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Quality Assurance

Quality Assurance

CRITERION 1: POLICY & PROCEDURES

 

1. Are there clearly defined vision, mission, goals, and objectives of the Institution in written?

 

Yes, Chitwan Medical College (CMC) has clearly defined vision, mission, goals and objectives (VMGO) written in its planning and statutory documents. Additionally, Memorandum of Association (MOA), the main legal document of the institution submitted in Company Registrar Office under Government of Nepal defines the objectives of CMC in terms of medical, education, paramedical and allied health education, and respective hospitals services.

 

 

2.       Are there clearly defined plans, programs and strategies to achieve its specific goals and objectives?

 

Yes, CMC has clearly defined plans, programs and strategies to achieve its specific goals and objectives written in its planning documents. The college Strategic Plan (2018-2022) has kept the provision of plans, existing and future programs, policies and strategies. Similarly, CMC Memorandum of Association describes the various activities that the institution should carry forward to achieve its objectives. There are six major activities and sixteen sub-activities mentioned in clause-4 of CMC MOA.  

 

 

3. Are there duly formed organizational structures where the policies of the Institution are formulated, reflected, reviewed and updated?

 

Yes, CMC has duly formed and defined organization structure as written in its statutory documents. CMC is established as per the Company Act 2063 of Nepal. The major documents of the company are Memorandum of Association (MOA) and Article of Association (AOA).

These two documents describe the structure of relationship of power, authorities and responsibility of Board of Directors (BOD), Management Team and Employees.  The Shareholders’ General Assembly or Annual General Meeting (AGM) is the supreme body that delegates power and authorities to Board of Directors (BOD) elected through majority voting system and appoints the Chairman/ Managing Director and the Chairman/ Managing Director is responsible for overall operation of the organization and implementation of policies formulated by AGM. The Managing Director appoints the Hospital Director and Academic Director and they are responsible for running the hospital and college respectively. Academic Director delegates authority to College Principal and Principal delegates authority to Vice Principals and so on.

The Company’s Article of Association (AOA) describes the provisions related to the selection of Board of Directors, appointment of Chairman and Managing Director, terms and tenure of Directors and rights and duties of Company Directors.

Additionally, the College has a Faculty Recruitment, Promotion and Professional Development Policy approved by college BOD and there is a CMC Organogram which is formulated as per the need of human resource management in this institution and has been regularly reviewed and updated by CMC Board of Directors.

 

 

4. Has the Institution adopted any mechanism/process for internal quality monitoring and checks?

 

Yes, the institution has an Internal Quality Assurance Committee (IQAC) that has been formulated under the chairmanship of Chairman/Managing Director. The committee has a monitoring role and acts as the academic evaluator of its key faculties to foster enhancement in the academic performance of the institution. Various Academic Departments are formed as per the requirement of course and curriculum. These academic departments are responsible for workload division, curriculum evaluation, quality monitoring and quality enhancement of the concerned subjects and departments. Also, these departments regularly conduct meetings to formulate planning of Academic Calendar and evaluate the progress to see whether the standards have been met or not.  The Heads of Departments (HODs) are appointed and their duly defined job descriptions mention the provision of internal quality checks and monitoring. HODs are responsible for curriculum implementation and evaluation of results as well as students’ performance measurement. The College Organogram depicts the provision of Department Heads in the Organization.

 

 

 

5. Is there any document of the institution to specify the job responsibilities of departments, units and individuals?

   

Yes, CMC has developed a job description (JD) booklet of 156 pages that mentions the available departments, positions and units in CMC and gives details of job responsibility of departments, unit and individuals. This booklet is the foundation of the clarity of roles and responsibilities of Chairman, MD, Principal, Department Heads, Chief Administrative Officer (CAO) and other professionals working in the organization.  Additionally, CMC Article of Association describes the roles and responsibilities of BOD, Chairman, Managing Director and CAO.

 

 

6. Is there any defined and written scheme to evaluate the pre-defined job responsibilities of departments, units and individual staff?

