In First Person: Jos de Blok

Simplifying Complexity with Autonomy

Jos de Blok is the founder and CEO of Buurtzorg (neighborhood nursing), a Dutch organization with more than 1,000 employees offering community-based home care services to more than 70,000 patients a year. Founded in 2006 with one team of four nurses, Buurtzorg has transformed home-based health care. De Blok sat down with People + Strategy Executive Editor David Reimer to discuss coaching strong teams, increasing autonomy and simplifying complexity. 

This article was published in print and online in the Winter 2021Issue of the Journal of HR People + Strategy.

P+S: Share the story of how you built your organization.

Jos de Blok: I worked for many years as a nurse, but I also studied economics, and I was always interested in how people can have as much control in their lives as possible and how we can avoid power structures that take over people’s lives. Being a community nurse in the 1980s gave me all I wanted. I had the freedom to decide how to take care of patients. I had very good colleagues. There was no management structure, we didn’t have strategic plans, and we didn’t have planning tools. We just did what was needed. It was effective.

In the 1990s, a lot of changes were introduced, and in Holland, it led to a very product- and activity-driven way of delivering health care, so health care was defined in terms of products and delivering activities instead of solving problems. It added layers of managers. And the language changed so that people were not talking any more about how best to take care of our patients. It was about growing revenue.

In 1994, I was asked to become a manager, and I saw how little interest there was in how the system was helping patients and I learned how management was frustrating the daily practice of good professional workers. In 2005, I decided with some friends that we can create an alternative with better quality of care, and an environment that our nurses will want to work in, and that will also have a big impact on society because it will be much cheaper than the current way of doing things.

My idea was to create small teams with nurses who organize everything themselves. We would let them focus on outcomes; let them work with patients in a way that they think is the best, based on professional standards; and create a support system around them, including a back office and IT system that helps them in their daily work. It would grow by itself and improve quality. I started with one team at the end of 2006, and I started to work again as a nurse myself. Based on these principles, we started to grow from one to almost 1,000 teams in around 10 years.

P+S: As you scaled, how have you stayed true to that principle of minimizing layers of management?

De Blok: If you create these small environments where people feel ownership, you can replicate it all over the country and all over the world. It has to feel organic and logical for everybody. We said let’s keep things open in terms of the support that was needed but we said that we are not going to use traditional approaches. We will not have an HR department. We will not have an IT department or a financial department. We will have the support that’s needed, in a way that is simple, can be understood by everybody and is integrated as much as possible in the daily work of people.

For example, we thought we would need some support for teams on some issues, like when there is a conflict within the team. We had an idea that perhaps it could be kind of a coach. And we figured one coach could help 40 teams, because we didn’t want the coaches to become managers. They had to be serving the teams. And we wanted people who were focused on helping the teams, rather than being focused on themselves. That’s a bit different than what you often see in management roles. All of the coaches have been nurses before they took on this new role.

The back office was the same. We said let’s make a simple contract that reflects what people want. Instead of the 20 products, we have one service and the billing is very simple. We have 30,000 patients and one person at the back office doing the billing. It’s all electronic and digital. The idea is always to make it simple, consistent and logical and ask the nurses if they feel that this is logical.

P+S: Can you elaborate on the role of the coach?

De Blok: Usually we ask teams to reflect on their own performance. There are certain performance indicators that they can track online compared to other teams on things like patient satisfaction, productivity and their own satisfaction. When they feel things are becoming a problem, then usually they ask the coach to join them for a while.

Most of the teams don’t need a coach. But there’s always 5 to 10 percent of the teams that are struggling. It might be a conflict within the team. It might be a problem in collaborating with the local hospital or doctors. A lot of those challenges are resolved by going back to our core principles of what is the vision, why did we do this, what do we want to achieve, and what does it mean in daily practice?

P+S: There is a longstanding tendency to say that a team needs to be managed and somebody needs to be monitoring them, which shifts the power.

De Blok: People always say that there has to be somebody who pounds the table as the manager. But that’s just a short-term solution. That’s not a solution, because it will damage people’s sense of ownership and responsibility. The lesson is that sometimes it’s better that it takes a while before you find a solution. A decision may feel important in the moment, but it often isn’t. It takes time to understand the best solution.

