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ACCREDITATION STANDARDS FOR AYUSH MEDICAL COLLEGES

0. INTRODUCTION

In order to promote excellence in the medical education in the Ayuvedic, Unani, Siddha and Homeopathic (AYUSH) fields, the Department of AYUSH has assigned the Quality Council of India the task of developing an accreditation programme for the AYUSH colleges. Accordingly, QCI has put together a group of experts to prepare the requirements for AYUSH colleges in this document which form the bais of the accreditation programme.

1. SCOPE

This document sets out the criteria for accreditation of AYUSH colleges and describes the requirements that the AYUSH colleges are expected to meet in order to obtain accreditation. The various parameters have been categorized based on their importance to the quality of education to enable colleges to put appropriate focus while implementing the requirements. 2. DEFINITIONS Critical (C): A requirement that is essential from regulatory and good practices point of view and if not implemented calls for an immediate correction .besides corrective action to prevent its recurrence Major (M): A requirement that is essential for good management of the education system and if not implemented calls for a correction within a time frame besides corrective action. Minor (MN): A requirement that is not essential but is good to have and may have relatively less impact on the operation of the system and its results.

http://www.qcin.org/documents/Ayushcollege/Draft_AYUSH_medical_colleges.pdf

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3. ACCREDITATION GRADES AND CRITERIA

3.1 Based on the categorisation of the parameters and compliance to them by the colleges, the colleges shall be graded as A, A+ and A++. Grade A 1. Compliance to all Critical parameters by the AYUSH College 2. Compliance to NABH’s structural standards by the associated AYUSH Hospital Grade A + 1. Compliance to all Critical and Major Parameters by the AYUSH College

2. Compliance to Patient Centric standards and Structural Standards by the associated Hospital as per NABH’s Accreditation Standards for AYUSH Hospitals

Grade A++ 1. Compliance to all Critical, Major and Minor Parameters by the AYUSH College 2. Compliance to NABH Accreditation standards for AYUSH Hospital

Note: Under each grade, if the college is empanelling other hospitals (than its own) for training purpose etc. they can do so, with the empanelled hospital fulfilling the Hospital requirements at the same grade level as prescribed above or higher.

4. STANDARDS

4.1 The standards to be met with by the Colleges are described in subsequent Sections .

     

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Section - 1 Governance

S.No. Parameter Category

1 Compliance to statutory and legal requirements

GOV 1 The institution shall identify and comply with the applicable statutory and regulatory requirements

pertaining to the services provided.

a The institution shall have due approval of the regulatory body. C

b This shall apply to all the courses offered by the institution. C

c The institution shall comply with the applicable legislations and regulations C

d The institution shall regularly update any amendments in the prevailing laws of the land and ensure

implementation of these requirements. C

e There is a mechanism to regularly update licenses/ registrations required under the law M

2 Leadership

GOV 2 The institution’s governance structure (s) and functions are defined.

a The governance structure (s) and functions are documented. C

b The institution shall disclose its ownership in a transparent manner and make it publicly available M

c. There shall be bylaws (either at institute or university level) including (but not limited to) the

responsibilities and privileges of administrative officers, faculty, students and committees. M

d Terms of governing board members should be as per guidelines of the regulatory body if not available then for a period of 3 years so as to enable them to gain an understanding of the functioning of the institution.

C

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e The composition of the governing body and the profile of the members shall be publicly available C

GOV 3 The responsibilities of the management are defined.

a Those responsible for governance lay down the organization’s vision and mission statement and make it publicly available .

C

b The management shall have a documented mechanism for consultations on key issues relating to its

mission, the curriculum, graduate outcomes and governance and fee structure with those groups that

have a legitimate interest in the course.

C

c Those responsible for governance lay down the strategic and operational plans commensurate to the

organization’s mission and vision. C

d Those responsible for governance shall involve all members of the institution in understanding and

implementing the mission and goals and/or objectives. M

e Those responsible for governance monitor and measure the performance of the organization against the

stated mission and vision by laying down goals and/or objectives. M

f Those responsible for governance communicate to all members of the institution the importance of

meeting the requirements of interested parties as well as the applicable statutory and regulatory

requirements.

