Humanity over bureaucracy: New models of care, by Alieke Van Dijken
Here is the full talk by Alieke Van Dijken of Buurtzorg, at the 2016 Transforming the Public Sector Conference we held in February 2016. Learn how Buurtzorg is able to give patient-focused care by having no management staff, with an organisation of 10,000 nurses. This allows them to have an overhead cost just 8%.
Humanity over bureaucracy: New models of care - full talk by Alieke Van Dijken
Well, here is a happy Nurse, coming from Holland and meeting you. I’m very happy, thrilled to get the invitation. Let’s start.
[Buurtzorg started] in 2006, and we have now 10 years of building up an organisation, and it’s now 10,000 colleagues all over the country and providing home care. So I am a nurse. For 50 years I’ve nursed in Amsterdam – through traditional homecare for 5 years, then I went for 4 years to work together with GPs as a practice nurse, and then I had to move, and I was thinking ‘OK, what should I do?’ again, and thinking ‘should I go back to home nursing?’ and then I knew about this sad situation in home nursing in the Netherlands, which I think is a bit like here. You’re not able to so much to provide really good care because of a lot of bureaucracy, because you have to work very hard for the productivity, so you’re not able just to provide good care. So I thought no, I won’t go back, and then somebody told me ‘hey, maybe you should join Buurtzorg, it’s different’ and I said ‘OK, well, let’s see what happens’ – and for now I’ve been 6 years there and I’m really happy!
I hope to explain a bit to you, though you’re not all in healthcare, how it can work if you really start the organisation and why you are working there at the core business of it, really think about what is the heartbeat of your organisation, and then from there, build it up. A lot of layers, bureaucracy, you just don’t need it, and you really can get rid of it.
We have no managers at all. I work in a team with 10 nurses, no managers. All those 850 teams: no managers.
We have Jos de Blok, the Director, and his wife, she’s Co-Director, that’s it. And all the so-called ‘management tasks’, well, we do it by ourselves. We have of course a kind of framework within the work, so we know about some targets, we can ask for help for contracts and stuff for new colleagues, and then we have this back office – only 45 people in the back office for a 10,000 organisation. And then you have an overhead cost of just 8% – instead of like 25, 30, 40% sometimes in Holland.
We have those coaches, and they are really not managers. They are going alongside the teams, and we can ask them for help if we need some help in whatever area it should be – we can ask them. Maybe when we have problems working together with each other and we cannot sort it out together, we can ask our coach. Maybe if there are some big projects all over the country, and as a team we don’t have the overview, we could ask our coach and they can give advice. But there is no decision-power with this coach, it’s all in the team, and it gives us a lot of freedom to choose what you really think is your job.
That’s what I’m so happy for, because now I have my job back – I can just take good care of clients.
I told you about all those layers, all those hierarchy you may not necessarily need. What Buurtzorg does, is the client and the client care is your main business. So building up this organisation was really around the client.
What nurses like to do is to strengthen the possibilities a client has. Maybe he’s very ill, but still likes to choose his own things – Maybe he can get a bit less ill, and nurses can help. So this self-management principle is very important. We are free to say ‘OK, now, this client is able to do without nurses’ and we’ll stop the care, and there is nobody who will say ‘well, now the productivity is going down, you are spending less hours on the patient’s care, so you should do it again and again’ – no, it’s not necessary, so we have freedom in that way. Around this client, the informal networks are very important. So the nurses in our teams really puts effort to strengthen these networks. This maybe is not what you might think nurses might do, they might treat our wounds and so on, but not having a chat with a neighbour, drinking a cup of coffee and chatting about the concerns that they have with their neighbour. We think it’s very important to strengthen the environment around the client, so the formal care can be much less. Though the system is not constructed in paying for all this preventative care, we choose to do that, and the figures prove out that there are less admissions into hospitals, happy nurses and happy clients. It profits.
Q: When you say you talk to the neighbours, do you mean you the nurses talk to the neighbours of the client?
Yes. For example, just to strengthen the network around them, so they don’t need so much nursing care and other professional care.
And then there is the Buurtzorg team of 10 nurses, and we also put in effort getting in touch with the formal network like hospitals and GPs. All the organisational structure should fit within this kind of ‘onion model’, it should all be at service of this model.
It’s just a theory, but Buurtzorg didn’t start because of a good, nice theory, it started with four nurses who thought “we’d love to deliver good care” and not about the theory, so the theory came after that.
Meet this Granny, and I’ll just give you an idea of how this theory of the onion model works in a situation.
I know this lady, she is 85, she’s widowed, suffering from COPD, Diabetes, Dementia. She has two sons, good neighbours. That was the start, when I met this lady. This lady was quite active, and the only concern the GP has and the practice nurse had was about messing up medication, and then I met this lady, and I thought ‘oh, things are going fine’. Then I met the son, who was not close, who was a bit like ‘my mum’s a bit crazy, she has dementia, I don’t want to connect with my mother that much’. Okay, okay. There were some good neighbours, and some nice sport friends.
Because there was this concern about medication, of course we started providing care. It was just once a day, to give this medication. My team is formed of highly, really highly educated nurses. Half of them have four years of training, the others have three years of training, and we did easy work there. Just every day, give some medication. Buurtzorg is one of the organisations that chooses to have highly educated people, in instances which may be very not complex and easy. I’ll show you why.
Of course we did some other things, maybe not for a nurse, checking her agenda, checking her fridge, just those little things – letting her get on her way, but with a little bit of guidance. We took time for that, though in the system, the paying system, it’s not ‘nursing’ so there was no money for it, but we knew it should be profitable if we did it. So we did.
