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Using Lean in Professional Services Guest was Dr. Sami Bahri The World’s First Lean Dentist

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Dr Sami Bahri, DDS runs a private dental practice in Jacksonville, Florida. The practice has three general dentists, one orthodontist, 10 chairs for general dentistry, and seven chairs for orthodontics. In 1990, after ten years of intense work in the teaching, administrative and private practice fields, Dr Bahri moved to Jacksonville, Florida. In the same year he opened his first Jacksonville practice with two dental chairs. He studied dental management and applied it in his practice. Eager to know how other industries manage their resources to satisfy their customers, he started searching outside dentistry, in the mainstream where many management experts are continuously trying to improve the way things are done. In 1996, Dr. Bahri read “Lean Thinking” by James Womack and Daniel Jones, and started implementing Lean Management principles in his dental office. This implementation has benefited patients, employees, dental laboratories, suppliers, etc. In 2006, Bahri Dental Group provided the same amount of dental treatments as 2005, but needed 40 percent less resources, thanks to the application of “Lean Dental Management. In March of 2007, Dr Bahri was invited to present his work as a keynote speaker at the “Shingo Prize for Excellence in Manufacturing” where he was recognized as the “World’s First Lean Dentist”. In March of 2009, Dr Bahri wrote Follow the Learner: The Role of a Leader in Creating a Lean Culture, published by the Lean Enterprise Institute. He lectures nationally and internationally to share his experience on implementing lean management in the dental practice. Bahri Dental Practice Jacksonville, FL 32256 http://bahridental.com

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Joe Dager: Thanks for every joining us. This is Joe Dager, the host of the Business901 podcast. Participating in the program today is Dr. Sami Bahri. In March of 2007, Dr. Bahri was invited to present his work as a keynote speaker at the Shingo Prize for excelling in manufacturing, where he was recognized as the World's First Lean Dentist. Dr. Bahri, let me start at the beginning, how did you get acquainted with Lean?

Dr. Sami Bahri: Joe, thank you for inviting me to your podcast. Well, actually, I was trying every management system I could put my hands on, in my practice. One day, I was listening to a tape by James Womack, and in the tape, he asks his daughter, while she was folding her mom's newsletters, he says, "Why are you folding all the newsletters, putting them all in the envelopes, addressing them all, and then stamping them all and sending the out? Why don't you do one? Fold it, put it in the envelope, address it, stamp it and send it out?" She said, "Because, it wouldn't be efficient." So that idea stopped me, because back in 1984 when I was in charge of a dental school in Lebanon, I had had a similar idea. I saw my patients, the patients in the clinic come in one day for a diagnosis. One day for fillings, the second day for crowns, the same people were coming back, day in and day out. I thought, "Why can't we put the patient into the chair, and have specialists from every specialty treat those patients and let them go to their lives?" Then I dismissed the idea because dental school had been around for a long time, until I heard that, and it was similar. It was a One Piece Flow, so I stopped the car and opened the book, and looked at the bibliography at the end of the book.

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There were books by Ono, and Shingo, and people I never heard of before. I thought, "Let me see if those books are still available." I got the books and started reading, and that's how it started. That was in 1996. Then in 2005, one of my patients, Jerry Bustle, was going to Japan, and he said, "Can you check my teeth, I don't want to have any problems while I'm abroad." I thought, "Jerry, what are you doing in Japan?" He said, "I'm going to Toyota City, because I do the Toyota System, the Toyota production system in my manufacturing plant." That was the first time I had encountered anybody doing Lean and Toyota production systems since 1996. I said, "Wait a minute," then I brought [out] all the books, all the tapes, and I showed him what I'm doing, then he called James Womack and said, "You won't believe it, my dentist is doing Lean." Then Jim came, and then John Shook came, and then a lot of experts came and the next thing I know, I was invited as a keynote speaker at the Shingo Prize. To my surprise, at the end of that presentation, they gave me that title of World's First Lean Dentist. That's how it happened. Joe: That's pretty interesting. You did not have any Lean consultant or anything else, you just started putting Lean principles into your practice?

