Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks...
Transcript of Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks...
![Page 1: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/1.jpg)
1
Audits, Benchmarks and Performance: What You Need to Know
Beth Burnside, MD, MPH
![Page 2: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/2.jpg)
Outline • Auditing our practice: WHY? • History
• Evolution from technical to interpretive • Quality Assurance and Quality Control
• Accreditation • Audit
• New modalities included • What is on the horizon?
2
![Page 3: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/3.jpg)
Accreditation and Audit–Why?
15-45% breast cancer mortality reduction
QUALITY WAS/IS CRITICAL Lancet 2012; 380:1778-1786
![Page 4: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/4.jpg)
Timeline ACR
accreditation
ACR BI-RADS
ACR NMD
BCSC
Technical Interpretive/Outcomes
MQSA
IOM Report
ACR BCOE
IOM NCPF
![Page 5: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/5.jpg)
Quality Assurance and Control
• Accreditation (technical) • ACR
– National Mammography Accreditation Program • established in 1987 as a voluntary program. • qualified personnel perform & interpret • dedicated mammography equipment
• MQSA – 1992 Congress passed – Mandated accreditation – Nationally based, nonprofit accreditation program
![Page 6: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/6.jpg)
6
Compression
• Why? • Contrast • Decreases dose • Reduce scatter • Reduce geometric blur • Decreased motion blur
![Page 7: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/7.jpg)
ACR Accreditation
![Page 8: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/8.jpg)
Submitting Clinical Images • Examples of facility’s best work • Supervising radiologist review & approve
images • Submit “negative” images
– BI-RADS 1 or 2
![Page 9: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/9.jpg)
Ultrasound Accreditation • Personnel • Equipment • Quality Control tests • Peer Review • Reporting • Clinical images (Exam ID) • Tracking non-definitive core biopsies
– Atypical/Radial scar (ARS) – Discordant – Insufficient
• Tracking biopsy complications
![Page 10: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/10.jpg)
Stereotactic Accreditation • Personnel • Equipment • Quality Control tests • Clinical images (Exam ID) • Tracking non-definitive core biopsies
– Atypical/Radial scar (ARS) – Discordant – Insufficient
• Tracking biopsy complications
![Page 11: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/11.jpg)
MRI Accreditation • Personnel • Equipment • Safety • Quality Control tests • Clinical images
![Page 12: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/12.jpg)
Breast Imaging Center of Excellence
• All accreditation standards met: – Mammography – Stereotactic breast biopsy – Breast ultrasound – MRI
![Page 13: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/13.jpg)
MQSA
![Page 14: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/14.jpg)
MQSA • Last reauthorized in 2004 • In preparation for reauthorization in 2007 • IOM report
![Page 15: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/15.jpg)
IOM Reports
2005 2015
![Page 16: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/16.jpg)
Components of MQSA • Protocols • Accreditation • Quality Control • Audit Data
![Page 17: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/17.jpg)
The MQSA Audit
![Page 18: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/18.jpg)
Heavy Lifting of Interpretive Quality
• Audit metrics: : ACR BI-RADS • Benchmarks: BCSC - NMD • Guidelines: Experts and the Literature
![Page 19: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/19.jpg)
Audit: ACR BI-RADS
![Page 20: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/20.jpg)
Audit • Purpose: To demonstrate success in detecting
clinically occult breast cancer – False Positives – True Positives – Cancer Characteristics – True Negatives – False Negatives
![Page 21: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/21.jpg)
Audit • Purpose: To demonstrate success in detecting
clinically occult breast cancer – False Positives – True Positives – Cancer Characteristics – True Negatives – False Negatives
![Page 22: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/22.jpg)
Positives • PPV
– TP/(TP+FP) • PPV 1 = # cancer / all recalls • PPV2 = # cancer / biopsy recommendations • PPV3 = # cancer / biopsies performed
• Recall Rate – TP+FP / all screens
• Cancer Detection Rate – TP / all screens
![Page 23: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/23.jpg)
Cancer Characteristics • Specifics about positives
– Size – Stage – Nodal status
![Page 24: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/24.jpg)
Cancer Characteristics • Stage 0+1 • Minimal cancers • Negative nodes
![Page 25: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/25.jpg)
Audit • Purpose: To demonstrate success in detecting
clinically occult breast cancer – False Positives – True Positives – Cancer Characteristics – True Negatives – False Negatives
![Page 26: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/26.jpg)
Negatives • Much more difficult to evaluate • Direct tracking is costly • Estimation using reliably tracked patients • How can it be done?
