A systematic overview of the literature in English on Buurtzorg Nederland: Part B — The Buurtzorg Organisational and Operational Model

Introduction

This paper advances the attempt for a systematic overview of the English-language record on Buurtzorg. Part A (available here) attempted to summarise the evidence on Buurtzorg’s performance as a health and social care organisation. This paper attempts to do the same for the organisational and operational model of Buurtzorg Nederland. Section A presents and describes the main components of Buurtzorg’s organisational structure while Section B offers accounts of working processes of self-management teams and in particular those of: decision-making, team meetings, rostering, expertise and specialisation in teams of generalists, peer coaching, forced dismissals and decision-making across teams.

Section A — Organisational configuration

Buurtzorg’s organisational structure is simple and flat with no middle management layers, no departmentalisation, minimal back-office functions and minimal employee monitoring and controlling functions. Home care employees are organised in independent, autonomous, self-managing teams with no team leaders and under no line-managerial direction or control. Buurtzorg’s organisational structure is depicted diagrammatically in Figure 1 below.

Figure 1: Simplified organisational chart for Buurtzorg Nederland. The chart omits the Clients’ Council, the Workers’ Council and the foundation’s management board

It is very simple with no intervening layers between the directors and the independent, self-managing home-care teams. The range of job roles is limited. In addition to the nursing teams which are comprised of nurses and nursing assistants (for details of their composition in terms of educational qualifications please see Table 8 of Part A) and the two directors, the remaining job roles are those of coaches and ‘back office’ business support roles in the organisation’s headquarters in the town of Almelo in eastern Netherlands. In Figure 1, the two close partners of Buurtzorg are also included: Ecare services which was also started by the founders of Buurtzorg to create, maintain and develop the IT systems used by Buurtzorg; and, Instituut voor Samenwerkingsvraagstukken (IVS — The Institute for Cooperative Issues, http://ivs-opleidingen.nl/) in Groesbeek, Netherlands which has been an important partner of Buurtzorg in providing training and coaching on self-management to its home care teams. Buurtzorg’s organisational structure is not departmentalised. As such there are no marketing and communications, human resources, strategic planning or finance departments organised in a hierarchical way. The ‘back-office’ functions comprise: reception staff, rental office administration, payroll, personnel, accounting, client administration, logistics, assessment and intake, and Ecare Helpdesk (Nandram 2015).

The self-managing home care teams

The home care teams do not operate under the supervision, instruction or direction of the directors, the regional coaches or the ‘back office’ staff. They are operationally autonomous and self-governing. The scope of their responsibilities includes:

• Finding, equipping and decorating (there is no centrally imposed branding requirements) office accommodation as the base of their operations. There is a centrally imposed limit on the cost of rented accommodation. Rental costs cannot exceed 1% of average team turnover. IT hardware (desktop and laptop computers, routers, WiFi, iPads, mobile phone SIM cards) and software (including iPad and mobile phone applications) are provided centrally.
• Hiring and firing home care team members. Employment contracts are initiated or terminated by the director, Jos de Blok, on the recommendation of individual teams.
• Care planning
• Care scheduling and work allocation
• Care delivery
• Deciding how many and which patients to serve
• Liaising with the family and friends of a client and with other involved health and social care professionals
• Creating, maintaining and updating client records
• Rostering, holiday scheduling
• Planning and attending team meetings
• Individual and team performance monitoring, appraisal and deciding on corrective action or suggestions for improvement
• Handling media and public engagement requests
• Continuous professional development — individual and collective. 3% of employees’ time can be devoted to education. Teams hold their own education and development budgets with limits set centrally.
• Teams can propose “projects to extend the reach and impact of the Buurtzorg model of care. For example, members of a Buurtzorg team in Amsterdam created a weekly radio show, Radio Steunkous (Radio Support Stocking), on which they broadcast neighbourhood health news and activities, live music and patient interviews. Other nurses regularly write articles for local publications about, for instance, the effect of mobility on patients with dementia. One team of Buurtzorg nurses organised a race for patients using walkers or other assistive devices after a patient pointed out how few competitions exist for the elderly. The first race was a success and led to the creation of several such races in the Netherlands. Finalists in local competitions participate in a national competition held in the Olympic Stadium in Amsterdam” (Monsen & de Blok 2013a: 56).

The home care teams however do not operate in an anarchic, lawless vacuum. They operate within a framework of constraints and supports outlined below.

