Buurtzorg and the power of self-managed teams of nurses

Lisa Gill: I'm super excited about this episode because I got the chance to spend an afternoon talking to three nurses from Buurtzorg in Houten, just outside of Amsterdam. Buurtzorg is an organisation in the Netherlands that delivers care in patients homes. It was founded by Jos de Blok, who was himself, formerly a nurse. And he was really frustrated with how mechanistic the healthcare system had become and turning patients into numbers and dehumanising them. So he started Buurtzorg, because he wanted to create a business model where teams of highly skilled nurses could control everything from their budget to their schedules, to what services they offered, all in service of helping patients lead more autonomous and fulfilling lives.

So today, there are some 15,000 nurses, and they're split into around 1,000, self managing teams supported by coaches. It's a business model that's inspired people all over the world, because it's achieved incredible cost savings. And patients and employees, of course love it because the relationship and the quality of care is much better. And employees feel like they can do meaningful work again, and they can be human again. So I've seen Jos speak a few times at conferences, and he's very charismatic and he talks about making things really simple and explains the business model. But it's quite another thing to hear it from the nurses themselves, the people on the frontline, and what it really feels like to work in a self-managing organisation.

So it was an absolute dream to find myself in the garden of Marian's lovely house, sitting having a cup of tea with two of her colleagues, Chila and Yolanda, and talking about what it was like for her to start the first Houten team. They talked about the transition from working in a large, traditional, top-down, hierarchical healthcare company, to suddenly being responsible for starting a new team from scratch and finding patients and deciding how they were going to do things. And now the Houten team has been running for more than ten years (they've since split into multiple teams). So it's really interesting to hear all of the insights and all of what they've learned over the years about communicating, giving each other feedback, what's really rewarding, what's really challenging. And I think probably my favourite bit is when I asked them at the end, what advice they would give to people who are interested in working in a self-managing way, especially managers or CEOs. And the advice they give is just priceless. It's brilliant. So it's an absolute pleasure to share this conversation with you. Here's me talking to Marian, who you'll hear first in the conversation; and Chila (you'll know her because she often chips into help the other two with their English make a joke – she's got a brilliant sense of humour); and Yolanda. And they are three nurses from Buurtzorg. So I hope you enjoy. Here's our conversation.

So Marian, you came across Buurtzorg and invited Jos de Blok here, to your house. How did you how did you find Buurtzorg?

Marian: I was working in another organisation and heard some people had started [a Buurtzorg team] in Utrecht. I went to see how they work and I got really enthusiastic and I was thinking "this is what I want to do!" Because I like my profession. So we did that. And it was a nice meeting here. A little bit strange here, having the director in your house, but it was...

Chila: Cosy! [Laughter] He's very normal and friendly and quiet and he just told us how it is. You thought: "Wow! Is that possible? You know, for work [to be] like that?" We didn't believe it, actually.

Marian: We were thinking "let's start!". We began with a few colleagues wanted to join us. I think we were five?

Jolanda: At first we started with four, but after a month Sheila joined. And then we were six. And now there are three teams in in Houten.

Marian: And what we had to do was look for a location. I spent the money for a location. We found it together and made our home, I think! Yeah, that was nice to do. A lot of fun. And then you have a laptop. And then you start! Together we were going to the hospitals to say that we are starting [a team] in Houten. And the patients started coming.

Chila: A few people from our old organisation wanted to come with us because we all left, six or so of us. And some patients were very panicky, "Oh, where are you going? And I want to go with you!" Yeah, so we had a few patients. And then the rest came through hospitals and doctors.

Jolanda: But we were very nervous to start with because you're doing the same job, but for yourself. It's your own shop. So you have to do a very good job, and we had to build a name here in Houten, that we provide good care.

Marian: So it's really very responsible. In the beginning I think we were thinking about it 24-7. It was a little bit heavy sometimes. But we have a lot of fun. And we like each other. Now it's family for us.

Lisa Gill: So you said it was kind of challenging and different? Because suddenly you were totally responsible for starting this up and everything. So how else is it different to the previous big organisation you worked for? If you were describing how it is to work at Buurtzorg to other people, compared to you know, more traditional healthcare companies?

Marian: You have more time for patients...

Chila: Communication is much easier. When patients tried to reach us, it was a big organisation, so they get a call centre, and they have to tell their story over and over again. And then nobody knows. But with us, we have one number. The patient calls. We know the patient. We all know everything. So that's a very big difference.

