Building a Company Based on Autonomy and Trust: Interview with Buurtzorg Founder and CEO, Jos de Blok
This week’s interview is with Jos de Blok, the founder and CEO of Buurtzorg, a Dutch healthcare organization that provides neighborhood nursing care throughout the Netherlands.
I was inspired to reach out to Jos after reading about the company in Frederic Laloux’s book, Reinventing Organizations. Like many of us, Laloux felt that many of today’s organizational practices are broken but wasn’t sure what an alternative would look like. His research uncovered an alternative in the form of real organizations, including Buurtzorg, that were already successfully operating in a different way (hint: no executive teams, everyone in the organization has the power to make decisions, workers able to self-manage in groups vs report to middle managers). Laloux’s research and Buurtzorg’s approach felt like a “No Directions” approach to company building; a topic that I hope to explore more in this blog.
This week’s piece is broken down into two parts:
Part I is a brief overview of Buurtzorg, the organizational practices that make it unique, and the successful outcomes that have resulted from the approach
Part 2 is the interview with Jos. We spoke about:
How his role differs from the traditional CEO role
What it means to get back to normal and design organizations that feel more human
The benefits of Buurtzorg’s model during Covid
What it’s like to run a “no decisions” organization with the advice process
The new organizational approaches he’s excited to be working on next
Note: The following interview has been lightly edited for clarity and length. While every effort has been made to preserve the integrity of the conversation, please be aware that the quotes may not be verbatim but reflect the essence of the dialogue.
Part I: Overview of Buurtzorg
Buurtzorg was founded in 2006 by de Blok and a small team of nurses in response to conditions they felt were undermining the relationship between patients and nurses, driving inefficiency, worsening outcomes, and skyrocketing healthcare costs within the Dutch healthcare system.
Jos believed that costs could be lowered and patient outcomes improved by focusing on professional ethics, giving workers more autonomy, and building a company based on an inherent trust of nurses. He hypothesized that by focusing on continuity of care and giving nurses the opportunity to have ownership over solving problems in their neighborhoods, that the nurses would default to using their capacity in an optimal way. In doing so, he believed that Buurtzorg would have a greater ability to measure outcomes, understand what interventions were truly needed, and create a continuous learning environment where the level of care would improve each year.
These assumptions led to a drastically different organizational model.
No executive team: Buurtzorg has a CEO but no executive team. The organization is divided into self-organizing teams of no more than 12 nurses. There are no layers of middle management between Jos de Blok (the CEO) and the nurses.
Self-managing teams: To ensure financial stability, teams must spend at least 62% of their time on billable patient care. To that end, self-organizing teams are responsible for everything that was previously fragmented across departments in the old model. They are responsible for providing care, deciding how many and which patients to serve, intake, planning, scheduling vacations, deciding how tasks will be distributed, monitoring their performance and undertaking corrective action when needed, as well as evaluating themselves each year with a competency framework they devise themselves.
Limited centralized staff functions: Because each team is responsible for most of its functions, there are limited centralized staff functions at Buurtzorg and very little administrative overhead. Examples of centralized functions include lease contracting and IT. When these functions do exist, they have no decision-making authority over teams.
Nurses are the experts: When expertise is needed, Buurtzorg largely relies on nurses building up expertise themselves and becoming contact points on their team. Nurses can find a list of nurses with expertise in their geographic area on Buurtzorg’s internal site. Occasionally, task forces are set up to investigate a new topic and build expertise across the company.
The advice process: Decisions are made using the advice process. In his book, Reinventing Organizations, Frederic Laloux describes how it works, “...any person in the organization can make a decision. But before doing so, that person must seek advice from all affected parties and people with expertise on the matter. The person is under no obligation to integrate any piece of advice; the point is not to achieve a watered down compromise that accommodates everybody’s wishes. But advice must be sought and taken into serious consideration. The bigger the decision, the wider the one must be cast — including, when necessary, the CEO or the board of directors.” Importantly, the CEO also has to engage in the advice process and cannot make decisions unilaterally.
Teams are responsible for their own problem-solving: Teams are tasked with finding solutions to their own problems and are extensively trained in a method called “Solution Driven Methods of Interaction” which focuses on promoting skills and techniques that lead to healthy and efficient group decision-making.
