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Implementing Lean: Change Management Theories to Consider

Posted on Wed, Dec 21, 2016
Implementing Lean: Change Management Theories to Consider

By John Bitting, RN, BSN, MA

The healthcare industry is continually changing, and as leaders, we help staff as they struggle through change management challenges every day.

Evidence-based practice is the cornerstone of today’s medicine, and new research seems to happen at phenomenal rates. Intellectually we understand the need to change in order to improve and that “change is good.” However, the human part of us that prefers to be comfortable approaches change kicking and screaming. The adoption of the electronic health record is a good example. Good healthcare leaders and lean proponents love the data that can be revealed with a good reporting system in an electronic health record. Younger, tech-savvy, practitioners are even more comfortable in using the electronic devices and interfaces. But, in every electronic chart conversion, it is all too common for providers, nurses and allied health professionals to fight the inevitable. Some are even left by the wayside due to an inability to make the change.

Change is the foundation of lean. Through a lean event, we are going to change processes and even our environment. So, when implementing lean, we must be prepared to encounter and neutralize resistance, confusion and habits. You want to have a clear vision of the future state as well as the path to get there. You also want to have several arrows in your quiver for managing change.

Force Field Analysis

One model of change is Force Field Analysis (FFA) developed by Kurt Lewin (1951). It represents the concept of opposing forces in change. Change is viewed as a process of modifying two types of forces in a system; one which tends to maintain the status quo and the other which pushes for change. For change to occur, the balance of driving forces needs to overcome the restraining forces. Strengthening driving forces may include building win-win solutions. In developing a plan of action, Lewin recognized that actions to remove or reduce restraining forces were more effective than actions to increase driving forces, which would serve to increase tension in the system.

To change behavior, Lewin gave us his three step process:

  • Unfreeze
  • Movement
  • Refreezing

The first step in Lewin’s process is breaking the existing situation or status quo. Driving forces must move the situation into an uncomfortable place. Comfort is a powerful motivator, in both positive and negative ways. Discomfort can set the stage for “movement” to a new level of equilibrium. This is done by getting the followers to agree that the status quo is undesirable or not beneficial and encouraging them to look at things differently. The final phase is refreezing, or making the new situation the new status quo. The phase of refreezing is the sustainment of the change. The challenge of staying lean largely depends on how well you refreeze the new expectations.

The Seven Phases of Change

Gordon Lippitt expanded on Lewin’s theories and added seven phases. The seven phases of change model is not rigid or necessarily sequential, but instead flows between the different stages. It focuses on the change agent and how to use the phases to help guide the change.

The phases are:
 
  1. Identification and diagnosis of the problem
  2. Assessment of the motivation and capacity to change
  3. Assessment of the change agent’s ability to lead this change along with motivation factors that may influence them
  4. Change agent assumes the appropriate role
  5. Level of involvement of the change agent is determined
  6. Maintaining the change
  7. Stopping the helping relationship

Only when the team has confidently worked through each phase reaching acceptance of change has change occurred.

Advanced Change Theory

Another model for dealing with organizational change is the 13-part Advanced Change Theory (ACT). This model requires a lot of practice. It is called “Advanced” for a reason. It is a complex model for dealing with change. The concept seems fairly simple; it is the alignment of the change agent, the change target and the current reality. Getting those things aligned is the difficult part.

The complexity of the assumptions makes it a cumbersome model for a leader to use to enact change. However, some of the concepts within the model can help the leader as a change agent. Each leader will likely find assumptions they feel comfortable using.

EmCare recently published “Making Healthcare Work Better™ with Lean,” a book and supporting workbook developed by the company’s clinicians and operational experts to help hospital leaders and process improvement teams better understand and implement lean process improvement techniques.

Advanced Change Theory is one of many subjects included in the book, which is a compilation of lean experiences and advice from nearly 30 practicing experts. The book is accompanied by a free, downloadable workbook with practical tips and exercises to help you break down barriers to getting lean in your organization. It’s the perfect reference book for someone who needs to understand what lean is about, how to make it work, how to overcome road blocks and how to gain buy-in.

To learn more about implementing lean at your facility and to download your free copy of “Making Healthcare Work Better™ with Lean,” visit our website.

