers and sets up inflexible tiers of management. Buurtzorg's organisational model is in direct contrast to this sort of command-and-control structure and its implicit distrust of the people actually doing the work. 
Jos's speech covered some of the important ways in which Buurtzorg's innovative organisational structure and methods of practice has quickly led to its rapid expansion. The Buurtzorg approach is not only applicable to healthcare; the Rotamap team has adopted part of Buurtzorg's model of distributed decision making.
Jos' talk was entitled "Keep it small, keep it simple".
Transforming neighborhood care
Buurtzorg, Dutch for "neighbourhood care", was founded in 2006 in the Netherlands by Jos and three fellow nurses on the basis of reforming the relationships held between care providers and their patients. Jos' own background as a trained nurse highlighted to him how changes in Dutch healthcare policy had compromised "the very vocational commitment that had brought them into the profession in the first place": that of patient-centred care.  As healthcare organisations grew in size, so too did the managerial superstructure of complexity and cost.
Buurtzorg's Jos de Blok discussing organisational structure - Photograph by Valerie Bennett
Nurses at most healthcare companies spend a significant proportion of their time on administration. Patients have to interact with numerous caregivers, each of whom performed distinct duties. For example a nurse might visit a patient to change only their compression stockings, while another might visit to give an injection. Consequently, patient care is fragmented and appears disjointed to the patient, their families and the nurses themselves. This leads to both poor quality care, and poor job satisfaction for the care givers. Cure, care and prevention at most providers are viewed as independent, rather than interdependent, and "standardisation" and a one-size-fits-all approaches are the norm.
In contrast, Buurtzorg’s approach is underpinned by the principle of trust - not just between clients and Buurtzorg's nurses, but between the nurses and the organisation as a whole. Nurses are trusted to do their job well. Buurtzorg's nurses have agency to make decisions that affect both patient care and the scope of their work. Nurses are enabled to both identify problems by their patients and within their work environment and create effective responses.
Devoting more time with patients
In an apparently paradoxical statement, Jos suggested that the nurses work "to make [themselves] redundant" by promoting self-care and the independence of their patients. Buurtzorg's "holistic perspective" recognises not only the interdependence of care and individual wellbeing, but also the fundamental role of the nurse as caregiver. This perspective has shown to be highly effective, and also very efficient. Buurtzorg's nurses have reduced the average time they typically spend with each patient by providing more effective care, and can see more patients due to devoting 10% more of their time to patient care than nurses from other organisations. These efficiencies are actively enabled by Buurtzorg's principle of "optimal autonomy and no hierarchy", exercised through small self-managing teams of between 10 and 12 nurses. 
In his talk Jos referred to Frederic Laloux’s book Reinventing Organisations (2014). According to Laloux, Buurtzorg's nurses are encouraged to bring not only their vocational training and education to their work, but also their individual experience, insight and talent. As Nel, a Buurtzorg nurse, states:
"We feel more liberated, appreciated, and fully in control of how we can provide the best possible healthcare to our clients. Instead of having to work with lots of frustrating bureaucracy, we can now do what we love to do: delivering care to clients". 
A wonderful example of how Buurtzorg's approach helps foster innovation can be seen in Buurtzorg’s "Rolympiade", held annually in Amsterdam. Jos recounted the origins of this event in 2010, when one nurse worked with her team and their elderly patients to self-organise a race. The walker race is now a key event in the Buurtzorg community calendar. The race empowers older people by instilling a sense of purpose, with walker race trials held across the Netherlands to determine who competes in the finals at Amsterdam's Olympic Stadium. This extraordinary event is indicative of the type of self-care that Buurtzorg cultivates. Success is not determined by conventional business outcomes, but by the engagement and happiness of patients. Additionally, it further instils a real sense of pride and ownership amongst Buurtzorg’s nurses who have the freedom to work together across the organisation to help their ideas take shape.
"The best ideas come from work in the field, not from management. People must have the opportunity to come up with their own solutions". 
A 'Rolympiade' participant competes in Buurtzorg's National Stroller Race - © Buurtzorg
Small teams helps to encourage collaboration and coordination amongst members, who are in turn supported by a central team of around 50 back office staff, around 30 of which perform tasks such payroll or invoicing. Twenty members of the central team are coaches who work with teams of nurses to resolve issues or provide training. Jos emphatically states that they are not managers, nor are the back office staff administrators or auditors — they work to help nurses devote more of their time to nursing.
