Tag Archives: requisite organization

How to Move a Team from BAMS to Work Mode

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This is the last of a series on Teal and Levels of Work. Here is the backstory for the series. The purpose is to explore the tenets of Teal through the lens of Levels of Work. Links to each post in this series, below.
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From the Ask Tom mailbag –

Question:
I have a question, what are the biggest challenges for companies starting self-organizing teams?

Response:
First, give any group of people a problem to solve and they will self-organize into a team to solve the problem. There will be discussion, disagreement, agreement and commitment. Some members of the team may fall out. A leader will emerge. Some would call this role a coach, others a manager.

You already have a self-organized team. The next step is to create an accountable team, where the team itself manages accountability. Some teams push accountability management to the leader (coach, manager) and given the opportunity, many leaders (coaches, managers) cannot resist. If the leader falls for (seduced by) it, the team easily succumbs into BAMS.

How does the leader/coach/manager resist the temptation? The most effective manager does not tell people what to do. The most effective manager asks the most effective questions.

Discontinuous Levels and Hierarchy

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This is a series on Teal and Levels of Work. Here is the backstory for the series in case you are interested. The purpose for the series is to explore the tenets of Teal through the lens of Levels of Work. Links to each post in this series, below.
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From the Ask Tom mailbag –

Question:
In your post yesterday, you said that growth (of capability) is nested in discontinuous levels and that these discontinuous levels were readily observable. What did you mean by discontinuous?

Response:
An electric car has a continuous power-train and no gears. It goes from minimum to maximum in one continuous power curve. Humans are more like a multi-speed transmission, where each gear winds out to its maximum, shifting into the next gear.

Jean Piaget was the pioneer who observed distinct stages in childhood development.
Non-verbal sensorimotor stage (birth to 2 years), where objects that cannot be sensed (seen or heard) do not exist. I have five fingers on each hand, but hands behind my back means I have no fingers at all.
Pre-operatonal stage (2-7 years) where symbolic language emerges to indicate relationships, though relationships are ego-centric, the child is the center of its universe.
Concrete operational stage (7-11 years), where the understanding of tangible concrete elements are organized, and abstract, conceptual elements are barely understood. Attention span (timespan) at age 6 increases from fifteen minutes to one hour at age nine.
Formal operational stage (11-18 years), where cause and effect logic, abstract conceptual elements are recognized and assimilated.

Elliott Jaques continued these observations of discontinuous stages throughout adulthood (age 20 through age 70).

  • Symbolic Declarative (S-I) – Timespan – 1 day to 3 months
  • Symbolic Cumulative (S-II) – Timespan – 3 months to 1 year
  • Symbolic Serial (S-III) – Timespan – 1 year to 2 years
  • Symbolic Parallel (S-IV) – Timespan – 2 years to 5 years
  • Conceptual Declarative (S-V) – Timespan – 5 years to 10 years
  • Conceptual Cumulative (S-VI) – Timespan – 10 years to 20 years
  • Conceptual Serial (S-VII) – Timespan – 20 years to 50 years
  • Conceptual Parallel (S-VIII) – Timespan – 50 years to 100 years

Cognitive development is not simply how many problems are solved within a time-frame. All problems are not created equal. Some problems are more complex than others, and that complexity is discontinuous.

For example –

  • Problem solving at S-I – Trial and error.
  • Problem solving at S-II – Cumulative diagnostics, comparative.
  • Problem solving at S-III – Root cause analysis, cause and effect, single critical path.
  • Problem solving at S-IV – Multi-system analysis, capacity, dependency, contingency, velocity.

