Simone Cicero

Hello everybody and welcome back to the Boundaryless Conversations Podcast. On this podcast, we explore the future of business models, organisations, markets and society in our rapidly changing world. I’m flying solo today on the podcast as a moderator, but I’m very happy to host, let’s say, another member of our pantheon of inspirations. I’m really glad to be joined today by Jos de Blok. 

 

Jos is CEO of Buurtzorg, the Dutch neighbourhood nursing organisation that has become a little bit of a, let’s say, global reference point, not only for community-based healthcare, but also for building organisations out of self-managed teams. Starting in 2006 with just one theme, Buurtzorg has grown into an international sensation. 

 

Let’s say 15,000 people who now deliver, let’s say beyond home care through small autonomous teams with a remarkably high level of patient satisfaction. So you have become a little bit of a legend in self-management. So thank you so much for joining us today.

 

Jos 

Yes, thank you.

 

Simone Cicero

So basically, instead of building more layers of management and control, you choose a different path, right? You choose to simplify the system. This is a consistent message in your work. And in the conversation today, I would really love to unpack the lessons and what can we generalize out of the specific experience that Buurtzorg has been.

 

As a starting point, think I want to say, as a conversation starter, I want to use one hook that came to my mind as I was preparing for the conversation. Essentially, I used to use a slide of yours when I did presentations with your face. It’s from one quote that I took from you at the Drucker Forum. 

 

It was in 2019. When you said something that stuck very much with me, you said, “we transform bureaucracy into software”, right? So that was, I would say that is still is a very characteristic, a key characteristic, let’s say of your adventure at Buurtzorg. So I would love to start from this.

 

What does it mean to transform bureaucracy into software? And what is the role of this into a more general transformation that helped your company to become what it is today?

 

Jos 

Yes, I think in many industries we are faced with a lot of bureaucracy. I think that if you look at the book of Gary Hamel, for example, Humanocracy, we see how much time it costs, how much money that takes, but most important, how it frustrates people in their daily work. So if you have to do things that are not meaningful, or you don’t even know why you’re doing it because somebody’s asking you to do it. That’s taking you away from the things that are really important. And in healthcare, the patients are the main focus. So what we did, bt we I mean, a friend of mine who designed the whole IT strategy and the software. So we also started the software company.

 

And he said, if you are able to support the daily work of everybody by developing software that is meant to support this, then we can reduce the bureaucracy enormously. But we had to do a few things for that because it’s in the systems we have, and especially, healthcare systems are usually very complicated.

 

You have to have a vision on how to deal with the accountability, for example, how to comply. So you can’t just do anything. You have to think about how to deal with institutions like you have to have insurance, have the inspection, you have the ministry and you have to be accountable for the things you do.I think because of also the experience I had in healthcare, we were very smart in how to simplify all the things in a way that translated into software was not that difficult.

 

But we couldn’t find it in any company. So we had to build our own IT company because it was based on this vision how to take away the mindless things from your work and translate it into software. That was one thing. 

 

The other thing is if you have information, then the idea is that you should use this information and I mean the information you need for example for billing or for the salaries or for other reasons. Then it’s also good to think about how to integrate everything in a way that if you just register things once that you can use it for these different purposes. 

 

There was a second thing, so that. So this kind of integrative thinking and turn mindless things into software hand in hand. What we and I think even a third element was also very important is that we say, you see that so-called supportive parts of the organisation are usually not felt as supportive. People think it themselves usually if you have departments at the office, the financial department or the quality department or whatever. So we said we want to build a back office that only does what’s for the teams we develop. So we try to reduce the amount of people at an office because the dynamic that comes out of an office is always much more complicated than you expect. And usually people, beside management, people at the back office.

 

are going to create rules and regulations and all kinds of things that people have to follow. So we said that’s a risk. It’s this philosopher Habermas said that this is the self-determined fact of people who have a job that’s not directly connected with delivering the service. That is, they have their own dynamics. They think they’re helping people, but actually, they’re creating all kinds of bureaucracy and rules that could be avoided if you don’t have these people. So, we have to be very careful and that’s also the reason that I’m very critical about management, because management roles also have this kind of impact.

