Humanity Over Bureaucracy: In Conversation with Stephan Dyckerhoff

Stephan Dyckerhoff, a presenter at Better Worlds 2018 and President/CEO of Buurtzorg Asia and Buurtzorg China, speaks with AgileTODAY about how the Dutch-based healthcare delivery system is being implemented across the APAC region.

Can you give our readers a little background information about the development of the Buurtzorg model?

To put it bluntly: Buurtzorg was developed by Jos de Blok as his response to the unsatisfying conditions of how home health care was delivered in Holland some 10-20 years ago. Care had been industrialised, forcing nurses to work like factory workers, delivering standard care items to their patients. Patients were receiving standard care instead of individualised care, while costs were exploding due to wrong incentives for the providers.

So, you could say that Jos de Blok’s strong trust in people and capabilities, in collaboration, and in keeping things as simple as possible in order to maximise the time nurses can devote to patients drove the development of the Buurtzorg model. And we try to apply these same principles in our roll out of Buurtzorg in APAC!

The cornerstones of the Buurtzorg model include leveraging networks, maximising back office efficiency, maintaining a neighbourhood focus, and Lean management. Can you provide some practical examples of how these cornerstones help you deliver quality healthcare while using minimal resources?

Our core belief is that there are not enough nurses in most countries in the world (the Philippines probably being the only exception) to properly care for all the people in need. So, rather than maximising the nurse hours per patient – which would give us a short-term revenue boost – we strive to do the opposite through minimising scarce nurse hours.

We do this by helping the client to regain as much independence as possible and leveraging informal networks (these could be family, neighbours, volunteers in a neighbourhood etc.). We empower nurses to organise their work by themselves. Nurses are responsible for overseeing quality control — most of our nurses work in the neighbourhood in which they live and thus have a high personal interest in ensuring that their work is perceived positively.

We support nurses with a highly effective back office organisation (50 staff for 14,000 nurses and care workers), in combination with a very user-friendly ICT solution, reducing our administrative burden to a minimum. Every nurse has an iPad which serves as their core working tool and which they can use while they are with the patient. Hence, what could have been ‘admin time’ can now become quality time with the patient.

When an organisation undergoes an Agile transformation, employees often find the transition to non-hierarchical management and self-organisation difficult. After all, it’s very easy to be told precisely what you need to do by your boss (and this way of working can be comfortable for those who’ve previously worked in a non-Agile workplace). In your experience, do nurses experience similar struggles when they first join a Buurtzorg team? How do you help them overcome this? What other challenges do nurses face when they begin working within a Buurtzorg team?

To be honest, my view is that Dutch nurses are actually the most autonomous working nurses. They love it. In other countries, it is more difficult to convince nurses to accept the idea of working in an environment without a boss telling them what to do. This is especially true in Asian countries, where hierarchical thinking dominates. We learned our lessons: in Japan, for example, our first nurse team left after some months because they were just overwhelmed by the situation of having to manage themselves.

We now work using a ‘step by step’ approach, encouraging nurses to take more responsibility over time but having a lead nurse and/or general manager in place at the beginning. Plus, we train coaches to guide teams as they adjust to this process.

In the APAC region, we face an additional challenge: home nursing is only an established sector in Australia/New Zealand and Japan. In most other countries, home nursing did not previously exist, making us a true pioneer. It’s been very difficult for us to convince nurses to join this new sector. But, given that there is a huge need for home nursing, this is a route that we have to take.

How do you view the role of a ‘leader’ or ‘CEO’ in an organisation like Buurtzorg, where decentralisation and autonomy are the norm?

In Holland, we have two managers for 14,000 people: with Jos de Blok as CEO and Gonny Kronenberg, his wife, as the back office leader. Jos’ role is being a leader and facilitator. Gonny’s role is more of a typical manager role – ensuring smooth back office processes – but, at the same time, she performs this role in a very collaborative, non-hierarchical way.

In Asia, we strive to do the same. Yet the ‘desire for management’ here is high, meaning that ‘leadership’ needs to be a mix of facilitation, guidance and management. Hopefully the role will develop over time to become similar to Jos’ role in Holland.

Are there any challenges associated with being the CEO of a flat organisation like Buurtzorg? How do you determine what degree of authority you need to exercise in complex situations or when a dispute arises?

There are daily challenges. When we started in Asia, we tried to roll out the model the same way as in Holland but we failed. My challenge is to try to manage as little as possible while still meeting the degree of management that is culturally expected. People understand the Buurtzorg model intellectually but living it is another ball game. It will take many years until we can come to embrace a model like we see in Holland.

In Holland, even Jos would not take a decision-making role in dispute situations. We have 17 coaches for around 1,000 teams. Teams can call these coaches if they need support in complex situations. But coaches cannot decide for the teams, they just facilitate towards a solution. And this is also Jos’ approach.