Jos considers that nurses in many other organisations, such as the NHS, are encumbered with administrative work which keeps them away from patients. Additionally, organisation structures work against the individual's sense of autonomy and stifles collaboration.
Buurtzorg is structured around what Jos calls their "onion model of care", with the client at its centre, starting "from the client perspective and work[ing] outwards to assemble solutions that bring independence and improved quality of life". With the client at the core of the "onion", the Buurtzorg team build upon both informal networks (such as friends and family) and formal networks (including other healthcare professionals) to tailor individual care plans. The structure of an organisation is in this way used for empowering both its employees and its clients.  Care is tuned for each client, rather than being prescriptive, and designed to "support people, not policy".
Buurtzorg's onion model of care - © Buurtzorg
As Jos remarks, if we "build on trust [we] create beautiful systems", referring both to the tangible networks and in-house IT systems that are integrated within the multi-layered onion model. Trust is supported by inbuilt IT systems and compliance tools, for example the OMAHA system and "Buurtzorgweb". The OMAHA system is a "research-based, standardised taxonomy for health care", and is used by teams to ensure quality control, to monitor patient satisfaction and to record care outcomes. "Buurtzorgweb" is the organisation's own web-based platform which:
[...] supports teams in their care-giving, teamwork and communication. It joins up all the teams and provides access to one Buurtzorg community. All the information on Buurztorg web on performance, interventions and outcomes are transparent and each team can compare their performance with other teams. 
The effectiveness of this approach is reflected in Buurtzorg's results. Buurtzorg's patient satisfaction is rated very highly and it has been awarded best employer in the Netherlands for the past five consecutive years. Not only this, but this unconventional business model resulted in a turnover of over €400 million in 2017. 
Jos' presentation was followed by a Q&A session led by Rotamap’s Jacob Kirk and Nick Edgeworth. When asked about how IT systems can encourage autonomy, Jos suggested that the new channels of decision making brought about by integrated systems "bring happiness" to users. Not only this, but the freeing up of time granted by new IT systems in the performance of administrative tasks further improves job satisfaction and performance as a result. For healthcare professionals, this inevitably means less time spent on admin and more time with patients.
Jos de Blok with Rotamap's Jacob Kirk and Nick Edgeworth - Photograph by Valerie Bennett
Jos was then asked how he viewed the role played by senior nurses in the NHS, which bore implications on how we adapt a Buurtzorg model to the multiple levels of seniority and expertise within the current hierarchy of the NHS. Many senior nurses spend a good deal of their time acting in a management capacity, which Jos believed represented a waste of their education and took away from the fundamental aspect of nursing: providing care directly to patients. He reiterates his point that there is no need for such a hierarchy, and that all nurses should be entrusted with providing and organising all aspects of their work.
A final question raised the issue of generalism versus specialisation, particularly when considering the numerous medical and surgical specialities practiced by users of our systems. Buurtzorg's nurses are generalists, providing overall care and organising complete processes, and Jos expressed his opinion that in the context of community nursing specialisation decreased flexibility, and that knowledge and skills should be made more generally accessible wherever possible to become standard practice.
Jos briefly discussed how Buurtzorg's approach can be incorporated into an existing organisational structure such as that of the NHS, by setting up small "greenfield" experiments that can tap into individual expertise and experience thereby leading to natural and spontaneous extensions into the organisation to undermine hierarchy. Wondering if "the hospital is dead", he suggested we dismantle the siloing of healthcare, focusing instead on the intersection between the collaborative expertise of healthcare providers and the needs of patients, to be provided directly on a community level.
Jos's concluding comments regarded the importance of valuing collaborative networks and systems as the heart of a healthcare organisation's structure. Ideas such as the walker race are formed and sustained through a culture of autonomy, collaboration and trust.
We were very lucky to have Jos come to speak to us in such a warm, enjoyable and straightforward way. We were particularly delighted since Rotamap's organisational structure has been greatly influenced by Buurtzorg: Our teams are largely self-managing and have the necessary skills to work across almost all aspects of the business, responding adaptively to new ideas and the changing environment. We also strive to keep the needs of our clients central to all that we do, and have been hugely fortunate to have clients reciprocate with ideas for new features or improvements.