 

So this philosophy on these three different things like how to deal with mindless activities, how to deal with bureaucracy, how to deal with the back office and how to avoid the necessary complexity in the organisation led to a way of developing software that was felt by all the nurses and all the healthcare workers as supportive. 

 

So for the first time, because there are people who have been working in many different organisations, for the first time they said, this is really helping us and we don’t need to do useless things. So we can spend our time on patients and on the meaningful things. 

 

So this is what I think I can say about it. I’m not an expert on software. I’m a healthcare person and I have an economic background. But this is how I look at these things.

 

Simone Cicero 

No, but I think this is extremely interesting. What I perceive from this first framing that you give of the role of the software head in your organisation is not purely a technological element. It’s more like an effort that the organisation weave to understand itself, the process, the context, the basic elements that run the organisation. Maybe there is a unit, there is an invoice, there is whatever. 

 

And then there is another part of the work which is about compliance and processes that are specific to your business. So I guess that you also had to update this rule engine, let’s say, as you moved into other business opportunities. And this is something I would like to discuss later. But I think this is an extremely interesting bit. It’s saying there is a part of our job that if we don’t automate and understand very well the role of, it tends to become a bureaucracy, tends to justify itself with many, many things that are not needed. So maybe we have to make this effort. 

 

And this is a good lesson for everybody listening here. Maybe you have to take a moment in your organisation to understand what runs in the back office, clarify that, and automate it as much as possible so that people can do the real work. And this is really interesting. 

 

We had a conversation with Lee Bryant a few months ago on the podcast, and we encourage our listeners to go there. And he said something that is very resonant with you. He said, in an organisation, the platform is what you can automate. And I think this is really interesting and resonating with you. unless you want to add something to that, there is another nuance that I would like to ask you, which is also something that was very interesting for me while listening to your talks. 

 

There is another thing that you don’t do at Buurtzorg, and it’s strategy, right? At least this is what you say in some of your talks. You keep saying, we don’t do business strategy decks. We don’t do plans, strategic plans, right? Am I right? So together with the bureaucracy that you put into software, there is another thing you don’t do. What does it mean to have an organisation that doesn’t make a lot of strategy, instead evolves in a more natural way.

 

Jos 

Of course, we think about what’s wise to do for the coming years. So what we do is to have dialogues with everybody. we build a platform where we set the principle, the idea is that communication should be horizontal. So you should talk with each other on an equal base and you should keep on doing that all the time. So that’s, it’s a kind of an ongoing process that if things are happening in society that have impacts on what you’re doing, you talk about it. 

 

The other thing is more that if you talk about healthcare, that’s sometimes a very complicated topic because you can look at it from a business perspective and you can look at it from a public society perspective. And when you do the second, so when you look at things from an ethical public perspective, then what I see is that it leads to very different discussions. And then you can, for example, the theme of prevention. If you have an idea about, you should focus more on avoiding healthcare problems. When they are there, of course we want to help people, but we also want to people live healthier. What can we do and make this just a discussion between all the teams and the nurses and we have all kinds of conferences where we talk about these things, but we don’t call it developing a strategy.

 

And what I think what would be helpful for a lot of organisations is make this kind of strategy development not an isolated process. So we usually we think that the CEO or the management or the special people are needed for developing strategies. 

 

What we say is if people want to feel or need to feel ownership about what’s happening in the daily environment and the daily work, then they should be involved with the talks. And usually that’s not seen as strategy, but it is fairly strategic. We don’t make these strategic plans. So what I want to point out is that all these plans have a dynamic in an organisation that people are going to listen on it and respond to it. But we said no, everybody should be part of, as you can say, making a kind of a plan, but making a kind of an organic way to move forward. 

 

And we are still, we are now existing for 19 years, almost 20 years and we are seen as a front runner still. So we are always the first that come with ideas in how things can be done differently in the healthcare system. So, but it comes from the daily experience of the people who are working in healthcare. So we have a very close connection between talking to the ministry at one time or the health insurance and the connection with the patients. 

 

So in this distance, in many organisations is very big. So you have on one hand, people who have to go out to another country, even sometimes to have a strategy week or a strategy weekend or whatever. And I think it’s, it’s silly and it’s helping the company at all.