M

h Those responsible for governance approve the institution’s budget and allocate the resources required to

meet the organization’s mission. C

i Those responsible for governance support research activities and quality improvement plans. M

j Those responsible for governance address the institution’s social responsibility. M

3. Responsibility and authority

GOV. 4 The institution shall have a designated head who works full time (Director / Dean /Principal

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/Superintendent ).

a. The designated individual must be qualified by education and experience as per regulations to provide

leadership in medical education, research activity, and care of patients. C

b. The designated head should have easy access to people responsible for governance. C

c. The responsibilities and authorities of the designated head should be clearly defined by people

responsible for governance. C

GOV 5 The institution shall have a reasonable mix of academicians and administrators and committees (both

academic and administrative) to help the designated head in running the institution effectively.

a. The roles and responsibility of each of them shall be clearly defined. M

b. In case of committees the composition, quorum and functioning of the committee shall be laid down and

adhered to. M

c. The minutes of committee meetings shall be documented. C

d. The institution shall have all the committees as required by statutory and regulatory requirements. C

GOV. 6 Responsibilities and authorities are defined and communicated within the organization.

a. The responsibility and authority for all staff shall be communicated within the institution. M

b. Every department shall have effective leadership. M

c. Departmental leaders are involved and contribute to achieving the institution’s goals and/or objectives. M

d. Policies and procedures for each department shall be maintained. C

GOV. 7 Institution should have internal coordination mechanisms.

a. There should be interaction between the Designated Head ,Administrators,all teaching faculty and other

support staff at least twice in an academic year. C

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b. This interaction should be planned keeping in mind the teaching calendar and should preferably be held

before the commencement of a new term. M

c. Department meetings must be held every month. M

d. Appropriate communication process should be established within the institution. M

e. The institution shall have initiatives for promoting co-operation, sharing of knowledge, innovations and

empowerment of the faculty. M

4 General requirements and accreditation documents

GOV. 8 The institution shall establish and maintain a formal educational system and continually improve its

effectiveness in accordance with the requirements of this standard.

a. The institute shall establish the processes needed for the educational system and their application

throughout the institution in compliance with applicable statutory and regulatory requirements . C

b. The institute shall establish criteria and methods needed to ensure that the operation, control and

continual improvement of these processes are effective in realizing the objectives set by the institution. M

c. The institution shall ensure the availability of resources necessary to support the operation and control of

these processes. C

d. The institution shall monitor, measure and analyze these processes. C

e. The institution shall implement actions necessary to achieve planned results and continual improvement

of these processes. M

f. Where an institution chooses to outsource any process that affects conformance with the requirements of

this standard, the college shall ensure control over such processes. C

GOV. 9 The institution should have an accreditation manual.

a The manual shall describe the profile of the institution. C

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b The manual shall incorporate the organization structure. C

c The manual shall portray its linkages / affiliations / recognitions. C

d The manual shall describe all the facilities in the institution. C

e The manual shall state the scope of educational services. C

f The manual shall describe the educational and support processes including their interactions. C

g It shall include or provide references to all documented procedures and other applicable criteria upon

which the educational system is based. C

i The institution’s vision, mission and goals and/or objectives shall be incorporated in the manual. C

GOV. 10 The institution shall have a documented procedure for control of documents.

a The procedure shall incorporate preparing, reviewing and approving internal documents including their

identification, revision and retention. C

b The procedure shall incorporate controlling external documents, including the relevant regulations that

should be continuously kept updated. C

c The procedure shall incorporate ensuring that relevant documents are available to all concerned within

the institution and to the interested parties. C

GOV. 11 The institution shall have a documented procedure for control of records.

a The institution shall identify and maintain records to provide evidence of conformity to this standard. C

b A documented procedure shall be established to define control of records providing for identification,

indexing, storage, retention time and disposal. C

c In addition, the institution shall also identify and maintain records based on the applicable statutory and

regulatory requirements. C

GOV. 12 The institution shall appoint an accreditation coordinator.

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a The institution shall appoint a senior staff member who, irrespective of other responsibilities, shall

monitor to ensure that the requirements of this standard are being implemented and shall report to the

Designated Head .

C

b The coordinator shall periodically report to the management on the compliance of standard and the need

for improvement. C

c The coordinator shall ensure communication within the institution on the information related to the

application and relevance of the standard in educational and support processes. C

5. Financial resources

GOV. 13 The institute shall provide financial resources which shall be capable of sustaining a sound educational

programme consistent with its stated mission and objectives for long term stability.

a The institution shall disclose the sources of finances C

b The institution should have an annual budget. C

c This budget must be adequate to sustain the education programme and to accomplish other institutional

goals. C

d In the case of self financing institutions unit cost of education should be calculated. M

e In case of self financing institutions the fee decided shall be based on the unit cost of education. The

fee structure shall be publicly available . M

GOV. 14 The budget shall have provision under separate heads for various critical activities.

a There should be a provision in the budget for carrying out quality improvement activities. M

b The budget shall have a separate provision for infrastructure development. M

c There shall be a provision for maintenance of infrastructure. M

d The budget shall incorporate provision for purchase of equipment. M

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e A portion of the budget should be used for facilitating faculty and students development. M

f The budget shall have a provision for encouraging research activities. M

g The budget shall make provision for addressing corporate social responsibility in case of private institutions.

