 Our first guest is, in a sense, a dear friend to the Agile People movement and starting to become quite a rock star within the movement, to be honest. He's built a nursing company from four people to 9,000 people in less than eight years, as I said before, which is quite an astonishing performance. In that, he's become, creating Birdsorg in Holland, and has sort of made him into a change-making in the healthcare industry. And we're really happy to have him here, because when he's not here and doing this, he's out in the world talking to governments and talking to healthcare bodies and different industries about how to build organizations in a completely new way. Jostelbock, very happy to have you here, welcome up. Again, while that is happening... Is it working? Yeah, yeah. Thanks for making us free heat. Oh, there we go, yes. Very nice. Yes, that was a big hand for that. I was here in 1977, and I had a girlfriend in Stockholm. All right. But it didn't work out, so these are the only words I know in Swedish. Okay, but that's not too bad. I wanted to impress her mother. Good, that didn't work out either. She still recognized me. I went back eight years ago, or 10 years ago, and I was standing for the front door, and she still recognized me. Okay, there we go. I made an impression. Okay, very good. We'll hope you make an impression today as well. What I didn't mention in the beginning was that you're also a nurse by education and background. You've been in management positions within this industry quite a bit. With that context, how does it feel going into different parts of the world seeing the practices you've developed actually coming to life? Because you've expanded to actually Sweden, the US, and elsewhere. How does it feel? I think for a nurse it feels quite normal, because I think there is a big underestimation about nurses. So as nurses we come in everyone's houses. There's a district nurse, and you work with professors and with all kind of people. And you know when people are at the end of life, it's a privilege to get to learn them and to learn about their lives. So I think a lot of nurses know a lot about what's happening in the world, and they use it in a daily practice. So that's what I try to do just as a nurse, but on a higher level, try to tell people how you can organize or you can do the things in a different way. I also mentioned that when you're not here, and you'll be traveling just after today somewhere in the world, I think. What do the government and industry bodies and healthcare bodies tell you when they call, we need to call Joss, we'll call Joss. What do they say? They say they learned about us. They say, oh, you have grown so fast in Holland, and we know Holland is a good example of good healthcare. So if you're good in Holland, then it probably will be good for us as a country. And they're all struggling with their own complexity. So they're all built very complicated systems, so they're struggling with the cost development, with the demographics, and with the workforce. So I said, all these three themes can be solved with one solution. So that's not really... One simple solution. You'll be talking more about that, so I'm going to steal your time. I'll leave the stage to you and humanity above bureaucracy. Before we start, on a scale from 1 to 10, how far are we in creating that? I think it depends on from which side you look at it. I think from an individual person live, I think we are at 7 or 8. But from the institutional level or the system level, we are in a 3. A weak 3 or a strong 3? A 3. Okay, awesome. Joss, take it away. Okay, thank you. I'll take some water first. That's a good idea. I was here around 1 o'clock last night, and there was only one beer in the refrigerator, and it was non-alcoholic. I saw it this morning. I thought, as Tommy said, I'm a nurse, but before that I studied economics. So I should have become a famous economist, I always say. I recently met the one who wrote the books at a secondary school. He's now 84, and he phoned me, and he said, I read about you, and I think you're the only one in Holland who understands my economics. And he said, how can I support you? Because everyone in Holland should be able to have healthcare from Buutsoch. So now we're working together. And I thank him for his beautiful books. I worked for 15 years as a nurse, so I quit my study economics after 2 years, and like the world of money, as I can say. And I started to work in the hospital, and I think for me it was very easy to have a meaningful job, because if you're dealing with patients, it's very easy to get connected, to give them a new perspective, to support them in what they're able to. So for me it was a profession that fits me very well. But in the 90s when I worked as a district nurse, the Dutch government decided to change the whole system, and that gave a lot of people a lot of trouble. So I will tell something more about it. But from my secondary school I had some trouble with hierarchical systems. So I was always sent out of class. I had a lot of punishment, and I was discharged from school several times. And it was written a book a few months ago by a Belgian guy. It's called Authority. And he shows that since the 50s we exchanged authority for power. So we built power organizations where people have power on others. And that's what I felt when I was 15, 16, that I don't have a problem with authority, but I have a problem with when people want to have power on others. So these ideas were as a red thread through my life. And I tried to look at it in the organization I worked for. After 15 years as a nurse, I worked for 10 years as a director into big home care organizations. I was director of innovations and medical services. So I've seen a lot of different roles, and also