The Buurtzorg Model with Arnold Stroobach

Self managed teams, 10 to 12 people in a specific geographic area and their specific role or goal in the world is to care for aged people. And then the idea of keep it small, keep it simple. If we talk about 9, 000 people and 45 back office staff, it must be a picture of simplicity. Because you can’t, implement anything complex with that fewer people to run it. So you’ve got this constraint based model where it has to be simple or it just won’t get done. 

And then you talked about economies of scale. So we bring in economies of scale and we bring in bureaucracy. I think about somebody I know in aged care In New Zealand, it’s dominated by big private companies. And if you think about the way people in retirement homes are fed, it’s economies of scale. They make it off site and they ship it to the site rather than having a small group of people serve their community. And so what happens is we get bureaucracy. We get other people deciding what the food is. We get other people deciding when it’s going to get delivered. It’s never delivered on time because there’s always a problem. So the system breaks down. 

I love the idea of coaches instead of managers and in this model, the coach is still a medical practitioner. They still been on the field. They still have that same goal and vision. I’m intrigued by how many teams they’re coaching because that builds a constraint based model where they don’t become a delivery manager because they just don’t have time. So with that simplicity we have to remove waste out of the system. 

And then you talked about this idea of adopting useful patterns. This idea that when everybody sees us working, everybody else is jumping on and going how do you deliver at that cost? How do you deliver it at that efficiency ratio? How do you deliver it at that margin or profitability or that success? And everybody wants to adopt it because it just makes sense. 

In New Zealand our culture of government is bureaucracy, hierarchy. I’d hate to find out how many people in our care organizations and government are frontline staff versus back end office workers. 

And then how do we scale? We just split the teams. And we just keep doing that. And if we’re going to design something, it has to be able to handle 5, 000 people, not five, because we know we’re going to split. 

And then the other one you talked about is reforming the team. So when a new set of skills come into the team naturally reform to say where are these skills fit? Not what’s the role. How do we adapt the team so that the work still gets done with it and we leverage that new skill. 

And then , I’m really intrigued about the rotation of informal roles. So you talked about planner , advisor, back office liaison, office housekeeper. The welcome, the onboarding of clients. The mentor for any newbies that come in. You naturally are a frontline worker and a team player and 85 percent billable. So this idea that you have a primary set of things you do in the team and then a secondary thing, but everybody does them. It’s not like the old hierarchical organization where one poor person gets left cleaning the kitchen because nobody puts their dishes in the dishwasher. By rotating it and by making sure everybody has those informal roles, there’s a sense of equilibrium and balance you talked about.

I can see how high performing teams adopt those patterns. But I can also see, especially in health, how very few organizations or countries do

Read along you will

Shane: Welcome to the no nonsense at your podcast. I’m Shane Gibson.

Murray: And I’m Murray Robinson.

Arnold: And I am Arnold Strohbach.

Murray: Hi Arnold. Thanks for coming on today.

Arnold: Thank you for having me.

Murray: We want to talk to you about Buurtzorg, which is a famous nursing organization from the Netherlands, which has almost no managers. Could I get you to introduce yourself to our audience to start with?

Arnold: My name is Arnold Strohbach. I’m originally from the Netherlands. After medical school I specialized in medical informatics, which is technology applied into medicine. I have been working in that field till about 2004. In 2005 I started working in Australia as the CEO of technology parks in Perth. Helped with startup companies biomedical funds international connections. And from 2008 to 2018, I was the Dutch consul to West Australia helping with economic development between two countries. At the end of it I was involved in Buurtzorg from the perspective of Australia. So the NDIS organization and the Royal commissions went to the Netherlands to visit Buurtzorg. And, the Buurtzorg model is based on another Dutch model from the organization BSO that started in seventies, eighties and nineties. And that was the first company I worked for. So for me, it was homecoming and knowing the model .

Murray: Arnold, talks about BSO a number of times in this interview, and we didn’t really ask him what it was, but I think it’s relevant. So I’ll just read you what corporate rebels has to say about it. BSO origin was founded in 1973 in the Netherlands by Eckard Winston as an it company. In the 20 years that followed the company grew to employ around 10,000 people across 75 cities in 20 different countries. The company’s progressive structure was based entirely on self-managing units, internally dubbed as cells that would divide themselves after growing to a certain size. These entrepreneurial cells were divided based on geographical areas. There was almost no headquarters, nor people serving in staff functions. Although BSO Origin doesn’t exist anymore, it was later acquired by Phillips, the cells model is still practiced by several other Dutch companies, including Finext, Rebel Group, and perhaps most notably, Buurtzorg. 