Sami: No, I didn't even know anybody else was doing it. I just went from one book to the other. I would take a book and understand one idea, not understand the rest of them, those specific ideas for manufacturing. Then I would read a different book, and then get

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another idea, until we built the system a little bit at a time, but I didn't have any consultants, no. Joe: Most dental practices that I've been around are pretty efficient. I don't go into a dentist's practice, and wait like I do at another type of doctors. A dentist's is efficient and most of the appointments are on time. How did you look at that as something that would really benefit you, because I think dentists are efficient? Sami: Yes, dentists are very efficient, actually. They're very well organized, and they thing a lot about the processes and how they want to do the treatment for their patients. That makes it, maybe, more difficult for me to find a new way, or be motivated to find a new way. On the other side, from the medical stand point, and the dental stand point, I'll give you, gum disease, for instance. If we want to treat gum disease, we are trained to read everything about gum disease, and understand everything about gum disease. Then, when the patient was present, and we check in their teeth and their gums, we want to know everything, and just pick whatever is appropriate for that patient. When I was managing my practices, I didn't feel that I was applying the same kind of scientific thinking to management. I would do things that were very, very organized, because I had thought about management since the early '80's and '70's, but I didn't have that feeling that scientifically, I had covered it all. I wanted to see, outside of dentistry, what are people doing. I studied Dr. Deming, TQM, I studied reengineering, that became Six Sigma later, the Theory of Constraint, and you name it. Then, at the end of the day, I wanted to decide

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what was best for my practice. Given the results we had, I landed on Lean. That's how it happened. Joe: You always talk in Lean principles as One Piece Flow, and you take a whole treatment, as a One Piece Flow? Is that how you try to look at it?

Sami: Yes. When we first started, I read the books and learned the principles, and you end up with so many principles that you really don't understand which ones are important. You don't have any kind of ranking. You don't know which one is important, which one is not, and how you get Lean? So for 13 years, I would study the principles, and apply them in my Batch and Queue system. I was getting frustrated that those Lean principles and Lean management is not giving me the results that I'm looking for, no breakthrough. I mean there were improvements everywhere, but no breakthrough. Then, one day I started thinking, "What is One Piece Flow? Why do we need to talk about One Piece Flow?" Then as I thought about it more and more and more, I started thinking, "Maybe that's the only principle that's in Lean, that does not apply to any other management theory." Like you take respect for people, for instance. You can respect people in any theory, in any management system. You take 5S's, you can organize yourself in any management system, and you take any other principle, it's the same, but you take One Piece Flow, and you can't be doing Batch if you're doing One Piece Flow. So I thought, "Let me pursue that."

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We started trying to do, let's say, one tooth at a time, or one procedure at a time. Like a filling, or a root canal, and then at the end, we decided on one thing, let's take the tooth for one piece, and the mouth for a lot. The minimum we want to do is the whole mouth, which is not possible every time, obviously, as you know. If you tell dentists, "I'm doing the whole mouth every time," they're going to say, "It's not possible," and they're right. But that is my goal, and every time I can, I'm going to do it. So once we started pursuing that, I understood a couple of things. First, I understood that I need to always focus on lead time. Then I started studying, "how do you reduce lead time?" Instead of studying all the principles, we ended up utilizing maybe three or four. You try to do a small lot, you try to synchronize the providers, and you try to work on your setups. You know, leveling, that's everything. With those principles, we were able to transform the practice from Batch and Queue to Flow. We took every one of these principles and went through three stages. First stage was to understand what it means for manufacturers. Second stage: How do you translate it in dentistry? Third stage: How do you actually apply it in dentistry? As we dissected it, we started seeing that once you apply one of them, then you see the second one running at you. It's like if you don't do leveling now; the system is not going to work. Then, once you do leveling, if you don't have synchronization between the providers, the system is not going to work. At the end, to make it all work together, we had the need for some kind of