the discussions in the management team. When I still was a nurse, I thought these people have all kind of important thoughts about what they're doing. But I was quite disappointed when I became a manager director. In 2006, together with some friends, we started to think about a new organizational model and new healthcare delivery model. Also my wife is involved and some friends, an IT specialist, and we said we can create an organization based on self-organizing teams with support of IT. That was the idea. And we started in 2007 with one team for nurses. I started to work again myself as a nurse. I still had the skills, so that was quite a pleasure for the patients. So, yes, of course. But I did the evening shifts and the weekend shifts to reduce costs. We were delivering community healthcare, so we said we need to go back to the community. So the home care organizations were more and more delivering tasks instead of delivering solutions. And when I was educated as a district nurse, the focus was on delivering solutions and working together with the community. And that's quite a big difference. For the people who work in healthcare, I think you probably know. And for who you are not working in healthcare, I will explain later more. We were also working together with GPs, because the GPs, the family doctors in Holland lost their district nurses because of all the changes in healthcare. And also, we connected again with volunteers and with a lot of other professionals. At this moment, we have 9,700 nurses. So it's growing every month with around 150 to 200 nurses. So around Christmas, we expect the 10,000 nurses. And next year, we have our 10th year anniversary. So then we have 10,000 nurses. And then we hope to grow to 100,000 patients and 1,000 locations. That would be nice. And then we will celebrate it on 10 locations. So that's a little bit symbolic. We have 45 staff at the back office. So we have one central office in the east of the country. And for example, six people working at finance. We don't have a CFO. So we have a turnover of 300 million euro. And I'm doing the CFO work for one hour per week, because it's only calculating. And plus and minus, it's not so difficult. Because I studied two years economics. So we're dealing now for 70,000 patients a year. Every year, we're growing with 10,000. And at the moment, around 60% of all the district nurses in Holland are working for Butzog. And there are 650 different home care providers in Holland. So we're spreading all over the country. There were several reasons to start this. And my main focus was that what we were doing in healthcare was not good for patients, not for elderly. So elderly got a lot of people at their houses delivering tasks. And sometimes it could be 40, 50 people at one month coming at a person's house. So when your partner or your family member has dementia, it's terrible that you have all the time, you have to explain what the patterns are of your daily life and how the care is as much effective. The idea of the government at the end of the 80s was when we create more market incentives and when we create bigger home care, professional home care organizations, the costs will decrease and the quality will increase. But the opposite happened. So the quality went down and the costs almost doubled in 10 years. Because of this growth and because all the organizations were delivering hours which were not always needed. But because of this growth we got also capacity problems due to the demographic developments. And of course as Sweden you are ahead of the demographic development. So we need to learn from you and from Japan as the two most, the countries with the highest elderly population. And at the same time we didn't have any knowledge or information about the outcome. So we spent a lot of billions of euros and we didn't know do we solve any problems with that. We only know how many hours care delivered. So that was for me, I think we need to learn from what we are doing every day. So to become better nurses. So that was for me something that you would be very normal. But it wasn't there. So that was some reasons to start something. And in 2007 as I said we started with four nurses. And the ideas were quite simple. I didn't know about agile. So I had some ideas about how to organize based on the primary process. So I said taking care for patients is a routine thing. So when someone calls you and needs support, then you go see what has to be done. And together with some colleagues you decide on how you are going to schedule it. This is the daily work of a district nurse. So it's every day again new patients and then when patients don't need help anymore, you just withdraw yourself. This process is a very simple process. But it's made very complicated in a lot of organizations. Because there is someone for the call center for example. There is someone for the scheduling. There is someone for managing the different tasks and so on. So my idea was if you just create an environment where nurses can do all these things themselves, it would be much better. They will have much more fun and it will reduce costs. So they are responsible for the assessments, for the scheduling, for the education. They decide on their own education. They decide on their own colleagues. So they hire their own colleagues. And when you hire your own colleagues, you try to find the best ones. And if you've got some colleagues who are hired by another, then you have to find out if he's good. And if he's not good, you can have a lot of trouble with it. So they are also responsible for finance. So lots of people think that nurses can't be responsible for finance. And I think nurses are very wise and the decisions they make at home, they easily can make at their work too. So the idea