So what is the Buurtzorg model?

Arnold: The most visible bit is the self managed teams. So we work in teams of 10 to 12 people in a small area. So Buurt is a Dutch word for neighborhood community. And zorg is a Dutch word for care. We call it here Neighborhood Care 

The Buurt is very important in the Dutch social fabric. So everyone lives in a Buurt. And a Buurt is your neighbors, the local IGA, the local butcher. It’s the small ecosystem where you live And what is expected from you that you give and take in the Buurt. That is expected from you, that you put in an effort to get to know your neighbors. To help assist whatever you can with each other. And so if I go to the IGA and I notice an elderly person living across my home, I ring the bell and say right, I go to the IGA. Can I get you something? It sounds a bit La La Land, but it’s still happening in Holland. 

So when BuurtzOrg started immediately everyone understood they stood for the care in your neighborhood, your small ecosystem. And that’s the whole basic idea. So to keep it small, keep it simple is one of the slogans of Buurtzorg. A small team in a small area. So the area knows the team and the team knows the area.

Murray: How does that differ to standard medical delivery models? What was the problem that they were trying to solve?

Arnold: Yeah. The problem that we’re trying to solve is that 20 years ago, all kinds of changes in health sector. The aging population. The move from aged care homes to home care. So how do we continue funding that and how do we do that and also keep the quality of life. You get some medical issues being old but it’s not a disease being old. So how do you stay connected? How do we get quality of life, early intervention, prevention happening?

The problem was that the demand was becoming more challenging because of the aging population but also because of what we medically are capable of nowadays. The cost went relatively more and it’s unsustainable. So how do we get it back? 

The response then was economies of scale. So the organization become bigger and with that bureaucracy started happening. In the old way of organizing with layers of management and a lot of instruction going down the hierarchies and reporting up. The head office became bigger and bigger. 

More managers who were a professional managers and no health background. So non health people, not knowing clients, not knowing their Buurt where they live in, instructing health professionals who know the client, who know the Buurt. And also the management thinking is that getting someone out of bed, anyone can do that there can be a lower rate person. Or the nursing bit. We need a registered nurse in that wound care. The result was that sometimes four people a day went through the doors. And often it didn’t make sense. So it went very inefficient and very difficult for the elderly person. 

So something different needed to happen. 

And Jos de Blok, the founder and the CEO of Buurtzorg and four others were all executives in those big organizations. And they said, it’s just nonsense what we’re doing. We try to repair something on the left and it falls over on the right. And you don’t know what to do anymore. So we just have to reset everything. We have to redesign. We have to rethink what is it all about what we’re trying to do. 

And they took a starting point, the front line. Because in the end, it’s someone who needs care and support and someone who can provide it. That’s the starting point. And just like Australia, Holland embraced the person centered care model, which means building up relationships. So you can’t have 10 different people all the time. You need a small team around this person, get to know each other because everyone is different and every day you’re different.

And how do you do that? How do you get that intimacy in the sense that you know what you’re doing? No more, no less. How do you do that? Because often decision making is done somewhere else.

So the whole idea is building up relationships and let the teams make most of the decisions themselves. And that’s where that self managed team come from. And that is very powerful because a team of 10 people can do a lot together. If you know the clients very well then it’s about quality of life and what is important to the person, what they can do with it. There’s no managers involved in that. Those kinds of things are done by the teams. Of course clinical governance is everywhere. You have to organize that. When they’re registered people, nurses and therapists, they know what to do. You don’t have to tell them what to do. It’s about letting go. 

So, to make sure that it’s not becoming anarchy it’s very important you got good system supporting that. We have coaches instead of managers. And the coaches are not the boss of the team. They are like an independent cluster who help with the team dynamics. Team can get stuck or you can have arguments that’s hard to resolve or chemistry is changing. So the coach to make sure that team health is guaranteed. 

And that makes it quite different, especially in a bureaucratic environment like health. It’s community money. And it’s lots of money. It’s billions. So how do you manage that as a country? In the end, is this person who needs care and support? How do you make sure that the dollar that’s meant for that person is mostly spent with the person and not in admin. At the same time, keeping it safe. Do the right thing and there’s quality and there is control about the processes. And that became the Buurtzorg model.

