Contents
In home care, it is often laid down precisely how many minutes a nurse has for a dressing, an injection or putting on compression stockings. That looks like order. Jos de Blok believed that this was exactly the problem. His alternative model shows what Mission Command means outside the military: leadership says what it’s about; the people on the ground decide how.
A manager who thinks managers are the problem
Situation
From 1993 to 2006, Jos de Blok works as a manager at two large home care organizations in the Netherlands. He sees how care is broken down into individual services, billed by the minute and controlled from the top. He concludes that this control holds back the nurses’ abilities instead of making use of them. In 2006, in Almelo, he founds Buurtzorg, Dutch for “neighborhood care.” The first self-managing team starts work the same year.
Link to the principle
Mission command begins with an insight about knowledge. Whoever is on the spot sees more than headquarters. In home care, the nurse in the patient’s home sees what this person needs today. A plan drawn up in an office cannot know that. De Blok draws the conclusion: place the decision where the knowledge is.
The objective is clear; the way is not prescribed
Situation
The teams are small. According to the available accounts, a team has about 10 to 12 nurses who care for around 50 to 60 patients in one neighborhood. Their task is to care for people in such a way that they can manage on their own again as soon as possible. To do this, they involve relatives, neighbors and family doctors. At least 60% of working time is to be spent directly with patients.
Link to the principle
This is the intent that everyone knows. It is concrete enough to guide decisions: Does what I am doing now help this person become more independent? And it is open enough for every team to find its own way for every patient. This matches the principle traced back to Helmuth von Moltke: a good mission names the what and the why, not every how.
Self-organized, but not left alone
Situation
The teams plan their visits, take on new patients, arrange vacations and cover, and select new colleagues. There is no middle management. Coaches help with conflicts or difficult questions. They don’t belong to any team and are not responsible for its results. Payroll, contracts and finances are handled by a small head office in Almelo. Information and communication technology keeps the planning effort low.
Link to the principle
Mission command does not mean that everyone does what they like. It pushes decisions down and at the same time relieves those doing the work of everything that is better handled centrally. The coaches don’t lead by giving instructions; they help people make judgments. The head office serves instead of controlling. That keeps the teams’ energy free for what really matters.
What the numbers show
Situation
A study by the consulting firm KPMG, commissioned by the Dutch Ministry of Health, found that Buurtzorg needs significantly fewer hours of care per client per year than other providers. When the costs of nursing homes, doctors and hospitals are added in, the total cost per patient was, according to the accounts, about average or slightly below. Since 2011, Buurtzorg has been voted the best employer in the Netherlands several times. According to the English-language Wikipedia, more than half of all the country’s community nurses work for the organization.
Link to the principle
Freedom in the way does not automatically lead to chaos or higher costs. It can save time, because well-trained people don’t wait for approvals and solve problems before they grow. The numbers don’t prove that this works everywhere. But they are a strong indication that trusting people’s judgment can pay off.
Where the model reaches its limits
Situation
Buurtzorg has been transferred to other countries, including Sweden, Japan and Wales. In Wales, a two-year pilot project ran from 2018; its evaluation did not allow clear conclusions about outcomes or savings. The German company, founded in Münster in 2018, went into insolvency proceedings by the end of 2021. When these were concluded, two sites remained, in Münster and Munich.
Link to the principle
Mission command has preconditions: well-trained people, a clear shared intent, trust and an environment that allows freedom in the first place. If billing rules prescribe every minute, there is little room for your own judgment. That is why the principle is not a recipe to copy. It is an attitude that has to fit the situation and the people.
Key takeaways
Key lessons
- Tell your team what a task is for, not just what has to be done.
- Leave decisions where the knowledge is.
- Relieve people of whatever is better handled centrally.
- Replace control with support that helps people judge.
- Check whether training and trust are sufficient before you give freedom.
Summary
With Buurtzorg, Jos de Blok built a home care organization in which small teams know the objective and choose the way themselves. A lean head office and coaches support instead of controlling. The model became the market leader in the Netherlands, but it also shows that mission command needs trained people and a suitable environment.
Sources
- Helmuth von Moltke the Elder: Verordnungen für die höheren Truppenführer (in German). 1869.