– Retrospective review of cases – Registry match
![Page 27: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/27.jpg)
Sensitivity and Specificity • Sensitivity
– TP/(TP+FN) – Of all cancer, how many detected
• Specificity – TN/(TN+FP) – Of all negatives, how many correctly assessed
![Page 28: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/28.jpg)
Sensitivity and Specificity • Sensitivity
– TP/(TP+FN) – Of all cancer, how many detected
• Specificity – TN/(TN+FP) – Of all negatives, how many correctly assessed
![Page 29: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/29.jpg)
Benchmarks vs. Guidelines • Benchmarks show existing performance • Guidelines convey desired/mandated
performance
![Page 30: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/30.jpg)
Benchmarks
Rosenberg RD, et al. Performance benchmarks for screening mammography. Radiology. 2006;241(1):55-66.t
![Page 31: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/31.jpg)
Benchmarks-Screening Mammography
![Page 32: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/32.jpg)
Guidelines
Carney PA, et al. Identifying minimally acceptable interpretive performance criteria for screening mammography. Radiology. 2010;255(2):354-61.
![Page 33: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/33.jpg)
Guidelines-Screening Mammography
![Page 34: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/34.jpg)
IOM Reports
2005 2015
![Page 35: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/35.jpg)
Databases
BCSC
NMD
1996
1997 2009
Breast Cancer Surveillance Consortium
ACR National Mammmography Database
![Page 36: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/36.jpg)
BCSC sites
• 5 participating sites
• 9.5 million mammograms • 180,000 biopsies • 113,000 breast cancers
http://breastscreening.cancer.gov/about/bcsc_fact_sheet.pdf
![Page 37: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/37.jpg)
National Mammography Database (NMD) • Gives a practice the ability to track performance and
compare to national and regional benchmarks • Participants receive semi-annual feedback reports that
include important benchmark data such as cancer detection rates, positive predictive value rates and recall rates. Comparison measures are calculated by Physician, Facility, and Physician group
• Participation in the NMD is free to Breast Imaging Center of Excellence (BICOE) facilities.
http://www.acr.org/Quality-Safety/National-Radiology-Data-Registry/National-Mammography-DB
![Page 38: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/38.jpg)
NMD Participation Process
Participation in NMD is easy! 1. Complete a new facility registration 2. Send a signed copy of participation agreement to
NRDR 3. Submit data
![Page 39: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/39.jpg)
NMD Participation • 383 registered facilities • 166 actively contributed To date: • 8,987,625 million
mammograms • 1,872,724 in the last year!
![Page 40: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/40.jpg)
NMD Screening Exams Annual Accrual Cumulative Accrual
2008 84,238 84,238 2009 319,555 403,793 2010 680,873 1,084,666 2011 1,105,268 2,189,934 2012 1,280,292 3,470,226 2013 1,728,815 5,199,041 2014 1,915,860 7,114,901 2015 1,872,724 8,987,625
![Page 41: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/41.jpg)
Mammography Screening Outcomes
![Page 42: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/42.jpg)
PQRS: Physician Quality Reporting System • American Taxpayer Relief Act of 2012: Participation in a “clinical data registry”
meets the requirement for satisfactorily reporting quality measure data • The ACR NRDR has been approved as a Qualified Clinical Data Registry (QCDR)
for the CMS PQRS in the 2016 program year. • Under the Medicare Physician Fee Schedule Final Rule, eligible professionals
and group practices will be able to meet PQRS quality reporting requirements by participating in a QCDR.
• There are 6 measures from NMD for physicians to be used in PQRS reporting • http://www.acr.org/~/media/ACR/Documents/PDF/QualitySafety/NRDR/QCDR/
ACR%20QCDR%20Measures%20Supported%202016_NonPQRS.pdf
Registry Participation is Important to Deliver Quality Care Participate in NMD!!!
![Page 43: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/43.jpg)
Benchmarks-Diagnostic Mammography
![Page 44: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/44.jpg)
Guidelines-Diagnostic Mammography
![Page 45: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/45.jpg)
US Audit • Breast US
– Unique: Standard views should be determined – Recall defined as additional images taken
• Either same day—aka online (~tech performed) • Or subsequent day (~automated full breast US)
• Screening US audit – Newly established based on:
• Limited research trials in high risk populations • May not reflect general practice
– Documented in BI-RADS V5
![Page 46: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/46.jpg)
Benchmarks-US Screening
![Page 47: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/47.jpg)
MRI Audit • Breast MRI
– Unique: screening = diagnostic examination – Audit will be based on rigorous collection of:
• clinical “indication” • Screening MRI audit
– Newly established based on: • Data from trials (high risk populations) • May not reflect general practice
– Documented in BI-RADS 5th Edition
![Page 48: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/48.jpg)
Benchmarks-MRI Screening
![Page 49: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/49.jpg)
MRI & US Diagnostic
![Page 50: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/50.jpg)
Conclusions • Quality is critically important • Accreditation is a lot of work
Is there a silver lining to accreditation?
YES!
![Page 51: Audits, Benchmarks and Performance: What You … Imaging Symposium 2016... · 1 Audits, Benchmarks and Performance: What You Need to Know Beth Burnside, MD, MPH](https://reader031.fdocuments.in/reader031/viewer/2022011803/5b6e31f07f8b9a4f3c8dc834/html5/thumbnails/51.jpg)
The Silver Lining • Defines the bar for all • Decreases variability • Combats turf battles
ENSURES BENEFITS!
Saves lives!
Thanks for you attention