(Healing)(Teal)(Bazaarmodel)(Harvard)(Buurtzorg) - '..hierarchies have a big negative influence on the leadership of the frontline..'

Posted by ProjectC 
'..hierarchies have a big negative influence on the leadership of the frontline.. “Keep it simple,” she said. “Communicate and be open—no hidden agenda. Keep it informal and be accessible.” .. “We don’t need middle management,” said Gonnie. “A good IT system is very important there.”..'

'Buurtzorg represented an alternative approach. Just before founding Buurtzorg, Jos had worked on a self-managed project in Ukraine to attain consensus among Ukrainian doctors, nurses, and other healthcare professionals in the primary-care system about the direction general healthcare should take. “I thought, ‘If I can do this over there, why can’t I do this in the Netherlands?’” (p. 3)


Back Office Support Buurtzorg’s directors, Gonnie and Jos, as well as the 50 back-office employees, saw their role as providing service to the nurse teams, rather than managing them. “I like to make procedures as easy as possible,” said Gonnie. Jos said that he saw leadership as inherent in each individual and that every time a nurse took responsibility for a patient, he or she showed leadership.38 He saw leadership through management, however, as something that led to poor outcomes: “In organizations, for example, if you have these different management layers, then usually management is connected with leadership. And I think that’s wrong . . . hierarchies have a big negative influence on the leadership of the frontline. That’s how people lose touch with the client.”

Back-office employees handled time-consuming activities requiring specialized expertise, including billing, financial reporting, lease contracting, car rentals, and IT. Jos and Gonnie wanted administrative processes to work efficiently and simply. “Keep it simple,” she said. “Communicate and be open—no hidden agenda. Keep it informal and be accessible.”

Despite the unusual level of flexibility, certain things were standardized. “All the teams work the same way, so it is not so complex,” Gonnie explained. “They have to use BuurtzorgWeb and the Omaha System. But they can make their own planning choices with patients, so it feels different.” “Buurtzorg behind us is our wall,” said Heleen. “We can work the way we do because they exist.”

BuurtzorgWeb and the Omaha System BuurtzorgWeb was an integral part of infrastructure. “We don’t need middle management,” said Gonnie. “A good IT system is very important there.”.. (p. 6)


Margreet van den Heuvel, a coach (and former nurse) supporting 43 teams, said, “As a coach, I’m a bit of a safeguard of the framework. It is not anarchy. We help teams work within the Buurtzorg framework and when we see them [go] outside the framework, we guide them back.” She described the four principles for self-managed teams as (1) solution-focused communication, (2) solution-focused meetings, (3) team decisions made in consensus, and (4) dividing and rotating roles and tasks. Coaches met with all the teams they coached once or twice per year but spent most of their time helping teams facing challenges. Each coach met with Jos and Gonnie about three times a year. The coaches themselves divided into teams of about six, which met every six weeks or so, mostly to discuss difficult

Within reason, nurses were free to decline coaches’ help. “You can just say, ‘No, go away,’” said one nurse. “I’ve even asked Jos if we could fire a coach.” (p. 7)


Such positions often caused tension between Buurtzorg and the government, but Buurtzorg had also shown itself to be a trusted and influential player, in part through Jos testifying in front of Parliament or speaking out through the public media. In 2010—2011, Buurtzorg ran a pilot to demonstrate to the Dutch government that the Care Needs Assessment Centre—part of what prompted Jos to found Buurtzorg in the first place—was undermining effective care rather than enabling it. The pilot was very successful, resulting first in the exemption of Buurtzorg from CNAC practices and oversight and, ultimately, in the government’s decision to wind down CNAC altogether.

Expanding Buurtzorg Domestically

As Buurtzorg’s nursing model continued to grow and mature in the 2010s, a frequent question emerged: where else might the model apply? Buurtzorg began investing in other areas within the larger market for client care, including domestic help, mental health care, maternity care, child care, assisted living care, hospice, and holiday care (see Exhibit 12). The first investment, in 2009, was Buurtdiensten—a company of small neighborhood teams providing domestic help (of which elderly people in the Netherlands were entitled to 1.5 hours per week without copayment), including shopping, cleaning, and cooking. By 2022, Buurtdiensten had almost 4,000 employees, in part because Buurtzorg had formed an agreement with the government in 2015 to take over part of a failing Dutch company, TSN, which Buurtzorg renamed Familiehulp. Buurtzorg then transformed Familiehulp into a self-managed organization before formally integrating it into Buurtdiensten in 2020. Despite such a significant change from Familienhulp’s hierarchical operating model, the acquisition was a success. (p. 8)

Expanding Buurtzorg Internationally

Buurtzorg had also extended its model outside the Netherlands (see Exhibit 13), partnering with other organizations with varying success. Buurtzorg teams had launched in more than two dozen countries, including Sweden, Germany, China, Brazil, and Australia. However, replicating the organization’s culture of autonomy and independence sometimes proved very difficult. For Buurtzorg Brazil, for example, “the main challenge was how to train people and change their minds,” said Martha Oliveira, executive director. “This type of responsibility isn’t something everyone wants to have. Still, after a year, we saw so much change in our teams. We said, ‘It’s possible.’” Iohanna Salla, the first nurse to use the Buurtzorg model in Brazil, agreed. “The hardest part is the change in mental model. [Nurses here] are used to a hierarchical model with the doctor as boss. This is very different.” There were concerns about brand reputation when launching a Buurtzorg team in a new country. “We can’t expand into a new country unless we are working with a partner that we completely trust,” said Thijs. It could take longer to find out if an international team was having a problem and the means of addressing it often were not the same as in the Netherlands. (pp. 8 & 9)

Learning and Evolution at Buurtzorg

Even as Buurtzorg explored domestic and international options for applying its operating model, it wanted to keep improving that model in Dutch neighborhood nursing. Good ideas could emerge from any nurse or nurse team, the back office, or Ecare. Different organizational learning mechanisms had emerged as teams sought opportunities and/or solutions to problems and as they shared their knowledge. Jos said, “How can we make a nursing team’s growth bubble out to others?” (p. 9)


Some projects followed nurses’ initiatives. For instance, Els Schopman, a nurse in Almelo, experimented with building a “vitality club” in her area; that is, a social group that allowed people to walk and exercise together, chat, and share meals. She had seen doctors from the Leyden Academy for Vitality and Wellness promote the concept. “I have 42 people in our group and they meet once a week,” she said. “The youngest is 49 and the oldest is 89. They just move and have fun.” While some other nursing teams adopted this idea for themselves per Els’s suggestion, others were not receptive, which frustrated her. “Some people said, ‘It’s all very wonderful what you do, but I am not interested, I just want to do my own work,’” she said. “I put it on BuurtzorgWeb, but didn’t get too many responses. Most people just focus on their core work.” (p. 10)

- Buurtzorg, Harvard, October 20, 2022 (Original source pdf - html)


'..I believe in responsibility but not in pyramidal hierarchy .. the negative value of structure. Structure creates hierarchy, and hierarchy creates constraint..'

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