KUHS QAS A+ Accredited Since 17.01.2024
Health Checkup details (to bring to the assessors on the day of assessment)
10.5 Media coverage, (• Documents on press releases/press meet • availability of media clippings coverage register)
1.2.4.2 Monthly Water testing report (1.2.4.2)
Water Purification verification, maintenance checklist
1.2.7 Canteen facility | 3. Biogas facility for food waste
1.1.9.3 Hospital Safety Management | Fare safety Equipments, installation, Third party fire audit and its implementation
1.1.9.6 Fire assembly areas Marked
1.1.10.1 Biomedical Waste Management 1.Certificate of Pollution Control board *RR of certificate
1.2.1 Approved building with Local Self Government 1. Approved plan with plinth area
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Items to be ready
4.2.5 Transparent remuneration system evidence, Audiat reprot
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1.1.5 Infection control practices in Mortuary | |Protocol for maintaining hygiene |
Folder | Faculties Master list
1.1.3 Update the faculty master as appointments and resignation happens (file) | • List of appointment orders of staff / employees from HR • Verify biometric punch report with MSR requirements • Attendance register of each department.
1.1.3 Update the Allied health staff master as appointments and resignation happens (file)
1.1.5 Support facilities | Dietitians Staff list | Drivers list, licences | mortuary Staff | Cleaning staff list | Allied Health staff list | Adequate Personnel for Mortuary| Adequate personnel available for cleaning and allied staff
1.1.8 Hospital Information System/ Electronic Medical Records/HER
4. Training for new employees | • Training schedule • RR of registers and photos of training • Programme schedule • Protocol for training of new employee
5.Periodic training for employees on new development and changes • RR of registers and photos of training • Programme schedule
1.1.9.2 Hospital Safety Management | Presence of training for employees on fire and safety | RR of training for employees on fire and safety
1.1.9.4 Mock drills conducted at least once in a year • RR of Mock drills conducted • Photos
1.2.6.3 Recreation facility 3. Picnic and retreat arranged for employees and students
1.2.7 Canteen facility 1. Subsidized canteen available, 2.Canteen staff health checkup
8.3.9 Performance appraisal of faculty and employees
8.3.8 Grievance Redressal for Employees
Credentialing
Privileging
8.3.3 Employee Induction/Refresher Training
1.1.1-1.1.2 Email the Bed strength and occupancy as it is sent to NMC also to rijumathew@bcmch.edu.in, bcmchquality9@gmail.com, manishm@bcmch.edu.in
8.2.8 Infection Control Committee (ICC), Office proceedings on ICC formation, Verify the documents on: • Appointment of Chairperson and members of ICC • MoM of ICC and ATR • Incident reports • List of activities of ICC including Continuing education of ICC protocols and other important topics especially when there are special out breaks • Availability of antibiotic policy . Surveillance activities • Infection control audit(eg:hand hygiene)
1.1.9.1 Fire safety manual, Fire safety officer
1.1.9.4 Code red Mock drill and fire training, PPT, Fire training Details (last one year)
1.1.1 Bed strength | According to KUHS Norms as stated in Minimum standard requirement (MSR) (Refer MSR which is available for each discipline)
1.1.2, 1.1.7 In the inspection day OPD stat & Bed Occupancy | (For each course and discipline bed occupancy varies. So assessors should verify after ascertaining with MSR) • Hospital census for the day of inspection • Details for 6 months obtained from medical records department.
