Buurtzorg Nederland: A Global Model of Social Innovation, Change, and Whole-Systems Healing

Buurtzorg Nederland

In 2006, Jos deBlok reintroduced the concept of district (community) nursing in the Netherlands at a time when the traditional and commercial home care industry was characterized as being costly, fragmented, and populated with caregivers who were overworked and dissatisfied. The focus had shifted from care to production, protocols, and administration. De Blok’s idea was very simple and practical—eliminate overpaid managers, luxurious offices, and layers of bureaucracy and give teams of nurses the authority and responsibility for providing care to groups of patients in neighborhoods or districts. In 2007, Buurtzorg Nederland launched with 1 team. By 2010, there were more than 250 teams scattered throughout the country and by the end of 2013, there were 630 teams employing 7188 nurses, providing care to about 55 000 clients. As of March 2014, there are 650 teams.

Key features of the Buurtzorg Model are described below.

Self-directed Teams: Buurtzorg employs teams of professional nurses and nurse assistants, provides coaching support, and trusts that professionals do not need to be managed. Buurtzorg exemplifies successful adoption and use of a business strategy known as self-directed work teams.⁵ Teams of up to 12 nurses manage themselves and their work, performing all of the tasks necessary to provide care for 50 to 60 patients. Team members decide how best to perform the work, determine schedules, assign roles, and optimize team outcomes. The microscale of Buurtzorg neighborhood-focused teams makes it possible to know and use the local resources, build and support formal and informal networks, and initiate prevention activities that enhance health and wellbeing.

Scope of Practice: Buurtzorg nurses work closely with general practitioners and other community healthcare providers. Decisions about what clients need are not based in a corporate office where knowledge is limited; rather, decisions are made in the home by the client and the nurse. The nurses provide comprehensive, holistic care based on what they and the client and family determine the client needs. This may include everything from a bath and bowel care to dressing changes and medications to preparing a simple lunch. Care is less fragmented when it is provided by the nurse rather than divided among a series of providers that could include personal care attendants and nurse specialists as well as generalist home care nurses.

Relationship-based Practice: Buurtzorg nurses are interested in clients’ life circumstances, the environment, and spiritual and social needs in addition to physical needs. The relationship between the nurse and the client is the core strategy of the organization. Teams work together to schedule and plan care for clients and to ensure that clients receive services from only 3 to 4 nurses to optimize relationships and decrease fragmentation of care. Buurtzorg clients appreciate the consistent, compassionate care, and this is reflected in the highest level of satisfaction in national surveys.

Empowerment of Clients: The Buurtzorg model emphasizes returning clients to independence as quickly as possible. The nurses “front load” care, working intensively with clients from the beginning, teaching and supporting them as they learn self-care and gain confidence. Clients value their independence and strive to achieve self-care goals. This is mutually beneficial for clients, families, the healthcare system, and Buurtzorg.

Simplified Billing:

• Nexxus Aloe Rid Detox Shampoo Review For Drug Test
• Ultra Clean Shampoo and Conditioner Reviews

Common in the industry is billing based on who provides the care or service, how much time they use, and what they do. Buurtzorg proposed to private and governmental contracts that the billing be simplified. Rather than having multiple rate structures that require significant bureaucracy to record and process, Buurtzorg proposed using one rate (57 euros per hour in 2013) for a visit, regardless of duration.

Financial Sustainability: When Buurtzorg Nederland began, there was great skepticism as to whether it would work and whether it was scalable. The fear was that without “controls” and with using highly skilled nurse caregivers, the costs would soar. The opposite occurred. On the average, Buurtzorg nurses use only 40% of the care hours that are allocated per client, resulting in significant annualized savings by the government. Buurtzorg has also demonstrated internal fiscal sustainability. Reported revenue at the end of 2013 exceeded 200 million euros.

