He has turned homecare in The Netherlands completely upside down. With Buurtzorg Nederland [Netherlands Neighbourhood-care], Jos de Blok has reintroduced the work of the district nurse. ‘I saw that the profession was dying a slow death and that is what I wanted to prevent.’
Jos de Blok (50) was originally a district nurse and, until 2006, worked for regular homecare organizations. He also had management functions in those organizations. ‘I entered the healthcare sector out of passion and compassion. I very much wanted to add something to the lives of others. District nurses don’t have a job, they are their job. Over the past few years, that has seemed to disappear. Providing care had become something entirely different. It was suddenly all about production, protocols and administration. It was heading in the wrong direction.’
De Blok made an agreement with himself that he would not be a contented person until the profession of district nurse had regained its explicit social value. He then decided to start organizing that care himself. It started out on a small scale, but his organization, Buurtzorg Nederland, has expanded to the current two hundred and fifty independent teams throughout the entire country.
Buurtzorg Nederland is an organization in which district nurses and district healthcare workers themselves have the authority. ‘Every team is responsible for its own clientele and is in close contact with family doctors and families. The teams are also responsible for their own financial results. The supporting office in Almelo is just that: supporting.’ For Buurtzorg, there are no fancy locations or luxurious offices. The supporting office operates from the extension to his private home and is run by his partner, Gonnie Kronenberg. The Buurtzorg teams throughout the country also work from simple locations. By acting ‘normal,’ the initiator is denouncing the system that has led to the over-paid managers of traditional and commercial homecare organizations. ‘These days, it is incomprehensible why all these middle managers are necessary. And that does not even begin to explain the huge compensation that these people are given for taking part in the ‘meeting circuit.’ I feel that it is unethical that top management in healthcare is earning so much money. What you must do, is to ensure that the people providing care to the clients are well paid. That is an important pillar of our organisation.’
The lightning-speed success in no way presents problems for the native of Zeeland who now lives in Twente. However, behind his down-to-earth attitude can be found an all-consuming passion. He seems almost prepared for the success. ‘If you do something precisely the way it is meant to be done, it can, I believe, hardly fail. District nurses and healthcare workers apply to us spontaneously. We have never had to do any active marketing. That certainly says something. Strangely enough, I had sort of expected this kind of success. I had heard from so many colleagues that they had had enough. This new approach with the re-establishment of the old-fashioned and universal care values could almost not fail.’
As early as September 2007, Jos de Blok announced that he was striving to achieve national coverage with Buurtzorg Nederland within three years. In February 2006, after ten years’ experience in management functions, he quit his permanent job with the Twente healthcare organization Carint and established Buurtzorg Nederland. With a business plan, he was able to secure a loan of € 250,000 from a bank. He also put in some of his own money. Wasn’t that risky? ‘I have always believed in this. But the risk lay, of course, entirely on my shoulders. If it were to fail, I would have had it. For the first six months, I did not take any salary.’ But it did not fail. After the first team in Enschede, a second team quickly followed in Utrecht. By September 2010, there are two hundred fifty teams. ‘By the way, the overhead has not increased accordingly: fourteen staff members at the head office in Almelo and ten coaches who each manage 25 teams. The annual turnover is also growing. For 2010, it is moving in the direction of ninety million Euros.
The spectacular growth can be attributed to the fact that entire teams from other homecare organizations transfer to Buurtzorg Nederland. For some time now, De Blok has been negotiating with dozens of regular homecare organizations for more intensive collaboration. De Blok certainly does understand that restructuring an existing homecare organization is much more difficult than starting a new one, just as he started Buurtzorg Nederland. They will have to dismantle a major part of their overhead, and that costs time. In the Buurtzorg formula, there is no place for schedule planners, coordinators and mid-level managers. ‘That restructuring takes years. We will probably start with a few teams which work according to the Buurtzorg Nederland method. In that way, an organization can gain experience and see if it suits them.’