is to just use your common sense. You have yours at home also at your work. Then you have all kinds of coordination activities. And we integrate nursing, medical and social care. So if you have a very patient-centered focus, then you should integrate as much as possible activities. Because then you try to go with the life of people and then you can deliver the best possible support. And if you split it up, then you just do a little part of someone and all these little parts never come together. So then it's very difficult to have a complete picture on the client, on the patient. That is how we perceive how we show our vision. Instead of making people depending on care, you should focus on independence. So you should empower people. And it's more about training skills, counseling skills, coaching skills. So delivering tasks and learning people how to deal with their handicaps and permits. It's quite a different thing. But in Holland we got paid for the hours care delivered. So if you prevent someone for needing care, then you don't get paid. So we built very ridiculous systems. So that's what I say to our minister. I said if you don't change the system, it's obvious that you will get more and more hours. So you have to focus on outcome. If you pay for good results, then you get good results. So it's, I think, not so difficult, but we do it quite different in all the systems we have. So we called it the onion model. And yesterday I heard that the onion in Holland is the most exported article. So what's the coincidence? Yes, tomorrow I'm going to Taiwan. So I'm going to export the onion model to Taiwan. Yes, and I will see how much onions we have there in Taiwan. Butchers works inside out. We work together with the community. So you have to have connections with everyone in the community. And for doing that you need autonomy. So you have to decide yourself on what kind of connections are useful. So you work together with volunteers, with the physiotherapist, with the pharmacist, and so on. And when you're doing that for quite a long time, on a small scale, for 5,000 to 10,000 inhabitants, then you know everybody and everybody knows you. So that's as simple as it is. And when you know each other, then you will connect and you will use each other for creating solutions for what you're meeting your daily practice. It's all based on the principles of self-organization. But I say the most important thing is trust. So the way we organize and the way we have all these control cycles and so on is, in my opinion, based on distrust. And I don't know any nurse who is not doing her work properly. Of course, we have some nurses with problems, sometimes with financial problems. You can't always be sure that everything is going well. But if 95% is going well, why should you focus on the 5%? It's better to focus on the 95%. So we say let's trust the nurses, give them the optimal autonomy and try to avoid hierarchy. So I don't know how it works out with you here, if someone is telling you what to do, what's your response? At home, for example. I think that we should try to avoid telling other people how to do what they need to do. And the other thing you can say is just ask, if you have a problem, I'm here for you and you can ask me. That's another way of dealing with things. To avoid complexity, because in the outside world, we have a lot of complexity in our system world. All the policy rules which are developed from the government or from insurance or whatever, they create a lot of bureaucracy. And what we said is we start an IT company which tries to get rid of all this bureaucracy. So we integrate all the bureaucracy in the IT so that the outside world is satisfied about what they get, the information they want. But we don't bother the nurses by it. And that was, I think, a good idea. We said, if nurses are working in a team with a maximum of 12, they can oversee everything. And we will not have dominant people getting the role of a leader. They take care for 40 to 50 patients at one time. They're generalists taking care for all types of patients, some real patients, people who had discharged from hospital, people with dementia. So when you work as a generalist, you learn every day. So from the different things you do. I'm not a very big fan of specialists. Specialists are focusing more and more on one thing and then they learn not so fast as generalists, is my opinion. We have higher educated nurses than the average home care organization. We have 70% registered nurses. And from the total amount of nurses, 40% has a bachelor degree. The average home care organization has around 15 to 20% nurses. They are responsible for their own education. So we just say 3% of the budget can be spent on education but decide yourself what kind of education you need and also organize it yourself if you like. Some of them do, for example, the medical-technical things with the hospital in the region they're working. So they have, at the same time, they have close connections with this hospital. We say that informal networks are much more important than formal organizational structures. So we try to avoid contracts. So we say just do all the connection based on your motivation, on your intrinsic motivation and what's useful for your daily work. You don't spend too much time on meetings you don't think are very useful. So try to avoid useless meetings. And that's an advice for everyone, of course. Try to avoid useless meetings. But we do a lot of useless meetings, you know. We schedule meetings and we don't know yet what we want to solve with it. But it's just a monthly meeting. So we try to avoid that. Then we give them support at the start when a team starts. It starts very natural. Normally there are four or five nurses who say, okay, we heard about