Each of these stages in problem solving requires capability at that level. Levels of capability are observable and distinct, become the basis to understand levels of work. Levels of work define the framework for organizational hierarchy.
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Here are all the links to this series on Teal and Levels of Work.
Teal and Levels of Work
Hierarchy is Just a Shape
All Problems Are Not Created Equal
The Question of Accountability
Teal and Theory of Constraints
Hidden Hierarchy in a Self-Managed Team
Accountability and Authority
Behaviorists Without Children
BAMS and Teal
Back to Hierarchy, For a Reason
Most Teams are Functional, Few Are Accountable
Manifest-Extant-Requisite
Stratified Levels of Self-Organization

Stratified Levels of Self-Organization

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This is a series on Teal and Levels of Work. Here is the backstory for the series in case you are interested. The purpose for the series is to explore the tenets of Teal through the lens of Levels of Work. Links to each post in this series, below.
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Some interesting responses, as this series evolved. Over the next few posts, I will feature some of these with my own thoughts. This post comes from Jan De Visch in Belgium. More of his thinking is in his book Dynamic Collaboration: Strengthening Self-Organization and Collaborative Intelligence in Teams.

“A false assumption in the Teal movement is that every employee can grow to a level of self-awareness from which self-management becomes possible. Scientific research shows that this is not the case. One needs to acknowledge the variety in developmental levels of participants in self-organizing teams. An essential insight is that self-organization only works in larger contexts if you start to distinguish different types of dialogue spaces (We Spaces), which are nested in each other, and each with their own dynamics. Hierarchy is sometimes an effective answer to breaking through downward divided team dynamics. Thinking through the stratified nature within self-organization is the first step towards Teal’s sustainable development. This notion is not elaborated in the Teal movement.”

I would break this down, that a person’s self-awareness is a product of their capability (observed) and that self-management emerges (and blossoms) within that capability. Cognitive development within individuals translates into cognitive capability in the team.

De Visch’s description of dialogue spaces is consistent with Jaques observation that timespan and its concommitant evidence is language. Our ability to imagine into the future begins at a very young age with the simple words, “Once upon a time.”

Self-organization exists within stratified levels of work. Growth toward that self-awareness (and self-management) is nested within discontinuous levels. These discontinuous levels are readily observable and create the hierarchy that Teal might resist, except where it acknowledges hierarchy of recognition, influence and skill. Elliott would argue that hierarchy is more precisely identified as capability.
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Here are all the links to this series on Teal and Levels of Work.
Teal and Levels of Work
Hierarchy is Just a Shape
All Problems Are Not Created Equal
The Question of Accountability
Teal and Theory of Constraints
Hidden Hierarchy in a Self-Managed Team
Accountability and Authority
Behaviorists Without Children
BAMS and Teal
Back to Hierarchy, For a Reason
Most Teams are Functional, Few Are Accountable
Manifest-Extant-Requisite

Manifest-Extant-Requisite

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This is a series on Teal and Levels of Work. Here is the backstory for the series in case you are interested in the context. The purpose for the series is to explore the tenets of Teal through the lens of Levels of Work.
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Who is accountable and what is the role of a manager? Teal would say the team is accountable and there is no manager, the team is accountable for the output of the team.

Jaques would ask the question again, who is accountable and what is the role of the manager? Laloux acknowledges that, on the nursing teams at Buurtzorg, there are nurses that contribute more than others, and that, on request, a coach can be summoned. There is no visible role of a manager, but leadership is certainly visible.

Leadership may be designated (in the role of a manager) or it may naturally emerge in a hierarchy of “recognition, influence and skill.” Jaques clearly addresses this issue, exploring three states of organizational structure. Organizational structure (hierarchy) is the way we define the working relationships between people.

The Manifest Organization is the structure of the organization represented on the official organization chart, “at best, only a very rough approximation to what is actually going on, if you can even make sense of it.” Laloux might argue, this is the documentation of the “chain of command” and serves to illustrate the evil in hierarchy.

The Extant Organization is the system as it actually functions, for better or worse. Misguided notions of “command and control” drive dysfunctional working relationships, AND also allow for the emergence of natural working relationships described by Laloux as “recognition, influence and skill.” Jaques describes that the Extant Organization “requires you to dig in and find who is actually being held accountable for what and what authority they are, in fact, able to exercise in relation to whom and to what.”

