How Buurtzorg Built a Self-Managing Organization

This post is part of the “Leadership Evolution” series, exploring how organizations navigate the messy, non-linear paths of transformation from conventional approaches to ecosystem-inspired models. Each post examines not just what these organizations became, but how they got there—offering insights for leaders navigating their own organizational evolution.

Introduction: The Before Picture

The Dutch healthcare system in the early 2000s was drowning in bureaucracy. Home care had become fragmented, with nurses spending 40% of their time on administration rather than patient care. Multiple caregivers would visit a single patient, each performing specialized tasks in strict time slots. Costs were rising while quality and satisfaction plummeted.

Into this environment, nurse Jos de Blok launched Buurtzorg in 2006 with a radical vision: self-managing nurse teams providing comprehensive care with minimal overhead. What began as an experiment with four nurses has grown to 15,000 professionals—without adopting the hierarchical structures that dominated healthcare.

But Buurtzorg wasn’t born fully-formed. Its evolution offers crucial lessons for leaders seeking to build organizations where coordination emerges without centralized control.

Crisis Points & Catalysts for Change

Buurtzorg emerged from a breaking point in Dutch healthcare. Nurses were leaving the profession, patients received inconsistent care, and costs were unsustainable. This crisis created both necessity and opportunity.

De Blok, then a middle manager at a traditional home care organization, experienced firsthand how centralized control degraded care quality and nurse satisfaction. His early experiments with more autonomous nurse teams within the conventional system hit resistance but demonstrated promising results.

The catalyst came when a small group of nurses decided the system couldn’t be reformed from within. Starting fresh allowed them to design around core principles rather than incrementally modify broken processes.

We didn’t start with a detailed plan. We started with experienced nurses who understood what good care required, and we removed everything that got in their way. – Jos de Blok

Evolution of Structure: The Coral Reef Foundation

Like coral polyps building calcium carbonate structures that enable reef biodiversity, Buurtzorg began by establishing minimal supporting elements upon which complexity could flourish.

Their initial structural elements were remarkably simple:

Teams of 10-12 nurses responsible for a neighborhood of 40-60 patients
Complete patient care responsibility within each team
Self-management of scheduling, client intake, and care planning
A coach (not a manager) available to support team development

What’s often overlooked is how this structure evolved through trial and error:

Early adjustments: The first teams quickly discovered they needed agreements around decision-making. They developed simple consensus protocols—not to control behavior but to enable coordination.

Technology adaptation: The initial paper-based systems proved insufficient as teams grew. Rather than adding administrative staff, they developed a simple IT platform allowing teams to manage their own administration while sharing knowledge across the organization.

Boundary experiments: Early teams struggled with defining when a team should split due to growth. After testing different approaches, they discovered that team effectiveness declined beyond 12 members, establishing a natural scaling model.

Failed experiments: Not everything worked. Early attempts at having teams share financial responsibility across regions created conflicts and was abandoned. Similarly, early efforts to avoid all specialized roles evolved as they recognized certain expertise benefited from focus.

The key insight: Buurtzorg’s structural evolution focused on maintaining the minimum supporting elements necessary for self-organization, adding complexity only when its absence clearly limited effectiveness.

Leadership Transitions & Distributed Authority

Jos de Blok’s leadership evolution mirrors the organization’s. Initially, as the founder with the vision, he made many decisions. But unlike many founders, he systematically distributed authority rather than accumulating it.

This transition wasn’t without challenges:

From answers to questions: De Blok shifted from providing answers to asking questions that guided teams toward their own solutions. This wasn’t an immediate transition but developed through conscious practice.

Authority distribution: Decision rights were methodically pushed to the level closest to the patient. When teams sought permission, the response became “what do you think is best?”

Protective leadership: When external pressures threatened the model (like insurance companies demanding standardized processes), leadership’s role evolved to protect team autonomy by managing boundaries with the environment.

Leadership development: As the organization grew, they faced the challenge of developing new leaders who embodied the approach. Their solution wasn’t a leadership training program but embedding potential leaders in teams where they could absorb the principles through practice.

I spent less time making decisions and more time creating the conditions where good decisions could emerge from those closest to the work. – Jos de Blok

Cultural Evolution: Growing Symbiotic Relationships

Buurtzorg’s culture didn’t emerge spontaneously. It evolved through deliberate nurturing of symbiotic relationships—both within teams and with the broader healthcare ecosystem.

Trust cultivation: Early teams brought habits from hierarchical environments—seeking permission, avoiding responsibility. Building trust in their own judgment required both encouragement and proof that mistakes wouldn’t be punished.

Relationship focus: The organization gradually recognized that relationships—not processes—were their core asset. They shifted from focusing on efficiency to focusing on relationship quality among team members and with patients.

Value articulation: The core values remained consistent, but their articulation evolved as the organization learned what enabled its success. The concept of “humanity over bureaucracy” became sharper through experience with its alternative.

