Dissatisfied with the delivery of health care by traditional home-care organizations in the Netherlands, Jos decided to create a new model anchored on the self-management capacity of nursing professionals, ultimately resulting to a more responsive, patient-centric system giving better quality care. In the long run, the model enables the patient to maintain independence from costly institutionalized care.
A nova ideia
With an increasingly aging population in the Netherlands and around the world, developing new and efficient ways to provide care for the elderly is a growing imperative. Considering that hospitalization is costly, the challenge is to provide efficient but effective models of delivering patient centered care. Recognizing the crucial role that nurses play in driving the wellness of patients, Jos provides an alternative grassroots model for home-care that places nurses and patients at the helm of decision making in care-delivery. With this model, Jos has not only created a way for patients to get better care and avoid hospitalization in the long run, he also paved the way for nurses to be central forces in healthcare delivery.
Jos believes that by nature, nurses are intrinsically motivated to work towards the betterment of their patients. By ensuring that they have autonomy, nurses would be able to act on this motivation and strive to find the best possible solutions for patients. With this in mind, Jos has created the architecture for a network of self-steering teams of nurses in communities that are empowered to work with patients to devise solutions to their home-care needs.
Through his organization, Buurtzorg (meaning “neighborhood care”), a network of over 8000 nurses organized into about 500 smaller autonomous teams work together to meet their patients’ needs. Within each neighborhood, the independent teams of nurses are responsible for the complete care delivery to their patients. Central to this approach is ensuring that these nurse teams have a high degree of autonomy to carry out their work. Because they understand that they are wholly responsible for the well-being of their patient, nurses take greater ownership over their work, and thus seek to provide only the best possible care. To do this, they share patient solutions, results and experiences with one another. A specialized digital platform facilitates this communication, linking not only nurses within a team but also to other nurses in the broader Buurtzorg network. This platform works across all aspects of care-delivery -- linking also to doctors and pharmacists outside the network to ensure sharing and proper management of patient information. The combination of autonomy given to nursing professionals and the use of a specialized internal intranet, enable Buurtzorg to be a leaner and more responsive model for homecare.
Traditional home-care models are often laden with expensive managerial layers and bureaucratic processes. They determine to a large degree what can and cannot be done for a patient. Instead of using the patients’ needs as the starting point for finding the best solution, cost reduction often becomes the main determinant of the kind of care patients receive. Jos’ model challenges this approach, by showing that care can actually be holistic and responsive and at the same time, have massive efficiency and cost-saving implications. Although it requires higher costs per hour, Jos’ model overall requires fewer hours in the long run. A 2012 KPMG study showed that “by changing the model of care, Buurtzorg has accomplished a 50 percent reduction in hours of care, improved quality of care, and raised work satisfaction for their employees." Furthermore, such a transformation in system ultimately resulted in a reduction of per patient costs, between 20-30 percent (Ernst and Young).
Believing strongly in the transformative capacity of supporting the self-management capabilities of professionals in a community and combining this with an integrated approach to localized informal and formal care systems, Jos envisions that the model can eventually be applied to other localized care systems – including psychiatric care, post-natal care, hospices and elderly home.
Currently, Jos’ idea is in use in the Netherlands, and spreading into Japan, Belgium, Sweden and now the USA.
In the Netherlands, as is often the case in other more developed countries, the growing ageing population, with its increasing demand for care services, presents a considerable burden on the healthcare system. Despite these growing needs, the current home-care delivery industry has shown little growth in actual efficiency of operations, and quality of care delivered to patients..
As it stands, the current homecare delivery system is fraught with inherent flaws. In the Netherlands, every citizen is required to have health insurance. It is then the insurance provider that covers the costs of health services used by a citizen. In the 1980s market incentives were introduced to reduce costs. Since insurance companies pay care-providing organizations for every hour spent on a patient, the focus on reducing costs meant that there is a strong force for care providers to deliver as few possible hours per patient. This distorts the market, and incentivizes care-delivery organizations to provide as few hours of care as possible. Instead of ensuring that the patient can be(come) independent of home-care in the long-run, the focus has become providing low-cost solutions that require as few hours with a nurse as possible. What happens, however, is that these solutions and the kind of care resulting from them make patients more dependent on the system for further treatment or continuing dependence of care.
As a result, the model has evolved into a highly regulated and more costly system, dominated by insurance companies and centralized care-providing organizations. With the additional costs of layers of management, bureaucratic processes and the consequent dependence of patients to the system, the outcome is a more expensive system overall.