 

And it’s creating more and more distance and more and more, I think, detachment of belonging. So if you say, so if I talk with the nurses that feel that they are part of something bigger and that have influence on what’s going on.

 

Simone Cicero

Buurtzorg has evolved towards more of a portfolio of initiatives within the years. Right now you have different business lines, if I understand well. And I’m curious to hear from you because, of course, I like it. We also are prominently advising companies to make innovation happen at the edge of the organisation, not as a centralized strategy process, rather as a collective you know, maybe something that you have to sustain the edges to create. So I’m curious to hear from you. How do you fit, let’s say, these emergent outwards focused employee focused approach to strategy and innovation and portfolio development together with things like, you know, capital allocation or entrepreneurship? 

 

So for example, who creates something new in your organisation? What kind of skin in the game do they have? What kind of incentives do they have to become a little bit more entrepreneurial, maybe than the usual employee that is still very entrepreneurial in your context, but maybe running some more consolidated parts of the business?

 

Jos 

Yeah, yes, can tell several things about it. I really think that if you look at behavior of people, that the psychological and sociological incentives in the environment have a big impact. We really underestimate that. If you ask just people how they think about developing something, then the brain starts working differently than when you’re telling them your ideas. So you have to find a good way. In my opinion, my vision is that people are in a certain way entrepreneurial in their daily life. So they have to find out how to deal with the daily things. They have to make decisions about their house, mortgages, schools for the children and so on. So you should use this kind of experience also in the workplace and if you perceive it like this, if you do it like this, then you see that there’s always, you always have a group of the most entrepreneurial ones.

 

So there is always a group that wants to move forward, that wants to participate. So that’s also a very useful group to discuss the first ideas, but when we start something new. So we started several new companies and then there’s always the same kind of process that you say, okay, we have a kind of an idea, also kind of a design that’s based on the same principles as Buurtzorg. And now we have to see if it fits the logic of the people who are doing this. 

 

So how can we create a logic process that leads to the same successes as what we have in Buurtzorg. So for example we started a mental care organisation with psychiatrists, psychiatric nurses and psychologists, and the dynamic in these teams is quite different from what we see with Buurtzorg.

 

So it’s very interesting to see how it fits there and how we can build it in a way that people feel the same kind of ownership as they feel with Buurtzorg. So we started with again, a kind of a design with the same elements like voting bureaucracy, professional ethics, not making financial incentives too important and self-steering, a self-steering organisation. But the things that are really different with the Buurtzorg are, for example, that we made it a steward-owned organisation. So the Buurtzorg is a foundation.

 

And the idea was how do we make this kind of this organisation sustainable? And we thought, okay, if we need capital for this organisation, partly we invested as shareholders. So I did it together with a friend who was a psychiatrist, took 50 % of the shares, and we said, okay, we do the first investment.

 

And then we’d come to find out what’s needed to build it. And then we got, because it was also growing very fast and we needed seven, eight, I think 8 million or so. So if to be able to pay for, to finance the growth that was. And we found this very exciting idea about steward ownership – So that people give a loan, but the company doesn’t belong to the shareholders, but the company belongs to its own. So, it’s the idea is that there is money to grow, but when there is enough profit, it can go back to the people who invested. 

 

And the next stage of the company is that it’s from its own. So I don’t know if you know the concept of the your own.

 

Simone Cicero 

Yeah, sure. Basically the company buybacks its own equity, essentially, just to clarify to the people that are listening.

 

Jos 

So we’re now in this process, which is very interesting. I am now a steward of this company. So I moved from shareholder to steward and the growth is going on every year we make next steps. The stewards now, because there are more stewards in the company, they’re thinking about, okay, what do we do with the profits? 

 

Because if if there’s more profit than we need, we can spend it on education, we can spend it on an extra bonus or extra. So that’s an interesting thing to see that it works out well in a way that it’s not commercial, but it gives the entrepreneurial attitude an extra incentive.

 

So that’s what I see with this. But every time again, when we start a new idea, we have a first design, we have an idea how the first parts of the process can look like. But always, we start talking from the beginning with these people who are in the front line. So it’s always the people who are, it has to follow the logic of the work.