Constraints

• The teams must be available 24 hours 7 days a week. There is no central call-centre operated by the organisation. The teams are responsible for the ways they can be contacted by clients.
• The maximum size of a team is 12 members. If a team grows larger than that it must split.
• Individual team members are asked to meet a productivity target of 60% i.e. 60% of their contracted hours must be billable. Individual and team productivity are monitored centrally. Team members whose productivity falls below the target are notified individually. Team productivity is visible to other teams through the organisation’s intranet called the BuurtzorgWeb. Other aspects of team performance are also visible to all other teams such as patient satisfaction ratings, number of clients and total number of client hours billed.
• Decision-making must be collective. There are no line managers, or team leaders or people of positional authority to make decisions on behalf of the teams.
• Tasks and responsibilities must be distributed widely.
• Teams must plan for, organise and attend team coaching meetings. According to Laloux (2014), certain teams allot a certain amount of time per month to peer coaching whereas others convene when team members request it.
• Team members must appraise each other on the basis of a competence appraisal system agreed by the team.
• Teams must produce yearly plans “for initiatives they want to take in the areas of client care and quality, training, organisation and other issues” (Laloux 2014: 70).
• Teams must use the organisation’s quality system which involves monitoring patient satisfaction and recording outcomes using the Omaha system. The adoption of this system was discussed and tested extensively in practice by the teams themselves. The process of adoption took four years (de Blok 2015).

Supports

• Training for new teams on: a) self-management. Home care workers are trained in the Solutions-Driven Interaction System (Laloux 2014) by Ben Wenting and Astrid Vermeer of the IVS (The Institute for Cooperative Issues). This involves topics such as group decision-making, conducting meetings, active listening, non-violent communication, conflict-resolution, and, problem solving; b) peer coaching. According to Laloux (2014: 157), at Buurtzorg, “all nurses are trained in “Intervisie”, a peer-coaching technique that originated in the Netherlands”. Laloux (2014: 341) states that he has not come across any material on Intervisie in English and that “Parker Palmer’s Circle of Trust® works on almost identical principles and steps”. Laloux (2014) advises interested readers to learn more in the book ‘Hidden Wholeness’ by Parker Palmer.
• Regional coaches at headquarters
• Coaches of IVS
• Peer support through the online community features of BuurtzorgWeb
• Teams can visit other teams in order to learn from them or can request visits from other teams
• Training and e-learning material and resources in the BuurtzorgWeb including the BuurtzorgAcademy
• Administrative tools, aids, forms are available in the BuurtzorgWeb
• Ecare Helpdesk (via telephone and e-mail and distant access to the screen of the user) for IT-related problems but also for receiving requests for changes or suggestions for development to the IT systems in use.
• Annual conferences bringing the whole organisation together
• Remuneration — under a union agreement nurses are paid according to their educational level with a standard annual increase and bonuses spent on years working for Buurtzorg (Gray et al. 2015). According to Monsen and de Blok (2013: 57), “nurses earn the highest salaries of any home care nurses in the Netherlands”. Sprinks (2014: 10) explains further that “nurses are paid more than other organisations but are not paid extra for specialisation”.

Regional coaches

Regional coaches employed at the Almelo headquarters tend to themselves have been nurses. Coaches support about 30 to 50 teams with:

• problem-solving, e.g. they share their knowledge of how other teams have solved similar problems
• allocating roles within the team
• working collaboratively without managerial direction
• building local and wider networks
• recruiting colleagues
• learning to use the BuurtzorgWeb
• supporting start-ups
• taking responsibility for their own affairs
• meeting productivity targets
• coping with difficulties, crises and emergencies
• sharing good practice
• raising a flag when they spot important issues

Coaches have no job description, no performance targets, no responsibility for team performance (clinical or financial) and have no decision-making or other authority over the team. Their pay is not subject to the teams’ performance and they are paid no bonuses.

According to Laloux (2014: 76), the regional coaches meet the CEO “four times a year with an open agenda”. This meeting frequency has been established to “prevent the risk of their taking the reins from the teams in a way that an executive team would”.

BuurtzorgWeb

The organisational intranet is central in Buurtzorg’s operational model. It was developed by Ecare (www.ecare.nl) a company founded by the founders of Buurtzorg specifically for the purpose of designing and implementing an IT system that could support self-management within a wider organisational community of peer learning and support through an online system. The founders decided to start the IT company after their failed attempts to source an IT from available providers at the time. Buurtzorg Nederland are making this system available, through Buurtzorg Services (https://buurtzorgservices.com/), to other organisations who wish to adopt the Buurtzorg organisational model.