Shane: So I just want to understand the scope of what happened in the Netherlands. When you first started I thought we were talking about an hospital or an organization. And then as you talked, I got the impression we’re talking about a system or a model for the entire health system in the Netherlands rather than just for an individual hospital. Is that right?

Arnold: It’s more for the home care side of things. The hospitals are the second line of health. It’s a very complex place. Community care is different. Home care is happening of in the place where the person lives. And that is the movement to make it sustainable. To do as much as you can, where the people live Hospital is very expensive, very complicated, also a dangerous place. So it’s an intervention place. You go in and magic happens, and then you go out as quickly as possible. And then the aftercare starts. 

The first line is the GPs, but also nursing the head of district nurse. But the shift to get as much as done in the home or in the community that is important because that makes the systems sustainable, but also that is what people want. For quality of life it’s just way better than being in a hospital. 

Shane: But it’s aged care across the entire Netherlands is what it’s managing right? 

Arnold: Yeah, it became so successful in a very short time because the government got interest in it. In Holland, it healths a different organized. It’s a lot of outcome measures everywhere. So the government could see things changing. So why is it changing? And it was every time to do with Buurtzorg organization. They did more trials and a KPMG report and it became 40 percent cheaper. And that was a very interesting phenomenon. So why is it cheaper? And one of the things is you cut out all this middle stuff and let professionals do what they’re good at and no more, no less.

In the European Union, you have PROM and PREM. Patients recorded outcome measures and patient recorded experience measures. This is compulsory. So you have to do that. And if you look at the outcomes, they were really superior, but also the client satisfaction, was always like 93, 94%. No one had that. And where is it coming from? And so great outcomes, how people wanted it, 40 percent cheaper. That’s a dream for any politician.

So when that happened more organizations were interested. So how do we do that? How do you get this outcome? And so politic jumped on it and they started spreading that model. And so other Buurtzorg helped other organizations who were interested to organize it like that. And nowadays it’s the default model for home care. 

Shane: Okay, and it’s a decentralized model. So we have self managed teams of 10 to 12 people that have a geographic boundary around the neighborhood and they’re caring for that neighborhood. They’re empowered, self sufficient, But rather than bureaucracy that tells them what to do, there’s a support system to help them do the right things. So a decentralized model for all age care across all of the Netherlands. 

Arnold: Exactly. 

Murray: So what proportion of the aged care community market has Buurtzorg got now in Netherlands? 

Arnold: About two third. It’s massive. It’s 16, 000 frontline people and their nurses and therapists and some support work. And more than a thousand teams. The population of Holland is 18 million. So a little bit smaller than Australia. The size is smaller than Tasmania. So it’s a big proportion of the market. And so you see also the growth plateauing because I think 70 percent of all the the professionals working in home care work nowadays for Buurtzorg. So it’s very hard to grow, but it’s still growing. 

Shane: How much of the success do you think is based on the culture of the Netherlands? That culture of community responsibility? 

Arnold: It’s a good fit for our culture. For Holland, the default model is a flat model. The governments and big institution, they have a still a traditional hierarchical model with layers of management but most of the organization are quite flat with a lot of responsibility and very dynamic. Everyone works in a team and if another team member comes in, then that will change your job. So the agility has been there for quite a while. That way of working is not strange. 

BSO started in 1978 and they had cells were a bit bigger, maximum 30, 35 people. And if the cell had to become bigger than they would be cell splitting like biology and became two cells. And so that company was quite quickly, 12, 000 people. And if you did an MBA in Holland one of the organization model is always the BSO model. Nowadays it’s the Buurtzorg model. What Buurtzorg did, taking the base of the model and make it more more modern and more extreme. So from 35 to 10 to 12 people, more catered to health. Even more liberty and freedom to operate and more responsibility. And so it’s just a step up again on that model. But it’s quite common in Holland, so that helped. too.

Murray: How does the funding model work for services? Because traditionally in Australia, America and in England, the government sets a price for a service to be delivered, such as getting somebody out of bed, we’ll pay 80 for that. And I know John Seddon at Vanguard said that it’s led to incredibly fragmented care with very big call centers and very high administrative costs driven by the funding model. That funding model wouldn’t work with Buurtzorg so how does the funding model work.