The study of the Extant Organization begins the quest, gives you clues “by giving you a picture of how people intuitively judge the place, and how it can be made to work best, in spite of confusions and lack of clarity – for, by and large, we do try to get our work done as sensibly as the situation will allow.”

Because the role of manager is “invisible” does not mean a lack of leadership. Indulge me (and Elliott) to make this distinction. Where Laloux describes the team as accountable, Jaques would describe the team as “managing accountability.” Managing accountability is different than accountability for output.

A manager is that person accountable for the output of other people. The manager controls all the variables around the team, they provide the system, the training, the tools, the facility. The manager (coach) intervenes when the team struggles. See my post on BAMS and Teal. All of these descriptions are consistent with “managerial” practices at Burrtzorg. The nursing teams attend training, work inside a structured system to solve problems and make decisions, are provided the tools with which to work and are supported by coaches and facilitators trained to assist the team to manage its own accountability.

Jaques holds the manager accountable for the output of the team. AND, the most effective teams are those that manage their own accountability. These statements are not exclusive, they are simultaneous. Further, the most effective managers are those that support the team to manage their own accountability.

Those teams that fail to manage their own accountability suffer from fight-flight-freeze-appease or dependence (on the leader). In Jaques world, these descriptions are all consistent with a set of requisite managerial practices.

My sense is this. Teal is an intuitive response against a conceptual construct of power and control. It acknowledges hierarchy of recognition, influence and skill. Buurtzorg created an inventive structure to ensure the absence of power and control and stimulate the emergence of recognition, influence and skill. This is not a designated (Manifest) organization, but one from the study of the Extant Organization.

Teal may be an effort in the evolution from Manifest to Extant to Requisite.
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Back to Hierarchy, For a Reason

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This is a series on Teal and Levels of Work. Here is the backstory for the series in case you are interested in the context. The purpose for the series is to explore the tenets of Teal through the lens of Levels of Work.
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If the purpose of hierarchy is not a power-grab, then why does hierarchy naturally exist as organizations form?

I recently ran into this issue in an organization with nine levels of managers. Without a guidepost to levels of work, people got promoted by reason of longevity, title instead of pay-raise, geography, too many people under a current manager, favoritism, nepotism. Totally out of control. The solution to organizational complexity was to add more people, more titles, more layers.

When hierarchy is grounded in levels of work (not power and not in nonsense), those layers naturally appear in the context of problem solving and decision making. AND, when we can see the distinction in the level of problem solving and the level of decision making, who-becomes-whose-manager is now a matter of organization sustenance.

We have explored the structure at Buurtzorg over the past couple of weeks. As an example of Teal, captured in Frederic Laloux’s Reinventing Organizations, the who-becomes-whose-manager is left to circumstance, not clearly defined and when it happens, designed to be temporary.

In Requisite Organization, based Elliott Jaques‘ levels of work, the who-becomes-whose-manager is based on accountability. Indeed, Elliott describes Requisite Organization as a Managerial Accountability Hierarchy, “a system of roles in which an individual in a higher role (manager) is held accountable of the outputs of persons in immediately lower roles (team members) and can be called ‘to account’ for their actions.”

Elliott would describe the accountability for each manager, to bring value to the problem solving and decision making in the team. This is not a suggestion, this is a mandate, an accountability. Managers are required to bring value to the work of the team. This is not a power structure, but a value-stream.

I was reminded that Teal is not structure-less. While the nursing teams are well described by Laloux, the rest of the structure is not, so let me make some guesses.
S-II – nursing teams, accountable to deliver direct nursing services. (Longest goals and objectives 3-12 months.)
S-III – regional coaches and institutional facilitators, accountable to ensure nursing teams are working effectively in that delivery. (See prior post on Teal and Theory of Constraints. Longest goals and objectives 12-24 months.)
S-IV – integration executives accountable to ensure the output of nursing services works within the medical community and government ordinances for financial accommodation and payment. (Longest goals and objectives 2-5 years.)
S-V – would be Jos De Blok, the founder of Buurtzorg, accountable for enterprise design and value in the marketplace. (Longest goals and objectives 5-10 years.)