it. Can we start something here in our neighborhood? And then we ask them, right, make some short analysis of why you think it should be useful to have a team here. And then they make a demographic analysis and they say we have these networks, we have conversations with the family doctors and we think it would be very useful. And then we say, okay, then we hire you and then start. And then within a few months they're running. So that's usually the process. The coach, we have coaches, 15 coaches, and the coaches are involved in this first period. They support the teams when it's needed. But sometimes the teams don't need support. So then they don't do it. This is one of our teams. They seem quite happy. This is one of our patients. This is now 105. So still quite vital living in Rotterdam. These are the different types of clients we are taking care of. And the idea is that we need to build an infrastructure in the community where every patient can be taken care of at home. And the idea is when you think for the coming 10 years, we have in most hospitals, we have 40 to 50% of the patients don't really need to be there. If the infrastructure in the community is good enough, then we can avoid people to go to hospitals. For example, people with dementia, usually they get birthed when they get out of hospital, then they get in. So you need to avoid people to get in the hospital when there is not an acute reason. That's my opinion. So the idea is for the future, build communities where you have an infrastructure where all these patients can be supported. I usually get a lot of questions about HR and quality. And I said we try to avoid to have HR and quality systems. So I don't know who from you has an HR role, but yesterday I had a meeting with some people from a very big organization in Holland. They're doing the social security and have 20,000 people working and they have 600 people at HR. So I came to ask me advice because we became the best employer of Holland, so they said we also want to become the best employer of Holland. So then I said I know where to start. And then I'm going to have a speech next week, Thursday, because they want to tell me about how can you create an environment where people have fun at their work. And I said you are the institute who are the biggest obstacle for us to have fun at our work. They have these very difficult procedures. So it's not a lecture. But as quality we said we want to focus on outcome and we want to trust on the education level and we measure the satisfaction, the client satisfaction. And from the start we had the highest client satisfaction. And we introduced the Omaha system, that's a classification system where you can show outcome and the Dutch minister of health decided to make it a standard for the whole of the country. So it took six years of discussion with the health insurance and with the ministry. But now we created the standard and it's much more supporting the nurses as the other old systems. As I said we have 45 people at the back office and 50 coaches and no managers. So it's not really true, my wife and me, we are something like a manager because I started together with my wife. But it's like I think most of you in the morning, six o'clock, she's awake and then she tells me what I've forgotten and what I need to do. That's our management team. But we never have management team meetings. So I never write strategic notes anymore, policy notes or whatever because it's not necessary. So if you just don't do it anymore you don't miss it. It's really just try it. It's with a lot of things. You are used to do it, but in the organization just wait and see. Just don't do it for some months and you'll see that nobody's asking for it. No, people are happy that they're not troubled by it. So if you create plans, I was in my other jobs, I was number one in creating plans. So I was every time I took several plans at one time. And I had the idea at that moment that I was doing useful things. If I look back now, I think, oh, I bothered so many people with all these silly plans of me. So I wrote them all excuse letters. But what we do at the head of this is try to get rid of all the bureaucracy. So all the administration should not be a problem for the nurses. They should focus on what I want to do is taking care for patients and working together in these beautiful teams. We had quite an important thing was the IT because we didn't have the software to support it in Holland. We looked everywhere and we said, no, we are not satisfied about how to support it. So we started our own IT company with some friends and now we're supporting a lot of other companies in Holland and now we're creating an international company to support people in Japan and other countries in the world. Three, four years ago we also started in Sweden. Mona and John are here and Mona will also take care, will take place tomorrow in the workshop. So if you want to know more about how it goes in Sweden, just ask for Mona. It was quite a struggle, I can say. If you look at what you can achieve for the IT is that you can reduce costs in every place and you can share knowledge in a different way. So the idea was Facebook was growing very fast at that moment, 2006, 2007. So we said we're going to make our own Facebook. Everyone can share their ideas and information and knowledge and on a horizontal way things cost much faster than you go all these things vertical. So we created this IT system and now we are in a stage that we are involving the clients to take part in the community. So the idea is that at the end the clients have to be in control. In healthcare you very easily take over control of patients. So when you have been in hospital you know that when you're waiting for a doctor then he's easily taking over from