Arnold: In the Netherlands health also been trying to avoid is false economies. The driver is efficiency but if you look at the total system you can see it’s so inefficient. How could it be efficient if four different people come through the home, travel up there. Do the staff have to read what the other one had done. Have to report sometimes different organizations. This can’t be efficient. It is not efficient. And it doesn’t provide the quality you need. 

I think the main difference between the Netherlands and Australia is the registered system. If you’re a registered person, you can make decisions. And I’ll give you an example. 

My parents are still alive. My dad is 92. My mom is 89. But my father has Alzheimer’s we know now. In 2019, I was in the Netherlands and I visited them and I was not sure. I knew I would be back in Holland in April 2020. So I thought, you know what I’ll have a better look. But then COVID happened. Couldn’t go back to Holland for the next two years. But I got a call from his GP like a year later. And he said, yeah, your dad, I don’t think they’re functioning anymore. So you need some home care. It was nine o’clock in the morning, Dutch time. So I called a provider in the town he lived. Unfortunately, Buurtzorg wasn’t there. So I called the competition and they work also in the Buurtzorg way. And I got a nurse on the phone, registered nurse from the local team.

And I explained the situation and that I live in Australia, so I can’t get to the Netherlands, in the COVID circumstance. And they said, no worries, let me have a look. Okay, she said, I’ll swing by around 11 o’clock and I’ll call you in the afternoon. I’ll check them out. Indeed. I got a call back early afternoon and she said, yeah, I swung by your father did the assessments. And we’re going to do this, and this, and we start tomorrow. I was so relieved that I don’t have to go to find a package or go through a process. No. You just call a registered person. They do the assessment and it’s funded a hundred percent. It doesn’t cost you anything. You don’t have a mean testing in Holland. Health and medication is free for everyone. Hospitals is free. And if you talk about efficiency, this is efficient and he got what he needed. No more, no less. That’s the problem with any package is too much or too less. That’s never what you need. And also my father sometimes had good days and sometimes he had bad days and the bad days he needed more than the good days.

Sometimes a nurse came in after five minutes. He thought, no, all good. I’m out of here. And so that’s it. And that’s the power of that system to use registered people. It’s their registration. They have to keep it alive. They have to do the right thing. They have to explain themselves. It’s not an organization’s responsibility. And they’re busy. They’re not going to drink coffee for two hours because they can. They can’t, they don’t want that. They’re in that profession for a reason. And that’s also where the trust come from. And government also have to let go. And they did. And that worked out fine, and it has good results, better results. And it became more efficient and more cost effective. 

And also it became a more attractive sector again. What happened in the beginning, when this organization became bigger and head officers started instructing professionals that didn’t make sense. They thinking, why am I doing this? I’m out of here. I can spend my life in a better way. Universities couldn’t get students anymore. You saw it spiraling down within 10 years and very quickly. And when they started introducing these concepts, you saw it spiraling up again. So it’s a good profession to be in health. You’re a master of your own destiny. You can really contribute to the society and to the community. And it’s sustainable. 

Murray: So it sounds like this model is dependent on having skilled, professional, ethical staff who are not trying to make as much money as possible by doing the least work possible.

Arnold: Yeah. So you can be cynical about it or you can have trust in the people and give them responsibility. The experience I have with Buurtzorg is that they get used to the responsibility and feel responsible for the mistakes, but also feel responsible for the great things they do. 

Working in a real team, like a sporting team, you can really have person centered care. You have this team effect with each other. Almost running your team, like a little business. You keep each other honest. Your team members relying on you, your clients rely on you. You feel that and you can make a difference. And you can see the difference if you do something good, and you see the difference if you do something stupid. 

One of the hardest thing from letting go is that the teams will make decisions, and therefore they will make sometimes wrong decisions, like we all do. We all make wrong decisions. If the organization comes after you like a ton of bricks and slap your around the face because you made a mistake, you never make a decision in your life anymore. 

And so these are the moments. Something is not right or something went wrong. It’s just about how do we fix it? Can you fix it? The person who was involved? Or can we fix it with the team? Or does the coach be involved? Does the backup be involved? Do I need to be involved? Doesn’t matter, it’s not finger pointing who done it. The team have to go through that process a couple of times and then they start think all right. I can do things. And if it goes wrong, it’s not the end of my career . 