Each level of work is defined by context in its decision making and problem solving. When this hierarchy occurs (naturally), it creates organizational sustenance, intentionally, with purpose.
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BAMS and Teal

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This is a series on Teal and Levels of Work. Here is the backstory for the series in case you are interested in the context. The purpose for the series is to explore the tenets of Teal through the lens of Levels of Work.
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Buurtzorg works with self-managed teams at Level II (S-II). These teams of 10-12 nurses handle the intake, scheduling and administration of their own patient load of approximately 50 patients. There is no “visible” manager assigned to hold them “to account” for performance.

When things go well, things go well. When things go adequately, no one rocks the boat. But, when things don’t go well, the mettle of a team is tested. And, Buurtzorg expects the team to handle its own issues, without the oversight of a “visible” manager.

So, what is going on here? Let me introduce you to Wilfred Bion. Bion was a psychiatrist, working for the British Army during World War II. His mandate was to take shell-shocked soldiers (current day PTSD) and return them to the battlefield to re-engage in combat. His background and academic training were suited to the task, but Bion had a problem. There were too many soldiers in this condition, the numbers overwhelmed the hospital resources.

Bion made a decision. There were too many PTSD soldiers to deal with 1-1, so he invented something called group therapy. He did not invent group therapy because he thought it a good idea. He invented it, because he had no other choice.

Working with soldiers in groups, with the purpose of returning them to battle, Bion observed the way the group worked, their interactions, dependencies and behavior to face the issues that landed them in the psych ward in the first place. Bion noticed two distinct behavior patterns, when the group appeared to be in “work” mode and when the group avoided work, or appeared to be in “non-work” mode. The distinctions were quite clear –

Work Mode – Non-work Mode
Rational – Irrational
Scientific – Un-scientific
Cooperative – Collusive
Controlled – Uncontrolled
Conscious – Unconscious

Groups moved from one state to the other state at will. Bion described this state as the group’s Basic Assumption Mental State or BAMS. Groups would move from Work to BAMS and back again. The movement from Work to BAMS occurred easily (unconscious), but the move from BAMS to work required very specific conscious behavior.

Working at the hospital, Bion attended meetings with other staff physicians, nurses and administrative personnel. The purpose of the meetings was to work together to solve problems and make decisions. Bion thought it peculiar that the hospital doctors and nurses displayed the same group behavior as the patients.

As part of military rigor, Bion was also required to attend meetings with upper echelons of military rank, to discuss strategies of war and resources of personnel, those going into battle, those recovering to return to battle. In those meetings, Bion was awestruck to discover the same behavior in military ranks, as the behavior in hospital personnel, mirrored in the patients. If it weren’t for the uniforms, you could not tell the difference between the generals, the doctors and the patients.

These behaviors would be readily observable in the (S-II) manager-less nurse teams at Buurtzorg. Take this tough problem – a team member, who after many opportunities (chances) is simply not a fit for the team. The most important cultural issue for every team is “who gets to be a member of our team?” This is the classic (though contrived) premise of the tv series Survivor. Faced with this decision, the team will either go into work or non-work (BAMS). Remembering that BAMS is an unconscious process, most teams automatically go there, observable in Fight-Flight-Freeze-Appease. They fight about it, blame each other (and the computer system). They flee, avoid, talk about the problem only in private (gossip at the water cooler). They freeze, make no moves at all (which ratchets up the tension). They appease, make excuses and generally cover-up.

The major BAMS move however is toward dependence. Dependence occurs when the tension in the group becomes so uncomfortable that the group deposits the discomfort on a designated leader. This dependence begins a subtle seduction on the leader of the team. At Buurtzorg, without a designated manager, this may be a moving target, but a leader will emerge. Or the team will self-select a leader. This is a slippery slope as an archetypal response in the dependence cycle. BAMS is collusive and most managers, given the opportunity (for new-found power) afforded by the group, can hardly resist.