Symbiotic balance: Teams developed increasing interdependence—sharing knowledge while maintaining independence in daily operations. This balance wasn’t designed up front but evolved through continuous adjustment.

The most important cultural evolution was the gradual shift from seeing organizational success as the goal to seeing it as a byproduct of creating conditions where people could do their best work.

Resistance & Adaptation Cycles

Buurtzorg’s evolution wasn’t linear but cyclical, with periods of growth followed by integration and occasional setbacks requiring adaptation.

External resistance: The healthcare establishment initially dismissed their approach as naive. Insurance companies demanded standardized processes and metrics incompatible with their model. Their response was neither capitulation nor confrontation but demonstration—proving through results that their approach produced better outcomes at lower costs.

Internal challenges: Some nurses struggled with the autonomy after years in directive environments. Rather than creating a less autonomous tier, they developed peer coaching approaches that helped these nurses adapt at their own pace.

Growth pressures: Rapid growth created pressure to add management layers. Instead, they invested in better self-management tools and regional coach networks, preserving their core model while adapting support systems.

Renewal cycles: Like coral reefs periodically shedding to enable new growth, Buurtzorg developed “organizational renewal” practices—regular reflection periods when teams questioned their own patterns and processes, preventing calcification of approaches that no longer served.

Their adaptation approach followed a pattern: when facing challenges, they first asked how to preserve self-organization while addressing the issue, rather than defaulting to conventional control mechanisms.

Scaling Without Standardizing: The Growing Reef

Buurtzorg’s growth from 4 to 15,000 professionals required solving the scaling puzzle without resorting to standardization and hierarchy. Their approach offers crucial insights:

Replication over expansion: Rather than growing existing teams, they replicated the small team model, maintaining the optimal conditions for self-organization.

Simplicity as scaling strategy: They maintained scale-ability by keeping the core model simple and transparent, allowing each new team to adopt it without extensive training.

Knowledge transfer evolution: Initially, knowledge transferred through direct contact between teams. As they grew, they developed a simple intranet platform where teams shared solutions while regional coaches cross-pollinated learning.

Minimum viable bureaucracy: Central support functions remained deliberately understaffed (just 50 people supporting 15,000 professionals), forcing simplification and pushing responsibility to teams.

Scaling tensions: Not everything scaled smoothly. They struggled with maintaining founder-level connection as they grew, eventually developing practices like large-scale dialogues and transparent communication to preserve connection to purpose.

The key insight: successful scaling wasn’t about standardizing practices but standardizing conditions that enabled each team to develop practices appropriate to their context.

Today’s Reality and Continuing Evolution

Today’s Buurtzorg isn’t a perfect implementation of an ideal model but a living system continuously evolving. They face real challenges:

Integration tensions: As they’ve expanded into new services like mental health and domestic support, they’ve struggled to maintain integration across service lines.

Succession planning: The organization continues working through founder succession, developing leadership that can maintain their approach beyond the founder’s direct influence.

External pressures: Regulatory changes and healthcare system pressures continually test their model, requiring ongoing adaptation without compromising core principles.

Cultural maintenance: Maintaining their culture with new generations of professionals requires continuous renewal of their story and principles.

Perhaps most importantly, they recognize these challenges not as problems to solve once but as ongoing evolutionary pressures that keep the organization adaptive.

Takeaways for Leaders

For leaders inspired by Buurtzorg’s journey, the path isn’t about copying their model but understanding how to nurture your own organization’s evolution toward greater self-organization. Consider these approaches:

Start with purpose, not structure: Begin by clarifying what your organization exists to do, then question which structural elements truly serve that purpose and which obstruct it.

Experiment at the edges: Create bounded spaces where teams can experiment with greater autonomy while containing risk.

Focus on conditions over control: Shift attention from controlling behavior to creating conditions where desired behaviors naturally emerge.

Develop supporting rather than directing leadership: Train leaders to ask “What support do you need?” rather than giving directions.

Build minimum viable structure: For each process or policy, ask: “Is this essential? What would happen if we removed it?”

Trust in stages: Extend trust incrementally, giving teams progressively more autonomy as they demonstrate readiness.

Reflection Questions for Your Organization

Consider these questions to apply Buurtzorg’s evolutionary lessons to your context:

What is your organization’s equivalent to Buurtzorg’s “minimal calcium carbonate structure”—the essential supporting elements upon which self-organization could build?
Which current processes or policies exist primarily for control rather than support?
Where might you create safe-to-fail experiments with greater team autonomy?
How might you shift from directing work to creating conditions for effective self-direction?
What would “success” look like if measured by the quality of relationships rather than just quantitative outcomes?

The most important lesson from Buurtzorg’s evolution isn’t their specific model but their approach to organizational development: patient cultivation of the minimal conditions necessary for human potential to flourish. Like a coral reef, they demonstrate that remarkable complexity and resilience can emerge from simple foundations when we trust in people’s capacity to self-organize around meaningful purpose.