And so you see a lot of transparency and openness. We have a very low threshold of incident management, reporting, just whatever you think, just report it, just put it in the system. So you get that early intervention, you get a lot of prevention. 

I think if you go in and out and just do your thing for your paycheck and off you go and perhaps you see the client never again. I think you introduce things that may not be the right thing to do. Especially in home care. If I’m the client and the doorbell rings and I open the door, I’ll try to imagine who do I want to be at the other side of the door. Is it someone I’ve never seen before? Probably I won’t see him again. He’s not happy working in the sector. He’s not happy working for the organization. Doesn’t know me. Is that just there for the paycheck? Or is it someone, Oh, I know exactly who we are, but you’ve been here all the time. I know you love working in the sector. I know you love your work. We can get along very well. And I just know it’s going to be a good day.

So how do I get number two? I don’t want a number one. I want number two. And that’s important for the quality of life. We’re not selling bicycles or something. We’re in human services and the product is dealing with two humans.

Murray: So do the teams manage their own economics and resource allocation and prioritization?

Arnold: Yep. So they plan their own work. They find their own clients. They find their own team members. Backoffice supports that. The coach support that too. They see from a dashboard how they’re fairing. 

And so the parameters are billable hours. you need a percentage to be sustainable. The team managed themselves, and they see the consequence of the choices. It’s almost like running your own little shop together while you’re being employed. We don’t contract as we don’t use agency. Everyone is employed.

Shane: So as soon as you get above 10 to 12 then you split. And another group start up to take up that demand. And then you carry on.

And you can see where a group of 12 aren’t delivering the same value as everybody else. And then it raises the question for the coach of why is that group not operating at the same level as the rest? What do we need to change for them to be as efficient, as effective as providing the outcome of value that everybody else is? Because we can see across a thousand different cells. Where the outliers are and go investigate why. So it becomes self organizing, self forming, self monitoring when you get to that scale. 

Arnold: Exactly. Yeah. 

Murray: How do you measure those outcomes? 

Arnold: It’s a classification system everyone uses. The default one is Omaha, it’s American. It’s from the seventies and that’s just like a taxonomy. So that is helping very much with the whole comparison side of things. And you can see why some things are different than other things and you can deep dive in that. So that’s part of it. PromoPrem is also standard. In Australia. We don’t have that. We don’t have that taxonomy. We don’t have an an Omaha like a system. So our outcome measures is our own way, how we do stuff. We do the client surveys and we do the staff surveys to find ways to compare it. At the moment we do mainly NDIS, we just started in aged care in Australia, because NDIS expressed interest into the model . So we don’t know about the aged care yet, how that’s going because it just started. NDIS work packages and goals and things. It’s harder to measure in an overall system that don’t have any infrastructure for that.

Murray: How do you deal with people who are inexperienced like graduates coming in They don’t have the same level of skills and competencies as the others.

Arnold: Yeah. We don’t have many of those at the moment. We have now an student OT first year working as a support worker, not as an OT but they blend in very quickly. And for a minimum of an certificate three for support work. And for the allied health, we have the more experienced people. So we don’t have a real graduation program yet. We’re quite young and quite small still in Australia. So we have two and a half team here in West Australia and two teams in Queensland. So we have relatively always had people with at least some experience and in qualifications.

Murray: How does Buurtzorg deal with people who are performing poorly? Not because they’re inexperienced, but they’re taking advantage.

Arnold: Yeah. 

The teams are dealing with those kind of things very quickly. It’s like a sporting team. Becoming a real team, you go through the highs and lows together and stick with each other and have feedback mechanisms. So the only way to become a team is to speak your mind and even, confront people. In sports that is common in Australia in the workplace, it’s not. So we have a training like giving feedback and it’s not a personal attack. That’s about trust again, and that will have to grow. And so you don’t become a team in six months time. That takes time to have that culture of giving each other feedback.

And I think talking about early intervention with clients, you also have early intervention within the team. You think something is not right. Every fortnight, every team have a team meeting and one of the points always on the agenda is team health. How are we going? Are there some concerns? You can say, all right, yeah, I don’t think we’re very good at the moment, or I think we need some improvement and we need to talk about it. If you bring people closer to each other a lot of things goes well automatically.