How leaders support, propagate and promote the change process will determine the success of the endeavor. The different theories are just that, theories. Some work very well. Others are hard to put into practice. Your personal level of comfort directly affects your ability to operationalize these concepts. New leaders must actively think about how to use these concepts with the lean team and other change processes. Seasoned leaders end up doing it as second nature. It is also easier when the leader believes in the change. It needs to be personal.

John Bitting, RN

John Bitting, RN, is a Divisional Director of Client Services for EmCare.
 

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Implementing Lean Processes in the ED Improves Metrics

Posted on Wed, Oct 19, 2016
Implementing Lean Processes in the ED Improves Metrics

By Christine Kelly, RN, MBA, FACHE; Amanda Maxim, RN, BSN, MBA; Jan Beck, RN, BSN; and Shayne Middleton, RN, BSN, CEN

Nowhere is a glitch in the patient experience more pronounced than in the emergency department (ED). The ED team's ability to provide fast, efficient, quality care has a signifcant impact on each patient’s perception of care and the management of life-threatening injuries.

The processes in use today to manage patient flow from arrival to treatment to disposition are widely seen as inefficient and cumbersome. These inefficiencies often lead to long wait times and a lack of attention to patient needs and, potentially, prevent needed access to care. Recent publicity surrounding patients leaving without treatment, deaths in waiting rooms and overcrowding has become a catalyst for change in the industry. As a result, we are seeing a significant increase in the use of lean at hospitals nationwide.

It’s important to understand that achieving lean in the ED may rely heavily on improving processes in other departments. Lean can be most effective for improving patient throughput, but this means looking at the ED as one part of the delicate ecosystem of hospital care. While lean implementation may start in the ED, to be most effective it needs to extend through all patient flow paths.

When lean is applied to the front-end processes, patients can be seen more quickly. Lean in radiology and ancillary services also can facilitate patient treatment and diagnoses more quickly. Extending lean into the inpatient setting helps cut unnecessary hours off of the length of stay, which opens inpatient beds for new patients to be transferred from the ED. Lean for the OR helps ensure efficient operation of surgical services, allowing accommodation of emergency cases. Lean methodology works best when it encompasses the entire path of patient care.

Implementing Lean in the ED

A lean consultant was asked to conduct an emergency department lean rapid redesign workshop with the goal of improving operational efficiency.

Patients were experiencing an increased length of stay due to delayed diagnostics. Further, without use of pre-emptive orders at triage, it was taking 35 minutes from arrival to order entry by a primary care nurse if immediate bedding took place (and longer if no beds were available).
 

  • Patient presents to triage = 30 minutes; to room 110 minutes, wait for provider 60 minutes, Medical Screening Exam = 10 minutes, 5 minutes to order entry = total of 215 minutes from door to order entry
  • Provider order entry was 74 minutes from arrival
  • With pre-emptive ordering at triage, 24 minutes to order entry
  • LWOTs were two times the national best practice of 2.0 percent
  • Decreased efficiency ancillary services secondary to wasted time/trips to the ED


Contributing conditions:
 

  • No prioritization of services ordered – X-ray may collect the patient prior to lab draw, resulting in delay in results due to collection time
  • Transport of lab specimen delayed, placed in box on counter
  • No communication between ancillary departments
  • Pre-emptive orders not consistently used by nursing
  • Inconsistent "pull ‘til full"
  • Some physicians delaying medical screening exam on low-acuity patients, some saving for advanced practice providers


The Lean Solution

The consultant worked with the hospital’s nurse leaders to reach the following goals:
 

  • Implement bedside triage and registration process 100% of time, with “Pull ‘til Full” concepts (Patient-Centric Care) implemented across all shifts/staff
    • Minimize redundancy
    • Standardize triage process
    • Target arrival to provider time: 40 minutes
    • Bed to provider time: 25 minutes
  • Create more organized patient flow with space for simultaneous processes to take place, eliminating wait time and redundancy
    • Adequate resources in the right place
    • Keep vertical patients vertical and give the beds to the sick
    • Use discharge sub-waiting area
  • Consider plant flow redesign with existing spaces to include reassignment of current rooms for more efficient flow
    • Use of triage preemptive protocols 70 percent of the time
    • Improved ancillary communication
    • Collection to receipt of specimen to take only 5 minutes 90 percent of the time
    • Door-to-doc time to meet 40-minute benchmark
  • Educate ED, evaluate cost and benefits, recognize waste, plan-do-study-act, gemba walks
    • Reinforce "pull ‘til full" policy with 100% use of bedside computers
    • Educate nurses/providers in use of pre-emptive protocols
    • Flag on specimen box as visual cue for specimen awaiting transport, ED to assist
    • Lab access to private tracker board to allow comments
    • Lab to notify nursing when draw complete so tracker can be updated for X-Ray
    • Educate Radiology staff on use of tracker notifications
    • Metric comparisons


