·
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
·
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