The early intervention and keep it discussable is so important. And keeping it on the agenda every time. How are we going? How’s team health? And you can see sometimes people get a bit quiet. Sometimes I’m also part of a team meeting. I just come in not too much, but you can see it that something is not right. Everyone sees that and then that is actioned. People don’t take it, don’t let it go.

And the coach is very important for the team dynamics to pick it up. The coach has to be careful because they’re not the boss. . So we try to avoid if something goes wrong, you throw it to hr or you throw to a manager, or you throw to your coach.

We don’t have managers. Our HR is very limited and the coach has to be an independent agent. But if the team doesn’t want to then it is getting very hard. I compare with a sporting team. It’s discussed and it’s handled. So far. So good. 

Shane: So I’m assuming the coach stays with the team on a permanent basis. 

Arnold: A coach has up to 45 teams. So even they want to manage it they can’t, it’s too many. So new teams often need more coaching. Very experienced teams need less coaching. So in the Netherlands I think there are about 27 coaches over a thousand teams. So it’s working very well. And the good thing is that you have so many teams to coach with that you have this bit of distance too, and they’re not part of the team.

It’s very important that they stay independent and they can suggest to the team and the team can say, no, we still do it the other way. So the decisions are always made by the teams. And a coach can assist or help. The team can also ask the coach to come along. The team always try to put it back to on as much as team level as possible. So try not try to have all kinds of one to ones with the people. If there are some issues, it has to be discussed in the team. Which is culturally a little bit easier in the Netherlands than here. In Netherlands giving feedback is very common. Very annoying too. 

It’s a bit in the Dutch culture. Feedback is here sometimes seen as a personal attack. In Holland if someone bothers you to give feedback it’s a present. So It’s more on a positive side and here’s a little bit more on a negative side. It’s about trust. You become more befriended. You don’t do it personally or it is not on the person, but it’s for the common good of the team. And it is scary, to give someone feedback because you don’t know what the response will be. So it’s takes time, but also in Australian context it just happens.

Shane: Do the coaches tend to come from a medical background? 

Arnold: All of them. They’re clinicians. In Holland, they’re all registered nurses or therapists. One of the things that is the most hierarchical part, but you have to do it is clinical governance. And the coaches are also part of the clinical governance because they’re clinicians. And most of the teams have clinicians in them. 

Shane: So the everybody that’s working in these teams have taken the medical oath. They’ve decided that their lives are to help people. They’ve got this foundational culture of the medical oath to give them grounding. And everybody else has taken it so they’re self monitoring or self managing or self governing. 

Arnold: Yeah 

Murray: Can I ask you about the percentage of administrative overheads or costs because I think you’re talking about something like 20, 000 people work for Buurtzorg in the Netherlands. You’ve got 47 coaches. How many other people are in central office administrative functions?

Arnold: Yeah. It’s a 16000 frontline people. It’s about 50, 51 people. It’s quite small. We got quite a lot of visitors in the Netherlands. But if you go to the main office it’s on an industrial area. It’s a two story building, very modest. So you get international visitors, they look at the building and they see 50 people. So is this the regional office or what is this? And they said, no, this is it. And then it starts to sink in what it is to be in distributed organization. So this small back office supports 16, 000 people and international because we’re in many countries nowadays. It’s all happening in that little building.

So scalability, whatever we do is very important. Everything we do the question always is, allright this solution works now for five, but would it also work for 5000? If the answer is no, we find another solution. Even it’s very tempting to go for the five and we’ll see when we get to six. No, we don’t do that. 

Murray: So half of 1 percent of your people are in either coaching or admin. And I would think that in a normal Australian organization probably 30% of people are in some sort of management or administration role. Maybe even more. 

Arnold: Yeah. You will be surprised. 

Shane: I was just looking at the website for Buurtzorg and in 2014 it says there were 9, 000 nurses and 800 teams, 45 people in the back office with 15 coaches, 70, 000 patients and 280 million Euro in turnover. So they’ve doubled the frontline staff size haven’t really increased the back office staff. That’s an unheard of scale. So how much admin then do the teams have to do? 

Arnold: Yeah. 

We create six informal roles. One is planner rosterer. So every team rostered their own work. One of the people of the team does the rostering and the planning. 

