Radical Autonomy At Scale

Pim de Morree
Written by Pim de Morree May 04, 2019

In our search for the most pioneering workplaces in the world, we’ve come across some extraordinary organizations. And this is an understatement. We’ve seen those where employees select their own leaders, others where any employee can make a decision on anything, and even those where staff set their own salaries.

But sometimes we are asked: “Which is the most radical?” This is a tough question. One candidate has to be Buurtzorg. Maybe you’ve never heard of them. Not surprising. But they are well known in the Netherlands, where we live, and worldwide in the healthcare industry.

From nothing to 14,000 employees

Buurtzorg is a home-care nursing organization that has grown from nothing to 14,000 employees in just 10 years. That’s impressive! But it’s not, in our view, the most impressive thing about them. They beat their competition on almost any metric you choose. Tick these off…

  • Highest client satisfaction
  • Highest employee satisfaction
  • Lowest costs (67% lower than their Dutch peers)
  • And they cure patients faster than the competition.

By the way, they have no planning, HR, or marketing departments—and there’s not a single manager in the place. How the hell did all that happen? Let’s explain.

The humble revolutionary

In 2006 a humble revolutionary, Jos de Blok, founded Buurtzorg. He was frustrated working in a traditional home-care organization. He was convinced that the command and control style hampered the delivery of good healthcare.

He set out to prove that an alternative – based on freedom, trust, and high levels of autonomy – would benefit everyone, including, most importantly, the patients. Starting with just four nurses they quickly became successful. From the beginning, they decided not to grow a traditional hierarchy. They chose instead to grow a network of teams.

Every time a team gets to 12 nurses, they split. The two newly formed teams grow until they reach that magic number before splitting again. This allows the organization to grow exponentially without damaging quality, satisfaction, and cost levels.

Each team is self-managed and fully responsible for a specific neighborhood. They do all the work required (i.e. nursing, planning, personal development, recruitment, hiring, firing, decision-making, etc.). Now, there are 1,000 self-managed teams, each enjoying huge amounts of autonomy.

Some might say that radical autonomy can also be dangerous: what if someone drops the ball and quality standards suffer? Wouldn’t you need extensive rules and policies to control quality standards?
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As one of the nurses said to us, “We feel more liberated, appreciated, and fully in control of how we can provide the best possible healthcare to our clients. Instead of having to work with lots of frustrating bureaucracy, we now do what we love to do: delivering care to patients.”

But some might say that radical autonomy can also be dangerous: what if someone drops the ball and quality standards suffer? Wouldn’t you need extensive rules and policies to control quality standards?

The beauty of the Buurtzorg model is that the organization trusts the trained nurses to do a good job. They don’t believe in standardization as it will directly reduce autonomy. Strange as it might sound to those working in command-and-control workplaces, the Buurtzorg model is based on trust – and it works.

The headquarters that supports this network of about 1,000 teams has only 50 people. This tiny group provides the bureaucracy that is, so far at least, inevitable (for things like contract negotiations with insurance companies).

More than the sum of the parts

But Buurtzorg's teams are more than just the sum of their parts. A self-developed IT system connects them, combining high levels of autonomy with advantageous scale throughout the organization. Their intranet allows teams to share knowledge, compare performance and create alignment. For example:

  • If nurses encounter issues they are not familiar with, they use the intranet to get advice from more experienced colleagues. Often, an answer arrives within hours.
  • Sharing measures like the percentage of hours spent with clients develops insights into the client focus of various teams.
  • And CEO Jos de Blok can communicate with everybody at lightning speed. He writes blog posts to instantly inform all colleagues of what’s on his mind—and invite their advice.

It’s no surprise more and more countries are adopting the Buurtzorg model. Buurtzorg is now supporting the export of their approach to the UK, Sweden, Japan, China, Taiwan, South Korea, and the US. And other organizations are adopting similar approaches—all inspired by Buurtzorg.

Buurtzorg shows the way towards a more human, motivated, and impactful future of work. It provides scale without hierarchy, alignment without bureaucracy, and autonomy without anarchy.
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Copy-pasting an organization's model can be dangerous. But adopting the underlying principles, and applying them in your context can deliver extraordinary outcomes.

This network of teams structure is based on some key principles. Typically, it is:

  • Radically decentralized.
  • Made up of multidisciplinary teams of 10 to 15.
  • Which have full responsibility for their part of the business.
  • And may have a financial stake in the outcome.
  • The teams are focused on a product, service, customer, or geography (like Buurtzorg).
  • They may be supported by a small, centralized function.
  • Strong IT systems allow for economies of scale.

Buurtzorg shows the way toward a more human, motivated, and impactful future of work. It provides scale without hierarchy, alignment without bureaucracy, and autonomy without anarchy.

This is what work in the 21st Century should look like.

Written by Pim de Morree
Pim de Morree
As co-founder of Corporate Rebels I focus on: researching, writing, speaking, and building our company.
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