1.1.2, 1.1.7 Last 6 month OPD stat and Bed occupancy | Student patient ratio for a period of not less than 6 months
1.1.8 Hospital Information System/ Electronic Medical Records/HER
1. EMR/HER RR of EMR/HER
2. Management software RR of management software
3.HIS RR of HIS
6. Local Area Networking Observe the presence of LAN
7.Cyber security implemented • RR of cyber security • Check for password
8.Confidentiality measures taken on patient records
Verify the protocol for delivering patient record
1.1.5 adequate equipments and materials for cleaning | equipments for standard precautions
Documents and records to be Kept by the PRINCIPAL'S OFFICE
1.1.7 Last 6 month OPD stat and Bed occupancy | Student patient ratio for a period of not less than 6 months
2.1.5 Teachers participation in university examination work, with evidence, appointment order
2.2.5 Academic Calendar
2.3.2 Pass percentage per year
2.3.3 No of working Days per year
2.3.4 Dropouts details
2.3.5 Special programs for advanced learns
2.4.1 IA time table
2.4.2 Model Exam notification
2.5.6 Transcript generation and maintenance
10.4.1 Year wise Academic performance: (Year wise result register for all programs)
10.4.2 Nonconformities pointed out (Copy of inspection report, • Copy of communication to university on rectification • Latest Affiliation order)
10.4.4 Healthy and meaningful Collaboration with KUHS (Document on the collaboration with KUHS)
10.4.5 No Disciplinary action from KUHS
Folder | Library Department Manual
Documents and records to be Kept by the Library
1.3.1 Automated library | 1. Library is automated
1.3.3 Number of books, periodicals, journals as per KUHS Norms
1.3.4 e- journals
1.3.5 Internet facility and Availability of software (eg: Plagiarism)
1.3.6 Photocopier facility
1.3.7 Book/ journal borrowing system
1.3.8 Gate Register -Library
1.3.9 CDs and e- learning facility
1.3.10 10% reference books
10.3.1 Availability of newsletters (Copies of news letters, available for verification, • Published in website)
10.3.2 Document on participation in health care activity organised locally in an year (Documents available on all Health care events participated by the institution in the last year)
10.4.3 Collaboration with professional societies (MoU document • Evidence on meetings related to MoU)
8.2.7 Pharmacy and Therapeutic Committee (PTC) Office proceedings on PTC formation Verify the documents on: • Committee members • Meeting minutes and ATR • Various report of the committee at the institute and the hospital N.B: This may not be applicable to nursing colleges and certain allied health science institutes
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Documents and records to be kept by the REGISTRAR'S OFFICE
1.1.4 Clinical Facility: It is all the documents of the facility and equipment that are submitted to NMC during the inspection, if it is a physical copy of soft copy it should be available for inspection.
1.1.3 & 8.5.7 Attendance register of each department
1.1.8.4 New Employees EMR training Register with photos
1.1.8.5 Periodic training register for the changes
1.1.10 Register for daily collection of BMW
1.3.3 Library Books, journals etc Register
1.3.5 Library internet and software usage register
1.3.7 Library book borrowing register
1.3.8 & 4.5.6 Library Gate Register with monthly cumulative entry
1.5.8 Food Quality Check register
1.5.10.4 Hostel leave register of inmates
1.5.10.5 Hostel Out Pass and Home pass Register
1.5.10.6 Hostel Routine Roll call register
2.1.1 Faculty attendance register
2.1.1 Faculty Acquittance register
2.2.5.3 Attendance register for Internal Assessment
2.2.6.2 Students Attendance register for library hours
2.2.6 Learning assessment register (slow learners)
2.2.7 Attendance register of journal club
2.3.4 & 8.5.6 Students permanent register
2.3.5 Learning assessment register (Advanced Learners)
2.3.6 Peer/participatory learning Attendance register
2.3.7 Self-learning Library gate register
2.3.7 Self-learning Attendance register
2.4.1 Sessional exam attendance register
2.4.2 Model Examination attendance register
2.4.10 Examination Register
2.5.1 Exam scrutiny cell Register
2.5.2 Schedule of examinations Attendance Register
2.5.3 Internal Assessment register
3.1.1 Teaching Register with Topics Marked
3.1.2 Learning Assessment Register
3.1.2.2 Student Incident report register
3.1.2.4 Internal Assessment Marks Register
3.1.3 Bridge Course and tutorial Marks Register for each batch
3.2.3 Faculty assignment book/ register
3.2.3 Faculty work report register
3.2.4 Register for curriculum committee
4.2.5 Remuneration register
6.1.1 Outreach Community attendance register
6.1.2 NSS Activities Register
6.2.1 Health Camps Report Register
6.2.2 Health awareness programs Report Register
6.2.4 Health Days Observation Report Register
6.2.6 Palliative care Report Register
7.1.1 SSGP Register