We have the advisor role. That is our linking pin between back office and the team for the quality of data. Because what we do centrally is mainly invoicing, payroll, and compliance and ICT development. So the advisor does that. 

Then we have a housekeeper. So you need someone who’s taking care of their own office or organizing that has been cleaned and the PPE is there. 

We have the welcomer. And that has to do with the complexities with NDIS to onboard clients. So it’s not welcoming for the staff, but the welcoming onboarding of clients. 

And then we have the mentor. That’s the person in the team. If a newbie comes in, that takes them under the wings and learn them the ropes. 

Everyone has two roles. So one is whatever you do as a frontline worker, is it support worker, is it nursing, is it therapy and being a team player. So these are permanent roles. And that last thing sounds a bit corny, but it’s so important because if you can’t be a team player, if you don’t want to be in a team, you don’t want to put effort in it. It’s not going to work and you have to leave the team. That’s the one that we’ve seen only a few times, fortunately, that don’t show up at team meetings regularly, not really a team player. Oh, can you take over from shift? Always no. It’s those kinds of things that are not taking any effort. 

The other roles are rotating. So you do for say six months and then everything rotates. And the beauty of that is you avoid little kingdoms. For example, if I’m the planner and you were not nice to me this week, I’ll make sure you have an shit roster next week. But six months time is the other way around perhaps. So it’s good to avoid that. But also you need different skills. If you’ve been planning for a couple of months, you need to know more about NDIS and soon also about My Aged Care. How things work. You need to know about broken shifts, travel. Making sure that you have a good routing of your clients.

And so what you can see, the teams are existing for a while. The people they know so much better what the job comprises because of that. And that is the operation side of it those informal roles. That costs some time. But everyone in the team is always billable. And we say 85%, you have to be billable as a team because you have small back office that’s enough to make it work. And for allied health is different percentage because it works differently for nursing too. And for support coordination, a little different percentage. But the sustainability is the dollar and the compliancy. And that’s for every team important and they see it from the dashboard. 

We call it an equilibrium. So it’s a triangle. So on the top, one of the corners of the triangle is the client. The client has satisfaction and also the outcomes, quality of life. The other corner is team health. Because it’s also in the interest of the client that the person, the team is healthy. And so we always looking for two way streets, give and take. The third corner is sustainability. And the role of the team is to balance and find this equilibrium. And sometimes the client have to give, sometimes you have to give, and sometimes the dollar have to give. That’s fine. But the team decides how the balancing and equilibrium is happening.

Murray: Can other organizations adopt this model?

Arnold: Oh yeah it’s happening already. BSO was in software services. You see law firms, accounting firms, a lot of professional industries using self managed teams.

Murray: But what are the challenges for management,

Arnold: Restructuring is not for the faint hearted. But it is so necessary. The world is changing rapidly. The traditional organizations like Industrial Revolution, that you make all these task based things and at the lowest end it’s very replaceable, so if you’re not good enough we kick you out and get someone else in with minimal training. For a lot of work that’s not relevant anymore.

And so you need the brain power of the people to be interpreting what’s happening and connecting the dots and be agile as required. And that is a very important. So I think try to have in a very variable world to cookie cutter into all little task and things is you can see the problems everywhere because of that.

The world’s not predictable anymore. That’s what the industrial revolution tried to do is constant quality and try to reduce it to all little steps. That works in a predictable situation. In home care. It is not predictable. It’s a complex world. And so processes and procedures don’t work. It’s not that if you follow those steps, you always have the same outcome. In health it’s not the case. So you need different ways of approaching the business you’re in. 

Murray: Shane, I think we better go to summaries. Do you want to kick us off?

Shane: I do indeed. Let’s go from the beginning. 

Self managed teams, 10 to 12 people in a specific geographic area and their specific role or goal in the world is to care for aged people. And then the idea of keep it small, keep it simple. If we talk about 9, 000 people and 45 back office staff, it must be a picture of simplicity. Because you can’t, implement anything complex with that fewer people to run it. So you’ve got this constraint based model where it has to be simple or it just won’t get done. 

And then you talked about economies of scale. So we bring in economies of scale and we bring in bureaucracy. I think about somebody I know in aged care In New Zealand, it’s dominated by big private companies. And if you think about the way people in retirement homes are fed, it’s economies of scale. They make it off site and they ship it to the site rather than having a small group of people serve their community. And so what happens is we get bureaucracy. We get other people deciding what the food is. We get other people deciding when it’s going to get delivered. It’s never delivered on time because there’s always a problem. So the system breaks down. 