As Laloux writes in Reinventing Organizations, “Nurses can’t offload these difficult decisions to a boss, and when things get tense, stressful or unpleasant, there is no boss and no structure to blame; the teams know they have all the power and latitude to solve their problems.”
Regional coaches vs middle management: When teams find themselves stuck, they can reach out to Buurtzorg’s network of coaches. Importantly, coaches have no decision-making power over teams. Their role is to ask insightful questions that help teams find their own solutions, as well as share best practices from across the organization.
Needless to say, the model has worked:
Buurtzorg has grown from one team to over 15,000 nurses operating across 950+ self-managing teams.
In contrast to their competitors:
Buurtzorg nurses spend 40% fewer weekly hours per client.
Buurzorg patients spend 50% fewer days in care and have 33% fewer hospital admissions.
Buurtzorg operates with 67% less administrative overhead costs.
In addition to their incredibly successful patient outcomes and efficiency metrics, Buurtzorg is profitable, generates over €400 million in annual revenue, and sees over 80,000 patients each year.
Part II: Interview with Jos de Blok
How would you describe your role at Buurtzorg? How is it different from a traditional CEO role?
I think it's very different. As the CEO and founder, I developed an organizational concept as well as a concept for healthcare delivery based on my own experience as a nurse. My idea was that nurses should have as much autonomy as possible in their daily work and should work together in self-organized teams. That design has a big impact on my role. Normally, the CEO makes policies that have a big impact on everyone in the organization. In my role, I don’t write strategy or policy notes. We don't have a management team. We come together in groups if needed.
As CEO, I don’t follow a structured agenda. My calendar is not full of meetings, although I will do things like give interviews, talk about the ideas I’ve developed, and meet with teams if they are running into problems. I do focus a lot on making agreements with the health insurers. I feel responsible for the overall health of the people doing the boots on the ground work and ensuring conditions that lead to high quality work and good financial results for the company as a whole.
What was it like for you to get comfortable with the model of self-management as a leader? What do you believe leaders looking to make the switch have to get comfortable with?
I always say to act the same way you might at home which is to say: be normal. As Laloux talks about in Reinventing Organizations, management and hierarchical structures aren’t really normal. We built them in the 20th century and we’ve come to see them as normal, but there are many ways to organize. My idea is that organizations should be serving the community and serving the people who are working there. I think a normal and humble attitude is what works best. I love it when nurses come in and say to me, “You are one of us.”
I listened to an interview of yours where you mentioned that you believe that leadership training can sometimes do more harm than good and spoke about the importance of dialogue and speaking in a language that reflects who people really are, what motivates them, and how they approach their work. Can you talk more about why you are skeptical of traditional leadership training?
You say the word traditional, but I don’t think there’s anything traditional about leadership training. If you go back some centuries to the traditions of native people then traditional means something very different. Leadership was based on authority. People might have said, “You are a very good team member. We have respect for you because you have shown who you are through your actions.” If you were good at something, you were seen as a leader. Nowadays, people go get a management education, get a management role, and then take courses in leadership. In my opinion, those courses have nothing to do with leadership. In hierarchical systems, it’s become better to say that you are a “leader” instead of a manager. I think a lot of it is bullshit. I see all these leadership courses as part of a society that is ending and don't think this whole paradigm of management and leadership will exist in 20 years. We need co-operative networks where people can hold different roles and be in flexible roles. For example, a Japanese professor, Ikujiro Nonaka, has written a lot about knowledge management and “distributed leadership,” the idea that everyone can be a leader of their own work. They can be an expert on one topic and a professional on another. People have to be able to support each other with natural, organic mechanisms.
It reminds me of what Laloux said about the idea of “empowering people” in organizations. He contends that type of language is emblematic of the problems with existing hierarchical management systems because the language suggests that power has to be given to people versus everyone being powerful in a system that supports natural, flexible hierarchies based on areas of demonstrated expertise.
It’s very arrogant to think that you are the one who can give power. I always say that you can take away power and autonomy but you can’t give it to people. I think we create organizations that make people powerless and take away autonomy. We then have to do all kinds of things with HR to give them power and field ownership. I think we are at the end of that management paradigm.
