Monday, May 23, 2016

Change from the bottom: community nursing in the Netherlands

Usually when we think of innovation, we assume that a small organization, even a single individual, will create something new, demonstrate it works, and then a large established organization will take it to scale. Very rarely will the innovators themselves grow to scale. In either case, the scaled-out innovation is supported by an organization with the usual management hierarchy and overhead.

Here's an example of an innovative care model and an innovative management model. Both aspects focus on what really makes a difference, understanding what is essential for the organization to nurture its people and its customers, and what is something best left undone or done by others.

This model for home health services builds on local teams of nurses who place high value on the relationships with the people they serve, favoring continuity of provider over specialized providers. It came out of nurse frustration with the fragmented care they had previously given.

Buurtzorg is a community nursing organization in the Netherlands. It started small, focused on the needs of the professional care team and the people in their community. It puts the local team in charge of the care and how they run the team to provide that care.

Buurtzorg provides high nurse satisfaction by "letting nurses be nurses", to build relationships with their patients, to be part of a small supportive team that shares the workload, to cover for each other, to build on each other's skills and knowledge, to access specialty resources as needed. A learning health system at the level of a team of ten or twelve.

A trio of remarkable outcomes were achieved.
  1. Extremely satisfied patients with excellent outcomes and reduced home care costs (40% below the expected cost). 
  2. Extremely satisfied workers. Buurtzorg was the Netherlands Employer of the Year for three years in a row.
  3. Explosive growth, from the first team of 4 nurses in 2007 to 9,000 in 2015. Buurtzorg now provides 80% of the community nursing services in the Netherlands. This has occurred with almost no corporate overhead (a central staff of 50 or so including 15 team coaches).

There are essential, but intentionally limited, services from a central support organization. A key central service is the team's coach, who facilitates communication within the team and helps them network with other teams, but who has no decision making authority.

Buurtzorg Organizational Structure

Shared IT focuses on
  • An electronic health record
  • A social network
  • A team dashboard
There are some outsourced services, such as payroll and legal. Buurtzorg has taken to heart the guideline of keeping the services that differentiate the organization and having others do everything else.

How to build on this?

While Buurtzorg has changed the home healthcare experience and cost, the total cost of care, including all other medical services, such as physician and hospital care, on a risk-adjusted basis, were no different from the average in the Netherlands. Are similar innovations possible in other areas of health and healthcare?

There have been studies of Buurztorg by many others from around the globe. What is special about community nursing in the Netherlands? How might this model be recast in other places?

Here are some references on Buurtzorg.

Buurtzorg Nederland (in Dutch. Google translates it remarkably well into English.)

Public World Consulting (2015): Repository of all things Buurtzorg

Frederic Laloux (2014): Reinventing Organizations (I first learned about Buurtzorg in this book on organizational paradigms. The information on Buurtzorg is spread throughout the book.).

AARP The Journal (2013): Buurtzorg Nederland: Nurses Leading the Way!

KPMG Insights (2013): Empowering caregivers