M

Section 2: Educational and Support processes

1. Infrastructure (including learning environment)

ESP. 1 The institution shall have adequate physical infrastructure to support educational and support processes.

a All regulatory and statutory requirements pertaining to infrastructure shall be adhered to. C

b There shall be adequate infrastructure in the form of lecture halls, laboratories, demonstration

rooms/libraries etc. to carry out academic activities. C

c There shall be adequate infrastructure in the form of lounge space, common rooms etc. to carry out co-

curricular activities. M

d There shall be adequate infrastructure in the form of playground, indoor stadium, auditorium etc. to carry

out extra-curricular activities. M

e There shall be adequate infrastructure in the form of swimming pool etc. MN

f Infrastructure shall include offices for administrators, all faculty and support staff. C

g The infrastructure for academic activities shall not be shared with other institutions. C

h The institution shall ensure sufficient hostel accommodation for its students. C

i The institution shall have sufficient accommodation for its staff in its campus. M

j The institution shall provide lockers or other secure space to store personal belongings of students in the

institute. MN

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k The infrastructure should accommodate the needs of differently enabled students. C

l When appropriate the institution shall provide transport facilities to its students. MN

ESP. 2 The institution shall provide necessary infrastructure to enhance the learning process.

a The lecture halls shall have good lighting and ventilation. C

b The lecture halls shall be equipped with audio-visual equipment. M

c There shall be a clinical skills lab with adequate mannequins in order to facilitate learning by students. M

ESP. 3 The institution shall ensure that its hospital has appropriate instructional facilities.

a The hospital being used for this purpose should have a quality assurance system in place. C

b In case the institution uses other hospital facilities for training in addition to its own ,it shall have a written

and signed affiliation agreement with the hospital. C

c There should be sufficient space and adequate facilities demarcated for conducting teaching activities in

the hospital. C

d Regulatory requirements pertaining to occupancy are adhered to. C

e The institution shall ensure that health centres used by it shall have adequate facilities to impart training

to its students. C

Esp. 4 The institution shall have well maintained library to support its education and research activities.

a The functioning of the library should be guided by a library advisory committee. C

b A qualified and competent staff should supervise the library. C

c The library shall stock sufficient quantities of all the reference material suggested in the syllabus, the

current number of which should be readily available. M

d There should be physical or electronic access to leading biomedical, clinical, and other relevant C

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periodicals, the current numbers of which should be readily available.

e The library shall subscribe to various regional, national and international databases. M

f The library shall have facilities to allow students to access information electronically, use audio-visual

learning resources and to use self instructional materials. M

g The library shall function for a minimum of 12 hours every day. M

h There shall be a provision to extend the working hours at the time of examinations. M

i The library shall be closed for the least possible number of days in the year. M

j The library shall have a provision for issuing books to the faculty. M

k The library shall have a process to ensure purchase of books, periodicals and other reading/information

material. M

l The library services shall be computerized. M

ESP. 5 The institution shall have adequate ICT facilities to support its education and research activities.

a The institution shall make use of information technology to facilitate teaching and learning. M

b The school has adequate information technology resources for the staff and student population to ensure

the effective delivery of the curriculum. M

c Faculty shall be facilitated to prepare computer-aided teaching/ learning materials. M

d The institution shall have a website which is updated at least once in six months. M

e The institution plans for the purchase and upgradation of its information technology on an annual basis. M

ESP. 6 A safe and hygienic environment is provided by the institution.

a Up-to-date drawings are maintained which detail the site layout, floor plans and fire escape routes. C

b There is internal and external sign posting in the institution. M

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c Potable water and electricity are available round the clock. M

d The institution has plans and provisions for early detection, abatement and containment of fire. C

e The institution shall have a fire evacuation plan which shall be tested at least twice a year. C

f Hazardous materials are identified within the institution C

g The institution implements processes for sorting, labelling, handling, storage, transporting and disposal of

hazardous material. C

h There is a plan for managing spills of hazardous materials. C

ESP. 7 The institution plans for the upgradation and maintenance of its infrastructure.