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communication system. We went back to what Toyota did and we found that you needed a Kanban, which we did in a form of a flowchart. So, that's how we ended up thinking that One Piece Flow and the pursuit of One Piece Flow is really what make a system Lean. Joe: You have so much variation, each patient is different. You go in and there's a discovery part to it when that patient sits in the chair. Correct? Sami: Yes. Absolutely. Joe: Then, at that point in time, you try to maximize that, and do everything that's needed in that one sitting? Sami: We try that, yes. Obviously, you have different value streams. And, so far, we think that the most difficult part in health care and in dentistry, is to synchronize the work of providers. So we do our value streams depending on how many providers you need to see. For instance, if you need to see only the hygienist, that is one value stream that's very simple. Now, you might need a hygienist and a dentist in the same appointment, it becomes a little bit more complicated. Or, you might need a hygienist, a dentist, and your lab or you might need a hygienist, dentist, lab, and a specialist. So, each one of these is a different value stream. Joe: They're all provided at one location. Sami: They're all provided in the same chair for the patient. Each one of us comes to the patient because it's so much easier and more economical for everyone to just move the providers, instead of moving the patient. Traditionally, we used to have the patient in the

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hygienist's chair. Then, if we found something that needs to be done, we would send them home. We would make another appointment to come back maybe two weeks later to the dentist's chair which is three feet away or six feet away from the hygienist's chair. So today, we don't do that anymore. We think, "If you are in my chair needing a filling, and you need a cleaning at the same time. The hygienist will come to that room when we have a little break in your treatment and she'll do your cleaning. That saves you an appointment that saves us an appointment." So, now, we're gathering all the providers around the patient. Even financial coordinators, assistants, they're all in the clinic. They hear each other, they communicate with each other. We try not to have people in offices that need to treat patients and to communicate with patients. They're all on the clinic floor. Joe: Now, when you learned this first, did you use any tools or just use the principles of Lean? Sami: Yes. At first, we used the tools as we understood them. Let's say we needed to do leveling. So, how do you do leveling? You need to learn your takt time. What is takt time? So, we try to understand takt time. Then, we want to use the 80-20 principle, but on what? On the patients that come most frequently to the office? On the procedures? On the amount of money we're making? We didn't know at the beginning. But then, when we started focusing--we started focusing on setups, and we learned that setups are really what stays, and the way of One Piece Flow. So we thought, then it is obvious then that we

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need to focus on the most frequent procedures because those generate the biggest number of setups. So, we would take each tool and apply it. But, as I said, if we said we need to remove the functional boundaries, for instance. I took functions from the front desk, put them in the room next to the patient. So now the assistant, by cross-training, the assistant can now make your appointment, she can walk you out. But, as we went, we started learning some lessons. You can remove boundaries between processes. But as long as you're not removing the boundaries between the value adding processes, in our case, between the hygienist and the dentist this is value adding, you won't see any benefits really or very minor benefits. So, if you take any of the support functions and work on them, and move them from here to there, in an isolated way, we didn't find any results. But, the day we decided that the hygienist and the dentist are going to treat the patient in the same chair, and then everything changed. Everything changed in the sense that waiting time in the waiting room is gone. Waiting time in the chair is gone. We were able to treat many, many more patients during the day. The thing that happened that I wasn't expecting was that the steps of Lean implementation started pushing themselves on me. Like, you have the hygienist and the dentist working on the patient, and then when we stand up, we don't know where to go. Now, you need some kind of communication, some kind of a person organizing. So, we created a position called the patient care flow

