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Lean in Professional Practices

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This is a transcription of a Business901 Podcast with Dr. Sami Bahri. Dr. Bahri utilizes Lean in his Dental practice and discusses how other professionals may be able to utilize Lean principles.

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Lean in Professional Practices

  1. 1. Using Lean in Professional ServicesGuest was Dr. Sami Bahri The World’s First Lean Dentist Business901 Podcast Transcript
  2. 2. Dr Sami Bahri, DDS runs a privatedental practice in Jacksonville, Florida.The practice has three general dentists,one orthodontist, 10 chairs for generaldentistry, and seven chairs fororthodontics.In 1990, after ten years of intense work in the teaching,administrative and private practice fields, Dr Bahri moved toJacksonville, Florida. In the same year he opened his firstJacksonville practice with two dental chairs. He studieddental management and applied it in his practice.Eager to know how other industries manage their resourcesto satisfy their customers, he started searching outsidedentistry, in the mainstream where many managementexperts are continuously trying to improve the way thingsare done. In 1996, Dr. Bahri read “Lean Thinking” by JamesWomack and Daniel Jones, and started implementing LeanManagement principles in his dental office. Thisimplementation has benefited patients, employees, dentallaboratories, suppliers, etc. In 2006, Bahri Dental Groupprovided the same amount of dental treatments as 2005, butneeded 40 percent less resources, thanks to the applicationof “Lean Dental Management.In March of 2007, Dr Bahri was invited to present his workas a keynote speaker at the “Shingo Prize for Excellence inManufacturing” where he was recognized as the “World’sFirst Lean Dentist”. In March of 2009, Dr Bahri wrote Followthe Learner: The Role of a Leader in Creating a LeanCulture, published by the Lean Enterprise Institute. Helectures nationally and internationally to share hisexperience on implementing lean management in the dentalpractice. Bahri Dental Practice Jacksonville, FL 32256 http://bahridental.com
  3. 3. Joe Dager: Thanks for every joining us. This is Joe Dager,the host of the Business901 podcast. Participating in theprogram today is Dr. Sami Bahri. In March of 2007, Dr.Bahri was invited to present his work as a keynote speakerat the Shingo Prize for excelling in manufacturing, where hewas recognized as the Worlds First Lean Dentist. Dr. Bahri,let me start at the beginning, how did you get acquaintedwith Lean?Dr. Sami Bahri: Joe, thank you for inviting me to yourpodcast. Well, actually, I was trying every managementsystem I could put my hands on, in my practice. One day, Iwas listening to a tape by James Womack, and in the tape,he asks his daughter, while she was folding her momsnewsletters, he says, "Why are you folding all thenewsletters, putting them all in the envelopes, addressingthem all, and then stamping them all and sending the out?Why dont you do one? Fold it, put it in the envelope,address it, stamp it and send it out?" She said, "Because, itwouldnt be efficient." So that idea stopped me, becauseback in 1984 when I was in charge of a dental school inLebanon, I had had a similar idea. I saw my patients, thepatients in the clinic come in one day for a diagnosis. Oneday for fillings, the second day for crowns, the same peoplewere coming back, day in and day out.I thought, "Why cant we put the patient into the chair, andhave specialists from every specialty treat those patientsand let them go to their lives?" Then I dismissed the ideabecause dental school had been around for a long time,until I heard that, and it was similar. It was a One PieceFlow, so I stopped the car and opened the book, and lookedat the bibliography at the end of the book.
