NABH Journey: A Chronicle of Excellence

The Beginning of a Quality Revolution: Our quality journey officially began on May 14, 2014, marking the start of an era committed to excellence in healthcare standards. This was a pivotal moment, setting the foundation for a series of initiatives aimed at elevating the standards of care and operational efficiency within our institution.

Pioneering Training Programs: On May 1, 2015, we held our first major training program at BCMCH: the Quality Training Program for Laboratory ISO 15189:2012. This event was a significant milestone, bringing together eminent laboratory professionals from across the state to enhance their knowledge and skills in quality management.

Key Leadership and Appointments: Our journey was initiated under the visionary guidance of Mr. Sunny Kuruvila. The first key appointment was Ms. Asha Mathew as the Quality Executive, who played a crucial role in shaping our quality framework. She was soon joined by Mr. Riju Mathew, initially appointed as the Lab Manager, who later took on the vital role of Quality Manager.

NABH Application Process: The formal NABH application process was a rigorous and meticulously planned endeavor. On Wednesday, August 12, 2015, the application was successfully completed by a dedicated team led by Dr. Elizabeth Varkey Cherian, the Quality Accreditation Coordinator. The team included Mr. Sojan Soman, Ms. Preeja Kumari, Ms. Devipriya, Ms. Asha Mathew, and Ms. Geeja Jacob. Their efforts were guided by Dr. George Chandy Mattethra and supported by Rev. Fr. Sijo Pandapallil, Rev. Fr. Dr. Daniel Johnson, Ms. Mini Sarah Thomas, and Mr. Ajith Kuruvila.

First NABH Accreditation: Our commitment to quality was validated on March 12, 2017, when we received our first NABH Accreditation, proudly bearing the accreditation number H2017 - 0459. This was a monumental achievement, reflecting our adherence to the highest standards of healthcare.

Sustaining Excellence: We continued our journey of excellence by achieving reaccreditation on March 12, 2020, under the NABH 4th Edition standards. This reaccreditation reaffirmed our ongoing commitment to maintaining and enhancing our quality standards.

NABH 5th Edition Accreditation: Our most recent milestone was the accreditation under the NABH 5th Edition standards on January 18, 2024. This accreditation, valid for three years, encompasses almost all clinical, diagnostic, and support services within our institution. It stands as a testament to our relentless pursuit of excellence in healthcare quality.

A Journey of Continuous Improvement: From our humble beginnings to the present day, our NABH journey reflects our unwavering dedication to quality and excellence. Each milestone represents not just an achievement, but a commitment to continuous improvement, ensuring that we provide the best possible care to our patients. Our journey is far from over, and we remain steadfast in our pursuit of excellence in every aspect of our operations.

NABL Accreditation: Elevating Laboratory Excellence

Initiating the NABL Journey: Following our success with NABH accreditation, the pursuit of NABL accreditation was initiated to further enhance our laboratory standards. This critical process was spearheaded by then Lab Director Dr. Vipin Sam Alexander, alongside Quality Manager Mr. Riju Mathew and Technical Supervisor Mr. Hari V.S. Their efforts were strongly supported by the Heads of Departments: Dr. Subaida (Biochemistry), Dr. Ajithakumari (Pathology), and Dr. Renu Mathew (Microbiology).

First NABL Accreditation: Our commitment to excellence in laboratory services was recognized on January 9, 2020, when we achieved our first NABL accreditation. The certificate, numbered MC-3293, was awarded for proficiency across 247 parameters, marking a significant milestone in our journey toward superior laboratory quality under ISO 15189:2012 standards.

Re-accreditation and Expanding Scope: On January 9, 2022, we successfully secured re-accreditation, this time expanding our scope to 259 parameters under the same ISO 15189:2012 standards. This re-accreditation was a testament to our continuous improvement and dedication to maintaining the highest standards of laboratory excellence.

Current NABL Certification: Our latest achievement in this ongoing journey is the current valid certification, awarded on January 9, 2024. This certification, valid for two years, now covers an impressive 361 parameters under the updated ISO 15189:2022 standards. This expansion reflects our unwavering commitment to enhancing the quality and reliability of our laboratory services, ensuring that we continue to meet and exceed the expectations of those we serve.

Quality Assurance Activities: As part of our commitment to maintaining high standards under NABL, our laboratory has implemented comprehensive quality assurance activities:

• Internal Quality Control (IQC): Our laboratory employs a robust Internal Quality Control (IQC) system across various departments, including Biochemistry, Immunology, Serology, Hematology, and Clinical Pathology. We rely on key providers such as Biorad, USA, Radiometer, Beckman Coulter, Snibe, Mindray, and Vitros, who supply a wide range of controls, including Lyphochek Assayed Chemistry, Diabetes, Immunoassay, Special Proteins, and Coagulation controls. These controls are continuously monitored using the Unity Real system, with levels ranging from 1 to 3. Additional contributions from providers like Fus DIRUI, J. Mithra, InBios, FAR Diagnostics, Siemens, and internal sources further ensure the precision and reliability of our test results.