 

And I think that would be if you talk about schools or education, if you talk about safety, police force or whatever, it should follow this kind of logic that people based on their profession, on their background, think that this is the best way to deal with the topics in my daily work.

 

Simone Cicero

Just curious of one thing, these stewards that sustain the creation of these new, let’s say, units in the organisation, are they often the people that actually also run the enterprise or are just external investors?

 

Jos 

No, no, there are people from the organisation. So there can be a psychiatrist, can be a psychiatric nurse. So at the first time, I think two years ago or three years ago, for the first time we had elections. So then people can say, oh, I would like to be a steward and I would like to think about these things. And then they represent their colleagues.

 

So, but we try to always to do it on different levels. So every year we have a conference that I think 80 % of all the people who are working there are coming and joining. So then we collectively, we discuss some of the topics that are relevant for that moment. And then during the year we have, I think four sessions with the stewards.

 

Simone Cicero 

That’s an interesting, very interesting approach. You have this kind of shared code, let’s say, that powers all these initiatives. I think it’s really playing an important role in ensuring that the organisation builds something that resonates with the system. So it’s more like you set this code and whatever we can build in social services or public services or something like that, it’s resonating with the rest.

 

So I have another question that I wanted to discuss with you. You always say that it’s about listening, it’s about simplicity, it’s about not changing things that go well. You have a very holistic approach to your business development and running. 

 

So a question that I wanted to ask you is in this framework, that is very holistic, very natural. What is that in your experience cannot be self-managed. If you look at your role at Buurtzorg, and the role of people that are similar than you, maybe they are not managers, but for sure you are the founder. So what is that cannot really be self-managed in an organisation?

 

Jos

Yeah, I would, I I think I would give it another, I would address it in another way. think the starting point for me is always what, how can you create as much as possible space for the things that can be self-managed. So if you look at the daily work, and it’s based on my own experience, I’ve been working for many years as a nurse. So I know very well what you need to do your work in the most optimal way. And so my ideas that if you have a team of people who have the same ideas about their work, and have the same logic behind it, that in their daily work, they can organize everything. So they can hire their own colleagues, take care for all the patients they need, they have their network with the doctors and the hospitals and they can arrange really everything. It’s often very underestimated what people can do. So I focus as much as possible on what they can do, not what they can’t do. Then there are some processes in every organisation, I think, that are asking for protecting this. 

 

So, and you know, the outside world, like regulations, there are many, many regulations that leads to bureaucracy. So how do you avoid that this is influencing all the time this process in these teams? That are the things that you need some people and I saw that office as my role that you’ll say, okay, if you want to keep these conditions, then you need to do something to this outside world. And there are just a few people who were involved in that. 

 

So mostly I did it always, now my son, we do it together, because he’s taking over.

 

Simone Cicero

So you mean new initiatives, outside growth, I did it very well, so more growth for the organisation.

 

Jos 

No, no, I mean more the inspection, the ministry, the systems in the healthcare. They develop all kinds of new ideas that goes hand in hand with bureaucracy. 

 

So they said, for example, they think that other things need to be registered and then a lot of organisations just do it. And we say, no, we only do it if it’s useful to make this decision and to create a kind of an opposition to these parties who want us to do that, that’s a role that not many people can do. And of course, if you look at the back office, we said there are things that are not in any way useful that they are done by the teams in the field. 

 

So like the administration of the salaries or the administration of the contracts or the billing procedures or so on. So we have special groups on the back office who doing that and they take away the burden for these kinds of things. You should not want that this is part of the daily work. So we create things that makes the daily work easier. That’s done partly by also the IT part. 

 

And all the time we follow, but we ask also, just the teams, we ask them, what else do you need? So from a management perspective, usually it does the opposite. So you have assumptions about what people can do or can’t do, and then you’re going to so-called support them but you don’t ask them first if they need it. Then one of the main principles is still the Needing principle. So don’t do things that are not needed. So and if you look at in total it and you see how many people are working for Buurtzorg and how many support we have, we have the lowest support compared with any company. 

 

So we did some benchmarks and some research and you see that, for example, in the Netherlands compared with other organisations, it’s only 10 % of the…

 

Simone Cicero 

You mean support related overheads in the organisation.

