Authority, structure, and organization
- 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.
Annual evaluation
- Describe what elements of the plan are annually evaluated for improvement.
- Identify how to monitor the effect of changes implemented from the decision-making process.
External entities
- Describe the effect of external entities--governmental agencies, accrediting bodies, and professional interest groups--on the quality and performance measure of an organization's decision-making processes.
Challenges
- Identify barriers that can interfere with the implementation or revision of quality measures.
- Determine strategies to ensure successful implementation of new quality measures.