The BuurtzorgWeb, a web-based application, accessible through mobile and desk-based devices offers functionalities organised in the following set of modules (according to Buurtzorg Services):

Client Compass: Electronic Health Record / clinical documentation application based on the OMAHA system (http://www.omahasystem.org/overview.html)

Team portal, a domain accessible only by the members of a particular home care team (Buurtzorg services, Laloux 2014, Nandram 2015). It displays the following information:

• Client population
• Team expenses
• Quality of care information
• type of clients
• number of interventions
• number of employees per client (minimising the number of care workers involved in the care of a person is an organisational goal)
• client satisfaction scores (information on patient satisfaction is collected at the completion of a course of care)
• Health analytics
• Attendance information
• Leave information
• Incidents and improvements
• Steering information for the teams which enables them to self-monitor their performance and to take corrective action e.g.
• the team’s average productivity
• productivity over the last year
• the number of client hours per week or month
• average score on team climate and employee satisfaction level
• comparison of the team’s performance relative to other teams. According to Laloux (2014: 110, 111): “..teams can see every month how their productivity compares to that of other teams. The data of other teams is not anonymised or averaged out. […] A team that struggles in one area can identify a team … with outstanding results and ask for advice and best practices.” Benchmarks for the whole organisation are offered in some cases.

Community module: Welinked

• The community model has been described by de Blok as a type of internal Facebook. According to Laloux (2014) and Nandram (2015), it plays a crucial role in collaborative learning and support between the teams. According to Laloux’s descriptions (2014: 70, 79, 80): ”[c]olleagues can locate each other’s expertise and specific skills and get in touch with each other directly”, and they can “post questions directly on the platform in a continuous Facebook-like stream […] The engagement level on the platform is so high (nurses tend to log onto it at least once a day, if not more) that within hour, a new question is seen by thousands of colleagues and will attract one or several responses”.
• It also plays a role in the communication between the CEO and the team members. This module hosts Jos De Blok’s blog which according to Laloux (2014) and Nandram (2015) exemplifies the organisational ethos of Buurtzorg. According to Laloux (2014: 102), “[w]hen the CEO or anybody else is contemplating changes that might affect a great number of co-workers (for instance, a decision about compensation), he simply puts out the issue and the proposed solution on the social network to collect colleague’s advice.” Laloux (2014) and Nandram (2015) claim that de Blok makes very clear to team members of the ways he takes their feedback into account. He modifies or withdraws his own suggestions or proposals and takes on the ones proposed by colleagues through Buurtzorgweb. Nandram (2015) claims that the content of the blogs is not managerial. De Blok in his blogs is sharing ideas, asking for advice and expressing emotions. According to Nandram (2015: 111), “[i]n total, 113 blogs were posted in the period 2008–02–17 until 2014–03–02, which is about 1 blog in every 3 weeks”.

Client and family portal

• care scheduling and provides notifications about appointments etc.
• access to the Electronic Health Record and the caregiver’s notes
• option to communicate with the caregiver

Education portal

• Set learning material per company or as general learning material openly available
• Share learning material between companies (once there are more home care companies using the platform)
• Place videos with learning material
• Follow learning path
• Earn points for following a training course
• Place updates about a software product (explain changes in videos)

My Employee portal:

• My data (information about contract, address, etc.)
• My hours (information about hours worked, hours at client, etc.)
• My Schedule (information about an employee’s time schedule, when to work)
• My Planning (Planning information, when to visit which client/patient)
• My documents
• My action to improve (feedback from the team about the employee)
• My Appraisal (information about quality of work)
• My Leave overview (manage absences and leave)
• My Payroll (overview of hours worked and pay-rolling)
• Salary portal
• Time registration (employee and client-time)
• Employee contract management
• Fee administration (miles, phone costs, etc)
• Pay-roll calculation

Administration

• designed to minimise paper flows, to reduce the administrative burden for nurses, to reduce back-office costs for the organisation

Business Intelligence

• Steering information on management and team level
• Data warehouse functions
• Key Performance Indicators
• Health Analytics

A Helpdesk service is available through the Headquarters via telephone, e-mail and remote access to the user’s screen. Buurtzorg Nederland pays Ecare a set fee per hour of care delivered. In the start-up stages of Buurtzorg, this ensured that financial risk was carried by Ecare.