• External Quality Assurance Scheme (EQAS): To benchmark our performance against external standards, our laboratory actively participates in various EQAS programs. Notable providers include Biorad, USA, which offers monthly programs for Clinical Chemistry, Immunoassay, Urine Chemistry, and Blood Gas, and CMC, Vellore, which provides EQAS for Chemistry, HbA1c, Hemostasis, Blood Banking, and viral panels. Additionally, AIIMS, Delhi, and RML, Lucknow, offer EQAS programs in Hematology, Histopathology, Microbiology, Molecular Lab, and Immunohistochemistry (IHC). The frequency of participation varies, with some programs occurring monthly, others quarterly or biannually. The laboratory also engages in Inter-Laboratory Comparisons (ILC) and Proficiency Testing (PT) through providers such as SGMMH, MAJ Hospital, Lal Path, DDRC, and BCMCH. These activities reinforce the quality and accuracy of our testing processes.

A Legacy of Laboratory Excellence: The NABL journey is a reflection of our institution's dedication to advancing healthcare through superior laboratory practices. Each accreditation and re-accreditation represents a step forward in our mission to provide the highest quality diagnostic services. As we continue to uphold these standards, we remain focused on our goal of excellence in every aspect of our operations.

CSSD ACE Certification: Acknowledging Sterilization Excellence

Achieving ACE Certification in CSSD: On April 7, 2022, following a thorough assessment conducted on March 12, 2022, our Central Sterile Supply Department (CSSD) was honored with the ACE Certification. This prestigious certification was awarded under the Large Healthcare Organization Category, recognizing our excellence in sterilization practices and the meticulous standards maintained within our CSSD.

The ACE Certification reflects our unwavering commitment to patient safety and infection control, ensuring that our sterilization processes meet the highest industry standards. This achievement highlights our dedication to providing a safe and sterile environment for all our healthcare services, reinforcing our position as a leader in healthcare excellence.

NABH ED Excellence Certification: A New Milestone in Emergency Care

Achieving Excellence in Emergency Care: On December 16, 2023, our institution reached another significant milestone by earning the NABH ED Excellence Certification. This prestigious certification, bearing the number E-2024-0060, is a testament to our commitment to providing exceptional emergency care services. The certification is valid for two years, further solidifying our dedication to maintaining the highest standards in emergency department operations.

This achievement underscores our ongoing efforts to deliver top-tier healthcare, ensuring that our emergency services meet the rigorous standards set by NABH. With this certification, we continue to build on our legacy of excellence, ensuring that every aspect of our emergency care is aligned with the best practices and benchmarks in the industry.

Mother Baby Friendly Hospital Initiative (MBFHI): Commitment to Maternal and Infant Health

MBFHI Assessment: On March 13th, 2024, our institution underwent a significant assessment as part of the Mother Baby Friendly Hospital Initiative (MBFHI). This initiative is dedicated to promoting and supporting breastfeeding, ensuring optimal care for mothers and newborns. The assessment reflects our commitment to adhering to the highest standards in maternal and infant health, emphasizing our dedication to providing a supportive and nurturing environment for both mothers and babies.

KUHS QAS: Achieving Academic Quality Accreditation

Initiating the Academic Quality Accreditation: The Quality Accreditation for academic activities under KUHS QAS was initiated by then Principal Dr. Girija Mohan, with significant contributions from Dr. Alex Varghese, then Deputy Registrar, and Dr. Abel Samuel, then Additional Vice Principal. This initiative marked the beginning of a structured approach to ensuring excellence in academic quality within our institution.

Formulation and Expansion of the Process: The process was further expanded with the appointment of Dr. Riju Mathew as the Nodal Officer, who played a pivotal role in creating various domains, each headed by dedicated professionals, with support from the Quality Department staff. The domains were established as follows:

• Domain 1: Infrastructure: Led by Dr. Jacob Jesurun and Dr. Manish Mohan

• Domain 2: Teacher: Led by Dr. Thomas Chacko, Dr. Dahlia Joseph, Dr. Srijith R, and Dr. Gowri

• Domain 3: Curriculum: Led by Dr. Abel K. Samuel and Dr. Reena Anie Jose

• Domain 4: Quality Assurance: Led by Dr. Thomas Chacko, Dr. Jiya Michael, Dr. Renji Mathew, Dr. Jeslin Treesa Thomas, and Dr. Arathi Krishna G.

• Domain 5: Research: Led by Dr. Jijo Joseph and Dr. Cleetus C. C.

• Domain 6: Outreach: Led by Dr. Sangeetha Jithin and Dr. Deepak Varughese

• Domain 7: Students: Led by Dr. Shaliet Rose Sebastian and Mr. Ajith Peter Lopez

• Domain 8: Governance: Led by Dr. Joji Joshua and Ms. Rosy Marcel

• Domain 9: Innovation: Led by Dr. Philip Mathew and Dr. Anjali Anne Jacob

• Domain 10: Feedback: Led by Dr. Alex Varghese and Dr. Abel Jaison

Key Assessments and Accreditation: The process included a Handshake assessment on October 18th, 2023, followed by the final assessment on Wednesday, November 29th, 2023. These assessments were crucial in evaluating the effectiveness of the academic quality processes implemented.

KUHS QAS A+ Accreditation: The culmination of these efforts resulted in our institution being awarded the prestigious KUHS QAS A+ Accreditation. This recognition highlights our commitment to maintaining the highest standards in academic quality, ensuring that our educational programs continue to meet and exceed the expectations of students, faculty, and stakeholders.

This achievement stands as a testament to the collaborative efforts of our dedicated team and reinforces our institution’s position as a leader in academic excellence.