Low Overhead: An explicit goal of Buurtzorg was to empower teams of nurses to provide care and to eliminate management that isn’t necessary and doesn’t add value. As the number of teams soared, the administrative costs have remained exceedingly low. Forty-nine staff members and 14 coaches support the teams.

Employee Engagement and satisfaction: Humanity over bureaucracy is the mantra of the organization. Buurtzorg nurses are highly creative and skilled human beings, nurses, and entrepreneurs. They have autonomy to work with clients and those in their networks to develop creative solutions for client problems. The psychological impact of this autonomy fosters a sense of satisfaction and wellbeing among nurses that extends to their clients and their families.⁶ In 2011 and 2012, Buurtzorg was recognized as the best employer in the Netherlands, edging out the previous winner Royal Dutch Airlines KLM.

Buurtzorg Web: Teams are interconnected through the Buurtzorg web, an intranet that enables all nurses to share knowledge and extend and receive support. In addition to the online community dialogue, business processes are managed through the web. The award-winning Buurtzorg web design was developed through a series of meetings with Buurtzorg nurses. Health information technology (IT) functions enable all teams to use online scheduling, billing, and documentation. Real-time financial reports are transparent at the organizational and team levels, which allows teams to self-monitor productivity and self-manage budgets. The Buurtzorg web is accessible through desktop and mobile applications. It is estimated that use of the IT platform for administrative functions saves approximately 20% of the costs of a typical home care agency.

Outcome Measurement: Buurtzorg uses the Omaha System⁷ within the IT platform to record nursing assessments and to document care. The networked electronic health record aids in individualized care planning and generates robust outcome data. In addition to tracking individual patient outcomes, Buurtzorg nurses can assess population health status by team and population of interest using the Omaha System data. Future plans are to use large data sets for intervention effectiveness research.

Theoretical Frameworks Underlying the Buurtzorg Model

The Buurtzorg Model reflects a merged theoretical perspective of the whole that overlays the notion of a patient-centered social-ecological framework⁸ on the science of networks.⁹ The key relationships between clients, informal networks, Buurtzorg teams, and formal networks are embedded within neighborhood networks. Buurtzorg nurses leverage powerful client and team networks to cultivate the health and wellbeing of the client and community as they provide care and support client independence. The positive outcomes of care have a ripple effect on the wellbeing of the neighborhood, community, and health system.

Social Innovation and Change

Social innovation, as noted by Phillis et al,¹⁰ is the best construct for understanding and producing social change. They define social innovation as a “novel solution to a social problem that is more effective, efficient, sustainable, or just than existing solutions and for which the value created accrues primarily to society as a whole rather than private individuals.” According to their definition, an innovation is social only if the balance is tilted toward social value—benefits to the public or to society as a whole. They also note that a social innovation can be a product, production process, or technology as well as a principle, an idea, a piece of legislation, a social movement, an intervention, or some combination of these elements.

Evaluated against this definition, Buurtzorg Nederland meets all of the requisite criteria. Healthcare across the globe is a social problem—access to care, as well as the cost, quality, and coordination of care. The solution or innovation offered by Buurtzorg produces a product or outcome that is more effective (improved clinical outcomes, client and family satisfaction, nurse satisfaction and engagement), efficient (utilizes fewer resources than other home care models), sustainable (generates significant cost savings), and just (provides access to clients and positive work environment for staff). The benefits to society are both indirect and tangible. The tangible benefits can be measured in improvement in healthcare access, cost, and quality. Indirect but not insignificant benefits include the impact on the community or neighborhood. Creating social networks strengthens the social fabric of the community and improves the overall quality of life and wellbeing of the citizens.

The magnitude and speed with which Buurtzorg grew is unusual and striking. The interest within the Ministry of Health of the Netherlands remains high and attempts are underway to replicate aspects of the Buurtzorg model within other sectors of healthcare, including hospitals and long-term care. There is also interest in evaluating whether this model of social innovation and change could be applied in sectors outside of healthcare such as education where self-directed teams, empowered teachers and leaner administration could positively impact school budgets and performance.