And of course, we have a lot of continuity in my team because we are only 10 nurses, and we visit this patient regularly. So when things are going wrong, you can see it easy. I worked in an organisation, there were 2 teams attending a lady like this, there was a day team, an evening team, and they all worked. Maybe 50 people would come around this lady, and then you cannot monitor so well. It seems small things, but they are important.
What we do as well, also not in the paying system, but we think the informal group around this lady is very important. So this son, for example, was very ‘ugh, I got a bit crazy about my mother’ and we thought ‘OK, we should try to connect with this guy, and put some effort in it, because he’s very important to help his mother when the dementia gets worse.’ I put an effort in, calling in, had a coffee, things like that, and it turned out in the end he felt overburdened because the situation got worse and worse of course because of the dementia, and this guy was so very grateful that he could call us 24 hours a day (our team is 24 hours a day reachable by phone), he was just so happy that he had a real relationship with me and my team, my colleagues as well. I could not do this in my former organisation, because there was just not the time to really get in touch with people, really build on relationships.
So I did with the neighbours, because they were really frightened about the safety, they thought maybe a gas explosion will happen one day. Of course, it was something real. And I thought ‘OK, we need to get them in touch and think together, what can they do?’ and the solution was, the neighbours said ‘OK, we want to prepare the meals for this lady.’ We would have never found a solution if my boss was telling me, ‘but there’s no time for connecting with the neighbours.’ So in this way we had a very safe solution, and she was well fed during her illness.
Another thing, in my team we do the planning by ourselves. So there is no special planner for it. Most organisations in homecare have their own department of planners, and they will fix your route. In that way, if that lady would maybe visit her son in the north of Holland, well, she would be told ‘no, the nurse is coming, so you have to stay home’. But because we are very flexible in planning our routes, and we have contact with our colleagues, and I’m one of the planners myself, we can even make a connection between our planning and the needs of the clients – which was very important for the social context of this lady. So flexibility in planning – to be a planner, to be honest, it’s not only the most lovely task if you’re a nurse, but you see the profits for the clients.
I told you this – it’s all about the relationships – there are quite a few homecare organisations in the Netherlands, especially in the beginning of Buurtzorg, they were getting a bit angry, because of all the good talk about us, but they were saying like “ah, they’re drinking coffee all the time, they are not working hard, we should get rid of them!” I hope my story explains why it’s so important to focus on this – it’s not only in nursing, it’s in all the jobs in the public sector.
If you focus on this, and you create an organisation focused on [relationships], and everything is supporting this – well, everyone gets happy, everyone gets motivated, and you get good results.
Well of course, this lady, her health did not improve because of the dementia, so I think after about 1.5 – 2 years after we started the contact, things were getting worse for her. She was getting very anxious and crying a lot and not feeling at home anymore, because she didn’t know that it was her home of course. We decided we have to visit this lady more, so Buurtzorg came 3 times a day, we had neighbours during the evening meals coming, and we had a kind of arrangement made, if the neighbours could not come, they could call my time and we could come instead. Or we could call the son and ask if he could come. So it was very easy contact – not calling a centre or something.
Oh really, that’s what people and clients and families are really hating, all those call centres. If you’re really in need, you should be able to get in contact with the nurse or the people that provides the care by themselves. It’s a very simple solution to give all the people your own phone and the team number and just say, phone us, and it can be in the night as well – do it, if it’s really necessary. And so sometimes I get a phone call at night, but rarely. Rarely.
[We began doing] a bit of the ‘real nursing’ stuff, like the medication again and the wound care. Giving the guidance, it became more. Safety was a very important thing. And again, we didn’t leave that completely up to the informal circle, because we were the ones visiting this lady three times a day, so we could see if this lady put candles on the table, which was very dangerous, so we’d give a call to the son and say, please, remove those candles, and don’t buy them again. And again, if you’ve built a good relationship with this informal network you can have these quick simple calls about these important things.
At the end, she needed some help with her personal care, and we are nurses, so we give it, but I took more time because of this overburdened son, and we had to think about a path of getting this lady to a nursing home. In the end this was the only way for this lady because she was so anxious. But because we had this good relationship, we could have this [conversation]. Admission went very smoothly, still very sad for this lady of course – but she trusted us, she trusted me. The relationships with her sons had improved a lot, and I think we helped a lot with that, and so at the end, she trusted us, she trusted her sons, and said “OK, I will move to a nursing home where I feel safe again.”
In the end [after] 2 and a half years, there were three times this lady had a serious infection, she had fallen down. But because we knew this lady, so we also saw the small changes in which the infection started very quickly, we very quickly called the GP, an evening doctor, we started medication. In those three years, there was no hospital admission. And I am sure that if I looked after this lady in my formal organisation, I could not so much rely on my colleagues. And it’s not because those colleagues were not good colleagues, but there was not that much continuity of care. There were those colleagues coming in from another organisation when somebody was ill who knew nothing about this situation, for example.
So, again, happy client, though she had to go to a nursing home, and happy nurses as well. It’s just one example, but I could give you loads of them.
So maybe good to know that Buurtzorg has this way of organising nursing home care, but in other areas in the public sector, Buurtzorg has started companies working with this model, this onion model, this focus on client care – seeing what you need and the rest getting rid of it. So we have hospice care delivered by this model. We call it Buurtzorghuis – so that’s a homecare team connected with Physiotherapists and Occupational Therapists, working closely together. We have BuurtzorgPension, for short stays. We have BuurtzorgT, psychiatric teams working the same way. Buurtzorg Jong, for youth care. And it all works the same good way.
And then, I think, important question – this is the Netherlands, the other side of the sea. Could this happen here in England, could it happen here?
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