you. So that's what we try to avoid. What you see is that and it was very surprising I was since 2007, 2008, I'm writing blogs every few weeks I write my ideas and then we get a lot of comments from the teams and then when the comments are going in a certain direction we just say okay let's make it our new policy. So that's much more easy than to think myself about what should I do. So now that's the reason that I'm so much away that they don't need me anymore in Holland and I can do it everywhere I am so I can just write my blog also in Taiwan. All the documents we have e-learning environment are on this web and it also creates something like shared values. So these teams are very focusing on a neighborhood on their own team and what it says okay if you know that there are other teams all over the country and you can learn from them you can consult them we have experts in different places on different diseases so and there was a very easy communication also with the back office by using this community. If you look at the feeling of the nurses they feel that they're working in a small own organization. So they don't see these 10,000 nurses they just only see their 7, 8, 9 colleagues and that creates an ownership which is I think amazing to see because they're very proud of what they achieved in their own neighborhood. From the start we are one of the most fast-going organizations in Holland we're all over the country now and I think the coming years we will double the amount of teams because they're splitting up all the time. So when they grow to 9 or 10 or 11 then they say okay the coordination is becoming a little bit more difficult so perhaps we should split up and we go on in two different teams in two smaller neighborhoods so it's a very organic way of growing and we don't have a target so we don't say we need to have this but we say when it's needed when people think it's good to have this then it will grow by itself and everyone who wants to work this way is very welcome so that's the reason that we have 400 people who apply for a job every month. There are some books yet and I think it's very interesting to see how the agile thinking developed and how we see now that things come together and all over the world you see it everywhere that people are struggling with the current systems Frédéric Lalloux I think a lot of you will know his book Re-Inventing Organizations even my son is reading it yes he also becomes a nurse it's a third year and it's terrible what he learns at school really half is about management and you said we will need management but that's one of my criticism I don't think we need management we need organizational talent and if you translate it into management then you reduce I think the possibilities I think we can use management theories Frédéric talks about self-management holders and evolutionary purpose and I really can support him in any way he was the first one four years ago, five years ago when he visited us when I thought he's really understanding what we're doing because usually people only reflect on what they see so they see these themes so they think oh it's a structured thing oh it's a different way to organize HR or it's but he I think saw the real difference and Sharda Nandram she wrote a book it's called Organizational Innovation by Integrating Simplification and she developed the Integrating Simplification Theory and I think it's a very nice book because she made connections between the old Indian philosophies and the day to day so I see she defines three principles the needing principle so do what's needed and don't do what's not needed so we do a lot of things which are not needed and if you don't do them anymore it saves you a lot of time then the rethinking principle try to reflect on what you're doing every day with your colleagues with your family and try to think am I doing the best possible things and the common sense principle just use your common sense and what you do and if you we say within boots of if you think something is silly don't do it don't do it because there is just a bureaucratic rule for someone let's discuss the rule and let's go to protest against the rule so that's what we did we like the inspection we invited the inspection because they have a lot of rules which are not improving healthcare but it just rules thought from behind the desk or something so then we said come and see how it works and if you have some advice please let us know but now they're learning from us and they're changing the rules which are more supportive to our way of working this is another team in one of our islands then about the employees how they perceive it we had a lot of competition in Holland as I said we have 650 providers and a lot of these CEO's the provider said the way boots of is working leads to a lot of pressure on these nurses they have to decide everything themselves they are accountable for everything so it's back to the middle ages for these nurses so that was the reason that we said let's start participating in the best employers research because our idea was of course that the nurses liked the way of working and since 2011 we became the best employer of Holland only 2013 we became second after KLM I'm sorry but now you know how it is with KLM with Air France not going very well I'm sorry I like KLM so we have an 8.7 and the second on the list has an 8.0 and we have a 9.2 on engagement and this is the highest figure ever measured and it's quite simple because the ownership of the teams it's quite logic that they feel engaged I think so we don't use it in improving things or something there's one critical thing in it and it's about the work-life balance so at the end of the year we pay an extra bonus and it's really meant for the partners of the nurses so we