  4. 4. There were books by Ono, and Shingo, and people I neverheard of before. I thought, "Let me see if those books arestill available." I got the books and started reading, andthats how it started. That was in 1996.Then in 2005, one of my patients, Jerry Bustle, was goingto Japan, and he said, "Can you check my teeth, I dontwant to have any problems while Im abroad." I thought,"Jerry, what are you doing in Japan?" He said, "Im going toToyota City, because I do the Toyota System, the Toyotaproduction system in my manufacturing plant."That was the first time I had encountered anybody doingLean and Toyota production systems since 1996. I said,"Wait a minute," then I brought [out] all the books, all thetapes, and I showed him what Im doing, then he calledJames Womack and said, "You wont believe it, my dentist isdoing Lean."Then Jim came, and then John Shook came, and then a lotof experts came and the next thing I know, I was invited asa keynote speaker at the Shingo Prize. To my surprise, atthe end of that presentation, they gave me that title ofWorlds First Lean Dentist. Thats how it happened.Joe: Thats pretty interesting. You did not have any Leanconsultant or anything else, you just started putting Leanprinciples into your practice?Sami: No, I didnt even know anybody else was doing it. Ijust went from one book to the other. I would take a bookand understand one idea, not understand the rest of them,those specific ideas for manufacturing. Then I would read adifferent book, and then get
  5. 5. another idea, until we built the system a little bit at a time,but I didnt have any consultants, no.Joe: Most dental practices that Ive been around are prettyefficient. I dont go into a dentists practice, and wait like Ido at another type of doctors. A dentists is efficient andmost of the appointments are on time. How did you look atthat as something that would really benefit you, because Ithink dentists are efficient?Sami: Yes, dentists are very efficient, actually. Theyrevery well organized, and they thing a lot about theprocesses and how they want to do the treatment for theirpatients. That makes it, maybe, more difficult for me to finda new way, or be motivated to find a new way. On the otherside, from the medical stand point, and the dental standpoint, Ill give you, gum disease, for instance. If we want totreat gum disease, we are trained to read everything aboutgum disease, and understand everything about gumdisease. Then, when the patient was present, and we checkin their teeth and their gums, we want to know everything,and just pick whatever is appropriate for that patient. WhenI was managing my practices, I didnt feel that I wasapplying the same kind of scientific thinking tomanagement.I would do things that were very, very organized, because Ihad thought about management since the early 80s and70s, but I didnt have that feeling that scientifically, I hadcovered it all. I wanted to see, outside of dentistry, whatare people doing.I studied Dr. Deming, TQM, I studied reengineering, thatbecame Six Sigma later, the Theory of Constraint, and youname it. Then, at the end of the day, I wanted to decide
  6. 6. what was best for my practice. Given the results we had, Ilanded on Lean. Thats 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? Isthat how you try to look at it?Sami: Yes. When we first started, I read the books andlearned the principles, and you end up with so manyprinciples that you really dont understand which ones areimportant. You dont have any kind of ranking. You dontknow which one is important, which one is not, and howyou get Lean? So for 13 years, I would study the principles,and apply them in my Batch and Queue system. I wasgetting frustrated that those Lean principles and Leanmanagement is not giving me the results that Im lookingfor, no breakthrough. I mean there were improvementseverywhere, 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 Ithought about it more and more and more, I startedthinking, "Maybe thats the only principle thats in Lean,that does not apply to any other management theory."Like you take respect for people, for instance. You canrespect people in any theory, in any management system.You take 5Ss, you can organize yourself in anymanagement system, and you take any other principle, itsthe same, but you take One Piece Flow, and you cant bedoing Batch if youre doing One Piece Flow. So I thought,"Let me pursue that."
