This Danish Municipality Changed Its Management Model Inspired By Buurtzorg
Since 2018, the Danish Municipality of Rudersdal has made profound changes in the management of its nursing care. The changes are inspired by Buurtzorg, a Dutch neighbourhood nursing organisation with an innovative leadership philosophy in line with the Beyond Budgeting principles. This management model is based on less micro-management and provides employees more freedom to take the citizen’s perspective on care. In a short period of time, this has led to remarkable results in the Municipality of Rudersdal, leaving both citizens and employees enthusiastic about the new management model.
We are set to meet Mayor Jens Ive, Chief Municipal Executive Birgitte Lundgren and Head of Healthcare Centre Ane Berg Frische at the Town Hall. All three have played key roles in connection with the new approach to nursing care in Rudersdal.
Nursing care is the Municipality’s largest welfare area with 2,000 employees and an annual budget of DKK 1.0-1.5 billion.
”We wanted our caregivers to be closer to the citizens – this is the simple explanation why we saw a potential in changing our management model. In our view, we had some very competent employees who were not always given sufficient room to do as they found best”, says Jens Ive, Mayor of the Municipality of Rudersdal.
‘Putting the citizen at the centre’ was not our only goal
”Roughly speaking, we went from an organisation with great focus on professional competences and hierarchical management to considering different ways of organising our citizen-focused role. We underwent a major process, involving employees, leaders, citizens and their relatives. This process was inspired by Buurtzorg and their ideas. We did not only want to ’put the citizen at the centre’; rather we insisted on taking the citizen’s perspective – and we have continued to ask for the citizens’ view on the various elements of the new model”, says Birgitte Lundgren.
More specifically, this has resulted in a merger of the administrative departments responsible for the former social area and senior citizen area, respectively, into today’s encompassing adult area. In addition, the Municipality eliminated up to two layers of management at five healthcare centres and two sheltered housing centres – and two of the home care districts are in the process of establishing self-governing groups responsible for arranging their work and activities together with the citizens.
Due to these changes, the employees now have more leeway to take decisions on what to do – together with the citizens. Previously these decisions were taken by top management – far from the citizens. The new model also means that the Municipality, to a higher degree than earlier, involves the resources available in the citizen’s network in its efforts to meet the citizen’s needs.
”We take a holistic view. We consider the resources available in the network and in civil society and apply this individually since each citizen is unique and different. This is important to take account of when assessing what each citizen needs from the Municipality”, Birgitte Lundgren explains.
Since 2018, the Danish Municipality of Rudersdal has made profound changes in the management of its nursing care. In a short period of time, this has led to remarkable results.
More leeway for employees and citizens
The Municipality of Rudersdal strives to develop a new welfare model for citizens who need care; a model where the relevant activities are agreed directly between citizens and employees. There is no longer a need to ask for permission beforehand and, therefore, the relevant services reach the citizens faster. The home care sector is striving to establish self-governing teams that translate the Buurtzorg model into a Danish context in the so-called Rudersdal model, where a self-governing team becomes responsible for delivering home care within a geographically limited area.
The step towards making both citizens and employees more influential has already been taken by the Municipality’s two sheltered housing centres for disabled citizens and five healthcare centres for senior citizens.
Birgitte Lundgren explains that, initially, the idea was to establish two areas with a District Manager leading each of them:
- One area for citizens living in their own homes
- One area for citizens in need of care 24 hours a day at either a sheltered housing centre or a healthcare centre.
”But then we got the idea that perhaps we should try to set the sheltered housing and healthcare centres even more free. In Ane’s case, this resulted in the elimination of two layers of management so that now she refers directly to the executive management. We were confident that Ane and her employees were capable of lifting this job on their own. They are so competent, and the entities are so stable that we did not consider it necessary for them to refer to so many layers of management. And we succeeded in getting political support for this change so now they stand on their own feet”, says Birgitte Lundgren.
Hierarchies provide a (false) sense of safety
Heading one of the healthcare centres that has been ‘set free’, Ane Berg Frische has experienced the new management model as a totally new management ideology, which has resulted in many good aspects, but which has also been challenging:
”It has also been difficult to change one’s management perspective because hierarchies also provide a sense of safety. After all, it feels safe to be able to ask your superiors whether the ideas are good. And you also get some extra time for more thinking while waiting for your superiors’ feedback”, Ane Berg Frische explains and continues:
”Now you cannot help acting if the initiative makes sense to the citizens and employees. We no longer need to wait for an approval, and this has also made it more acceptable to test things and to experiment. We have had an open dialogue about the importance of not having a ‘zero-fault’ culture – rather there should be room for testing things. So now we dare do more.”
We have had an open dialogue about the importance of not having a ‘zero-fault’ culture – rather there should be room for testing things. So now we dare do more.
When asked whether her management responsibilities have become more demanding after the ‘setting free’ of her healthcare centre, Ane Berg Frische promptly answers:
”Yes, but it has also become more fun. The liberation provides the healthcare centre with autonomy to launch those initiatives that we find most meaningful. The autonomy comes with a greater feeling of responsibility for ensuring success with the prioritised initiatives. This is the case both for me as the head of the institution and for my colleagues in the healthcare centre. So we are now more enthusiastic and dedicated in our work.”
‘Setting free’ requires cross-institutional cooperation
After the healthcare centres have been set free, their heads meet across the institutions to exchange experience and to spar.