It is not surprising that the nurses are so happy at Buurtzorg Nederland. At many homecare organizations, they are becoming alienated from their profession. They have become imprisoned in administrative tasks. Their skill and expertise are barely called upon at all, anymore. ‘In the hbo-v [Nursing College] there is barely any enthusiasm at all now for public health and district nursing. That is now dangling at the bottom of the list, while it used to be the highest possible achievement. As a district nurse, you no longer have a position of status alongside of the family doctor in the neighborhood. You are only busy managing caregivers. District nurses are seeing their profession crumble.’
At Buurtzorg Nederland, that is a completely different story. There, they are the pillars of the organization. Teams of highly-trained nurses manage a whole range of things themselves. ‘Often, administrators do not understand that the commitment of highly-trained personnel is much more effective and yields better care, as a result of which organizations can operate up to thirty percent more cheaply. Every district nurse understands this immediately. ’
The cause of the malaise is, according to De Blok, the product-oriented approach that first appeared around ten years ago in the homecare sector and is, by now, widespread. In this vision, care is seen as a product that you can chop up into various activities. You then try to carry out these activities as cheaply as possible. The entire fundamental process of registration, intake, planning and supply has been divided up. These activities are all done by different people. The idea behind this is that, if you subdivide the processes, it is more efficient and, therefore, cheaper per hour. However, according to De Blok, that is precisely wrong. The subdividing leads to all sorts of coordination moments. Homecare organizations have, therefore, hired coordinators for this who must make sure that everyone works well together. Above them, there is then a manager who is responsible for the success of the entire process. And, thus, an enormous overhead system is created that can only be maintained by sufficient turnover. ‘If the financial pressure increases, there is the tendency to subdivide the process further and, increasingly, to hire people who have an even lower level of training. There are homecare organizations which put together “dream teams” in which the indication is the guiding factor for the level of people you hire. You have people who have reached the level of administering pills and giving injections, others are allowed to do bandaging and some are even allowed to do specialistic tasks, such as connecting morphine pumps. That is crippling for the motivation of the nurses and the quality of the care and, moreover, it costs society barrels of money.’
The product-oriented approach leads to homecare organizations wanting to increase production as much as possible. The central focus is on the execution of tasks, such as washing and putting on stockings. That is diametrically opposed to the vision of care that Buurtzorg Nederland has. ‘The focus of district nursing must be the relationship with the client and the solving of problems. Patients are insecure, must be given self-confidence after an illness or if the body is starting to deteriorate. That process is of vital importance. You must be able to anticipate how the client perceives his illness, how the environment is dealing with it, how the interaction is playing out and how you can support the volunteer help as much as possible so that the client feels secure. In this way, you create a restful atmosphere. That increases the capacity. The question is how to find other solutions within that process. That demands nursing expertise. The tasks that the nurse carries out here are of secondary importance.’
How is it possible that Buurtzorg can indeed hire expensive nurses while regular homecare organizations say that they hardly have any money for them? ‘Our average salary costs are, of course, somewhat higher,’ acknowledges De Blok, ‘but I have removed all of those coordination moments. We do not subdivide the care. The nurse who comes to the home of a client does everything: intake session, personal care, dressing wounds, medical-technical activities. The advantage of having one person do everything is that the average contact time increases. If you send four people, then each of them must travel there, be busy short time and also gear their activities to one another,’ says De Blok with a smile.
Furthermore, Buurtzorg has computerized the entire work process as much as possible. The employees do not have to do their own administration. That all works via an intranet system, where they enter data, starting with the intake session. The indications, planning, scheduling and their own data are all there. Time-keeping is, for example, not necessary. It is sufficient to correct any deviations in the planning. The employees do have a workstation and much more time for consultation than in other organizations. Finally, the lines of communication at Buurtzorg are short because there are no managers. ‘Teams may operate according to their own judgment. That is also the way we used to do it in home nursing.’
The Buurtzorg Nederland work method leads to remarkable results. Not only are the employees and the clients extremely satisfied, the organization has also measured how the care supplied is related to the indication. Buurtzorg supplies, on average, only 45 percent of the care that is indicated. If the lead time is counted – how long people are in care – then it is even only twenty percent of the indication.
To the website of Buurtzorg Nederland
In oktober 2011 Jos de Blok visited the US on invitation of the AARP Internation. Click here for more information.