What a group of Dutch nurses can teach Silicon Valley about the future of work

by Jeremy Heimans and Henry Timms

If you wanted to learn something about the future of the workplace, you probably wouldn’t begin your quest by heading to the Netherlands and inquiring about the state of nursing.

But Buurtzorg — a decentralized network of nurses who engage with their communities on their own terms — has shaken up the profession. Its story is a master class in how to scale that “founder feeling” and create a workplace built on new power principles.

Buurtzorg began in 2006 with a vision of what nurses would not do. They would not be drowned in paperwork. They would not let strict procedure trump healthy culture. They would not be governed by out-of-touch paper-pushers at HQ.

Instead, they wanted to do the work that inspired them in the first place: caring for patients. They would connect with their community and make the decisions that matter themselves. They would decide when and how to visit people in their homes, dealing with everything from changing bandages to making end-of-life plans. They would be in charge of their own world.

This was not an original dream. Their list of hopes will be familiar to many who work in old power institutions and imagine a Jerry Maguire moment, when they finally say, “Enough!,” stick it to the man, and blaze their own path forward.

But Buurtzorg had a plan to go with the fantasy. To get community health care right, it would put all the power in the hands of small, self-directed teams of ten to twelve nurses. Each team would take charge of the complete process of caring for their patients — and for the running of their own small enterprise. They would make their own decisions, minimize administrative oversight, and be connected to the other teams via a shared technology platform, allowing all the nurses in the network to learn and work together. They’d be free to experiment with new and creative ways to deliver care.

Ten years on, Buurtzorg has over 10,000 nurses in the Netherlands, operating in 850 teams, serving over 70,000 patients a year. To support all this, it has a back office of just 45 people. A KPMG study shows that its model delivers “a 50 percent reduction in hours of care, improved quality of care and raised work satisfaction for their employees.” Its overhead is much lower than the average. So are its sick leave rates. So is staff turnover. And Buurtzorg has been repeatedly scored as having the highest employee satisfaction among all Dutch companies with more than 1,000 employees.

Its nurses are also achieving higher rates of patient satisfaction, even as they provide fewer care hours. With the patient at the center of their mission, and with the removal of the heavy hand of bureaucracy, they get better results in less time. Their patients get their autonomy back more quickly and have shorter stays in the hospital.

Contrast this with the traditional role of the nurse who, across the world, feels under-resourced and unable to spend sufficient time to support her patients. Research by the International Council of Nurses and Pfizer showed that aggression against nurses is widespread, with a quarter or more in almost every country reporting workplace bullying by colleagues. This culture is costly: a 2015 survey by the Royal College of Nurses showed that almost a third of UK nurses are seeking a new job.

What life is like at Buurtzorg: One founder’s story

Madelon van Tilburg, a nurse for Buurtzorg based in Den Haag, isn’t seeking a new job any time soon. But if you met her, you might be struck by a sudden wish to quit your job, move to Holland, and become a home- care nurse. She beams when she talks about her job, brimming with professional pride and purpose.

It hasn’t always been this way. She used to work in a corporatized home-care organization that was obsessed with hierarchy and bureaucracy, targets and time slots. She was always rushing: clocking in and clocking out. She ended up being punished for spending too much time with her elderly patients, even when doing preventive care. “I had this meeting with the same manager every week and she would say, ‘Oh, you work with Mrs. Brown. On Thursday you went over five minutes longer than was estimated. Why was that?’ ”

As she explains, life at Buurtzorg is very different. “When you start a new team, you have to find your own office . . . Setting up an office is the starting point of the team because you have to find your place in a community and find your way around the community . . . It’s also very good for building up your team. You’re working together, you decorate it together, and your team decides who’s going to find chairs, who’s going to paint the walls, and all that. It really feels like your own business . . . You do it together and then you have the common responsibility — that’s very important.”

This might seem like a needless distraction, something that would be more efficiently provided as a shared service by a specialist at a head office. But asking nurses to own the whole start-up process is a very intentional step. It is part of building a culture that feeds individual agency, and builds collective bonds among the nurses.

This culture continues in their daily operation. Like start-up founders, the nurses on Madelon’s team find themselves doing a bit of everything, juggling nursing, making care plans, managing the office, hiring and firing, budgeting and connecting with the local doctors and hospitals: “Sometimes you find out about new talents of your colleagues or about yourself. Someone might say, ‘Oh, no, I don’t want to do the planning. I’m no good at it.’ We’ll say, ‘Just try it,’ and then maybe she’ll find out that she really likes it and she’s really good at it.”

Every member of the team can freely view its budget and billable hours (with help from Buurtzorg’s own “nurse-friendly” software, which makes this transparent across the whole network). No one can question the motives of the boss, because management in each team is a shared responsibility. The teams are deliberately small enough that consensus-based decision-making is workable.

