Describe the authority structure of the plan’s implementation.

  • Describe the authority structure of the plan’s implementation. This must describe who is responsible for implementing the plan. Include a description of the specific role of each of the following as it relates to the identified QI opportunity:
    • Governance; (i.e., Board of Directors/Trustees)
    • Executive Leadership (CEO, Chief Nursing Officer, CFO, etc)
    • Quality Improvement Committee
    • Medical Staff
    • Middle Management
    • Department staff
  • Identify who is responsible for overseeing data collection and preparing data reports.
  • Identify who the performance activity outcomes are communicated to and who does the communicating. Describe the specific changes to be implemented.
  • 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.
  • Describe how the specific elements of the plan will be regularly evaluated.

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