The interest in Buurtzorg is rapidly becoming a global phenomenon. Buurtzorg teams were launched in Sweden in 2011, in Minnesota in 2013, and it is anticipated that organizations modeled after Buurtzorg will emerge in Japan, Switzerland, and Belgium within 2 years.

Social Entrepreneurship

Buurtzorg has clear social entrepreneurial features. Austin et al define social entrepreneurship as an innovative activity that creates value and can occur within or between two or more organizations in the nonprofit, business, and governmental sectors.¹¹ Social entrepreneurship is often associated with initiatives and processes that have been set up by non-government organizations or social enterprises.^12,13 Experts Dorado,¹⁴ Mair and Marti,¹⁵ and Zahra et al¹⁶ argue that the fundamental distinction between social entrepreneurship and commercial entrepreneurship is that social entrepreneurship creates both economic and social value. By this definition, Buurtzorg meets the criteria for a model of social entrepreneurship.

Innovation is an important aspect of social entrepreneurship.¹⁷ Three types of innovations in social entrepreneurship have been described by Alvord, Brown, and Letts.¹⁸ These innovations focus on:

• increasing the ability of local actors to solve their own problems,

• disseminating a package of innovations to serve a need, and

• setting up a structure to challenge the structural causes of social problems.

At Buurtzorg, encouraging the clients toward self-management of their problems is one of the main goals. Clients should not become dependent on the care they receive. To enhance the quality of their lives, they learn how to mobilize their social ties to significant others such as family members and neighbors. This allows Buurtzorg to expand services to larger target groups so that more people can benefit from their care.

The populations served—the elderly, people with serious chronic disease, and youth with mental health issues—have significant needs and create a financial burden on the Dutch healthcare system. The establishment of a neighborhood Buurtzorg team in many ways creates an infrastructure that begins to ease social problems experienced by clients and their families.

Whole-Systems Healing

In many ways, Buurtzorg is illustrative of whole-systems healing—a way of cultivating the health and wellbeing of individuals, communities, organizations, societies, and the environment by living and acting with awareness of the wholeness and interconnectedness of all living systems.^19,20 Buurtzorg embodies whole-systems healing in the way that it is embedded in neighborhoods. The central tenet is that care needs to be provided within the context of an individual’s life—home, family, and neighborhood.

Whole-systems healing requires an understanding of several critical key concepts:

• Complexity science/Chaos theory: All living systems, from individual humans and communities to the ecosystem of the planet, are complex systems that are constantly adapting and evolving in response to changing conditions from within and outside.

• Social networks: Social networks are social structures made up of individuals or organizations that are connected or inter-related. The ties can be social, economic or organizational.

• Social change: Social change is a process whereby values, attitudes or institutions of society become modified.

• Gentle action: As articulated by Peat, gentle action is the use of grassroots efforts and collective intelligence to focus many small, coordinated efforts on the best point of leverage within a given system.²¹ It is the strategic implementation of highly coordinated, low-intensity actions.

Within the complex system of healthcare in the Netherlands, Buurtzorg stepped in and peeled away complexity to enable the nurses to provide care and receive the support they needed. Simplified billing, sophisticated IT, supplies distributed and delivered to the client’s homes, and coaching made available to the teams created a healthcare product or service that is superior and less expensive. Buurtzorg has also demonstrated the capacity to be nimble and responsive to changing conditions.

The capacity to build and leverage social networks is one of the most distinguishing features of Buurtzorg. The networks are multi-level and include networks of physicians and other health professional colleagues that interface with local teams of nurses; networks of nurse-led teams that interact with each other; strong connections between local nurse teams and community-based organizations; and on a national level, Buurtzorg has a strong network with governmental entities.

The Buurtzorg values that are embodied in self-directed teams and the phrase “humanity over bureaucracy” represent radical departures from the inclination of modern society to manage, control, create bureaucracy and in the process, dehumanize patients This new organizational form represents social change of a large magnitude.