a The institution shall ensure optimal utilization of its budget for infrastructure development and

maintenance. M

b The institution shall enlarge its infrastructure to keep pace with its growth, mission and vision. M

c There is a documented operational and maintenance (preventive and breakdown) plan. M

d There is a designated individual responsible for the maintenance of all the facilities. M

e Response times for maintenance are monitored from reporting to inspection and implementation of

corrective actions. M

2 Human resources

ESP. 8 The institute shall have adequate administrative, teaching and support staff, with appropriate

qualifications and competencies to carry out the institution’s programmes, services and activities.

a The institution shall meet the regulatory requirements related to adequacy and competency of all its

administrative, teaching and support staff. C

b The job description and job responsibility shall be well defined for each category of staff. C

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c The job responsibility shall identify the key performance indicator (s). M

d The education, registration, training and experience of every staff is documented and updated

periodically. M

e Persons appointed to a teaching faculty position must have demonstrated achievements commensurate

with their academic rank. Experience shall not be the only criteria. M

ESP. 9 The institution shall have a procedure for staff appointment, confirmation and promotion.

a The procedure shall adhere to regulatory requirements. C

b The institution’s employment practices are gender balanced and culturally inclusive. C

c The appointment letter shall have written information about the terms of appointment, responsibilities,

monetary benefits (including if relevant, the policy on practice earnings). M

d The staff should be made aware of the criteria for confirmation and promotion at the time of joining. M

ESP. 10 The institution shall conduct induction training for each staff joining the institution to ensure that they are

oriented to the institution’s environment, its vision, mission and goals.

a The training shall be conducted within 10 days of the employee joining. M

b Orientation towards the vision, mission and goals shall be included. M

c Every employee is made aware of the service rules of the institution. M

d Awareness regarding performance appraisal criteria needs to be imparted. M

e Every employee is made aware of the institution’s welfare schemes including health schemes. M

ESP. 11 The institution shall provide opportunities for professional development to enhance faculty members’

skills and leadership abilities in education and research.

a The institution shall have a policy to encourage its faculty to take part in various scientific programmes. C

b There shall be a provision for the faculty to take leave (e.g. study leave/sabbatical leave/overseas M

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deputation leave) to enhance their qualifications and/or skills.

c The institution shall have an incentive policy to encourage its faculty to join national and international

professional associations. M

d The institution shall (or strive to) host regional, national and international conference (s). M

e The faculty should undergo training programs on Pedagogy, delivery of curriculum and Participatory

learning exercises. C

ESP. 12 The institution shall have a documented performance appraisal system.

a Performance shall be evaluated based on the key performance indicator (s) mentioned in the job

responsibility. M

b It shall be carried out at least once every year. M

c The appraisal system shall be used as a tool for further development. M

d The key parameters used for performance appraisal of teaching faculty shall be teaching and research. M

e The performance appraisal shall take into account the contribution of the faculty in helping the institution

to meet its vision, mission and goals. M

f Based on the performance appraisal, the staff shall receive feedback on their academic performance and

their progress toward promotion. M

ESP. 13 The institution shall have a documented disciplinary procedure.

a This shall be in consonance with the prevailing laws. C

b This shall be based on the principles of natural justice. C

c There is a provision for appeal in all cases. C

d The disciplinary procedure shall be incorporated in the service rules. C

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ESP. 14 The institution shall have an internal grievance handling mechanism .

a The internal grievance and complaint handling procedure shall be documented and made available to

all the employees . C

b The institution shall ensure that staff are not victimized for complaining. C

c . The institution shall have a committee to address complaints of sexual harassment C

ESP. 15 The institution shall have welfare schemes for its staff.

a The institution shall adhere to all statutory requirements (e.g. ESI, provident fund). M

b Procedures pertaining to pension and gratuity shall be defined and documented in the service rules. M

c The institution shall have a procedure to take care of the health needs of its employees and they shall be

taken care of in accordance with the procedure. C

d Any other welfare scheme shall be documented and the staff shall be made aware of the same during

induction training. M

ESP. 16 There is documented personal information for each staff member.

a Personal files are maintained in respect of all employees. C

b The personal files contain personal information regarding the employee’s qualification, experience and

disciplinary background. C

c All records of in-service training and education are contained in the personal files. C

d Personal files contain results of all performance appraisals. C

3. Admission policy

ESP. 17 The institution shall establish documented policy and procedures for admissions including policy on

concessions.

