Primary Team Nursing Model

Terms of Reference (ToR)

Date: …
1. Project Summary
Project Name Sasaran Mutu Inpatient Department
≥95% Follow Up Pasien pulang via telepon 2x24 jam
Project Sponsor Head Division of Nursing
Begin Date Juli 2017
Expected End Date Juli 2018

2. Approvals & Distribution

Distribution for
Approval Sign Off Name Role
Signature

Distribution for
Ns. Wardani Arsyad, S.Kep., M.Kep HDoN
Information

3. Communication Plan
List each stakeholder affected by the project (during or after). This can be individuals or groups of
people (internal and/or external)

STAKEHOLDER How frequently will I

What information is
Name communicate with them
necessary?
and in what form
Ns. Wardani Arsyad, S.Kep., M.Kep Laporan Follow Up Pasien 1 x dalam sebulan
Pulang
dr. Finna E. Indriany, MM Laporan Follow UP pasien
1 x dalam sebulan
pulang

4. Project Specifications
Project Background What triggered the start of the project?
Mengetahui keadaan pasien setelah perawatan dirumah dan kepuasan
pasien selama dirawat di rumah sakit
Goals & Objectives What are the goals/objectives? All projects start with a business
problem/issue to solve
Lebih dari 95% follow up pasien pulang di lakukan
Project Scope What are the organizational & functional boundaries of the project
Inpatient Department
Exclusions Specifically state what is NOT included in the Scope (if applicable)
Out Patient Department
Project Where does it stop in terms of other inter related projects. What do you
Dependencies depend on and what other projects depend on you?

Wardani Arsyad Project Terms of Reference 9/27/2018

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 Primary Team Nursing Model
Terms of Reference (ToR)

Date: …

Project Deliverables What will we have at the end of the project? The statement should be short.
(This can be listed as It should be measurable.
short/medium/long  Pada akhir juli 2018 Follow Up pasien pulang 2x24 jam dapat
term with timelines) dilakukan ≥95%
Assumptions What am I assuming within this project (if applicable). This should be about
external things that cannot be controlled but necessary for this project to
succeed
 Nomor telepon pasien tidak dapat di hubungi

5. Project Organisation Structure

Project Sponsor Julie McCaughan
Ns. Wardani Arsyad, S.Kep., M.Kep
Head Division of Nursing
Senior Customer Clinical Staffs, Subcommittee
dr. Finna E. Indriany, MM
CEO
Project Manager Lisa Sutriska Bujung, AMd.Kep
IPD Nurse ……………..

6. Outline Project Plan

High level project List the key steps to be taken to deliver this project
plan 1. Memastikan Nomor telepon pasien aktif/bisa di hubungi
2. Follow up pasien pulang di lakukan setiap hari oleh perawat
3. Kontrak waktu dengan pasien/keluarga jam untuk bisa di hubungi
4. Membuat buku Follow up pasien pulang
5. Menginfokan kepada pasien dan keluarga Nomor telepon rumah
sakit
6. Menginfokan kepada keluarga dan pasien dalam waktu 2x24 jam
rumah sakit/IPD akan melakukan Follow Up

7. Measure of Success
Acceptance Criteria Define the acceptance criteria for each of the deliverables listed in Section 4
and who/how they will be measured. This must be using the SMART criteria
(specific, measurable, achievable, realistic, time-measured)
Follow Up pasien pulang di IPD SHBG dilakukan dalam waktu 2x24 jam
sejak pasien pulang dengan target 95% follow pasien pulang dapat di
lakukan dalam periode Juli 2017 sampai dengan Juli 2018

8. Key Risks (identify all potential risks to your project)

Total
No Key Risks Likelihood Impact Mitigation / Resolution
Score
1 Nomor telepon tidak bisa di Unusual Minor 4 Menginformasikan kepada pasien
hubungi dan keluarga IPD SHBG akan
melakukan Follow Up pasien
pulang dan 2x24 jam

Wardani Arsyad Project Terms of Reference 9/27/2018

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 Primary Team Nursing Model
Terms of Reference (ToR)

Date: …
2 Aktivitas yang tinggi diruangan Moderate Posibble 9 Membuat Jadwal siapa yang akan
membuat perawat lupa jadwal melakukan Follow Up
follow Up
3
LIKELIHOOD
Remote Unusual Possible Probable Almost
IMPACT Certain
Catastrophic 5 10 15 20 25
Major 4 8 12 16 20
Moderate 3 6 9 12 15
Minor 2 4 6 8 10
Negligible 1 2 3 4 5

Produced by:
Project Manager Lisa Sutriska Bujung, AMd.Kep

Wardani Arsyad Project Terms of Reference 9/27/2018

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