say that you should go on an extra holiday or something because it's taking a lot from your family so I got a lot of pictures when they're going to Portugal or Spain from the partners thank you for the holiday this is another team in the north of the country then about the clients the focus all the time is talk about the purpose where we are there for talk about the clients compared with the other organizations in Holland we did some research from 2009 but every year there is a research we have 9.1 we are supported by patient and elderly organizations we work very closely together with them also with the union so we say because we got questions what's the sign? oh I thought it was a sign for me oh ok you were just waving friendly people these Swedish thank you yes I think it will be different than Taiwan as I have to speak at the Chenkai check building ok some history and there are less admissions and readmissions in hospitals and nursing homes so we are trying to focus on more research on that because I think it's very important to show that the coast of the care goes down by working this way and the quality goes up then we have very nice innovations this is an example from Amsterdam it's called radio stockings so it's about the pressure stockings when you get elder and this nurse she was a former journalist before she became a nurse and she said we can reach out to much more people if we have a radio program so that's what she started in Amsterdam every week she had this radio program and she invited a mayor and she invited specialists and other people to talk about the life in Amsterdam and now all the cities are taking over so they are making their own radio program together with nurses another thing and I can advise you to look at it at home you will get the slides it's about a walker race and it's about one of the nurses who had this patient she was 85 and she said there are competitions for everybody but not for us elderly behind the walker and then she said it was 2010 and then she said let's organize this and then she went to the city hall and to the health insurance she got 10,000 euro and in 2010 on a Saturday morning I was reading the newspaper there was this big picture with two old ladies behind the walker and it said underneath it is organized by Butoch and I didn't know so I could remember that I had some emails from Amsterdam and I always say very good so I phoned her and said oh that's great how can we learn from it and then she put it on the web and at the moment there were competitions all over the country and we had in September we had the Olympic Yates in the Olympic stadium in Amsterdam so there were buses with hundreds of people coming to Amsterdam in the Olympic stadium and they are really trained for 400 meters 800 meters, 1200 meters and they had a medal and they were there together with families just imagine what happens what the difference is when you focus on the abilities of people instead of the disabilities when people are just sitting behind their screen at home and waiting to have some contact or going out and meeting other people in a very enjoyable environment so this quite becomes a symbol we want also to connect with other Olympic stadiums so I'm now talking with people in Tokyo to start something the same there and we are also working in Seoul and Korea and we try to start, say okay if you really want to involve elderly in the daily participation you should do other things so and it leads to another profession and another way of organizing so all these things come together this is creating meaningful relations between people and when you create meaningful relations you will get other results it's much happier lives I think if you look at the cost for the organization we reduce the overhead costs by organizing this way we have only 8% overhead cost so we can spend the money on care innovation Butsoch is a non for profit organization so we have profit we spend it on most of it on innovation and on having some financially reserve for some things which can happen in the future because we have struggled from the start with the payment system they didn't pay always what we are doing so in 2013 we didn't get paid 9 million euro the health insurance so now they pay everything because they were a little afraid that people were not going to insure anymore with these health insures and now at the moment we are creating our own health insurer so that will be the next step they are already nervous the other ones the sickness rate is 4% we try to reduce it it's lower than average but we think we should go to 2% so I asked everyone what can we do to become the most healthy organization of Holland what is the idea about mindfulness about massage at work what kind of things more holiday days also so we have to see what works and not then if you look at the cost benefits for the care what we wanted to show when you work this way it reduces the hours of care so what we have shown is that we did research with the Ministry we show that we deliver 35% less hours than the average in Holland the clients and the employees are very satisfied in the process we had a lot of discussions with a lot of stakeholders one of the most important one was in 2007 the Minister of Health and she was really touched by talking with the nurses and she received a difference in how they worked before and how they are working now and then we worked together quite closely she asked me to come to the Hague to talk with her people at the Ministry what can we do, what can we change and at the moment all the payment system the regulations are changed in a way that it's supporting our way of working last week there was a big debate in the Parliament and it was all about district nursing and how district nursing can contribute to