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a The admission policy and procedure shall comply with the applicable statutory and regulatory

requirements. C

b The institution’s admission practices are gender balanced and culturally inclusive. C

c The institution shall ensure wide publicity to the admission process (applicable only if the institution or the

university to which it is affiliated conducts its own admission process). C

d The institution shall prepare the application form/ information brochure/ prospectus, describing the

information on its policies and programmes. It shall provide for easy and un-ambiguous understanding of

qualifying criteria, admission process, available facilities and financial obligation (including concession)

on part of students/parents. It shall also mention the various categories of seats available (applicable

only if the institution or the university to which it is affiliated conducts its own admission process).

C

e The institution shall ensure transparency in the entire admission process. C

f The institution shall keep a track of the cut-off percentages for various categories of students and

analyse the same. M

g The admission process shall be completed within the stipulated time. C

h The institution shall provide for safe custody of the documents submitted by the students including birth

certificates, certificates of previous school levels etc. C

ESP. 18 The students joining are oriented through an orientation programme, to the institution’s environment, its

vision, mission and goals.

a The programme shall be conducted within 15 days of the students joining. C

b Orientation towards the vision, mission and goals shall be included. C

c Every student is made aware rules and regulations concerning conduct/discipline, attendance norms. M

d Awareness regarding evaluation needs to be imparted. M

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e Every student is made aware of the institution’s welfare schemes including health schemes. M

4. Curriculum

ESP. 19 The institution shall adopt/develop course curriculum based on requirements specified by regulatory

bodies and keeping in mind the requirements of the community.

a The institution’s curriculum shall adhere to requirements of regulatory bodies. C

b The institution must define the objectives of its educational program. M

c These objectives must in turn be broken down into more specific outcomes or objectives for each year of

the course. C

d The core curriculum must set out the essential knowledge, skills, attitudes and behavior students must

have by the time they graduate. C

e The curriculum shall incorporate the needs of the community. C

f The programme must include instructional opportunities for active learning and independent study to

foster the skills necessary for lifelong learning. M

ESP. 20 The curriculum shall be designed to provide professional education which shall prepare the student for

entry into practice.

a The curriculum shall incorporate the fundamental principles of medicine and its underlying scientific

concepts. C

b The curriculum shall allow students to acquire skills of critical judgment based on evidence and

experience; and develop students’ ability to use principles and skills wisely in solving problems of health

and disease.

C

c It shall include current concepts in the basic and clinical sciences, including therapy and technology,

changes in the understanding of disease and demands on care. C

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d Global trends in medical education shall be reflected in the curriculum. M

e Clinical training shall include understanding of promotive, curative, rehabilitative and end-of-life care. C

f Clinical experience in primary care must be included as part of the curriculum. C

Esp. 21 The curriculum shall strive to develop the all round personality of the student by providing value added

education and ensure that they develop into humane, ethical and research oriented doctors.

a The curriculum shall introduce students to the basic principles of research. It shall emphasize the

importance of research in advancing knowledge of health and illness and encourages, prepares and

supports student engagement in medical research.

C

b Communication skills including communication with patients and their relatives, colleagues, and other

health professionals shall be incorporated in the curriculum. C

c Curriculum shall prepare the graduates to know about and understand the main ethical and legal issues

they will come across. C

d The curriculum shall inculcate spiritual values to its students and make them understand the religious

and cultural differences. M

e Basic tenets of quality in health care shall be included in the curriculum. M

ESP. 22 The curriculum shall be revised at regular pre-defined intervals (applicable for module added/designed

by the institution).

a The curriculum shall be revised by a committee. C

b Feedback from faculty, students, parents, community, alumni and academic peers shall be taken for

revision of curriculum. M

c For curriculum which cannot be modified by the institution/ university this feedback shall be

communicated to the regulatory authorities. C

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d The revision shall take into account the changing epidemiological patterns of diseases and give added importance to diseases affecting national development.