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manager. That's a position that is a copy of the team leader from Toyota, with the same job descriptions. So, that person would tell me where to go, would tell the hygienist where to go, and would tell the other doctor, the other hygienist where to go. So now, that step being done, she was talking to a person, let's say, she was talking to you, and I am done, I need to go somewhere else. She wasn't able to talk to me at the same time. So, we went like an emergency meeting and we said, "How can we communicate?" I thought, all of a sudden, that Toyota communicates through Kanban. I said, "We need a Kanban. Let's make a flowchart and follow the patient's treatment." Then, we took that piece of paper; she started giving that piece of paper with two times on it. One time tells you, "I gave you that piece of paper." We'd call it "time given," at two o'clock, for instance. "I need you in chair number five at 2:15." So, she gave me 15 minutes to organize myself and delegate to my assistant and then at 2:15, I need to be exactly there because the hygienist is going to be done. We tried that for a while and it works very well. The thing is everybody started depending on everybody else. So, everybody needs to do their jobs correctly and to be alert all the time, and everything functions like a ballet. Joe: How have you been received by other dentists? Sami: The ones that I have communicated with so far have received it very, very, well. Actually, they have been very encouraging and that is encouraging me to go forth and manufacturers have been asking me to speak. Manufacturers know that Lean is, if not the best, one of the best systems today. They want to know how someone has applied it in a

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non-traditional industry. So they know Lean is good. They just want to know how I did it. With dentists, as we said, they are very well organized. It is going to be tough for me to convince them that change is possible and that Lean is the best change to go. And what is Lean and how to apply it. So I have many more steps to go in my own profession. Joe: What have you learned from this that you think applies to other professional practices? Sami: I think Joe, not only Lean, but any management theory. I am going to talk about the same ones that we already mentioned; TQM, theory it of constraints, Six Sigma, they all apply to anything that you are doing. Joe: They all apply to a process and if you are doing a process they apply. Sami: You can use any, right? So it is just which system or which theory gives you the best results. And so far, in our practice, Lean has given the best results. I really think it applies to everything. Now the key is, what do we teach people? And my experience is really in that regard. I learned it on my own from books and I have fallen in a few traps. The first one, the first trap that I fell in would be eliminating waste. You teach someone who doesn't know about Lean and you say, "Lean is about eliminating waste." And you say anything that you do not need to apply right away is a waste. So what we did was looking around us and eliminating waste and eliminating waste going nowhere. Why? Because, we were not eliminating waste in our main flow, the patient. I would eliminate waste at the front desk and the way they are handling insurance. Or how they are filing insurance, or verifying insurance.

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But, I was still making several appointments for my patient. Until we decided what our main flow is. The principal flow is the patient flow. Anything else: like how to prepare the appointment, how to set up the room, how to prepare the insurance verification and the patient's file in the computer. All of these are support flows. As long as you are working on improving your support flows without really paying attention to the main flow, we didn't see any improvements. My main message would be if you want to learn the Lean tools at least learn them while you are improving your principal flow. Decide what your principal flow is and work on that. That is where Lean is. Anything else like improving operations which is the same as support flows did not give us the results that we were looking for. That is probably one of the main lessons that I learned.

Joe: How was it received internally? Was it "here comes Dr. Bahri. He read another book." Was that how they looked at it? Sami: You're touching a very sensitive point here. For a long time, I would read a book come up with an idea, and you would see the eyes rolling in the room. But, the thing is I never called it anything. We never called it Lean management. We never called it the Toyota production system. We never called it anything. We were just improving our service for our patients. So you can say from 1993 [when] I read the book Kaizen by Imai, and I started applying the principles and learning from books and applying the principles but we never called it anything. Until James Womack came and said, "You are applying Lean." My assistant started asking, "What are you talking about?" I said, "Yes, that is what we are applying. We have been applying this for many, many years."

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I think it is probably one of the factors that allowed me to sneak up on them and apply the system. I feel had I called it "Lean management" and said we were going to transform the practice into "Lean management" I would have found much more resistance. To be totally truthful I did find a lot of resistance from staff. And I attribute that to my lack of knowledge, as far as Lean leadership at that time. I was learning how to introduce improvements.