After implementation, the team’s results included:
 

  • Streamlined patient flow
  • Decreased throughput time
  • Decreased left without being seen (LWBS) rate
  • Improved patient and employee satisfaction
  • Improved quality in delivery of care
  • Reduced financial losses


EmCare recently published “Making Healthcare Work Better™ with Lean,” a book and supporting workbook developed by the company’s clinicians and operational experts to help hospital leaders and process improvement teams better understand and implement lean process improvement techniques.

This case study is one of many included in the book, which is a compilation of lean experiences and advice from nearly 30 practicing experts. The book is accompanied by a free, downloadable workbook with practical tips and exercises to help you break down barriers to getting lean in your organization. It’s the perfect reference book for someone who needs to understand what lean is about, how to make it work, how to overcome road blocks and how to gain buy-in.

To learn more about this case study and to download your free copy of “Making Healthcare Work Better™ with Lean,” visit our website.

Christine Kelly, RN, MBA, FACHE, is Vice President of Clinical Services for EmCare. Amanda Maxim, RN, BSN, MBA, is Vice President of Clinical Quality for Valesco Physician Services, Inc. Jan Beck, RN, BSN, is a Director of Clinical Services for EmCare. Shayne Middleton, RN, BSN, CEN, is a Divisional Director of Clinical Services for EmCare.
 

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EmCare Writes the Book on Lean

Posted on Mon, Sep 26, 2016
EmCare Writes the Book on Lean

By Kirk Jensen, MD, MBA, FACEP

We in healthcare are passionate about providing exceptional quality, safety and service to our patients.

Applying lean principles to streamline our systems and processes can free us to focus on delivering high-quality care, leading to increased satisfaction both for patients and for healthcare teams.

Quality and performance advances in the automotive industry are the foundation of what we now call lean manufacturing and lean services – standardizing processes to reinvent a business, department or even a country. Lean emphasizes processes that deliver client value, eliminate waste, promote flow and encourage the practice of continuous improvement.

In healthcare, an industry focused on quality, safety and patient care, the stakes can be high and the challenges all too real – at times literally a “matter of life or death.” We all want, and seek to build, environments where our people - talented, trained and motivated healthcare team members - can focus on their mission of delivering superior healthcare and service. The systems and processes in place must facilitate, rather than hinder, the attainment of these goals. Lean provides a philosophy, an approach, and effective tools to advance and enhance our work on all levels.

Peter Drucker said, “The only things that evolve by themselves in an organization are disorder, friction and malperformance.” Disorder, friction and malperformance exist in the complex world of healthcare, with resultant catastrophic consequences. Healthcare administrators increasingly are examining and retooling processes to improve safety, quality and efficiency while wringing out waste. For many organizations, this means implementing lean.

EmCare recently published “Making Healthcare Work Better™ with Lean,” a book and supporting workbook developed by the company’s clinicians and operational experts to help hospital leaders and process improvement teams better understand and implement lean process improvement techniques.

The goals for the publication are:
 

  • To highlight the application of lean principles in the healthcare sector, using practical real-world examples informed by the people who have actually done the work;
  • To illustrate the tools, approaches and philosophy that have enabled multiple departments and services to significantly improve their operations;
  • To put lean in its proper place or perspective as an adjunct in improving the lives of our patients and our people; and
  • To infuse a note of optimism into the current healthcare delivery conversation as we press forward in the face of healthcare delivery challenges.

The book is a compilation of lean experiences and advice from nearly 30 practicing experts. It covers a broad base of healthcare services within and beyond the walls of the hospital. It is accompanied by a free, downloadable workbook with practical tips and exercises to help you break down barriers to getting lean in your organization. It’s the perfect reference book for someone who needs to understand what lean is about, how to make it work, how to overcome road blocks and how to gain buy-in.