M

5 Teaching and learning

ESP. 23 The institution shall provide appropriate support and resources to implement and deliver the course

curriculum.

a The institution shall ensure that it has the necessary infrastructure within its premises for effective

delivery of the curriculum. C

b This shall adhere to regulatory requirements. C

c There should be sufficient teaching aids including audio-visual equipment to take care of teaching

requirements. M

d The institution shall guarantee the effective use of ICT for the delivery of curriculum. M

ESP. 24 The delivery of curriculum shall be planned, implemented and monitored by the institution.

a The institution shall plan and organize the teaching-learning schedule by preparing an academic

calendar. C

b The academic calendar shall be prepared at least once every year. C

c The academic calendar shall mention the minimum number of days for instruction and mention the list of

holidays. M

d It shall also mention days set aside for examinations, co-curricular and extra-curricular activities. C

e Based on the academic calendar a time table, term wise, weekly and yearly, shall be made and

implemented. C

f The academic calendar shall be strictly implemented. In case of deviations the cause of deviation shall

be analysed and appropriate action taken. C

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g The implementation of the delivery of curriculum shall be monitored by a committee (e.g. course

monitoring committee/ college coordination committee/curriculum committee). C

h This committee must monitor the content provided in each discipline so that the institution’s educational

objectives will be achieved. M

i In cases of non delivery of the curriculum, there shall be a mechanism to bring this to the attention of the

management. M

ESP. 25 The teaching staff shall implement the course curriculum through a range of approaches and teaching

strategies that recognize diverse learning style relevant to the learning needs.

a The teaching and learning methods are appropriate for the content and outcomes of the course. C

b The institution shall lay emphasis on development of required skills, adequate knowledge and

appropriate attitude to practice medicine. M

c The institution shall encourage student-centred learning rather than teacher-centred learning. M

d Students must have different teaching and learning opportunities that combine an appropriate balance of

teaching in large groups with small groups, practical classes and opportunities for self-directed learning. M

e Every department shall deliver the curriculum by preparing a lesson plan (which is documented) which

shall be approved by the committee monitoring the implementation of the curriculum. C

f The institution shall explore and, where appropriate, provide opportunities for students to work with the

community (not just visit them) and learn from the experience. M

g Clinical education must reflect the changing patterns of healthcare and provide experience in a variety of

environments including hospitals, general practices and community medical services. M

h The institution shall have department libraries for the enhancement of teaching and learning. M

i Exchange education programs by emeritus faculty should be organised at inter and intra university levels.

M

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ESP. 26 The institution shall ensure that the curriculum is taught by competent faculty.

a The institution shall make sure that every person involved in educating medical students has the

necessary knowledge, skills and attitudes. C

b The institution shall have a medical education unit to enhance the teaching learning process. C

c The institution shall ensure that the faculty has undergone a training programme on teaching before they

are allowed to teach students. Till such time the faculty can teach only under the supervision of a senior

faculty.

C

d Staff-development programmes which promote teaching and assessment skills and which make the staff

aware of advances in medical teaching must be conducted by the medical education unit at regular

intervals.

M

e Every faculty shall attend one such programme at least once in a year . M

ESP. 27 The quality of teaching shall be monitored.

a The institution shall have a system of evaluation of the teachers by students by taking feedback from

them. C

b The feedback shall be taken at least once every year. M

c The student shall evaluate and provide feedback on every faculty who has taken a course for them

during this time interval. C

d The feedbacks shall be analysed and the results of the analysis provided to the concerned faculty. C

e Wherever necessary remedial action shall be taken by providing the faculty advice/ training to improve

teaching. C

f The results of this remedial action shall be specifically looked for in the subsequent analysis. M

6. Evaluation

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ESP. 28 The institution/affiliating university shall have a documented examination procedure.

a This shall adhere to regulatory requirements. C

b The procedure shall mention the timeframe of all examinations including the declaration of results. C

c The criteria for progression and gradation shall be stated in an unambiguous manner. C

d The procedure shall include the criteria explaining as to who are eligible to take the university exam. C

e There shall be weightage for internal assessments. C

f The student shall be provided a copy of the examination rules at the time of joining and also in case of

any modifications. M

g The confidentiality of examination process shall be maintained. C

h The results of examination are communicated to the students and their parents. C

ESP. 29 The evaluation must be an ongoing continuous assessment that assures students have acquired and

can demonstrate on direct observation the core clinical skills, behaviours, and attitudes that have been

specified in the institution’s educational objectives.

a This shall be done either when the curriculum is being delivered (e.g. seminars, case discussions,

practical record review) and/or by internal examinations. However, it is preferable that a variety of

methods for assessment are used.