Then little by little I learned that you don't want to rock the boat too much. You start as little as you can, as small as you can, with one assistant maybe. To give you an example, I wanted my assistant to start scheduling appointments from the room. I did not ask her to schedule appointments from the room. I just placed a computer in one of the rooms. Then went home, and learned the program, and how you schedule appointments and then when I came back the next day, whoever was helping me I said, "Can you please go and push that button?" and she did and it came up on the schedule. I said, "Can you click on that slot?" and she clicked. I said, "Can you enter the patient...?" So I walked her through the process. At the end of the process, she made the patient appointment. We did it a couple times, and then she started making appointments on her own. Then the assistant next door was watching, she said, "Well, I can do that, too. Why don't you get me a computer?" I got her a computer in the room and then little by little everybody started making appointments. I did the same thing with walking the patients out. I did the same thing with explaining treatment benefits to the patients. So without really giving a lot of noise and saying we are doing this, and we are doing that, I just took them through the steps to show them that it is easy, and it can be done.

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That made things much, much easier for me, much less resistance. And now you see that people are with us for 12, 13 years. Some of them have been with us for six years. So we do have a very, very good retention rate. Joe: Now, you even wrote a book about what you did? Sami: Yes. I wrote a book. It is called Follow the Learner. It is published by the Lean Enterprise Institute. After my Shingo presentation, they said, "If you want to write a book, please talk to us first." They sent Michael Brousard, who is very knowledgeable, and he stayed with me a little bit and he said we are going to do the book on leadership. I said, "What do you mean leadership? I am just a dentist." He said don't worry we will walk you through it. He made me write everything that I know about my professional life, and then he sorted them into principles. And he said "That is what you have been doing." Actually, I had been living all of that, not knowing exactly that it is going to end up with a book. The goal from the book was to really show the experience we went through and the transformation that we were able to do from Batch to Lean. We made it like a story, but in the story, I put the lessons I wanted to tell people to learn, without really telling them, "That's what you need to do." I should have probably said it more bluntly, "I think, you need to do your setups first. I think you need to do this and that first." When I read the comments, a lot of people say, "It's about Dr Bahri's story." Actually, it is about the Lean transformation, as I see it, put in a story.

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Then, after we finished the book, we met with Michael Brousard, and he said, "Sami, who's your audience for this book?" I said, "My audience is someone who has tried to implement Lean, just like myself, and who's probably still struggling with it. Or, if they want to benchmark and see how other people are doing. I want to describe to them what I've done. Then, maybe, we can communicate and exchange information and data.“

He said, "What about the beginner?" I said, "I don't know. You assume that people know some Lean when you're at your workbooks. This book is going to be the same." He said, "No. We need to simplify it to where the beginner would understand what we're talking about. We need to make it small enough for anybody to be willing to read it." We know that 80 percent of business books are bought but never read. Why? Because the boss bought the book, he gave it to an employee and said, "Go read this book and you'll be smart." So, people don't read it. We wanted to make the book small enough and easy enough for everyone to think, "OK, I can read it in an hour or two." So, we spent a couple of years simplifying the book and making it smaller and smaller. Our target goal was 60 pages. Now, when you add the tables and when you add the pictures to it, it ended up being 88 pages. So, it's pretty simple. It was Lean, on purpose, so you can read it. Joe: Where is that book available at? Sami: It's available on Lean.org, which is the Lean Enterprises' website. It's also available on Amazon and Barnes and Noble's website.

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Joe: I know that Mark Graban at the Lean Blog has talked to you a lot and, I think, had a podcast and blogged about your book. He wrote the book, The Lean Hospitals. You two have discussed your book in great detail, can you share some of the conversation? Sami: First, I started communicating with Mark after my Shingo presentation. He called me one day, to do a podcast with me. We chatted a little bit and we became very good friends. Then, one time, he came and visited the office because it just happened that he was in Jacksonville. Mark, since the beginning, has helped me by telling people what I'm doing on his podcast, on his Lean Blog. So, I'm very thankful for everything he's done for me, and he's a very, very good friend. Now, in the healthcare arena, I don't think he learned anything from me. Mark has been in healthcare for a long time. I'm not sure with which companies, but I know one of them was working with Johnson & Johnson.