Unfortunately, BAMS (non-work) never solves the problem, and neither will this dependent relationship. The ONLY solution is when the leader (manager, coach) puts the issue quite squarely back on the team, in the midst of discomfort. Without a doubt, when the leader-manager-coach puts the issue back on the table, the team will panic.

“The reason for this meeting today is to discuss Fred’s underperformance in relationship to the performance standards set by the team. The decision we make today is whether Fred continues as a member of the team or if Fred’s membership on the team should be terminated.”

The leader’s role is very simple – outlast the panic. Any issue that affects the team, the effectiveness of the team, must be dealt with by the team. Staying in “work” mode can only happen as a conscious decision to do so. That is the role of the leader. This has little to do with power, more to do with “work.”

At Buurtzorg, teams that recognize they are in BAMS can reach out for a coach. The structure at Buurtzorg defines this relationship with strict parameters to prevent group dependence. Laloux describes, “If teams get stuck, they can ask for external facilitation at any time, either from a regional coach or from the pool of facilitators of the institute.” Again, I think we found the manager.

In Requisite Organization, Elliott Jaques would describe this identical scenario, AND have a designated role of MANAGER. The manager would be in touch with the team sufficiently to recognize the team going into BAMS, to put real issues squarely on the table for the team to grapple with. High performing teams are those that are comfortable with discomfort and run toward (not away from) tough problems. The function of the manager is to keep the team in “work” mode.

It might be construed that Teal and Requisite Organization are identical, except for their terminology. I think not. The distinction is stark, has to do with hierarchy, which should be worthy of discussion in my next post.

Behaviorists Without Children

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This is a series on Teal and Levels of Work. Here is the backstory for the series in case you are interested in the context. The purpose for the series is to explore the tenets of Teal through the lens of Levels of Work.
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My last post on Accountability and Authority kicked up a question. Here’s the context. Buurtzorg works with self-managed teams at Level II (S-II). These teams of 10-12 nurses handle the intake, scheduling and administration of their own patient load of approximately 50 patients. There is no “visible” manager assigned to hold them accountable. Here is the question –
Can a person (or a role) hold themselves accountable?
Can a person (or a role) hold another person accountable?

Before I mince words, what is the purpose of accountability? Is it to give someone, with the authority of oversight, the power to scold an under-performer against the wall? Oh…so momentarily satisfying, but what’s the point?

The only people, who think that anger and yelling has an impact, are behaviorists who have no children. If you have children, you know it is futile to raise your voice, repeat your guidance (if I told you once, I told you a thousand times).

The point of accountability is to assess effectiveness toward the goal and re-direct new energy to get back on track.

In the face of under-performance, the point is to fix it.

The only person who can hold you accountable is YOU. Invite and give permission to others to examine and challenge your commitments, AND understand that you are the only one who can keep those commitments. The only accountability is self-accountability.

We cannot hold people accountable, we can only hold people “to account.”

This is not a nuance of language. Holding others accountable is a myth. We cannot hold others accountable. We can only examine and challenge commitments. We can only hold people “to account,” to themselves for the commitments they make with themselves.

This accountability conversation (constructive criticism, reprimand, coaching) about commitments is necessary because the easiest commitments to break are those we make with ourselves that no one knows about. Praise in public, coach in public. Any issue that impacts the team needs to be handled by the team.

Would Buurzorg call this self management?

The accountability conversation, by the team, with the team, is pure Wilfred Bion. With this post as a prelude, perhaps we should look at Bion’s Experiences in Groups next. It might give us an insight about the team accountability dynamics inside Buurtzog.
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Wilfred Bion was part of the collective clan around Elliott Jaques during his tenure with the Glacier Metals Company, London, England, circa 1950’s.