At the front end of this system are nurses who find themselves unable to act upon their initial motivation for entering the home-care profession. Individuals who genuinely want to extend care for those in need of it, find themselves in a position of very limited decision-making power, making it hard to create improvements, and take ownership of their work. With the structure of the current system, there are few opportunities for a nurse to decide about and deliver home care in such a way that they can put the patients’ needs at the center. What results is that nurses find themselves lacking in emotional fulfillment, and overburdened with administrative workload.
The fragmentation and bureaucracy of the system only creates further disincentives to those in the nursing profession to work in the home-care system. The direct link between the needs of the patient and care-giving is broken by the top-down approach of how home-care is organized. As a consequence the profession is depleted. Nurses have low job satisfaction. Young people consider it as a low-paying option for a profession, one with little autonomy and personal fulfillment. As such, the sector is in serious need of opportunities to reinvigorate the profession, and restore the pride and motivation of being a caregiver.
The fundamental difference between Jos’ approach and the current homecare model is that Buurtzorg places the patient and the nurse at the center of decision-making, rather than having the administrator and management be the one to decide on solutions. The belief that nurses do not need more management, but instead need each other, moved Jos to create an entire system of nurse-driven and responsive home-care delivery.
The first principle of Jos’ strategy is to ensure self-steering teams of nurses in every neighborhood. There are a maximum of 12 nurses in each team within a community of about 10,000 inhabitants. This team is responsible for providing care for about 50 patients at any given time. Most patient referrals come through primary-care doctors or hospitals. Patients include the elderly, chronically ill, functionally disabled clients and patients who have been released from the hospital but have not yet fully recovered. Each team meets weekly to discuss its patients and problem-solve. The team develops its own personality and functions as a unit that is recognized by the larger Buurtzorg organization for its collective wisdom on what is best for its patients.
In order to carry out its vision of dramatically improving quality of care, Buurtzorg ensures that nurses who are qualified, educated and able to make the best decisions for their patients form the network. To do this, Buurtzorg evaluates teams who have formed themselves independently and have approached the organization with a request to become an official team in the network. In this process, nurses are interviewed and evaluated. About 70 percent of Buurtzorg nurses have the equivalent of a Bachelor’s Degree and the remainder has at least three years of nursing training. By having trained and highly motivated care providers, Jos believes that patients can get better care and thus increases the likelihood of patient independence in the long run.
The second principle of Jos’ strategy is in the holistic approach to home-care itself. Buurtzorg nurses strive to address the needs on all aspects of their patients’ lives, aware that wellness of patients relies on a supportive network within the broader community. To accomplish this, the nurses rely heavily on teamwork and collaboration. Not only do they work with other nurses in their teams and in the greater network, (for example, as many as 5 nurses may work together on one patient depending on the situation, the timing and type of patient needs) but they also seek out the support of the community around the patient. Nurses connect with the families, healthcare providers and local general practicioners to create simple and creative solutions for their patient’s needs while also building health awareness in the community. For example, some teams created a weekly radio show on healthy habits while other teams wrote articles in local newspapers. Ultimately by creating a community that supports healthy living and preventative healthcare in their neighborhood, nurses create an environment of wellness surrounding their patients.
The third principle of Jos’ strategy is minimal administration and management. By having highly independent and educated teams that can be trusted, coupled with an effective technology platform to link and integrate them, there is less need for massive administrative support. In fact, even with over 8000 nurses in the network, the Buurtzog core team comprises of just two leadership members and very few administrative staff. The role of this team is solely to ensure that outside matters do not interfere with the nurses’ ability to complete their work and to maintain the organizational principles and strategy worldwide. In 2014, Buurtzorg was listed as the fastest growing organization in the Netherlands. In spite of this growth, costs have largely remained stable precisely due to the emphasis placed on nurse autonomy, and minimal administration.
The success of the model does depend on a lean and effective technology infrastructure. The eCare platform, developed by Jos and a friend, ensures that nurses can access electronic records, scheduling and support services from each other. eCare is designed with patient-care at the center: nurses can log a problem, find solutions that others have tried and provide feedback. The entire system reduces the administrative burden on nurses by 45 percent.
eCare is developed and owned by a separate and independent IT company of which Jos is a shareholder. This is to ensure the alignment between the nurses’ needs and the technology produced and made available for their use. Believing in continuous improvement, Buurtzorg invests about 1 percent of its budget in innovation to keep introducing new efficiencies into home-care delivery.
One of the newer innovations is Myshopi. It is a purchasing platform for nurses to order medical equipment needed in home-care. By bundling purchasing power, reduced prices can be negotiated with suppliers. This then adds to reduced costs for care. With his aim to improve care delivery overall and not just for Buurtzorg as an organization, Jos is currently in the process of opening this purchase platform to other care providers, to increase purchasing power and decrease costs of care on national level.