Marian: Yes and the planning you do on your own. And when a patient needs more time, then you make the plan bigger. We have enough time.

Chila: It's nice to work here and it's nice to be a patient here. Those are the biggest differences.

Jolanda: We are all from a higher level [of qualified nurses] so we all know what to do and we all have the know-how.

Marian: Because you are a professional. We've worked for a lot of years. We know what we have to do. In a bigger organisation, THEY say what you must do but WE know what we CAN do.

Chila: And that's also the philosophy of Jos: as professionals, if you let them do their thing, it will be okay. That's what he does. And that's true.

Marian: And you speak a lot with each other...

Chila: Yeah, there is a good communication in the teams.

Marian: We give each other feedback.

Chila: That's also a problem sometimes in the self-leadership thing. Because if you cannot do that in a team, if it's not safe enough to talk with each other about mistakes or problems or whatever, then you can end up with very big problems.

Lisa Gill: So how do you do that? Have you learned something about how to create that safety in a team so that that communication happens?

Jolanda: Yeah, well, we, we have a course, a training on how to do that. But it's also the feeling of how to communicate with each other. We've known each other a very long time. But with new people, you have to have to have the feeling that they belong with us. Because we have made a mistake with someone in the past and it didn't feel right but we wanted to give her a chance.

Chila: But it didn't work out very well so we learned from that!

Lisa Gill: So how did you handle that? How did you deal with discussing that it wasn't quite working out? Did you ask her to leave? How does that work?

Marian: We asked our team coach: how can we do this? And eventually we found another job for her.

Lisa Gill: You helped her find a different job?

Chila: Yeah it was not good for her. You are very alone with the patients all the time, whereas she needed to be in a team team, like on a ward or something. And in her new job she does very well.

Marian: We were all thinking: "What can we do for her? What's possible?"

Jolanda: It was for two years on our list, and it cost money.

Chila: She was also depressive and so it was quite complicated. But we have our team coach. If it's too complicated for us and you don't know what to do, or you have legal problems, or with the police or something, or whatever, you can call the coach, and she helps.

Lisa Gill: So how did the coach help in this instance? What support did they give you in terms of having conversations with this woman?

Chila: At a certain point, she took over and had conversations and filled out the illness report - it became too big.

Lisa Gill: What other sort of challenges or difficulties have you had in the team and how have you overcome them?

Chila: Production is a challenge.

Lisa Gill: In what way? What do you mean by production?

Chila: You have to have enough clients to get enough money. Because only clients generate money. But if you work in your office, or you're sick or on holiday, it's unproductive time, and there's no money for the company.

Lisa Gill: Ah, like productivity.

Chila: Yeah. So that's always a challenge, because you have the holidays, and you have to go to courses and people get sick, and you have to go to the office. But [the organisation] wants about 60% , 61% productivity. So it's always challenging to get that right.

Lisa Gill: Do you bring that up as a team? You know, when there's an issue, or when you think something is not working out? Is it easy to bring those things up and work on it together?

Chila: Yeah, when we're in a meeting, we discuss things and ask: What can we do? Or we ask the coach.

Jolanda: Well, we have a day of work: we start at eight and we end at four. And then you have several hours where you have no clients from 12 to three, three hours. And when we don't do anything for Buurtzorg, we cannot write them down. So it's very difficult to get enough hours to work. Yeah, but there are several people who have different tasks. So planning the clients or planning the people who have to work. So we all have different roles. So you can make office hours, but not so much as we have three hours in the afternoon.

Lisa Gill: And do you ever have conflict in the team? Like something going on between two people, like a dynamic or something? And if so how do you handle that?

Chila: We sometimes have had some of those things. You have to talk about it. You have to. It's Buurtzorg policy. And if you cannot work it out, you call the coach, and then there has to be a solution sooner or later. So we do that. Sometimes it's difficult, but most of time we manage. And it's been ten years, so...

Jolanda: But there are a lot of teams that have a lot of problems.

Chila: Yes, of course, it is difficult.

Marian: It's not possible that you have any one leader, everyone is the same. And when there is in a team a leader, then you have a problem. And when you have only busy people, then you have big problems. It's good to have a balance between people who are busy or quiet, and no leader.

Chila: For some people, that's very difficult. They want to control, they have to let go, you have to put it on the table and then everybody can say something and everybody is equal. And then you have to have a consensus. And when one person does not agree with something, you cannot do it.