P+S: What reach are you having globally?

De Blok: At the moment, we have 28 countries around the world where we are working with partners. A few years after we started, we had interest from Japan, Sweden, the United States and other countries. Sweden became a success and we are in all the Scandinavian countries. The process is more or less the same everywhere, with partners who want to use the Buurtzorg ideas and brand.

But the U.S. was difficult and in the end, we left. It was a combination of a few things. The system’s quite difficult, and it was hard to get the right income to cover the costs for the nurses. The attitude of a lot of American people I met with was that we should bear all the financial risk. In Russia, it was the opposite. They agreed to fund it, but we would take responsibility for running it. The U.S. is very profit driven and also risk avoidant. With all the other partners we have now, they take responsibility and they also take on the risk.

P+S: Health care is often held up as an example of a problem that’s just too complex to simplify, and yet you’ve offset that complexity with simplicity.

De Blok: It’s not only about simplifying complexity. It’s also about seeing where the complexity is and how you can simplify the environment so that you can deal with the complexity in the most effective way. Every day, nurses have to deal with sometimes very complex situations with a lot of uncertain factors. They have to make their own choices in the moment to have the best result. They have to foresee what’s likely to happen.

In health care, that’s very complicated because there are many factors that influence outcomes. My idea is to have people around these problems who feel connected to them and can make the choices they think are the best choices. Then you create an environment that’s simple so they don’t have to put any effort into thinking about what management is saying and what the strategic plans are saying. That way, the routines don’t really change over time.

There are patterns in how you care for people, so you should build on these patterns, and every time you get new insights based on what you’re doing, you share that knowledge. The support systems should be logical and simplified, but you should not underestimate the complexity of what’s going on.

P+S: Given that, how do you think about long-term planning? For example, do you write five-year strategic plans?

De Blok: Three or four times a year, I have a meeting with my board, and for my most recent meeting, I wrote a strategic plan for 2020 to 2024. It’s just three pages, and it’s more or less the patterns that I see, and that are shared by most of our nurses, and how to translate them to certain programs or ideas. But I’m not describing them as target goals. I’m just describing what’s going on.

For example, I think prevention should have a bigger place in our health care system, and every nurse should have a preventive mindset. How can we look at problems in a way so that we can prevent them from happening the next time? How can we prevent the things that are getting worse, and how can we focus on healthy aging and healthy living?

Another important topic is e-health. How can we use technical solutions to improve things? The third one is hospital at home. My opinion is that 40 to 50 percent of the people who are in hospitals don’t need to be there because we can monitor them at home.

How can we make the work even more meaningful, more joyful, with more variety, and create a healthier lifestyle for our nurses? I said we have to focus more on how to stay healthy. One of my ideas is to give everybody a budget to stay healthy. Think about your own risks. When are you stressed? When are you out of balance? What keeps you in balance? What kind of programs or training would help? Perhaps it’s more of a spiritual approach. Maybe you want to start a yoga program or do meditation. Make your own health plan, talk about it with your colleagues and here is the money to make it happen.

P+S: Can you just tell me a little bit more about you? What were you early influences for you? What were you like when you were a teenager?

De Blok: I always had problems with authority—not real authority but people who wanted to have power over me. I wanted to be independent. I had my first doubts about the meaning of life when I was 12. I was interested in a lot of different topics, but I was also not a very optimistic boy. I thought that life was quite useless because there was a lot of pain and a lot of bad things in the world because of things like the war in Vietnam. I said to myself that, yes, there are a lot of problems in the world, but I’m here now, so I have to make the best of it. So that was my simple way of dealing with things.

I was always inspired by my mother, who had solutions for everything. She’s 85 now, and she’s a very joyful, very wise woman who says that you have many choices to make things better. My family led a simple life when I was growing up. My father worked in a factory, and my mother took care of the children, but we enjoyed ourselves. We didn’t have much money, but we never had financial problems. That was an important influence.

I also realized that things are not as complicated as they sometimes seem. I had problems with some teachers. For example, my best subject was economics. I would often say to the teacher that these things are not so complicated. They would say, it’s not so easy. They always wanted to convince me that things in life were very difficult. I said, no, I don’t think so. I have problems with people who are very academic and try to create very complex theories about what you should do.