7.1.2 Mentor mentee meeting Register
7.1.5 Students Counselling Register
7.3.4 Grievance register (with Reply and Dispatch Register)
7.4.2 Seminar on Career Guidance Register
8.1.6 Office Inward register
8.1.6 Office Dispatch register
8.1.6 & 8.5.7 Fee Register
8.2.2 College council register
8.4.3 Cash register /Acquittance register
8.4.8 Register for imprest money
8.5.1 work assignment register
8.5.6 Admission Register
8.5.7 Admission Withdrawal Register
8.5.6 Transcript Register
8.5.7 Register or other record of address of students
8.5.7 Register of staff with Qualification
8.5.7 Scholarship Register
8.5.7 Register of Medical Inspection
8.5.7 TC counterfoil Register
8.5.7 Duty Leave Register
8.5.8 Purchase gate Register
8.5.8 Purchase Register
8.5.8 Maintenance Register
8.5.10 Biometric daily attendance register
10.3.5 Media Clipping Coverage Register
10.4.1 Year wise result register for all programs
10.5.2 Category Wise Feedback Register
8.2.9 Safety Committee (SC) Office proceedings on SC formation, (Verify the documents on: • MoM of SC and ATR, • Safety measures like fire exit, Electrical safety, lab safety, Radiation safety, mock drill, • Verify safe handling practices of drugs, blood and blood products and other body fluids (hospital) and other materials including Biomedical waste management)
1.1.6 Bank/Blood Storage Unit liscene and NABL/NABH Accreditation
1.1.10 Biomedical Waste Management | 1.Certificate of Pollution Control board RR of certificate
1.2.5 RR of RC books, no of vehicles available, ownership of vehicle, • Verify License and eligibility of driver and cleaner • Verify the documents for maintenance of vehicle
1.1.5 Transport: mobile clinic, ambulance with life saving measures, mobile van, facilities for patient transportation, transportation of dead body, and emergency transportation. Its the statutory requirements like driver’s license, Insurance papers BOOK etc
1.1.10 Biomedical Waste Management: IMAGE Mou in the web site
3.2.1 Core competencies are listed and published through web site/ student hand book or through the course book prepared
3.2.4 Programme/ Course outcome statement s specified 1.Core competencies written and exhibited in the website
3.2.4 Programme/ Course outcome statement s specified 2.Intended outcome specified for each course and displayed in the website: Verify web site for objectives for each course and their outcome statements for each course and programme
3.5.3 Alumni : Verify the availability of feedback form on website
3.5.5 PTA : Verify the availability of feedback form on website
4.1.3 Quality Policy and Objectives
7.5.2 Alumni activities : Verify online activities and website
8.1.1 Institution has a well-defined vision, mission and core values and quality policy with quality objectives: Website
8.1.4 Organogram : Display on website
8.3.5 Admission Prospectus : Prospectus in printed and online (website)
9.5.5 Endowment talks /speeches: Documents on such events-Brochure,upload on website
10.3.1 (Copies of news letters, available for verification, • Published in website)
Faculty profile
with department as header and in the order of faculty with Name, photo, Qualification, Short biopic, and Publications (available in google sheets) & Achievements (editable)
Committees
List and members populated from a google sheets
Department Displays
3.1.2.8. Teacher made study materials/ handout/audiovisual aids/ graphic displays for slow learners,
3.2.2.1 Well-developed academic calendar available to each faculty and displayed on notice boards
8.1.2 Department wise vision, mission and core values and quality policy with quality objectives: displayed in strategic areas
8.1.3 Display of accreditation certificates outside the offices
Institution wide Displays
4.1.3 Quality policy with objectives Vision & Mission for the institution:are displayed in prominent places
8.1.1 Institution has a well-defined vision, mission and core values and quality policy with quality objectives: Noticeboard
8.1.2 Department wise vision, mission and core values and quality policy with quality objectives: displayed in strategic areas
8.1.3 Display of accreditation certificates outside the offices
8.1.3 Display of exhibits and trophies obtained
8.1.4 Organogram : Wall mounted display
8.1.5 Well documented road map(Gantt Chart) for the next five years: Gantt chart display in the main office
9.4.5 Signage on Energy conservation: Display boards (water, electricity, green, plastic free)
1.9.6 Fire Assembly areas
1.2.8 Common rooms for boys and girls
1.4.2 Logistics (sports items/ jersey) 1. Separate room for student union and sports materials
1.5.6 Hostel: Sick room and health care facility
1.5.9 Recreation facility/room
5.1.8 Research logistics: computerized room with internet facility and printer
7.4.1 Career Guidance and Placement Cell: office space
2.5.1 Exam scrutiny cell Office space,