  7. 7. We started trying to do, lets say, one tooth at a time, or oneprocedure at a time. Like a filling, or a root canal, and thenat the end, we decided on one thing, lets take the tooth forone piece, and the mouth for a lot. The minimum we want todo is the whole mouth, which is not possible every time,obviously, as you know.If you tell dentists, "Im doing the whole mouth every time,"theyre going to say, "Its not possible," and theyre right.But that is my goal, and every time I can, Im going to do it.So once we started pursuing that, I understood a couple ofthings. First, I understood that I need to always focus onlead time. Then I started studying, "how do you reduce leadtime?"Instead of studying all the principles, we ended up utilizingmaybe three or four. You try to do a small lot, you try tosynchronize the providers, and you try to work on yoursetups. You know, leveling, thats everything. With thoseprinciples, we were able to transform the practice fromBatch and Queue to Flow.We took every one of these principles and went throughthree stages. First stage was to understand what it meansfor manufacturers. Second stage: How do you translate it indentistry? Third stage: How do you actually apply it indentistry? As we dissected it, we started seeing that onceyou apply one of them, then you see the second one runningat you.Its like if you dont do leveling now; the system is not goingto work. Then, once you do leveling, if you dont havesynchronization between the providers, the system is notgoing to work. At the end, to make it all work together, wehad the need for some kind of
  8. 8. communication system. We went back to what Toyota didand we found that you needed a Kanban, which we did in aform of a flowchart. So, thats how we ended up thinkingthat One Piece Flow and the pursuit of One Piece Flow isreally what make a system Lean.Joe: You have so much variation, each patient is different.You go in and theres a discovery part to it when thatpatient sits in the chair. Correct?Sami: Yes. Absolutely.Joe: Then, at that point in time, you try to maximize that,and do everything thatsneeded in that one sitting?Sami: We try that, yes. Obviously, you have differentvalue streams. And, so far, we think that the most difficultpart in health care and in dentistry, is to synchronize thework of providers. So we do our value streams dependingon how many providers you need to see. For instance, ifyou need to see only the hygienist, that is one valuestream thats very simple. Now, you might need a hygienistand a dentist in the same appointment, it becomes a littlebit more complicated. Or, you might need a hygienist, adentist, and your lab or you might need a hygienist,dentist, lab, and a specialist. So, each one of these is adifferent value stream.Joe: Theyre all provided at one location.Sami: Theyre all provided in the same chair for thepatient. Each one of us comes to the patient because its somuch easier and more economical for everyone to justmove the providers, instead of moving the patient.Traditionally, we used to have the patient in the
  9. 9. hygienists chair. Then, if we found something that needs tobe done, we would send them home. We would makeanother appointment to come back maybe two weeks laterto the dentists chair which is three feet away or six feetaway from the hygienists chair. So today, we dont do thatanymore.We think, "If you are in my chair needing a filling, and youneed a cleaning at the same time. The hygienist will cometo that room when we have a little break in your treatmentand shell do your cleaning. That saves you an appointmentthat saves us an appointment."So, now, were gathering all the providers around thepatient. Even financial coordinators, assistants, theyre all inthe clinic. They hear each other, they communicate witheach other. We try not to have people in offices that need totreat patients and to communicate with patients. Theyre allon the clinic floor.Joe: Now, when you learned this first, did you use anytools or just use the principles of Lean?Sami: Yes. At first, we used the tools as we understoodthem. Lets say we needed to do leveling. So, how do youdo leveling? You need to learn your takt time. What is takttime? So, we try to understand takt time. Then, we want touse the 80-20 principle, but on what? On the patients thatcome most frequently to the office? On the procedures?On the amount of money were making? We didnt know atthe beginning. But then, when we started focusing--westarted focusing on setups, and we learned that setups arereally what stays, and the way of One Piece Flow. So wethought, then it is obvious then that we
  10. 10. need to focus on the most frequent procedures becausethose generate the biggest number of setups.So, we would take each tool and apply it. But, as I said, ifwe said we need to remove the functional boundaries, forinstance. I took functions from the front desk, put them inthe room next to the patient. So now the assistant, bycross-training, the assistant can now make yourappointment, she can walk you out.But, as we went, we started learning some lessons. You canremove boundaries between processes. But as long asyoure not removing the boundaries between the valueadding processes, in our case, between the hygienist andthe dentist this is value adding, you wont see any benefitsreally or very minor benefits.So, if you take any of the support functions and work onthem, and move them from here to there, in an isolatedway, we didnt find any results. But, the day we decidedthat the hygienist and the dentist are going to treat thepatient in the same chair, and then everything changed.Everything changed in the sense that waiting time in thewaiting room is gone. Waiting time in the chair is gone. Wewere able to treat many, many more patients during theday. The thing that happened that I wasnt expecting wasthat the steps of Lean implementation started pushingthemselves on me.Like, you have the hygienist and the dentist working on thepatient, and then when we stand up, we dont know whereto go. Now, you need some kind of communication, somekind of a person organizing. So, we created a position calledthe patient care flow
