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Describe the authority structure of the plan’s
implementation. This must describe who is responsible
for implementing the plan. Include a description of each
role involved in the plan:
 Board of directors
 Executive leadership
 Quality improvement committee
 Medical staff
 Middle management
 Department staff
Communication
o Identify who the performance activity outcomes are
communicated to and who does the communicating. This
describes who is responsible for overseeing data collection
and preparing data reports.
Education
o Describe how staff will be educated regarding the plan. This
covers how each staff member will be initially oriented to the
plan and how each employee fits into the plan based on job
responsibilities.
Monitoring and Revising
o Annual evaluation
 Analyze what elements of the plan are annually
evaluated for improvement.
 Analyze how to monitor the effect of changes
implemented from the decision-making process.
Regulatory and Accreditation
o External entities
 Analyze the effect of external entities, such as
governmental agencies, accrediting bodies, and
professional interest groups, on the quality and
performance measure of an organization’s decision-
making processes.
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