improving healthcare I think what we achieved and what we see is that a lot of other organizations are also interested in the model so I have banks banks have a lot to do except for Handelsbanken I think that's a very important difference they could learn from Handelsbanken too there are hotel chains there are schools, police in every field you see that they are trying to find new ways of organizing network creating networks and trying to avoid all the hierarchical structures this is what we want to achieve if you look at the demographics we need to attract more younger people in healthcare and I'm not for the innovation part but I think that we have so much wisdom in the organizations people who women who have because 97% of the people are working for are women they have so much wisdom about how to deal with daily things and how to organize how to develop strategies which are working in their community so we should use their wisdom and we should attract young nurses to come in to work in healthcare because we need them when we are depending on the healthcare system so this is what I wanted to share with you and I'm looking forward to the discussion thank you from four people to Olympics, insurance company IT company and what have we next I didn't mention yet the different other parts we are developing we have a mental healthcare part so focusing on mental problems youth care hospices maternity care and we have also domestic care so it's focusing on cleaning houses and supporting people in their daily activities and they all have their own development so we'll see what comes out of it we'll open up for questions and then we'll have a mingle break there's so many things popping when listening to you and one thing obviously is from everything that you guys have done what is the things that are easy to relatively easy to extract and apply to if I'm in the steel industry or I'm in the auditing business or I'm a bank for that matter what are some of the things I think when you start with the product or the service you are delivering and you say okay what the logic in this process and you take that as a most important principle for organizing it can be a depth everywhere in my opinion and it's not so you should try to get the complexity out of your head which is perfectly easy Monday morning after the weekly meeting where do you start then because I imagine in Sweden we have obviously a lot of public healthcare organizations then we have a number of private healthcare organizations that are either privately owned or venture capital or what have you how easy would it be to just go to one of the big ones and say guess what do you do it this way instead we did several of these transformations in Holland so I have some friends who are CEOs of bigger organizations usually there are women because women understand more easily what it is about so excuse me gentlemen but it's part it's intuitive and one of these organizations we just separated a small part of the organization disconnected it from the rest from the managers and from the back office and we said nobody can interfere we just asked them to do what they want to do and within a few months we had the same results as what we were doing so then these teams were somehow advertising to the other teams and then within two years we did transformation and the most important thing was that what I said to the CEO was also a friend of mine I said you have to be very consistent so you should not make any compromise if you mix two paradigms together then it won't work but if you really think that is a better way to organize just start a discussion with everyone explain what you want to achieve and how it works and why and we made a lot of trips they came and see how we did it and the awareness grew and now they are one of the best performing organizations in Holland and now they become a role model and an example for other organizations to make the same shift so it's really about daring to think that you can do something different going into the very hardcore logic of the business and start turning stones in your head you have to imagine how it looks like when you have made the change in that three step process turning the stones is the last one I never think in a linear process of course sorry my bad I work in a consulting profession okay anyway you go to Vietnam Taiwan where do you because you are scanning the world at least more in this topic than I do where can we turn where are we relatively better in doing this Holland the golden star in the world where you have all these best examples I think everywhere I come people recognize these things so this wisdom is everywhere so you should just use what's there and then connect with people who are supporting the change but like we work now together with for five years with a lot of people in Japan but the Japanese people are doing it themselves they just visit us and we do some training but the paradigm shift is happening in their heads and they find out how they can deal with it in their history and their system and then something beautiful happens which is extra fascinating because Japan is not necessarily the most agile and self-managed culture in a sense maybe they will alright I have more questions but let's invite the audience and see what's cooking and we have microphones if we need here's a question in the middle of the middle can you hear me it's fascinating to hear what you have achieved but have you ever failed have you ever failed with teams and if you have do you know why it hasn't worked out yes I think in total we have had two or three teams who didn't succeed and it was I think for two of these teams it was a wrong estimation if they were would really be accepted so in Holland it's when you don't have a good connection with