Today, he works with LEI, the Lean Enterprises Institute, where they have a joint venture with ThedaCare, where they're promoting Lean healthcare. He wrote the book from his own experience. He has a lot of experience, and Mark is a very good friend. Joe: Where would you like to take Lean? What is your personal ambition? Sami: Well, first, I think that Lean is not only for the experts. I think Lean is for everyone. We need to teach the principles to our kids in schools. Kids need to know how to be productive. Kids need to know what the best way for making things happen. I think that, today, Lean has proven to be the best way. Maybe some people would argue that Six Sigma is better or as good, and I have no problem with that. It's just we need to teach them these things. We need to teach these things to our kids to make sure that their future is secured in the global economy.

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Now, as my immediate goal, obviously, I want to prove it more and more in my practice. I want to prove that it works better and maybe grow my practice through it. I want my colleagues to learn it because it can benefit so many patients. But, with today's attention given to healthcare, I really hope that the Lean community could change things today. I was very, very lucky to have the size of practice that I have. I have 17 chairs, four dentists working here, and 25 people on my staff. So, compared to a large company, like the huge companies you know, I can be the CEO. I am the consultant to my employees. I am constantly in communication with them. I go do the work with them on the chair. So, I have all the steps for a leader to be able to implement a system, which probably, managers and people responsible of larger companies don't have the opportunity to do that. So, I was very lucky in that regard, and we were able to implement Lean. But most importantly, we have learned a lot of things from that experience, what's important, what's not important. So, I really hope that I would be able to teach people or to communicate with people and share with them all those experiences, hoping that many patients and many businesses would benefit from our experience. Joe: Is there anything you would like to add before we finish up here? Sami: Anything I would like to add. Yes. I would like to add that we think that variation is the problem in business, and in healthcare. It is true, but I think the best way to contain variation would be to eliminate departments and remove functional barriers. In our case, it's between hygienist and dentist. But, in the hospital, it would be removing the departments and synchronizing the work of providers. That's one thing. Now, once we have that elimination of departments, you would have the doctor and the patient and

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whoever is helping them. That would be a group with its own variation, because in my experience, doctors have their own variation, too. Like if I'm fixing a tooth, for instance, if I'm doing a crown on a tooth, it might take me two hours, whereas the other doctor might take one hour. That's my own variation. Take that group and its own variation, and then ask them to work each on their own variation. I think, we'll be able to handle it and to control it much better. That's what we've been doing in my practice and it's been very successful. The second thing I want to add is, please, do not waste your time using Lean tools, whatever they are, in a Batch and Queue system. If you want to have good results, you need to decide what your main flow is. What is the product that needs to flow? Make sure that you're working on the value stream of this product flow. That is my main point. Thank you. Joe: I would like to thank you very much, Dr Bahri. It was a very pleasant experience, and I enjoyed it very much. The Business901 podcast is available on iTunes, at the Business901 store or on my website.

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Joseph T. Dager Lean Six Sigma Black Belt

Ph: 260-438-0411

Fax: 260-818-2022

Email: jtdager@business901.com Web/Blog: http://www.business901.com

Twitter: @business901 What others say: In the past 20 years, Joe and I have collaborated on many difficult issues. Joe's ability to combine his expertise with "out of the box" thinking is unsurpassed. He has always delivered quickly, cost effectively and with ingenuity. A brilliant mind that is always a pleasure to work with." James R.

Joe Dager is President of Business901, a progressive company providing direction in areas such as Lean Marketing, Product Marketing, Product Launches and Re-Launches. As a Lean Six Sigma Black Belt and a certified coach of the Duct Tape Marketing organization, Business901 provides and implements marketing, project and performance planning methodologies in small businesses. The simplicity of a single flexible model will create clarity for your staff and as a result better execution. My goal is to allow you spend your time on the need versus the plan. An example of how we may work: Business901 could start with a consulting style utilizing an individual from your organization or a virtual assistance that is well versed in our principles. We have capabilities to plug virtually any marketing function into your process immediately. As proficiencies develop, Business901 moves into a coach’s role supporting the process as needed. The goal of implementing a system is that the processes will become a habit and not an event. Part of your marketing strategy is to learn and implement these tools.

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