 

Jos 

Overheads in the organisation. So it’s 10 % compared with the other organisations. So and, and the thing that’s, that’s very nice is that it’s the teams, they experience it, like they have more support than ever. So the funny thing is you have only 10 % of the support that other organisations are having, but management structures and back office and other overall. But at the same time, the perception of the healthcare workers is that they have a lot of support. And the support they have is very functional. They can, it helps them to do their work in the most effective way. 

 

If you look at, we did last year, a benchmark on these things and you have something like the Net Promoter Score. And I was surprised that in the Netherlands, similar organisations who deliver what we also do, they have a Net Promoter Score of 4%. And I thought, how can that be so low? And then I was, of course, curious what that was with us. And the Buurtzorg has 66%.

 

So most of the nurses and most of the patients, are advocates working for Buurtzorg or having the healthcare from Buurtzorg. So it’s funny to see these are not small differences, they are very significant differences. Engagement, for example. So the thing that you see that’s a big problem in the world, if you see that Gallup is doing they’re saying the engagement is how is it 20 % and it’s within business 92 % of the people feel engaged and it’s all part of a kind of a culture where you talk about the things with each other where you were horizontal things are much more important hierarchical things and the brains because that’s why I said why should you only use the brains that are in the office or in management, that you say, no, we have a collective brain. So all the people are thinking and feel responsible. 

 

The funny thing now we have the last week, the Netherlands that’s not happening so much, but we have a lot of snow throughout the country. And what happens now is what is on television is that whatever got stuck, the traffic or whatever, home care, home nursing just goes on. And what do we see in the news? Every time again, you see an Buurtzorg nurse there and a Buurtzorg nurse there and they’re talking about their work. They said, we don’t have a problem at all. We just find ways to do our work. 

 

And even in the north, there were some people who organized some farmers to take them to their work in a tractor. So, and you see that…

 

Simone Cicero

It’s probably out of policy, right? But it does the job. Yeah, yeah, I’m joking.

 

Jos 

No, we don’t have a policy. It was the same with COVID, with Corona. When you have these dramas, we heard from a lot of people that it looked like everybody got in panic and didn’t know what to do anymore. Only these nurses of Buurtzorg just found their way and moved on and developed ideas and knowledge. The nice thing that we saw was that they shared this knowledge.

 

So the first team that had to deal with this corona, she had the knowledge with the other teams. So they already knew what they found out so also the knowledge sharing goes much and much faster than in a traditional organisation.

 

Simone Cicero

Was there any, I mean, first of all, I want to underline one thing. It looks like that your work is, there’s a lot of understatement, you know, that you try to say, you know, it’s very simple. It’s about keeping it simple. It’s about just protecting the vision, listening. But that’s a lot of work. No, that’s very important work. It’s crazy how much companies do not do that. So don’t invest time, energy of the leadership into keeping it simple, sticking to the vision, protecting the vision, sticking to the culture, listening to the people, what they need, create the things that people need in the organisation. I think this is a really important point that I want to stress. It’s simple work, but it’s very important work. It’s hard, simple, I would say. So I think this is worth saying. 

 

One question I have for you, was there any time in your organisation where you had to say, “No, we don’t do this. We’re not doing this because this is not our business. This is not what we do.” So did you have to exercise maybe your creative leadership, the role of yourself as a source of this business to constrain a bit the direction maybe?

 

Jos 

Yeah, no, certainly there is. You have to be honest and clear about what’s possible and what’s not possible. But you have to do it in a way that you have a good conversation about it. So it’s not, it’s never, it’s never working when it’s an instruction.

 

So you said you have to, you need to have a dialogue and you need to organize the time for the dialogue. If you know, if it’s logic, people will really say, okay, we understand. We understand that this is a part of how we should deal with things. And so I always did once in a while in a few years, I made it around throughout through the country invited people to think with us about a few topics that were interesting or important for the future. And then we had enough kind of response and enough dialogue to say, okay, if these people who are there are representing their teams, then probably everybody will think this way. 

 

And if we didn’t know that, we just checked it. We put a post on our platform, we asked for reflections. And sometimes we had hundreds and even thousands reflections on things. And then you see that as long as you’re honest and open, and you are talking in the language of the people we are working with, then you’re surprised in how easy it is.