Lisa Gill: So how do you make decisions, then?

Jolanda: We talk a lot about it and sometimes there are two or three people that see it another way. So then we decide not to do it. Because when some people have good reasons why they don't want it, then we decide to follow.

Chila: It's not like we're going to put some water in the wine! [Laughter]

Jolanda: It's all about communication.

Chila: And when you have a good team and you feel safe, then you always have a solution.

Lisa Gill: It sounds like there's a lot of personal development.

Jolanda: Yes, yes. And you can decide what you want to do with your team. So you can ask someone to come and give a training.

Chila: Or you say to a colleague "you're not good at that. It's best if you go do some training," we will also do that. I'll have some personal training because this and that is a problem...

Marian: And everyone likes to do different things. Some people like theory, others like other things. So you have different skills in your team.

Jolanda: And Buurtzorg is also very far ahead in terms of the digital stuff, with planning for example. We have a very good ICT system.

Lisa Gill: Tell me about that. How does that support you, the IT system? Because I understand it's quite key to having self-managing teams at Buurtzorg.

Chila: Because it makes everything very simple. You can find everything. So for one client, you can order stuff for the client or materials for the wound or bed or whatever. So if you have the client in the system, then everything hangs on that client. So you don't have to fill any forms or make a lot of phone calls or whatever. So it makes it very easy. And a nursing plan. We make the plans. One time you have to invest in making a good plan and then everybody can see what you have to do, and you can change it very easily.

Jolanda: Yeah, but it took a lot of time to learn it in the beginning.

Chila: We're all very old! [Laughter]

Jolanda: But when you are together, you have to learn it together. So you can help each other. That's very nice. Chila is very good at it.

Chila: It makes it very transparent and quick to work. That's the most supporting thing.

Marian: You never feel alone.

Jolanda: And you can also always call Almelo, where the headquarters is.

Chila: Yeah, there's very good support, I think, from Almelo for everything... administration things or when you want something special or one colleague, she wanted a month free to get a bit more relaxed. And then she could turn her contract from 28 hours to eight. And then she had four times eight hours holiday, and she was free for a month. And that's possible.

Marian: Almost everything is possible. There are so many solutions.

Jolanda: And they are thinking with you. Not FOR you but WITH you.

Chila: Mmm... no one is above you.

Lisa Gill: So say some more about that because I've heard a lot about how Buurtzorg evolves in a very collaborative way. It's not like Jos has a grand idea and then everything follows. It's very transparent and sharing ideas...

Chila: Anyone with a good idea can post the idea on the web. We have a sort of Facebook for Buurtzorg, and then they put their idea there and people like it...

Jolanda: You could bring in a project. For example, a few years ago we had a special lady who oversaw projects. There were 100 projects from all over the country that you could sign in, if you had a good idea, and you got some money to try to develop it. So we have a walker race. You know, people who walk with [walking aids]? We have a race in Amsterdam in the Olympic Stadium every year.

Marian: A man in his nineties won!

Jolanda: And Radio 'Steunkousen'. 'Steunkousen' are the supporting stockings. So they have a radio programme in Amsterdam for Buurtzorg.

Chila: No, but Jos is also there. If Jos also has an idea, he puts it on the web and then he asked for comments. And everybody comments "I think this, I think that" and then he takes everything into account and then he goes on. So he's not a dictator. No. Absolutely not. He is very democratic. Everybody's equal. And everybody gets a share.

Jolanda: Everyone is on the same salary...

Chila: Jos has a slightly larger salary, but he works about 300 hours in a week so, that's good for him! [Laughter]

Jolanda: That's also the danger for us. In the beginning, we worked and worked and worked and it was always on our mind. Because you have to do it very well. You feel that.

Marian: Yeah. The responsibility.

Chila: It feels like your own business.

Marian: But there were times when your colleagues said to you, "It's alright, we can do it."

Jolanda: We can take over. You don't have to worry.

Marian: In the beginning you feel it so much.

Jolanda: Yeah, because we started it.

Marian: And it's alright that the others say, "Hey, you are not the boss here."

Lisa Gill: So how did that shift? Did you find ways of becoming less anxious or new ways of making sure that you weren't working too much or too hard? How did you overcome that?

Marian: You say it to each other. The others say, "Oh, I can do something for you." We take care of each other. Sometimes we say to a colleague "maybe you do too much." That's how you take care.