Undertaking a complete organisational restructure and culture change is a daunting, expensive task. With this in mind, is there anything that leaders of conventional, hierarchically-structured organisations can take away from the Buurtzorg model and easily apply within their own organisations?

I am not an expert in transforming existing organisations towards the Buurtzorg model. Other than in Australia/New Zealand and Japan, we have had to build our APAC organisations from scratch. Yet, I know from our colleagues in Europe that the transformation is a huge challenge. Most organisations fail because their management cannot give up control or being in control.

Because there are so many requests for support in such transformation processes, we train various consultancies in how to drive and support transformations – with Buurtzorg not having enough resources to do this on our own. The good news is that we have Future Proof as a consulting partner in Australia. We have trained and skilled them based mainly on our experiences implementing Buurtzorg in the UK, Germany and France.

Ard Leferink of Buurtzorg Holland has stated that creating a back office culture that supports independent teams is one thing, but actually maintaining this culture is far more difficult. How do you maintain a culture that supports self-functioning teams?

Over time, people tend to retake more control. It is a key role of the back office leader to maintain a culture of supporting instead of controlling. We have various feedback mechanisms in place where nurse teams can express their experiences with the back office team.

Many would say that Agile involves experimentation, valuing people over processes, accepting the likelihood of failure, and trying things multiple times until you get it right.

At the same time, healthcare requires a level of exactness, precision and procedural adherence that few other sectors demand – mistakes can cost lives (and, at the very least, nurses are dealing with patients who are in a sensitive, vulnerable state). How is Buurtzorg able to embrace an Agile mindset under these conditions?

By placing trust in our people and, consequently, by delegating responsibility. Most nurses have families. They are able to take care of their families in complex situations. So why should they not be able to do this in a professional context? The moment we start to ‘micromanage’ quality, we take away team members’ sense of responsibility and ‘invite’ them to rely on others. In our organisation, the professional attitude of the nurse and their team is key to quality management. Most nurses live where they work. They don’t want any ‘black sheep’ in their team, as this would create problems in their own environment.

We have to leave behind the dogma that through micromanagement and control we can ensure better quality. Numerous cases across the world show that – even with the most detailed regulations in place – we cannot avoid mistakes! In Holland, there is a government institution where families can file formal complaints against their care provider. The large providers get around 50 complaints per year. Buurtzorg has not received a single one within the past 10 years!

What inspired you to bring the Buurtzorg model to the Asia Pacific region?

I got into elderly care when I was still working for SCA/TENA, the global market leader for adult diapers. When doing consumer research, my fast conclusion was that many Chinese elderly needed quality diapers but, more urgently, they needed proper care. Hence, in 2011, I founded China’s ever first home nursing company as a pilot project for SCA/TENA. When looking for partners and best practices, we came across Buurtzorg.

I met Jos de Blok and together we travelled through various Asian countries. We both concluded that his Buurtzorg model fits well in an Asian context, mainly because of the tradition of home-based filial care and the strong importance of neighbourhoods and communities. We first tried to partner with SCA, but they are a product company with little understanding of the care business. So Jos and I decided to try it on our own – this is how Buurtzorg Asia was born in 2014!

In what ways have you had to adapt the Dutch Buurtzorg model to account for cultural differences in Asia?

There are a lot of adaptations needed, like integrating the care workers into our care process and offering a broader portfolio of services within the communities. In Asia, there is also a greater emphasis placed on facilities (you have to be able to show “something” to stakeholders – a rather virtual organisation, like we have in Holland, does not create credibility). We’ve also had to adapt our management model to account for a greater need for defined hierarchies, at least at the beginning.

Of course, we also have to adapt to regional payment systems and market practices. The most extreme example is probably in India. Here, the market standard is to send nurse attendants to families for 12 or 24 hour shifts. We cannot change the market before we are in. We follow the same practices, but our nurse attendants are supervised by a lead nurse and they use our care process, ensuring individualised professional care. Over time, we will try to move to four hour shifts and then later to one hour shifts – at higher hourly rates but with a lower cost per patient. But this will take time. Despite this, patient-centricity, nurse-centricity and a focus on neighbourhoods are key elements of the Buurtzorg model that work well everywhere in Asia.

Do you foresee the Buurtzorg model growing in Australia? If so, would it need to be adapted in any way to suit Australian culture, practices or attitudes?

Well, from the outside-in perspective of a foreigner who loves Australia and has lots of experiences in Australia both professionally and privately, I would think that Australians are probably second after the Dutch in their wish for autonomy. So it should work well!

Also, we’ve recently seen a huge interest in our model from a variety of health and allied health industries. We are just now moving from ‘talking to walking’ in Australia, together with our Australian representatives at Future Proof. There has been much work undertaken to have the model suit an Australian context from both a delivery and legislative perspective. Excitingly, I am sure we will soon be able to support the first Australian care provider to start working the Buurtzorg way!