”I believe that we have become more aware that the more we can cooperate across, the stronger we are; both across institutions and across areas. In this way we can also be more flexible as regards the citizens’ needs”, says Ane Berg Frische and continues:
”Earlier I experienced a great separation between day-care facilities, 24-7 care facilities and dementia facilities. But since we have combined the finances and resources for these areas, the employees can follow citizens who change from one category to another. After all, I have citizens who start out using day-care facilities, move to 24-7 care facilities and, ultimately, use our dementia facilities if the need arises – now our employees can follow the citizens. This was impossible earlier. So, the result is freedom and flexibility – and this provides safety for the citizens who are moving as well as for their relatives. Thus, what we do now is characterized by coherence.”
The above is merely one example of what the heads of the healthcare centres have been able to do almost overnight – and which was not possible earlier due to silos with separate budgets. From an operational point of view, it has also resulted in greater flexibility as regards the possibility of relocating employees if needed.
”We have simply made our central finance department provide direct support to Ane and her colleagues. Usually we work with decentralised finance departments in our various areas (our school area, social and health area, etc.). But here we are trying to incorporate our finance department in a different way. As regards management and financial thinking, I feel that the healthcare centres have moved distinctly in terms of connecting things compared to earlier when things were more sectionalized”, says Birgitte Lundgren.
Leaving sub-optimisation for the benefit of the overall economy
Previously each area in the Municipality of Rudersdal has fought to get as much funding for itself as possible, and Ane Berg Frische says that she constantly had to sub-optimise:
”I had to share my finances with our District Manager and I did not have any overview of the pooled funds received and where they went. We had an operational budget, but no insight or influence on where funds went. I have a feeling that the District Managers tried to secure as much funding as possible for their own areas. But we have to be able to cooperate across the different areas and ensure the optimal use of funds among our citizens and their needs”, says Ane Berg Frische.
The liberation provides the healthcare centre with autonomy to launch those initiatives that we find most meaningful. The autonomy comes with a greater feeling of responsibility for ensuring success with the prioritised initiatives.
As an example of the increased holistic view, Birgitte Lundgren says that the healthcare centres and the sheltered housing centres now cooperate about optimisation of duty scheduling.
”This is about prioritising the welfare activities and not a classic savings exercise. But, nevertheless, you have delivered a lot financially that we have been able to re-allocate to the specialised adults’ area and the children area”, says Jens Ive and elaborates:
”Earlier we looked in the catalogue of services offered and said, for example, that ‘the elderly are no longer to go for a walk every day, now they will get a bit of fresh air only every fourth day’ – so we reduced the service. You have actually managed to maintain the service – or perhaps even increase it a bit – while delivering on the finances.”
Though the nursing care sector is changing, the citizens have a new sense of calm
Though the new management model has enabled the nursing care sector in the Municipality of Rudersdal to improve its finances, this was never the primary goal. Right from the outset, the main priority was to improve the care for – and together with – the citizens.
The Municipality of Rudersdal is actively striving to involve the citizens and their relatives in the activities offered in the nursing care area. They have, for example, been involved in the development of the long-term plan and activities of Ane Berg Frische’s healthcare centre Frydenholm.
”Involvement of the citizens and their families has been at the core of this project right from the start, and I also think that the citizens acknowledge that they have had a significant say in connection with the activities and efforts that we are working with. This means that we agree on which activities and efforts to focus on”, says Ane Berg Frische.
We are now more enthusiastic and dedicated in our work.
”Seen from my chair, the number of complaints is not increasing. On the contrary, we are receiving much recognition. And when their old dear ones pass away, the relatives write us to say that they think they have had a fantastic experience. It is very interesting that the nursing care area has never been characterised by as much calm as now even though we are in the midst of a significant change process”, says Jens Ive and ends by saying:
”We have decided that, this year, we will take the new management model one step further. Among other things, this means that the management group that has already been set free becomes responsible for co-opting itself, thereby ensuring that future management colleagues have the competences needed to continue the liberation. Thus, the management group gets an even stronger, cross-sectional responsibility for developing activities and efforts together with their employees. It is important that everybody is moving in the same direction and does not close around oneself. In 2020 we will continue working on relation coordination, i.e. even more common focus, cooperation and a holistic approach across the areas for the benefit of our citizens.”
This guest blog is written by Anders Olesen. Anders is partner at Basico and senior advisor at Beyond Budgeting Advisory.
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Well done! We have been trying to do this many times in England, and have found that, despite great Prototypes proving the outcomes, central decision-making structures are not prepared to change. One of the problems is that we have politicians involved in Healthcare strategy and structures!
The part about management playing the role of Co-opting their function is particularly compelling.
My experience is that this can cause fear in the management layer. How how did the Municipality of Rudersdal deal with management concerns of obsolesces? I’d love to hear more about the challenges and dialogue that took place with this layer of the organization.
"I dispensed with the false comfort that making detailed plans can bring – and falling back on the notion of control – in what was a highly uncertain environment. Detailed annual plans may have been standard practice a hundred years ago, but in our modern world this is far from ideal.”
Most of us know monopolies are bad. “They have no incentive to deliver better products or to get more efficient.” And if a monopoly can do whatever it likes, the victim is likely to be the customer. If it exists outside an organization, measures can be taken to end that. Within organizations, creating monopolies seems standard practice, but why!?