Jolanda: Yeah. You take take of each other.

Marian: You know each other very well.

Jolanda: Yeah. But in the beginning, it was hard. The first two years.

Lisa Gill: Do you guys give each other feedback in the team? Is that something you do?

Chila: Yeah, always. Sometimes too much!

Jolanda: Sometimes you cry!

Chila: "I didn't mean to do that!" [Mimics crying. They all laugh] But that's good. Sometimes it's hilarious.

Jolanda: It's finding a way of how to say something. It's also a communication that's very important.

Marian: You must do that.

Lisa Gill: Did you always do that from the beginning? Or was it something that you had to learn and practice?

Chila: Oh, we always did it but not always in the right way! We had to learn to do it the right way.

Lisa Gill: And what is a right way? Or a good way of giving feedback?

Chila: Gentle but clear. And sometimes somebody is so gentle that the other person doesn't get the message. So you have to get the... It's quite difficult. And there's no boss. Normally, you go to your boss, [and complain about someone] and then your boss solves the problem. But you cannot do that. So you have to do it yourself! [Laughter]

Jolanda: So it's also a lot of self development. You learn a lot. You have to.

Marian: But it's nice. We like it all!

Lisa Gill: So nine years, then. How have things changed? Have you noticed big changes? How are things different now?

Chila: It's bigger. And Jos has a lot of extra things like Buurtzorg in foreign countries, so he's busy with all sorts of things, all sorts of groups, and

Jolanda: Jos isn't coming to our homes now anymore!

Chila: No it's not possible now, but the concept is still the same.

Jolanda: We're working with iPads now. That was a big change. Very good. But a big change was also when we became big. We had 16 people in our team. It was too big. You have to have [no more than] 12. So we had to split. And that was a very difficult period. Who moves to the other team and so on. And what was a very hard time.

Lisa Gill: Yeah. Was it like splitting up the family?

Marian: Yeah! [Laughter] Yeah. And now we are three...

Chila: In the beginning it was not very hard. Right? We took people from a nearby village. We took them just for that team. And then when it was okay, they left. That was okay. But the second time we were just one team ane we had to split in two. That was pretty hard. Yes.

Lisa Gill: So what what advice would you give to people listening who are in organisations, maybe not even healthcare, maybe they're in an IT company and they're inspired by Buurtzorg and they want to work in a more self-managed way. What advice would you give them about how to make it work?

Chila: Communicate.

Marian: Yeah. And no leadership. Everyone has same responsibility,

Chila: And honesty. Trust. Transparency. Safety. If you have that together, you can do it.

Marian: Everyone has their qualities and uses them. Nobody is more than the other.

Jolanda: You can get more quality out of a person when you are a team. You can get more out of person.

Marian: Yeah, stimulating each other.

Chila: And if you're more responsible, you want to do more, your best. If your boss says you have to do that, you think "F**k you!" [Laughter] But if people in your team say "Oh you do that so well. Will you do this?" you say "Yeah!" That's a big difference.

Lisa Gill: And what about for people listening who are owners of a company or founders or CEOs? What advice would you give to

Chila: Let go! [Laughter]

Marian: Trust.

Chila: Trust. That's what Jos does.

Jolanda: He gives trust, "You can do it." And you do what you have to do.

Chila: And goodbye.

Jolanda: And what you think you have to do.

Marian: Coach. Only coach.

Jolanda: And listen to the people who say, you can do it better. They are from the working floor.

Chila: Yeah. They know best, actually.

Marian: Listen very well.

Jolanda: Yeah, you don't need a manager. [Laughter]

Chila: No, we really don't need a manager.

Marian: We have had in the other organisation so many managers.

Chila: They were only a pain in the ass. Sorry!

Lisa Gill: No, I love it! [Laughing] It's great.

Chila: You can go edit it.

Jolanda: You get progression of learning how you have to deal with problems. And you find out things that you didn't think you could do.

Marian: And you stimulate each other. "You can do it! Go for it!"

Chila: And if one person cannot do it, another one can.

Marian: Yeah.

Chila: So if you don't like it, or you cannot do it, then you don't. Somebody else does. Together you are strong.

Jolanda: But you have to feel it and must want. And that's maybe a bit difficult to begin with. And to think differently, that's difficult.

Chila: I don't think everybody is capable or wants to be like that. Some people want a boss who says "You do that, you go there at that time, and bla bla bla." And then they feel safe. If they have to think for themselves, they don't like it.