M

b The institution shall ensure that the performance and progress of students is evaluated in relation to the

curriculum and the outcomes of the PROFESSIONAL course. M

c The institution shall ensure that there is uniformity in conducting these assessments across various

departments. C

d There must be evaluation of problem solving, clinical reasoning, and communication skills. M

e The institution shall strive to have objective structured clinical examination. M

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f Examiners are trained to carry out their role and to apply the institution’s assessment criteria

consistently. M

g The examiners shall have clear guidelines for marking assessments, which indicate how performance

against targeted curricular outcomes should be rewarded. C

h Records of stage wise course delivery and student evaluation shall be maintained. C

ESP. 30 The institution/affiliating university shall have a transparent examination process.

a There shall be a designated individual in charge of the examination process. C

b There shall be a mechanism for redressal of grievance regarding evaluation. M

c The institution/ affiliating university shall strive to make reforms in the examination process if necessary . M

e The institution shall keep a track of and analyse the performance of its students in examination. M

7. Research and Scientific activities

ESP. 31 The institution shall have an active research programme.

a The institution shall support and encourage research by both faculty and students. M

b It shall have a research committee to facilitate and monitor research activity. M

c There shall be effective utilization of the budget for research activity M

d There shall be incentives for carrying out research. M

e The institution shall provide for research facilities within its premises. M

f The institution shall strive to engage in collaborative research. M

g All the faculty and interested students shall be trained in research methodologies. M

ESP. 32 The institution shall monitor its research activities and their outcomes.

a The institution shall keep a track of all research that is carried out including the number and progress. C

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b The institution shall ensure that no research is carried out without the approval of ethics committee (the

research and ethics committee shall be separate in order to prevent conflict of interest). C

c The institution shall keep a track of the outcomes (patent, publications-national and international,

conference presentations etc.) of its research activities. C

d The institution shall maintain a record of the various clinical trial activities going on in the institution including the grant received for the same.

C

8. Student support and progression

ESP. 33 The institution shall provide appropriate student support, including counselling and academic advisory

services, to cater for the needs of students including social, cultural and personal needs.

a The institution shall have a student counseling programme which promotes the well being of students. C

b The institution shall have provision for stress management exercises, yoga and counselling by

psychiatrist/psychologist if need arises. M

c The institution shall provide appropriate support for students with special support needs (e.g. disabled,

students having language problems etc.) M

d This shall be available for the entire duration of the course. M

e There shall be appropriate scholarship programs to aid education of economically or physically

challenged students. M

f The institution shall have an academic advisory service which the students should be able to approach if

they need any academic guidance. M

g The institution shall have procedures to detect and support students who are not performing well

academically. M

h The institution shall ensure that the teacher student ratio (for counselling) does not cross 1:10. M

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ESP. 34 The institution shall ensure that there is an appropriate procedure to deal with student grievances.

a The institution shall develop anti-ragging procedures and ensure the total implementation of the same. C

b The institution shall have a sexual harassment prevention committee headed by a senior lady faculty

member. C

c There shall be a grievance handling procedure which ensures that the grievances are sorted in a fair and

objective manner and ensuring that no victimization occurs. C

d The students should be made aware of these procedures at the time of orientation. M

e The institution shall have norms for appropriate disciplinary procedures for students. C

ESP. 35 The institution shall monitor the performance of its students both during and after completion of the

course.

a The institution shall conduct a comparative analysis of the institutional academic performance with

reference to other colleges of the affiliating university and the university average. In cases of single

college university the comparative analysis shall be done against another university having a similar

curriculum.

M

b The institution shall track its performance over the years and identify areas for improvement. M

c The institution shall keep a record of the performance of its students in various competitive exams. MN

d There shall be an alumni cell/registry in the university which is updated at regular intervals. M

ESP. 36 The institution shall provide facilities to the students for extra-curricular and co-curricular activities and

encourage students to take part in them.

a The institution shall have a student council or similar body. M

b It shall ensure equal gender representation in this body. M

c The institution shall have an annual college day wherein the students get an opportunity to exhibit their M

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skills.

d The institution shall bring out an annual college magazine with significant literary contribution by the

students. M

e The institution shall encourage its students to take part in various community outreach programmes. MN

ESP. 37 The institution shall provide a safe and healthy environment to the students and ensure that their health

needs are met.

a The institution shall ensure that there is adequate security within its premises to prevent thefts and anti-

social activities. C

b The institution shall ensure that it is a “no smoking” premise. C

c The institution shall educate its students the ill-effects of substance abuse and in spite of this if such

instances happen provide for counseling. C

d The institution shall take care of the health needs of its students. C

e Where appropriate the institution shall provide immunization to its students. M

9. Equipment purchase and maintenance

ESP. 38 The institution shall have a documented procedure for planning and purchase equipments.