 

But what we do often is, in many organisations, we use a kind of a management language that people are afraid or perhaps not afraid, but a bit conscious about what do they really mean? And is this a way to get us somewhere where we don’t want to be? So management is and steering in the word steering.

 

So we have to, I always said in Dutch it’s called “aansturen”. So then it looks like you put a steer on somebody and try to move them. I said, it’s crazy. This is not in any way based on the philosophy that you see this person as a real autonomous person. 

 

And as soon as you do that, then you see that all these persons also have lot of wisdom and brains and they almost don’t have surprises throughout the years that we say, what a calamity or what a terrible thing that happened. 

 

So mostly I’m surprised by all the positive things that happen without all this steering.

 

Simone Cicero 

That’s great. So we are approaching the end of the conversation, and we have finished our time. So I wanted to ask you maybe just as a closing to share, since you are so inspiring to some of the people that have been listening to this conversation, I’m pretty sure, maybe what inspires you, what has been your inspiration during the years, if you want to share what we call the breadcrumbs. So anything, books or even theories or ideas or people that people should be checking in.

 

Jos 

Yeah, yeah, I myself was very inspired by Professor Nonaka. He wrote a lot of books about knowledge, tacit knowledge, and knowledge management. And, but I think what we throughout the years forgot, I think, is to use experiences of people tested knowledge that they learn in their daily practice and integrated in the way you build your organisation. 

 

So we focus too much on efficiency, for example. and efficiency leads to processes that people don’t do the things anymore that they would do if they have the space. So Nonaka, I met him a few times in Tokyo. He died a few years ago, but he was a very, very wise man. And he talked about practical wisdom, about intuition as a tool and tacit knowledge. So that’s for me a very important thing. Then, I’m mostly inspired by philosophers that are looking at the world on a more abstract way. So there’s a Dutch one called Arnold Cornelis, and he wrote a book, The Logic of Feeling. So he said, every, every person in the world is born self-steering. You want, you want to have a say of your own development. You want to be the person that you are.

 

And these ideas about what does that mean for example for education programs but also for organisations that people can keep on developing themselves in their daily work and based on that be as productive and effective as they can be. And then they go home with the feeling that they have done a very meaningful thing that they talk about it with their children, and their children also want to become this kind of person. it has a big impact. Then the whole idea is about ecosystems. That’s, I’m doing a project now myself, the last one before I retire. It’s called the neighbourhood as ecosystem. So how can we change patterns in society, that health and healthy behavior becomes more visible and in a way that people are also supporting themselves in that way. And that we create neighbourhoods and environments in the neighbourhoods that are stimulating healthy behavior. These are all things that I feel that I have a connection with it. And I really think that it’s helping people, but it’s also helping organisations to develop in a more positive way. 

 

And it takes away the stress, you know, we should be more relaxed. There’s too much pressure on everything and we put and the other person puts pressure on the other person. And they’re both dissatisfied about that I have to work under such and it’s not needed. Really, you can you can do much more without pressure.

 

Simone Cicero 

I feel like it’s a very natural evolution of your thinking that of thinking about ecosystems based healthcare because at the end of the day, all your work so far in all these years has been about encouraging these natural behaviors and natural inclination of people. And I think when we, and I have learned a lot with that, when we move the post from making something that is maybe economically viable into something that generate outcomes and real outcomes for people, I think we are really going towards this idea of continuing this path towards what’s natural for people, right? 

 

So I think, as you say, building institutions, organisations that can cater to this natural set of outcomes that people want, healthcare, not money, right? People don’t wanna make something economically viable. They wanna make something healthy.

 

So I think this is really resonating with you, your work, your heritage. And I encourage the people that are listening to follow your work, especially this latest project that you’ve been talking about. Thank you very much. It’s been very inspiring. And I hope you also enjoyed the conversation a little bit.

 

Jos 

Yes, I did a lot. Thank you. Thank you very much.

 

Simone Cicero

Thank you so much. For our listeners, of course, you can head to the website, boundaryless.io/resources/podcast. That will be this conversation on top of the page with all the links, the things that you also mentioned. Yours thanks again and to our listeners until we speak again, remember to think Boundaryless.