Employing the same logic, Jos is developing the Omaha system, envisioned to be used by all home care organizations in the Netherlands. The system aims to register solutions to home care health issues so that home care organizations can compare best solutions. The Omaha system enables nurses to compare different solutions to a certain problem, and its effectiveness.
Unlike the existing system, the focus of Buurtzorg is on finding the most effective solutions for patients and not logging as few hours as possible. But in so doing, Buurtzorg has shown that efficiency and effectiveness can actually go hand-in-hand. An independent study by KPMG shows Buurtzorg is able to deliver better quality of care, in fewer care hours. On top of that, customer satisfaction is higher. External research has shown outcomes from the Buurtzorg model have been consistently better than every other homecare organization. Nivel, the Netherlands Institute for Health Services Research, found (in 2009) that Buurtzorg had the highest satisfaction rates among patients anywhere in the country. Ernst & Young showed (in 2011) the average costs per client were 20-30%% less than other homecare organizations. In 2009 Ernst & Young computed that if all home care organizations would start working like the Buurtzorg care delivery system, it would create potential national savings of € 2 billion Euro per year.
Buurtzorg has experienced rapid growth and international uptake since its establishment as a non-profit organization in 2006. The reason is simple to grasp: Buurtzorg’s bottom-up approach makes it very easy to replicate in other countries where a group of community nurses just want to start and delivery high quality care. It isn’t Jos’ aim to increasingly grow his own organization. He hopes that others can pick up the idea, replicate the core principles but adapt it to their own contexts. With this in mind he openly shares his model and tool to others.
Jos has authored and co-authored books on the management theory upon which Buurtzorg is based. Because of its unique structure, and the role by which this structure plays in the effectiveness of his strategy, Buurtzorg is included as one of the cases in the well-known book “Reinventing Organizations” by Frederic Laloux. By sharing his model, Jos hopes this will disseminate the knowledge and experience of Buurtzorg worldwide and even influence fields beyond home-care delivery.
Jos’ decentralized scaling strategy is not without its challenges – Buurtzorg is currently experimenting with different organizational structures that best support its network design. For example, a franchise model is used in Japan versus an affiliation model elsewhere. After comparing results, Jos ultimately hopes to settle on a clear model that places social impact at the heart of everything they do.
Buurtzorg’s success and quick growth has also attracted many potential investors, but their emphasis on financial returns has prompted Jos to decline their support. Jos is working with the Buurtzorg Foundation Board of Supervisors to work toward bringing together Buurtzorg’s many components under one nonprofit umbrella organization that publically shows the importance of social impact first.
Jos was always fascinated by what he could mean for others by being a nurse. Growing up as a son of a nurse who believed that her sons needed to learn how to provide for themselves very early in life, Jos took up his first job in a care-providing organization while he was still in high school. When his friends chose to study at Eindhoven, he followed them and began his studies in Economics. He soon found out however, that although he was good with numbers, he did not like his focus of study (not being focused on humans). But through this experience, he discovered his interest in business administration, business engineering and the sociology side of business.
Jos completed his HBOV (higher professional education for care giving), and proceeded to work in different care organizations. Because of his fascination about the value of work nurses do, he took up extra roles in these organizations – such as being part of the Works council ( (“ondernemingsraad”). It was in these organizations that Jos began to share his opinions about how things could be organized differently. He started to see and believe that the way of centralizing the management of care organizations was not effective for him as a caregiver to do his job and that it hindered his professional development and that of his colleagues. He strongly believed that they should work from the ground up, focusing on delivering better care by putting patient needs first.
But this was the exact opposite of what centralized management decided to do. They insisted on measures they deemed more effective and efficient but in reality, was causing more administrative burden. Jos’ rebellious behavior grew, and he became more convinced that the decentralized model, where nursing professionals are enabled to determine for themselves the best way to deliver care, was the right path forward.
Jos wrote several opinion pieces and even wrote a letter predicting where centralization trends in the 1990s would lead to. He wrote proposals about how things could be organized differently. In the end, he was asked by his organization to become the regional manager of a certain district. After a couple of years, however, he found out that his proposal for a different way of management was not implemented as quickly and as efficiently as he thought they should be.
At this point, he submitted the proposal of the care delivery model of Buurtzorg to the directors. However, they did not want to implement it. This was the moment Jos engaged four other nurses, and together quit their jobs to start the first team of Buurtzorg nurses. What Jos started with a team of 4 nurses in 2006, has grown into a self-sustaining organization growing with over 1,000 nurses a year (2015).
In 2014 Jos received The Albert Medal of the Royal Society of Arts (UK), following Marie (Madam) Curie, Stephan Hawkins, and the likes, for his work as founder of Buurtzorg, a transformational new model of community health care.