The deep sense of ownership and collegiality Madelon feels produces the kind of job satisfaction that even the fanciest all-you-can-eat Google cafeteria lunch spread cannot buy. It also provides a foundation, based in trust, transparency, and mutual accountability, that enables her to focus on outcomes, rather than just manage workplace politics or hit corporate targets imposed from the top down. Like any good start-up founder, she sees her job as locating customer pain points and coming up with solutions in innovative ways.

What is particularly surprising is that Madelon has developed this sense of ownership while being part of a much bigger organization, which usually tends to kill the founder feeling. But for a large company, Buurtzorg is remarkably flat. In place of six layers of management occupied by people with titles like “Advice and Support Officer (Systems and Operations Management),” it employs just fifteen “coaches” across 850 teams to support and advise around any issues that come up. Coaches are typically more experienced nurses, not administrators or managers who have never been on the front lines. And they don’t have management authority or hiring approval or veto rights (formally or informally)— they’re more like mentors and advisers. The fact that each is assigned fifty or sixty teams acts as a check on coaches becoming managers. Other than the coaches, the teams are left to get on with it. Buurtzorg’s motto sums it all up: “How do you manage professionals? You don’t.”

Madelon’s most vital piece of infrastructure is her access to all the other nurses. BuurtzorgWeb is a kind of new power network that facilitates learning, peer support, and the development of shared resources across teams. It allows Madelon to confer with 10,000 other nurses if she has a question about a particular disease or a tricky patient situation. She can find a nurse with more expertise on a particular topic than she has, or someone in another region beyond the confines of her local team. Nurses share their knowledge by creating online courses for one another; Madelon has found the one on dementia especially helpful. This online community is much more vibrant than the usual corporate intranet because in a world without managers, peer support becomes key to professional development and problem solving.

In her old job, Madelon often used to hope that patients wouldn’t ask her a question on the way out, knowing this would push her way over her allotted time quota. But at Buurtzorg, making time for a cup of coffee comes with the job. That can make all the difference, not just for her and her patient, but for health outcomes. Once people start talking, she finds, truths and solutions often emerge.

She proudly tells the story of one patient who started sharing her concerns about her ninety-six-year-old neighbor, also a patient of Madelon’s. And she offered to help. So Madelon recruited her to stop by next door at the end of each day to help the older woman remove her support stockings. This not only saved Madelon the task, but also added a little more glue to her community.

What Buurtzorg gets right that Silicon Valley got wrong

An ocean and a continent away, another experiment with self-managing teams has taken place. Holacracy is a radical new management philosophy and system, invented by software engineers, that digital outfits like Zappos and Medium have been enthralled by in recent years. Zappos took it so much to heart that it restructured the entire company, eliminating bosses and departments altogether. On the surface, Holacracy appears very new power, offering a “new way of running an organization that removes power from a management hierarchy and distributes it across clear roles, which can then be executed autonomously, without a micromanaging boss.” It boasts more flexible roles for staff and greater transparency.

Holacracy might sound a lot like Buurtzorg, only with better software. It is far from it. In fact, the differences between the two models help us understand the real secret to Buurtzorg’s success, and what the rest of us might try to emulate. Nurses like Madelon and her teams have huge freedom to define their own working methods while Holacracy is highly structured and directive, perhaps more so than many old power organizations. A sample instruction from the forty- page Holacracy constitution reads: “As a Partner assigned to a Role, you have the authority to control and regulate each Domain of your Role. You may do this on a case-by-case basis when others request permission to impact one of your Domains, by considering the request and allowing or withholding permission.”

Restrictions and protocols, with a good sprinkle of jargon, become the focus under Holacracy, not the work itself. Medium abandoned Holacracy after initially embracing it with gusto, saying it was “getting in the way of the work,” and Holacracy is partly blamed for the departure of an unprecedented nearly one-third of the Zappos workforce in just one year, 2015, and for the company’s being left off Fortune magazine’s annual list of the best places to work for the first time in eight years.

Holacracy is like new power for robots. Julia Culen describes her experience when a long- standing Viennese-based consulting firm of which she was a managing partner adopted Holacracy: “It felt like being part of a code . . . an algorithm that is optimized for machines, but not for humans. Instead of feeling more whole, self-organized and more powerful, I felt trapped. The circles I was being part of did not feel empowering at all but [instead took away] my natural authenticity as well as my feeling of aliveness.”

What Buurtzorg gets so right is it puts human beings front and center. It focuses on how to get teams of people to form deep connections with one another (which is why they turn nurses into interior designers). Buurtzorg uses technology to enable better peer coordination, but it doesn’t lead with it, a lesson the Holacrats (and some in Silicon Valley) have yet to learn.

Excerpted from NEW POWER by Jeremy Heimans and Henry Timms. Copyright (c) 2018 by Jeremy Heimans and Henry Timms. Excerpted by permission of Doubleday, a division of Penguin Random House.