the family doctors it's becoming difficult to get the referrals so in some places then the team stays very small so then you have three people and then you have delivered 24-hour day care so you have to be available also at night and pressure on a small group is too big so then we say we can try it for some months but if it's not working then we divide the nurses on different teams so we ask them to find out if they will but it's only two or three times happened up till now so some of the teams have some struggles in time but it's part of the process and how to deal with it makes them learn how to deal with difficult periods ok questions in the back so here we go now don't be so Swedish so just put it up you guys hear me I hear myself so this question is related to to taking this concept to other geographies and cultures right you touched upon Japan and I find it amazing that could actually work there based on my own experience with Japan but that's good to hear but I work in an American company and I'm wondering about your experience with the US how does this work in the US yes we're experimenting in Minnesota so we also have an American company it's Butzok USA it's quite struggle with the American system but I went to San Francisco a few months ago and there's now a group also with some authorities from San Francisco who want to experiment and then we get the backup from top down and that will I think help more but I've talked with senators a lot of people with the ARP and the American Association of Retired People and they all think that this concept can contribute to the development terrain so and we try to find several ways to learn about the American system and then try to find different small projects and then we'll see so I also did a project before I started with Butzok and then I started with the European on primary health care and that became national policy and I think it's always because you said about Japan I think one of the the main things is try to understand their language Japanese is quite difficult but the nurse language in a lot of countries is the same so they say that what we are doing in Europe so when I go back to things which are logic for them and then from the policy of the government in Japan they said in 2025 we need to make a big shift from hospital care to the community and it also works so I'm also talking with the Ministry of Health and the Ministry of Finance in Japan I try to connect all the time the system world to the daily practice that helps question there and then down there all right this sounds really interesting say that the team of 12 really like working together can they self manage to be more than 12 or is it forbidden by policies we just say if you're happy and then you don't have problems you can go to 15 but the logic is that when you have more patients and you have more colleagues the coordination becomes more difficult so some of these teams they say we want to stay together because sometimes it feels like like a divorce when they split up so afterwards you see the same kind of problems as a bad divorce but they're not very strict we have some guidelines so we said it's you will experience that it becomes more difficult okay I think there was one down there as well but and then here and then we'll see how many more we have time for but let's keep it rolling let's see if I can, yeah hello my name is Charlotte Breton I work for the Swedish management organization I mean my colleagues have been interested in the sickness rate I think it was four compared to seven and you also mentioned something about is that why it's quite high or is that just my interpretation can you explore a little bit about work-life balance? I think it influences I think what one of my concerns is all the time the discussion about how to keep your own borders clear because this engagement has another side so 9.2 on engagement is that they are so motivated they like saying no to patients the teams are first years they were growing so fast and they didn't want to say no some of them were working much more hours but I think more and more we learn how to deal with it so we say use your meetings every month try to think about do you have enough colleagues to take care of the patients you have and how to use your hours but I think there is a connection thank you have a question over here I was wondering about all the as the company grows there is more and more questions that are in common you have said for example that you decided to invest in an insurance solution and you got your common IT system so who takes the decisions that sort of come in for everyone that's bigger than the unity the idea like the insurance companies is an idea for different people from different places in society so I'm also president of a foundation called Hollands is Flipping I work together with some different professors one is Jan Rodmans and what we want to achieve is this movement to go beyond different sectors industries or whatever and one of these ideas what came out of it is this alternative in the health insurance a lot of strategic decisions not so many but are made by me yeah but what we try to do now we had an interesting discussion two weeks ago with for example with the coaches and we said how can we decide on different subjects just some people together who are checking without my active role in it but during the growth and also keeping all the difficult things outside there was quite a big role for me and I want to reduce it now so I want to create a distributed ways of decision making okay hey we'll meet you in the panel after lunch you'll be here all day so if you want to continue to pick Joss's brain in a sense the sample time to do that thanks a lot good luck in Taiwan and with all the endeavors big hand please