Content Highlights

The publication includes chapters on:

   
  • Implementing Integration Strategies
  • Lean in the ED
  • Case Study: Lean Tabletop Simulation Exercise
  • Process Improvement in Perioperative Medicine
  • Why do you need Lean in the OR?
  • Improving Value
  • Hospital Medicine Was Born of Lean Thinking
  • Culture Change versus Secret Sauce
  • Technology that Supports Lean Process Improvement
  • Strategies for Improvement: Tried and True, Bold and New
  • Creating a Lean-focused Transitional Care Team
  • Lean Beyond the Hospital Stay
  • A Lean Solution: Mobile Integrated Healthcare
  • The Value of Lean in Radiology
  • Changing Mindsets at Every Turn
  • Lean Processes for Leaders
  • Applying Lean and Creating a Culture of Excellence
  • Lean Terms and Tools
  • 10 Rules of Engagement for Change Management


Every one of our patients, every one of our client hospitals and every one of our healthcare workers deserves an environment and a department that works – people, processes and performance that reliably deliver the care, services and outcomes we want.

To learn more about “Making Healthcare Work Better™ with Lean” or to download your free copy, visit Our Website.

Kirk Jensen

Kirk Jensen, MD, MBA, FACEP, is the Chief Innovation Officer for EmCare.
 

 

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12 Tips for Better Meetings: Part 2

Posted on Wed, Apr 27, 2016
12 Tips for Better Meetings: Part 2

By Sabrina Griffin, RN

This article is Part 2 of a two-part series. Read Part 1

For leaders, a lot of the work you do is accomplished in meetings. But, for many us, planning for meetings is close to last on our list of things to do. Unfortunately, a poor process for arranging, conducting and using meetings can result in a significant waste of time and effort.

So, how do we elevate the effectiveness of our meetings? As someone who relies on lean for process improvement in the hospital setting, I immediately looked to the principles and tools of lean to help improve my process for meetings. Applying lean methodologies such as value-stream mapping and 5S has helped me identify what brings value to meetings and how to standardize meetings so that they run most efficiently. Here are the last six tips to help you meet smarter, not longer.

7. Prioritization.

You’ve nailed your purpose, bullet points for your agenda and expectations for the team. You have your timing set appropriately and a time-keeper to keep everyone on track. So, why do I need to prioritize? What could go wrong?

Even with the best-made plans, the meeting may uncover unexpected topics that are critical to the primary purpose of the meeting. Be sure to prioritize the topics so that important decisions are made first and less urgent topics are covered time permitting.

Is this a recurring meeting? If so, be sure to table the lower-priority topics and bring them up at the next meeting.

8. Productivity.

Closely tied to the purpose of the meeting is the productivity of it. The question of the hour, or whatever time you have allotted for your meeting, is can we come to a conclusion at the end of this meeting? If we have effectively prepared for the meeting, invited the right people, and followed our process, chances are we should be able to arrive at a decision or other desired purpose.

How many times do you leave a meeting and feel that you accomplished nothing? That’s the kind of response that will make people not want to be involved in a meeting. Don’t let that be the case with your meetings. Have a plan for how this is going to culminate in a take-away the group can feel good about. Now, keeping in mind, there may not always be a consensus on every decision. But providing people the opportunity to weigh in, using a fair process where all interested parties have a say, and seeing the result unfold real-time still can give members a sense of satisfaction even if the decision didn’t go their way… this time.

9. Power.

A lot of good meeting time goes to waste because those involved in the meeting ultimately do not have the power to make or implement the group’s decision. Whether it’s a lack of authority, resources, budget or expertise, the inability to act on the next steps can paralyze the group, and all of the good ideas and plans for improvement go down the chute. So when planning your meeting, one of the first questions to ask is “Do we have the power to make a decision?” If no one in this group has the authority or can’t act on behalf of someone who does, your meeting will likely be a futile effort.

10. Permission.

Slightly akin to power is the question “Do we have permission?” In some cases, there are actions we have the ability to implement. But just because we “can” doesn’t necessarily mean that we “should.” Will this change have a legal impact on your organization? Are there others outside of your group who will be impacted by the change? If they have not been included in the meeting, do you at least have someone who can sign off on behalf of the other departments you may impact?