Accountability and Authority

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This is a series on Teal and Levels of Work. Here is the backstory for the series in case you are interested in the context. The purpose for the series is to explore the tenets of Teal through the lens of Levels of Work.
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My last post on Hidden Hierarchy, took a close look at Buurtzorg, where nurses in self-managed groups of 10-12 make decisions related to intake, scheduling, planning, holiday and vacation coverage. These are all decisions well within the timespan capability of each team. This slice of the organization has clear accountability for those issues and with that accountability must come the authority to make those decisions.

Laloux describes the authority exists because there is no managerial hierarchy with oversight that might question or reverse a decision made collectively by the team. Elliott Jaques, in the schema of levels of work would describe the authority as “timespan of discretion.” Each team has full discretion to make decisions and solve problems related to tasks identified at that level of work. The authority doesn’t exist in the absence of management, the authority is expressly assigned to the team.

With authority must come accountability. Laloux describes the nursing teams as accountable for their own output, without managerial oversight. This appears to work well, until it doesn’t.

When, it doesn’t, there are “coaches.”

Elliott would always be looking for “who is the manager?” He would not be looking for the mandated manager, but the observable manager. Who is bringing value to the problem solving and decision making of the team? At Buurtzorg, there are coaches who provide facilitation along defined problem solving models (I am reminded of Eli Goldratt’s Conflict Resolution Cloud).

It is incumbent on the coach to set context (in the form of questions), seek clarity in the issue or problem and bring the team to its own resolution. I think we just found the manager.

In short, the founder of Buurtzorg, Jos de Blok, found a way to grow the organization by driving decisions down to the appropriate level of work, organizing small teams to do that work. The design is perfectly scale-able to the current tune of approximately 10,000 nurses.

There is a hierarchy, not a hierarchy of power, but a hierarchy of accountability.

Hidden Hierarchy in a Self-Managed Team

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This is a series on Teal and Levels of Work. Here is the backstory for the series in case you are interested in the context. The purpose for the series is to explore the tenets of Teal through the lens of Levels of Work.
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At Buurtzorg, nurses are grouped in teams of 10-12. Laloux describes, “They deal with all the usual management tasks that arise in every team context: they set direction and priorities, analyze problems, make plans, evaluate people’s performance and make the occasional tough decisions. Instead of placing these tasks on one single person -the boss- team members distribute these management tasks among themselves.”

The description is agreeable and I assume that Laloux is describing the phenomenon accurately. Each nursing team is dubbed self-organizing and self-managing, without hierarchy. In my post Teal and Theory of Constraints, “little surprise that a team of a dozen nurses could solve most problems and make most decisions related to intake, planning, scheduling and administration.” It is highly likely that in a pool of skilled nurses there would be a number of them with S-II capability (capable of effectively completing task assignments and projects 3-12 months in timespan). My suspicion is there is plenty of leadership talent in the team.

Laloux validates my suspicions. “the idea is not to make all nurses on a team equal. Whatever the topic, some nurses will naturally have a larger contribution to make or more say, based on their expertise, interest, or willingness to step in.” My suspicions say the difference can be measured in timespan and directly relates to capability.

Laloux continues, “In any field, some nurses will naturally have more to offer than others. Some nurses will build up reputations and influence even well beyond their team and are consulted by nurses from across the country on certain topics of expertise.”

My observation is that leadership is NOT a mandated phenomenon, but an observed phenomenon. Give any group of people a problem to solve and a leader will emerge, in Laloux’s words, “naturally.” I believe that natural emergence is consistent with capability measured in timespan. Leadership is an observed phenomenon.

I am reminded (thanks to Bruce Peters) that “the concept of Teal is not to be structure-less or for that matter leader-less.” My thoughts conclude there is plenty of leadership on display AND it is occurring in a natural hierarchy. Laloux would describe this as a hierarchy of “recognition, influence, and skill.” I would press and call this a hierarchy based on capability, and this capability drives both context setting and ultimately accountability. Elliott would describe it as an accountability hierarchy. Note that all of these descriptions of hierarchy are absent the word power.