  11. 11. manager. Thats a position that is a copy of the team leaderfrom Toyota, with the same job descriptions.So, that person would tell me where to go, would tell thehygienist where to go, and would tell the other doctor, theother hygienist where to go. So now, that step being done,she was talking to a person, lets say, she was talking to you,and I am done, I need to go somewhere else. She wasnt ableto talk to me at the same time.So, we went like an emergency meeting and we said, "Howcan we communicate?" I thought, all of a sudden, that Toyotacommunicates through Kanban. I said, "We need a Kanban.Lets make a flowchart and follow the patients treatment."Then, we took that piece of paper; she started giving thatpiece of paper with two times on it. One time tells you, "Igave you that piece of paper." Wed call it "time given," at twooclock, for instance. "I need you in chair number five at2:15." So, she gave me 15 minutes to organize myself anddelegate to my assistant and then at 2:15, I need to beexactly there because the hygienist is going to be done.We tried that for a while and it works very well. The thing iseverybody started depending on everybody else. So,everybody needs to do their jobs correctly and to be alert allthe 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 havereceived it very, very, well. Actually, they have been veryencouraging and that is encouraging me to go forth andmanufacturers have been asking me to speak. Manufacturersknow that Lean is, if not the best, one of the best systemstoday. They want to know how someone has applied it in a
  12. 12. non-traditional industry. So they know Lean is good. They justwant to know how I did it. With dentists, as we said, they arevery well organized. It is going to be tough for me to convincethem that change is possible and that Lean is the best changeto go. And what is Lean and how to apply it. So I have manymore steps to go in my own profession.Joe: What have you learned from this that you think appliesto other professional practices?Sami: I think Joe, not only Lean, but any managementtheory. I am going to talk about the same ones that wealready 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 aprocess they apply.Sami: You can use any, right? So it is just which system orwhich theory gives you the best results. And so far, in ourpractice, Lean has given the best results. I really think itapplies to everything. Now the key is, what do we teachpeople? And my experience is really in that regard. I learnedit 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 eliminatingwaste. You teach someone who doesnt know about Lean andyou say, "Lean is about eliminating waste." And you sayanything that you do not need to apply right away is a waste.So what we did was looking around us and eliminating wasteand eliminating waste going nowhere. Why? Because, wewere not eliminating waste in our main flow, the patient. Iwould eliminate waste at the front desk and the way they arehandling insurance. Or how they are filing insurance, orverifying insurance.
  13. 13. But, I was still making several appointments for my patient.Until we decided what our main flow is. The principal flow isthe patient flow. Anything else: like how to prepare theappointment, how to set up the room, how to prepare theinsurance verification and the patients file in the computer. Allof these are support flows.As long as you are working on improving your support flowswithout really paying attention to the main flow, we didnt seeany improvements. My main message would be if you want tolearn the Lean tools at least learn them while you areimproving your principal flow. Decide what your principal flowis and work on that. That is where Lean is.Anything else like improving operations which is the same assupport flows did not give us the results that we were lookingfor. 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: Youre touching a very sensitive point here. For a longtime, I would read a book come up with an idea, and youwould see the eyes rolling in the room. But, the thing is Inever called it anything. We never called it Lean management.We never called it the Toyota production system. We nevercalled it anything. We were just improving our service for ourpatients. So you can say from 1993 [when] I read the bookKaizen by Imai, and I started applying the principles andlearning from books and applying the principles but we nevercalled it anything. Until James Womack came and said, "Youare applying Lean." My assistant started asking, "What are youtalking about?" I said, "Yes, that is what we are applying. Wehave been applying this for many, many years."