a The equipments shall be purchased keeping in mind the vision, mission and objectives/goals of the

institution. M

b Where applicable regulatory requirements shall be adhered to. M

c The institution shall maintain a list of authorized vendors. M

d It shall do a structured evaluation (based on the vendor’s ability to supply equipments as per institution’s

requirements) of all its vendors (total business more than 50,000 per year) at least once every year. M

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e There shall be criteria for selection and evaluation of vendors. MN

f Equipment shall be selected by a collaborative process. MN

ESP. 39 The institution shall have a programme for equipment management.

a All equipments are inventoried and proper logs are maintained. M

b Qualified and trained personnel operate and maintain the equipment. M

c Equipment are periodically inspected and calibrated as per manufacturer’s recommendations. M

d There is a documented operational and maintenance (breakdown and preventive) plan. M

10. Higher Education and Job opportunities

ESP. 40 The institution shall provide counselling and guidance to the students in regards in higher education and

career path. M

a A cell to be created in the institute having counsellors who provide detail information regarding our

country specific requirements in terms of specialities which commensurate to the disease profile and

incidence and prevalence rates.

M

b Career development guidance to be provided to the final year students. M

Section 3: Performance, Measurement and Improvement

1. General

PMI. 1 The institution shall periodically monitor and measure the effectiveness of the educational and support

processes as required in the respective clauses of the standard.

a The institution shall identify suitable indicators to monitor and measure its performance. C

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b It shall have institution level indicators and department level indicators. C

c All indicators shall be measurable. M

d The data shall be collected on a monthly basis and analysed at least once in six months. M

e The institution shall monitor student satisfaction. M

f The institution shall monitor employee satisfaction. M

2. Self assessment

PMI.2 The institution shall perform self assessments at regular planned intervals to assess the compliance to

this standard. C

a The self assessment shall cover all the departments. C

b Academic audits shall be done as a part of self assessment. M

c The assessment criteria, scope and frequency shall be documented. M

d Assessments shall be conducted by trained (either trained internally or externally) assessors who shall

ensure that it is done in an objective manner. M

e Assessment shall be done by assessors independent of that area of activity. M

f Results of self assessment shall be recorded and maintained. M

g The institution shall take necessary action (correction/corrective action/preventive action) based on the

findings of the self assessment. M

h This process shall be used as a management tool for an independent assessment of educational and

support processes and performance of indicators thereof. C

3. Complaint handling

PMI. 3 The institution shall have a documented complaint handling procedure.

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a The documented procedure shall provide information regarding complaint handling process to all

interested parties. C

b The document shall be publicly available C

c The procedure shall address the issue of handling verbal complaints. C

d The procedure shall deal with the issue of anonymous complaints. M

e The institution shall acknowledge every written complaint. C

f There shall be a procedure for redressal of complaint. C

g The institution shall communicate with the complainant for satisfactory closure of the complaint. C

h An analysis of complaints shall be done to identify frequent complaints and accordingly the institution

shall take action to prevent recurrence. C

i Records of all complaints and actions taken for the above shall be maintained by the institution. C

j A designated public grievance officer shall be appointed C

4. Continual Improvement

PMI. 4 The institution shall continually improve the effectiveness of its education processes.

a The institution shall regularly assess the effectiveness of teaching and learning. C

b The institution shall identify and initiate continual improvement projects through involvement of students,

teachers and other stakeholders. C

c The projects shall be identified based on feedback, data collection or as a part of meeting its vision,

mission and objectives/goals. M

d The effectiveness of the improvements carried out shall be analysed. M

e The institution's management shall ensure effective management, collection, validation and analysis of M

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data to monitor the institution's performance.

f Where possible, the college shall collect/share data from/with other colleges and benchmark with its own

data to improve upon in deficient areas. M

5. Performance review

PMI. 5 The institution shall carry out periodic reviews in order to assess the effectiveness in the fulfilment of

requirements of the standard.

a This shall be done by a management committee. C

b The periodicity of review shall be documented but it has to be at least once in six months. C

c Compliance to statutory and regulatory requirements shall be reviewed by the committee. C

d The committee shall review mission and objectives/goals and indicators. M

e The committee shall review the results of self assessment including corrective and preventive actions. M

f The committee shall review the analysis of feedback and complaints from students. M

g The academic results shall be reviewed by the committee. M

h The results of analysis of suitability and effectiveness of curriculum shall be presented. C

i The committee shall assess the adequacy and utilization of resources. C

j The committee shall review the compliance status of this standard. C