11. Projects.

We’ve finished the meeting. Now what? Who was assigned projects (or should have been)? Record the projects in the meeting notes and have the leader schedule dates to follow up on progress. Also, make sure everyone understands what success looks like for the project and what will need to happen before you can call the project completed.

12. Promotion.

You’ve made such great accomplishments and decisions that will help the organization, but none of this does any good if you don’t let people know. And don’t kid yourself. In these days of information overload and exorbitant competition for attention, telling people once is simply not enough. Plan on five to seven messages to make sure everyone knows about the changes. Not every message has to be the same either. The change may be the main focus of one announcement and the P.S. to another announcement days later.

Ultimately, lean methods along with the tactics shared here can help make meetings work better, saving you time, improving engagement and productivity and helping improve the quality of your work life.



Sabrina Griffin, RN, BSN, CEN, is the Divisional Director of Clinical Services in EmCare’s Alliance Group.

Sources and references: 

  • Studer Group article “How Cascading Information Creates Consistency” Posted April 21, 2013 by Quint Studer, https://www.studergroup.com/resources/news-media/healthcare-publications-resources/outcomes-driven-communication-series-with-quint-st/june-2012/how-cascading-information-creates-consistency
  • Association of American Medical Colleges, “Leadership Lesson: Tools for Effective Team Meetings - How I Learned to Stop Worrying and Love my Team” by Yvette Pigeon, Ed.D., and Omar Khan, M.D., M.H.S.
  • https://www.aamc.org/members/gfa/faculty_vitae/148582/team_meetings.html
  • Mind Tools “Running Effective Meetings - Establishing an Objective and Sticking to it” https://www.mindtools.com/CommSkll/RunningMeetings.htm

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12 Tips for Better Meetings – And Happier Attendees

Posted on Wed, Apr 20, 2016
12 Tips for Better Meetings – And Happier Attendees

By Sabrina Griffin, RN

This article is Part 1 of a two-part series.

For leaders, a lot of the work you do is accomplished in meetings. But, for many us, planning for meetings is close to last on our list of things to do. Unfortunately, a poor process for arranging, conducting and using meetings can result in a significant waste of time and effort.

So, how do we elevate the effectiveness of our meetings? As someone who relies on lean for process improvement in the hospital setting, I immediately looked to the principles and tools of lean to help improve my process for meetings. Applying lean methodologies such as value-stream mapping and 5S has helped me identify what brings value to meetings and how to standardize meetings so that they run most efficiently. Here are a few tips to help you meet smarter, not longer.

To make the process of conducting lean meetings easier to remember, I have developed the 12 Ps or 12 Principles for Ensuring Efficient Meetings:

Lean Meetings Checklist 

1. Purpose.

Even parties have a purpose. Why do you need to gather multiple people together for concurrent thought, interaction and communication? How is this going to be more effective than a survey, email, bulletin or another method of communication? What do you need to achieve that can’t be achieved without meeting? How would you achieve this if you were not able to have a meeting?

You can eliminate the waste of unproductive, non-priority meetings with this one easy word: No. Ok, so it’s not always easy to say. The ability to say “no” at the right time for the right reasons (and in the right way) is one of the most powerful drivers of efficiency. If the meeting does not meet the criteria for “purpose” in terms of the questions above, there’s your answer. Presenting the “no” as a question can make it a little easier. For example, you might say, “In the interest of everyone’s time, would it be just as effective if we posted a bulletin?”

Also, as the decision makers, leaders often are approached as to when a meeting is appropriate. What’s the best way to manage a situation when someone in your department (or anyone else for that matter) requests a meeting with your team? Ask the instigator the same questions you ask yourself when you want to conduct a meeting. Any weakness in the answers to those questions will help you position your message if you are inclined to say no.

Once you have agreed to accept this meeting, how do you make sure it lives up to its “purpose?” What will a successful meeting look like? Are you anticipating change and new results? Can the impact be measured? When can you expect to see the results? Reporting outcomes and results is an important factor in tying meetings to purpose, and as such should be included in the follow-up projects of practically every meeting.

2. People.

So you have determined that you “have to” have a meeting because the task or goal cannot be achieved unless all of these people contribute to the thought process at the same time. Now you need to determine who must be included (If someone else is making the suggestion, ask “Who are all of these people and who can we manage without?”).

