The facility's compliance rate on pain assessment is shown below:Compliance Rate on Pain AssessmentJanuaryFebruaryMarchPhysicians40%50%20%Nurses80%75%83%Physical Therapists60%55%50%To...

Comprehensive and Detailed Explanation From Exact Extract:

Under the Performance and Process Improvement domain, once data analysis reveals underperformance (as shown by the low physician compliance), the next appropriate step is to develop an action plan collaboratively with department leaders.

This action plan should identify causes for variation, set measurable goals, and implement targeted interventions. Merely continuing to monitor or sharing results does not address underlying barriers. Hiring external staff is not justified without identifying the root cause of the problem.