The BuurtzorgWeb is dynamic. According to Nandram (2015: 100), team members can request changes or additions which are evaluated by Ecare in terms of a set of criteria: “ a) does the proposed change serve the client and/or the professional?; b) does it create additional complexity?; c) in what ways is this change beneficial to clients or professionals?”

Section B — Accounts of self-management team processes: how is self-management performed in practice?

The following section presents examples of how the organisational processes of decision-making, team meetings, rostering, expertise and specialisation in teams of generalists, and forced dismissals are undertaken in Buurtzorg on the basis of examples offered in the English-language literature retrieved for this paper.

Decision-making within teams: the advice process

[The interested reader can also refer to the Reinventing Organizations wiki (www.reinventingorganizationswiki.com) set up by Frederic Laloux and his collaborators for examples of other organisations using similar processes.]

Laloux (2014) names the approach taken by Buurtzorg teams and other organisations operating on similar principles of organisational decision-making as the ‘advice process’ after the name given to it by the energy company AES. The advice process comprises the following principles: a) any member of the team can bring to the table a suggestion or proposal for change; b) the proposal is discussed at a team meeting or between the people affected by the proposal which then inform the whole team; c) the proposal is accepted and put into practice if no member of the team has a principled objection to it (Laloux 2014, Nandram 2015).

The consequence of this practice is that team members with the motivation to proceed with implementing changes cannot be blocked by other team members on the basis that a better proposal may be possible but one that no-one is willing to champion. Laloux (2014) emphasises that this is different from purist variants of the consensus process in that team members do not have to agree fully with a proposal. It is enough that they do not object to it. This means that team members do not have to be in full agreement with suggestions made in order for these to be implemented to the extent that these team members do not have a part in or are not substantially affected by the suggestion.

This approach according to Laloux (2014) and Nandram (2015) is underpinned by the idea that suggestions, practices and ways of working are kept under constant review and are subject to quick change and so suggestions can be tried out, modified, developed, embedded or rejected in fast iterations to the extent that they do not have severe impacts. I am not clear on whether Buurtzorg teams are asked centrally to make decisions in this way or whether they can develop their own processes and procedures. As a contrasting example, Ricardo Semler in his book ‘Maverick’ explains that Semco teams that want to organise themselves in an hierarchical fashion are free to do so.

Team roles

According to Nandram (2015), Buurtzorg home care workers are offered guidelines in their training about using different, but not imposed, roles to accomplish their teamwork successfully. These roles according to Nandram (2015) are the following:

• Housekeeper and treasurer (task role): This role is about ensuring that team practices and activities comply with contractual obligations; that equipment and materials (clinical and office) are available and in good use. The role is also about monitoring budgets and income and expenditure streams relative to team and organisational goals.
• Monitor (performance — clinical and financial) (task role): The role is about monitoring the home care hours provided, the care hours contracted the team’s financial standing and the performance indicators.
• Developer (task role): This role is about representing the team in working groups inside and outside Buurtzorg.
• Planner (task role): This role is about care scheduling and rostering.
• Team player (social-emotional role): The role of the team player is to question the way team operates “through questions such as: why are we doing things the way we currently do; what are the challenges we face” (Nandram 2015: 72).
• Mentor (social-emotional role): This role is about advising and coaching people who are new to the team and helping them to develop themselves.

The IVS, according to Nandram (2015), recommends that teams rotate the roles amongst team members although there are no set arrangements and teams can undertake these in the ways that best suit them. Certain teams rotate the roles twice a year, others less often and others only if a team member requests a role change.

Team meetings

Home care workers, as mentioned above, are trained in the Solutions-Driven Interaction System (Laloux 2014) by Ben Wenting and Astrid Vermeer of the IVS (Institute for Cooperation Issues). This involves topics such as group decision-making, conducting meetings, listening, non-violent communication, and conflict-resolution.

Laloux (2014: 67) offers the following description of a team meeting:

1. The group chooses a facilitator. The facilitator does not make “any statements, suggestions or decisions; she can only ask questions: “What is your proposal?” or “What is the rationale of your proposal?”

2. An agenda is put together on the spot “based on what is present for team members at that point in time”.

3. Agenda items are discussed and proposals are made which are all listed in a flipchart.

4. In the second round, “proposals are reviewed, improved, and refined. In a third rounds, proposals are put to a group decision”.