  14. 14. I think it is probably one of the factors that allowed me tosneak up on them and apply the system. I feel had I called it"Lean management" and said we were going to transform thepractice into "Lean management" I would have found muchmore resistance. To be totally truthful I did find a lot ofresistance from staff. And I attribute that to my lack ofknowledge, as far as Lean leadership at that time. I waslearning how to introduce improvements.Then little by little I learned that you dont want to rock theboat too much. You start as little as you can, as small as youcan, with one assistant maybe. To give you an example,I wanted my assistant to start scheduling appointments fromthe room. I did not ask her to schedule appointments from theroom. I just placed a computer in one of the rooms.Then went home, and learned the program, and how youschedule appointments and then when I came back the nextday, whoever was helping me I said, "Can you please go andpush that button?" and she did and it came up on theschedule. I said, "Can you click on that slot?" and she clicked.I said, "Can you enter the patient...?" So I walked her throughthe process.At the end of the process, she made the patient appointment.We did it a couple times, and then she started makingappointments on her own. Then the assistant next door waswatching, she said, "Well, I can do that, too. Why dont youget me a computer?" I got her a computer in the room andthen little by little everybody started making appointments.I did the same thing with walking the patients out. I did thesame thing with explaining treatment benefits to the patients.So without really giving a lot of noise and saying we are doingthis, and we are doing that, I just took them through the stepsto show them that it is easy, and it can be done.
  15. 15. That made things much, much easier for me, much lessresistance. 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 myShingo presentation, they said, "If you want to write abook, please talk to us first." They sent Michael Brousard,who is very knowledgeable, and he stayed with me a littlebit and he said we are going to do the book on leadership. Isaid, "What do you mean leadership? I am just a dentist."He said dont worry we will walk you through it.He made me write everything that I know about myprofessional life, and then he sorted them into principles.And he said "That is what you have been doing." Actually, Ihad been living all of that, not knowing exactly that it isgoing to end up with a book.The goal from the book was to really show the experiencewe went through and the transformation that we were ableto do from Batch to Lean. We made it like a story, but inthe story, I put the lessons I wanted to tell people to learn,without really telling them, "Thats what you need to do."I should have probably said it more bluntly, "I think, youneed to do your setups first. I think you need to do this andthat first." When I read the comments, a lot of people say,"Its about Dr Bahris story." Actually, it is about the Leantransformation, as I see it, put in a story.
  16. 16. Then, after we finished the book, we met with MichaelBrousard, and he said, "Sami, whos your audience for thisbook?" I said, "My audience is someone who has tried toimplement Lean, just like myself, and whos probably stillstruggling with it. Or, if they want to benchmark and seehow other people are doing. I want to describe to themwhat Ive done. Then, maybe, we can communicate andexchange information and data.“He said, "What about the beginner?" I said, "I dont know.You assume that people know some Lean when youre atyour workbooks. This book is going to be the same." Hesaid,"No. We need to simplify it to where the beginner wouldunderstand what were talking about. We need to make itsmall enough for anybody to be willing to read it."We know that 80 percent of business books are bought butnever read. Why? Because the boss bought the book, hegave it to an employee and said, "Go read this book andyoull be smart." So, people dont read it. We wanted tomake the book small enough and easy enough for everyoneto think, "OK, I can read it in an hour or two."So, we spent a couple of years simplifying the book andmaking it smaller and smaller. Our target goal was 60pages. Now, when you add the tables and when you addthe pictures to it, it ended up being 88 pages. So, itspretty simple. It was Lean, on purpose, so you can read it.Joe: Where is that book available at?Sami: Its available on Lean.org, which is the LeanEnterprises website. Its also available on Amazon andBarnes and Nobles website.
