Buurtzorg, a Dutch nationwide nursing organization, operates entirely using self-managing practices. Teams are fully self-organized, and the organization has developed a culture where these independent teams are supported by the back office. Their IT system was developed in an agile way to help teams deliver nursing care to their patients.
Ard Leferink, agile coach at Buurtzorg, spoke about the agile journey of Buurtzorg at the Agile Consortium Belgium 2017 conference. InfoQ is covering this conference with Q&As, summaries and articles.
The Netherlands has a system which provides medical care at home from trained nurses. General Practitioners (GPs) and hospital specialists can give an indication for the care needed for a patient. Patients get this care through local organizations where nurses are employed.
Buurtzorg was started by Jos de Blok in 2006. Working as a nurse, he felt that there were too many rules and too often managers were telling nurses what to do and how to do it, which prevented nurses from carrying out their work in an effective way. He also felt that that this made medical care more expensive. He had a vision on how home nursing care could be done in a better way, by nurses working in self-organized teams.
Buurtzorg started with one team. There were people with different skills and roles within the team. Together the team members would be able to give the care that their patients need. Leferink worked as a consultant for Buurtzorg to help teams start up.
Teams are fully self organized. They plan and track the work that they do to deliver care to their patients, and they carry out the work. Teams also have their own education budget.
Every team has their own mobile phone. There wasn’t and isn’t a call center or central number at Buurtzorg, said Leferink. New teams visit GPs based on the area where their patients are, and ask them to call the team if there is anything they can help with. This is a first step in building a relationship between the team and a GP.
When teams grow to over 12 people, they are split up. This can be challenging at times, said Leferink, as people get used to working with other team members. However, in the end teams manage to deal with this.
Currently, Buurtzorg has 9000 employees in 900 teams. They have a back office with 50 employees and there are 20 coaches who support the teams.
It’s important to have a culture of supporting independent teams in the back office. Creating such a culture is one thing; maintaining it is even more important and not always easy, said Leferink.
When Buurtzorg started out, there was no IT available that suited their needs. They decide to develop a cloud application that nurses could use to organize their work and get paid for the work that they did for their patients.
The first Buurtzorg nurses team worked together with a software engineer to create the system. The engineer worked in a way similar to Scrum, but in stead of having sprints of one or two weeks they did six sprints in one week, said Leferink. The engineer listened to the team, and implemented the things they needed. Nurses would call the engineer if they needed something that the system didn’t have yet, and then the engineer would develop it and then check with the nurses if it suited their needs.
In the beginning the business was growing very fast. To facilitate growth, Buurtzorg had a double agile loop, consisting of agile IT development and agile business management. IT has to support the work of the teams. Leferink stated about the IT systems at Buurtzorg: "If Buurtzorg teams don’t like it, it’s not good enough".
Earlier InfoQ interviewed Frederic Laloux about Reinventing Organizations. He explained how Buurtzorg operates as a teal organization with an evolutionary purpose:
Buurtzorg is a spectacularly successful Dutch home care organization that operates entirely in self-managing fashion. (...) It has a clear sense of purpose, but no strategic document, no three-year and one-year plans. Just like in a living system, innovations keep happening at the fringes, and if they prove to be successful, spread throughout the system.
There are no strategy meetings or other structured meeting, as there’s no need for them, said Leferink. Nurses and back office employees can see 24/7 what’s happening in the organization. From the start, Buurtzorg integrated social communication into their way of working. They established closed on-line communities where nurses could ask questions and learn from each other.
Working with other organizations as a consultant, Leferink sometimes hears people say that self-organizations won’t work for them as their organization does not have the right people. In this situation, he suggests to start self organization with innovators and early adapters; his experience is that the rest will follow. In the end there can be problems with laggards.
Sometimes managers think that they can manage self organization. You can’t manage the new direction, said Leferink, you can only serve, guide, and cut complexity. Firing managers and expecting teams to take charge doesn’t work. You have to work hard if your culture isn’t social, said Leferink. You can’t schedule a culture change. Also, it can’t be done without restructuring the back office, which is the most difficult part. Advice Leferink gave was to start with a minimum viable back office.
Self organization isn’t anarchy; you need a framework to make it work. The proof of the pudding is in the eating. Start doing it and see how it works for you, is what Leferink suggested.