I assume that in many cases power and hierarchy are named hand in hand. Laloux has gently teased them apart so that we can see the difference. But now we have to deal with another “A” word. With accountability goes authority. So how do we address an understanding of authority without the menacing connotation of power-mongering? I suppose that is next?
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Comments are welcome. If it is your first time posting here, your comment will go into a temporary queue. Once approved, future comments will post in real time. If you receive this blog by email, you will have to click through to the site to see posted comments.

Teal and Theory of Constraints

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This is a series on Teal and Levels of Work. Here is the backstory for the series in case you are interested in the context. The purpose for the series is to explore the tenets of Teal through the lens of Levels of Work.
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In his book, Reinventing Organizations, Laloux cites several examples as evidence of the success of Teal. I like examples, they provide detail excluded from a more statistical approach.

Laloux takes a large excursion through Buurtzorg, founded in 2006 by Jos de Blok. De Blok created a nursing organization unlike others, distinctive in its use of self-organizing teams. Each team of 12 serves approximately 50 patients with discretion over intake, planning, scheduling and administration. Buurtzorg now employs 10,000 nurses organized in this way with quality measures (patient outcomes) exceeding competing organizations. Here’s the punchline – these patient outcome measures required 40 percent fewer resources (hours of care) than the competition. This would seem a resounding endorsement for self-managed teams.

Here are my observations, based on Levels of Work, nested working relationships (hierarchy) related to problem solving and accountability.

Laloux described de Blok’s dilemma after spending years as a nurse. The evolution of nursing in the Netherlands had transformed into a Laloux’s Orange machine, with efficiency quotas of shots administered, medicine delivered and bandage changing. Nurses were routed and timed for patient visits with assignments tightly scheduled. De Blok observed that, while efficient, nurse morale suffered along with patient outcomes. Could a different organization make a difference? Self-organized into teams of 12?

First, little surprise that a team of a dozen nurses could solve most problems and make most decisions related to intake, planning, scheduling and administration. Most roles in nursing require S-II capability. This means that problem solving and decision making falls within S-II time frames (3-12 months). Highly likely these teams have requisite capability to make those decisions.

But that, for me, turns out NOT to be the insight. The state of nursing in the Netherlands was clearly focused on system efficiency, which is the hallmark of S-III. Unfortunately, the Dutch health care program was dealing with an S-IV problem. Eli Goldratt’s Theory of Constraints (TOC) lends insight.

The constraint in the system had nothing to do with bandage changing. The constraint in the system was the patient. Nurses could change bandages (efficiently) all day long, but the patient doesn’t get better until the patient gets better.

“Buurtzorg places real emphasis on patients’ autonomy. The goal is for patients to recover the ability to take care of themselves as much as possible.” The constraint in the system is the patient. Changing a bandage in seven minutes does not necessarily make the patient better.

Goldratt would tell us this. Identify the strategic constraint and subordinate everything else to the constraint, even if it means leaving a sub-system to idle. In nursing, leaving a sub-system to idle may mean having a cup of tea and conversation with the patient. It is certainly not efficient, but contributes to overall throughput. Sorry this sounds like a machine (Orange).

De Blok brilliantly identified the constraint in the system (the patient), abandoned (correctly) the KPIs related to bandage changing and focused on the patient. Efficiency had been killing the patients. Literally.

In the end, patient outcomes improved, costs reduced by 40 percent, team morale improved. Laloux would attribute all this to self-organized teams. Rather, I think de Blok intuitively understood the constraint in the problem better than the Dutch government.

Next, I think I want to explore what is happening inside these teams. What are the dynamics of self-organized?
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Comments are welcome. If it is your first time posting here, your comment will go into a temporary queue. Once approved, future comments will post in real time. If you receive this blog by email, you will have to click through to the site to see posted comments.