  17. 17. Joe: I know that Mark Graban at the Lean Blog has talked to youa lot and, I think, had a podcast and blogged about your book. Hewrote the book, The Lean Hospitals. You two have discussed yourbook in great detail, can you share some of the conversation?Sami: First, I started communicating with Mark after my Shingopresentation. He called me one day, to do a podcast with me. Wechatted a little bit and we became very good friends. Then, onetime, he came and visited the office because it just happened thathe was in Jacksonville. Mark, since the beginning, has helped meby telling people what Im doing on his podcast, on his Lean Blog.So, Im very thankful for everything hes done for me, and hes avery, very good friend. Now, in the healthcare arena, I dont thinkhe learned anything from me. Mark has been in healthcare for along time. Im not sure with which companies, but I know one ofthem was working with Johnson & Johnson.Today, he works with LEI, the Lean Enterprises Institute, wherethey have a joint venture with ThedaCare, where theyrepromoting Lean healthcare. He wrote the book from his ownexperience. He has a lot of experience, and Mark is a very goodfriend.Joe: Where would you like to take Lean? What is your personalambition?Sami: Well, first, I think that Lean is not only for the experts. Ithink Lean is for everyone. We need to teach the principles to ourkids in schools. Kids need to know how to be productive. Kids needto know what the best way for making things happen. I think that,today, Lean has proven to be the best way. Maybe some peoplewould argue that Six Sigma is better or as good, and I have noproblem with that. Its just we need to teach them these things.We need to teach these things to our kids to make sure that theirfuture is secured in the global economy.
  18. 18. Now, as my immediate goal, obviously, I want to prove it moreand more in my practice. I want to prove that it works betterand maybe grow my practice through it. I want my colleagues tolearn it because it can benefit so many patients. But, withtodays attention given to healthcare, I really hope that the Leancommunity could change things today.I was very, very lucky to have the size of practice that I have. Ihave 17 chairs, four dentists working here, and 25 people on mystaff. So, compared to a large company, like the huge companiesyou know, I can be the CEO. I am the consultant to myemployees. I am constantly in communication with them. I godo the work with them on the chair.So, I have all the steps for a leader to be able to implement asystem, which probably, managers and people responsible oflarger companies dont have the opportunity to do that. So, Iwas very lucky in that regard, and we were able to implementLean. But most importantly, we have learned a lot of things fromthat experience, whats important, whats not important.So, I really hope that I would be able to teach people or tocommunicate with people and share with them all thoseexperiences, hoping that many patients and many businesseswould benefit from our experience.Joe: Is there anything you would like to add before we finish uphere?Sami: Anything I would like to add. Yes. I would like to addthat we think that variation is the problem in business, and inhealthcare. It is true, but I think the best way to containvariation would be to eliminate departments and removefunctional barriers. In our case, its between hygienist anddentist. But, in the hospital, it would be removing the
  19. 19. departments and synchronizing the work of providers.Thats one thing. Now, once we have that elimination ofdepartments, you would have the doctor and the patientand whoever is helping them. That would be a group withits own variation, because in my experience, doctors havetheir own variation, too.Like if Im fixing a tooth, for instance, if Im doing a crownon a tooth, it might take me two hours, whereas the otherdoctor might take one hour. Thats my own variation. Takethat group and its own variation, and then ask them to workeach on their own variation.I think, well be able to handle it and to control it muchbetter. Thats what weve been doing in my practice and itsbeen very successful.The second thing I want to add is, please, do not wasteyour time using Lean tools, whatever they are, in a Batchand Queue system. If you want to have good results, youneed to decide what your main flow is. What is the productthat needs to flow? Make sure that youre working on thevalue stream of this product flow. That is my main point.Thank you.Joe: I would like to thank you very much, Dr Bahri. It wasa very pleasant experience, and I enjoyed it very much. TheBusiness901 podcast is available on iTunes, at theBusiness901 store or on my website.
  20. 20. Joseph T. Dager 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. Joes 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 companyproviding direction in areas such as Lean Marketing, ProductMarketing, Product Launches and Re-Launches. As a Lean SixSigma Black Belt and a certified coach of the Duct TapeMarketing organization, Business901 provides and implementsmarketing, project and performance planning methodologiesin small businesses. The simplicity of a single flexible modelwill create clarity for your staff and as a result betterexecution. My goal is to allow you spend your time on theneed versus the plan.An example of how we may work: Business901 could startwith a consulting style utilizing an individual from yourorganization or a virtual assistance that is well versed in ourprinciples. We have capabilities to plug virtually anymarketing function into your process immediately. Asproficiencies develop, Business901 moves into a coach’s rolesupporting the process as needed. The goal of implementing asystem is that the processes will become a habit and not anevent. Part of your marketing strategy is to learn andimplement these tools.

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