Covid was a challenging time for businesses all around the world, particularly in healthcare. What did you see were some of the benefits of Buurtzorg’s approach during Covid relative to more traditional top-down, hierarchical approaches?
I think covid helped demonstrate just how flexible our networks are. We used the first teams that were confronted with treating covid in the south of the Netherlands, as well as some of our partners in China, to create a crisis team for different disciplines that the organization could continuously learn from every few days. We split the covid routes from the other routes and made a special covid team so that we weren’t transferring the virus to vulnerable people.
We saw other organizations throwing out protocols in a way that seemed to paralyze their organizations. People said, “When we see these nurses at Buurtzorg they just act and do and feel a personal responsibility to do things themselves based on their professional background.”
Buurtzorg’s model is built upon an inherent trust of nurses and the company’s employees to be responsible, learn, and do what’s right. What have you learned about building trust in an organization and keeping that trust alive?
I think it starts when you grow up in a safe environment and you learn as a worldview that you can trust people. Because of the way I grew up, it was strange to me not to trust people. The lack of trust has grown throughout the years based on these mechanisms of control; all these ideas about controlling people and creating more efficiency. All these mechanisms are very threatening and create very unhealthy and unhappy situations in work environments. My thinking is that trust should be natural and normal. I don't know any nurse or doctor who wakes up in the morning and says, “I'm going to do my work in a terrible way today.” People want to have a good life and do their work in a good way. You have to show trust in your daily behavior. Sometimes I talk to teams who want to build trust and yet have all kinds of protocols that contradict the idea of trust.
You have to have a dialogue with people. How do you perceive your daily work? What are the concerns? What are the problems? How can we work together to move forward? Sometimes things do happen where things don’t go as planned, but I don’t think that has to be a reason to make a new protocol.
The advice process is a very unique process for decision making. What do you think are the benefits of this method vs concentrating decision-making authority on the executive team and making decisions via a top-down process?
I think we make this whole idea about decision making much too important. I think it’s become a very American thing to think that the world depends on our decision making process. What we do at Buurtzorg is build on the wisdom of the people who are working, their foundation of professional ethics about the right things to do, and the information and knowledge they exchange with each other. So we haven’t really focused on the decision making process, we’ve focused on solutions. Use your energy and ideas to find out what is needed. Ask your colleagues: What’s happening? What’s the best way to move forward? Treat it simply like you would at home. You don’t sit at the dinner table at home with your family and ask: What’s our decision making process here? We make all these things too important.
I try to make it organic. When we encounter a problem, I’ll say to a nurse with twenty years of experience: How would you approach this? Now we have an alternative idea. Then there’s probably someone else who has another idea that we can combine theirs with. We’ll try it out. If it doesn’t work, we’ll try something else. We are almost a decision free organization.
What’s important is that someone is a good nurse and that they understand the physiology, the pathology, the patterns that people have, and the symptoms that people can have from certain diseases, and are able to act on what they see. Looking at what’s important to execute your profession as well as possible is more important than all these other things.
A Belgian philosopher wrote a book called, Authority, where he showed that since the 70s there has been an authority shift from professional people toward management. Before that, you had doctors who had authority because of their skills as doctors. Now doctors are managed. We lost a lot of wisdom and organizational talents by looking at the world from a top-down management perspective.
This blog was founded on the belief that there are endless ways to live, work, and build companies. Are there any unconventional or new ideas you have about ways to manage an organization that you are curious to explore next at Buurtzorg?
I’m now working with 15 competitors. I said, “If you want to change the healthcare system in the country. We have to work together.” So I invited them into a plan I call “Neighborhoods and Ecosystems.” I said, “We are going to start again in defining what the real problems are and how we’re going to solve them. We are going to work with communities in the communities.” This program is actually being funded by the government. We are going to build a new healthcare standard for the next 5-10 years and an example that shows how you can move from a competitive model to a cooperative model.
If you are interested in learning more about any of the concepts and ideas discussed today, below are a few places to dive in:
Reinventing Organizations by Frederic Laloux
The Big Idea: The Wise Leader by Ikujio Nonaka and Hirotaka Takeuchi from the Harvard Business Review