I love the idea of coaches instead of managers and in this model, the coach is still a medical practitioner. They still been on the field. They still have that same goal and vision. I’m intrigued by how many teams they’re coaching because that builds a constraint based model where they don’t become a delivery manager because they just don’t have time. So with that simplicity we have to remove waste out of the system. 

And then you talked about this idea of adopting useful patterns. This idea that when everybody sees us working, everybody else is jumping on and going how do you deliver at that cost? How do you deliver it at that efficiency ratio? How do you deliver it at that margin or profitability or that success? And everybody wants to adopt it because it just makes sense. 

In New Zealand our culture of government is bureaucracy, hierarchy. I’d hate to find out how many people in our care organizations and government are frontline staff versus back end office workers. 

And then how do we scale? We just split the teams. And we just keep doing that. And if we’re going to design something, it has to be able to handle 5, 000 people, not five, because we know we’re going to split. 

And then the other one you talked about is reforming the team. So when a new set of skills come into the team naturally reform to say where are these skills fit? Not what’s the role. How do we adapt the team so that the work still gets done with it and we leverage that new skill. 

And then , I’m really intrigued about the rotation of informal roles. So you talked about planner , advisor, back office liaison, office housekeeper. The welcome, the onboarding of clients. The mentor for any newbies that come in. You naturally are a frontline worker and a team player and 85 percent billable. So this idea that you have a primary set of things you do in the team and then a secondary thing, but everybody does them. It’s not like the old hierarchical organization where one poor person gets left cleaning the kitchen because nobody puts their dishes in the dishwasher. By rotating it and by making sure everybody has those informal roles, there’s a sense of equilibrium and balance you talked about.

I can see how high performing teams adopt those patterns. But I can also see, especially in health, how very few organizations or countries do. Murray what you got? 

Murray: What you’re talking about Arnold is very much the same thing we’ve been talking about in the agile software development community for the last 30 years. But it’s all been bastardized by deeply hierarchical management who’ve taken these ideas, implemented them and turned them into a form of micromanagement. So the problem comes back to leadership. I’m convinced that leadership drives culture. And the reason why you’re not going to get much competition and you’re going to succeed is because there’s very few leaders who will willingly give up all of their power and hierarchy to implement this model.

I think that there are areas And times in larger organizations where you have enlightened leadership who would be able to implement this but it goes very strongly against the basic assumptions of most managers I’ve ever worked with.

Arnold: Yeah. Maybe it’s the new generation. I have my hopes up in that regard. The first thing we hear if you go to another country oh yeah, it may work in the Netherlands. It won’t work here. And guess what? In the end, we’re all humans and we like to freedom to operate. We like responsibility. If we can. For most of the people better responsibility is a big driver. If they can control their life in a better way. No one’s like to be a minion. And I see more and more leaders and especially the younger generation, they’re open to other ways. 

Murray: I would hope so. I see lots of people using the words. I don’t see many people carrying out the actions.

Arnold: Yeah. Yeah.

Murray: What are three books that you would recommend people read to understand this model

Arnold: So Frederick Lallou, Reinventing organizations is quite a famous one. That is a great book. The Starfish and the Spider, that’s quite a small book from Beckstrom and someone else about distributed organizations.

Murray: All right. And now how can people contact you? Do you provide consulting and training or are you just highly focused in the medical sector or what? 

Arnold: So Buurtzorg Australia, it has two arms. The care provider arm, we translate it to Neighborhood Care for clients. So for a client side, aged care, disability care. We also do have Medicare and we have the accident side of things in Western Australia. 

The consulting advisory arm, it is about the model itself. We do keynote speaking. I got support from people from the Netherlands. Jos de Blok comes sometimes over. We do workshops. We have trainings. We do also transition programs. If you’re interested to transition your organization or part of your organization into a Buurtzorg way of working go to the website Buurtzorg com. au or Arnold at Buurtzorg com. au. We have an one 800 number you can call. It’s all on the website andwe have a nice partner network here in Australia. We have some partners in Sydney. And also people flying in from all over the place.

Murray: Excellent. Well, thank you very much for coming on.

Arnold: yeah. It was a great pleasure to be here. Thank you for having me.