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· Medical staff · Middle management · Department staff Communication · 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 · 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 · 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 · External entities