5. “The basis for decision-making is not consensus. For a solution to be adopted, it is enough that nobody has a principled objection. A person cannot veto a decision because she feels another solution … would have been preferable. … As long there is no principled objection, a solution will be adopted, with the understanding that it can be revisited at any time when new information is available.”

6. “If, despite their training and meeting techniques, teams get stuck, they can ask for external facilitation at any time — either from their regional coach or from the pool of facilitators of the institute they trained with. A team … can also turn to other teams for suggestions using Buurtzorg’s internal social network platform”.

Ben Wenting has uploaded a staged meeting of a home care team on YouTube available here in three parts:

https://www.youtube.com/watch?v=ff-FRhO5QmM [Accessed 29 July 2016];

https://www.youtube.com/watch?v=Ay41B7Z4HxE [Accessed 29 July 2016];

https://www.youtube.com/watch?v=35RhQ8s1rVQ [Accessed 29 July 2016].

Rostering

Two examples of how rostering is accomplished in a bottom-up, collective manner in two Buurtzorg teams are given here:

http://www.workplaceinnovation.org/nl/kennis/kennisbank/care-in-the-neighborhood--buurtzorg-elst-2--/191?q=buurtzorg [Accessed 11 August 2016]

http://www.workplaceinnovation.org/nl/kennis/kennisbank/youthful-buurtzorgteam-brunssum-onderbanken-takes-care-herself-of-her-rosters/189?q=buurtzorg [Accessed 11 August 2016]

Borth articles make clear that care teams “have the freedom to choose the method of scheduling themselves”.

In the team of Buurtzorg Elst2, the rostering is done about 3–4 weeks ahead with the roster finalised one week in advance. An initial schedule is made by a coordinator in a spreadsheet software. The coordinator indicates the amount of shifts that are needed for each client on the basis of the client’s care plan. Periods of annual leave for team members and public holidays are indicated. The coordinator marks gaps on the spreadsheet. This initial schedule is circulated via e-mail to the team members who are asked to fill the required home care hours. The completed rosters are returned to the coordinator. The coordinator then tries to resolve any overlaps and indicates any remaining gaps. The revised roster is re-distributed. The process is repeated until the roster is acceptable to team members. The roster is also discussed in staff meetings. If there are unresolved issues, the coordinator will assign shifts as a last measure. Staff can exchange shifts between them. If a team member cannot do certain shifts because of illness, team members coordinate collectively to provide cover. Doing the roster in this way is a collective skill that develops over time so that the time to finalising the roster reduces over time: “The client schedule which must be redistributed every week takes about one hour per week.”

In Buurtzorg Elst-2, the shifts run from 8.00 to 12.00 (or from 9.00 to 11.30), 12.00 to 14.00 and from 15.00 to 17.00. The evening shift starts at 19.00 and runs until 23.00. The weekend shift pattern is different with fewer shifts which result in one less person being needed in the weekend.

The team of Buurtzorg Brunssum-Onderbanken has two coordinators which prepare the scheduling process two weeks in advance. There are three shifts 8.00–12.30; 13.00–18.00, 18.00–22.00.

Expertise and specialisation in teams comprised of generalists

According to Laloux (2014: 72), learning and expertise grow out of the initiative of teams which choose to develop the knowledge and skills required to care effectively for their clients. The BuurtzorgWeb enables colleagues to easily identify and communicate with colleagues with relevant expertise in a specific subject matter. When collective effort across teams becomes necessary, volunteer task forces of nurses are set up that in addition to their work with patients investigate a new topic (Laloux offers the example of Buurtzorg needing to adapt to a new legislation) and build up expertise which they then share with the organisation (e.g. the task force creates self-help sections of FAQs on BuurtzorgWeb). Laloux clarifies that, when needed, an expert can be hired centrally as a freelancer, rather than brought into a staff role. If a staff function is hired, that person has no decision-making authority over teams.

Forced dismissals

Laloux (2014: 148) offers the following account:

1. If a person has lost the trust of the team, the team tries to find a mutually agreeable solution.

2. If that doesn’t work out, the group calls in its regional coach or external facilitator to mediate.

3. If that doesn’t work out, the team members can ask Jos de Blok, the founder, to mediate.

4. If that fails to lead to a mutually accepted solution, the team can ask Jos de Blok to end a person’s contract.

Decision-making across teams

This seems to be coordinated by the two directors. It is a topic that needs further explication.

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