This checklist can help with this decision:
 

  • Decision maker (or influencer) – If your meeting is to result in a conclusion, you will need a final authority or someone who will present the group’s findings to the final authority so that the change can be adopted. If there is no final authority, determine in advance how a decision will be made. Majority rule vote is one way.
  • Knowledge resource - Who has the most knowledge, or at least adequate knowledge, about the process or topic to provide expertise to the group? Be sure to invite an expert even if his or her role will be limited to providing information.
  • Cascade/communication resource - Depending on how your organization distributes information, this may need to be a representative from all affected shifts or departments or a member of your internal marketing communications team.
  • Others – who else will benefit and contribute to the meetingThere are people you must have, people it would help to have and people who don’t need to be there. Sorting these out through a lean mindset can improve the effectiveness of your meetings.

3. Preparation.

You have heard the saying “pay now or pay later.” By putting the time and effort in on the front end, you will save your group wasted time (and frustration) on the back end. Ensuring people have enough time to prepare and thoughtful scheduling will make the actual meeting that much more efficient.

It’s not enough just to make sure you have the invitations sent and the resources (conference room, call lines) reserved. Think through what you need each person to review in advance, prepare for or bring to the meeting to make the most effective use of the together time. This will help you set expectations for each individual and the group. Reach out to each person who has a task to explain what you are going to be requesting of them and let them know what they will see included on the agenda. Check in as appropriate before your meeting to make sure each contributor is on track. While all of this seems like a lot of extra work, the time saved for the entire group will far outweigh the investment on the front end. In addition, as your team becomes more accustomed to the meeting requirements and expectations, these steps can become a quick formality.

When people know the point of the meeting in advance and what they and each of the other members of the group will be expected to provide, you are more likely to get buy-in. And, when those involved in the meeting have a sense of purpose, there is much greater engagement.

4. Process.

Lean meetings will have standardized processes. Having an agenda should be the No. 1 standard process for your meetings.

Standardize as much of the process as possible. Identify the leader, reporters, time keeper, decision maker and other roles. Have standards to address what is to be done in the meeting and take care of tasks like including everyone’s contact information on the agenda. Finally, since you’re there, if there is a need for a follow-up meeting, set the date before the meeting adjourns.

5. Points.

Based on the purpose of the meeting, there are no doubt key points that “must” be covered to attain your goals. Those bullet points should be clearly defined in your agenda. Then, let’s take this one step further. Each member of the group will have points he or she wants to cover. The agenda should accommodate space for key questions or discussions from others in the meeting as well. Part of each person’s responsibility before attending the meeting should be to submit any relevant questions they would like to see discussed at the meeting in advance.

This will ensure the topic is well developed in advance and should minimize the new questions that erupt during the meeting.

6. Polish.

Meetings also give the members a chance to share their ideas in a way that impacts and influences others. Help your members understand how to be an active and important contributor to the meeting through their mastery of effective presentation and delivery. Any Dale Carnegie graduate will tell you that 90 seconds will provide more than enough time to make a point. Help your teams learn the art of the 90-second presentation. Why do most presentations take longer? Often because we are unprepared, and we are rambling and scrambling, hoping somehow we will say something important.
 
Check back next week for the final six tips.

Sabrina Griffin

Sabrina Griffin, RN, BSN, CEN, is the Divisional Director of Clinical Services in EmCare’s Alliance Group.

Sources and references: 
  • Studer Group article “How Cascading Information Creates Consistency” Posted April 21, 2013 by Quint Studer, https://www.studergroup.com/resources/news-media/healthcare-publications-resources/outcomes-driven-communication-series-with-quint-st/june-2012/how-cascading-information-creates-consistency
  • Association of American Medical Colleges, “Leadership Lesson: Tools for Effective Team Meetings - How I Learned to Stop Worrying and Love my Team” by Yvette Pigeon, Ed.D., and Omar Khan, M.D., M.H.S.
  • https://www.aamc.org/members/gfa/faculty_vitae/148582/team_meetings.html
  • Mind Tools “Running Effective Meetings - Establishing an Objective and Sticking to it” https://www.mindtools.com/CommSkll/RunningMeetings.htm

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