Jolanda: We also had in the other team one person [like that]. She left, she couldn't do this. She needed leadership.

Lisa Gill: And would you like to see this way of working spreading around the world?

Jolanda: Yeah, absolutely. It's much better for the patients. And for us.

Chila: Yeah, it's better for everyone.

Jolanda: But you also have to take care of not to burnout because illness in Buurtzorg is high. So there are, I guess, a lot of people who feel too responsible. They cannot let it go. So that's also what you have to learn.

Lisa Gill: Yeah, it can be a shadow side of being really committed and passionate, where you work too hard. So how is Buurtzorg dealing with that? As an organisation, are you finding ways to address that and support people who are burning out?

Jolanda: Yeah, well the coaches do that.

Chila: And Jos has all sorts of ideas about sports, and keeping an eye on each other. And all sorts of tips he gives about what you can do to prevent to prevent illness.

Marian: He writes on the web [blog] how we can do this.

Jolanda: But there are also a lot of difficult things. We lost a colleague a few months ago, and she was from our 'family'. And those are very hard things to handle.

Lisa Gill: Mmmm. So is there anything else that you would like to share with the world if you if you would wish to, you know, spread some wisdom? Or what else would you like people to know about Buurtzorg or about this way of working?

Jolanda: Trust yourself that you can do it.

Chila: Yeah, I think it's possible anywhere, in any company. If you let the professionals do their thing together, if you support that in the right way, you don't need any manager, anywhere. I really believe that. We can do it so everybody can do it!

Jolanda: But it's also nice to have a coach. That's different to a manager. They support you. They don't say you have to do this or that. But they support you. And that's what you need. No leadership.

Marian: Never!

Lisa Gill: It's interesting that distinction between a manager and a coach, how different that is...

Chila: Yeah, the coach is equal to us. Not above us. She asks, "What do you want for the team?" And then she does it. She doesn't say "You have to do this." She asks, "What do you want?" And then she looks with, she walks along with you to solve the problem together.

Jolanda: She's also a very nice person. We got a voucher to buy flowers, because we lost our colleague. And we had a hard time. So she came by and she brought us that. But she also has many difficulties in teams to solve. And sometimes they are not to be solved because there are people who don't see that they don't belong there. They want to be a leader and it doesn't work.

Lisa Gill: And then what happens?

Jolanda: Uh, they still have the problems. And it would be nice if that person who has the problem would leave. And sometimes they go away. It has to, to make a team work. But they have to see it by themselves, you cannot say "you have to leave."

Lisa Gill: So is it always the case then that people choose to leave? They're never asked to leave or fired?

Chila: Fired? I don't know about that. No, I never heard that. No. You always try to solve it or the person leaves because they cannot work here. I've never head of someone, somewhere being fired. I don't think that's possible.

Marian: Maybe if you start making the same, many mistakes?

Chila: Jos always tries to solve things. He doesn't want to [dictate]. Fire? I never heard of it happening.

Marian: It couldn't be worse in other organisations.

Jolanda: What do you think? [About this conversation]

Lisa Gill: I think it's great. This is like, better than I even imagined it would be. It's like a dream sitting here.

Marian: Really?! [Laughing] For us it's so normal.

Chila: It sometimes feels like working in a dream. Sometimes when I'm not satisfied, I don't want to work and this and that, and I think about the past, my other [previous] organisation and I think, "I'm in heaven." Really.

Lisa Gill: I left Marion's house that afternoon in quite a haze. I think I was on cloud nine, really. Nothing is more inspiring to me, or emboldening, than hearing real stories and getting a sense of what's possible when you work like this, the difference that it makes. And with all of our ageing populations and the constant pressure to make cuts in the public sector, perhaps we'll see many more Buurtzorg-inspired examples popping up like Helen Sanderson's Wellbeing Teams in England, or Cornerstone, the social care company in Scotland. If you haven't heard those Leadermorphosis episodes, I really recommend them. I've put the links in the episode description on the website. It's interesting, the advice the ladies give about no leadership. I can't be sure if that's just a language thing. Maybe they meant no management, you know, the kind of stereotypical top-down behaviours that we associate with managers anyway. In any case, I think my interpretation, or maybe my belief in general is that there is leadership in self-managing teams, but it's a chosen kind of leadership. It's a leadership where we all step into our own authority in different ways and it's dynamic. Its leaderful, I think.