   

Yes, CMC has developed and implemented an Employee Administrative Regulation- (2070) comprising of 33 page document. This regulation clearly mentions the scheme of evaluation of pre-defined job responsibility of departments and individual staffs. It is included in Annex 9 (ka) of Employee Administrative Regulation- (2070). There are 16 domains of performance in case of evaluation of Doctors and 18 domains of performances in case of employees,  that are rated in five dimensions. Attendance and punctuality, clients relationship, knowledge of work, peer relationship, work volume, integrity etc among others are the main domains of evaluation.

 

 

7. Does the institution have strategic plan and action plan emphasizing on team work and participatory decision making and a scheme for information sharing?

   

Yes, the CMC Strategic Plan (2018-2022) has emphasized the team work and participatory decision-making for information sharing and organizational effectiveness. In Strategic Plan section 1.8 (d), the organization development strategies which focus on group work, team learning and information sharing for better organization development have been mentioned.  Moreover, CMC, in practice, has various committees working together to achieve their specific goals and responsibilities. CMC is exemplary for team work; CMC has a culture of team work and the participatory decision-making process. Every major decision is taken in meeting of Board of Directors with sufficient discussions and justifications. Hospital employees and college employees work together to achieve the overall goals of CMC. Being a company with more than forty shareholders, CMC has the practice of sharing information within the members in every Annual General Meeting. It prepares the Annual Progress Report and Audit Report which are distributed to each shareholder for information sharing.  

 

                                                                                                  

8. Does the institution have program(s) to strengthen the regular academic programs through other self-sustaining programs/courses and others?

 

Yes, CMC has a separate teaching hospital that runs a number of self-sustaining programs and departments like surgery department, general medicine, dental, laboratories, pharmacy etc. These departments/ programs are helpful for clinical teaching/ practices and also for financial support to college. As reported in Audit Report of CMC, major portion of CMC revenue has been generated from the hospital services.

 

                    

9. Are there any formal provisions under which the institution brings stakeholders or community feed backs and orientation in its activities?

 

Yes, CMC has the practice of taking feedbacks and suggestions from stakeholders and community members from time to time regarding the planning, policies and activities of the college. Chitwan Secondary School provided the land to hospital in lease as rental. Hence, CMC Board has nominated the Chairman of Chitwan Secondary School as Member of the Management Committee. CMC conducts frequent meetings with Mayor, Deputy Mayor and Ward Chairperson of Bharatpur Metropolitan City. Such meetings and interactions provide feedbacks and suggestion to college for improvements and community activities. These suggestions are addressed by the college administration. For example, CMC has started free OPD tickets to women since Chiatra 24, 2075 for treatment of gynecology related diseases,  considering the request of Renu Dahal, Mayor of Bharatpur Metropolitan City.

 

 

10.  Were any committees/external agencies appointed during the last three years to improve the organization and management?

Yes, CMC has been working together with various external agencies and consultancies for improvement of its management and education delivery. For example, recently it made an agreement with Real Solution (Human Resource Consulting) firm to improve the Human Resource Management System of the college. After detailed observations and study of college and hospital, this consulting firm has provided a Report with the details of the descriptions and recommendations. The recommendations of the report are being implemented gradually. Similarly, CMC has been accredited through ISO 9001-2015. CMC hospital is going to be accredited through Joint Commission International (JCI).

 

 

11.  Are the students involved in institution management system and quality assurance?

Yes, CMC has a provision of students’ class representatives (CR) from each class. They are engaged with college management team and faculties to discuss with course related activities and for their planning of educational excursion, field visits, community works etc. These student representatives actively involved in controlling the class discipline. Further, they are called in college management meetings for some special issues related to the students’ welfare like, solving the student-centered problem if exist. Moreover, students are also involved in classroom monitoring. Students meeting are conducted before any field and industrial visits and community clinical.

 

12.  Has there been an academic audit? Justify it.

 

Yes, CMC conducts academic audit of hospital and college regularly by ISO 9001:2015. The recent academic audit report of ISO 9001:2015 has been presented in this document. Besides, the Institute of Medicine (IOM) also conducts visit for fulfillment of criteria of admission each year.

 

 

13.  Is there any specific mechanism to combine teaching and research?           

Yes, CMC publishes its journal bi-annually for disseminating findings of research work carried out by faculties. CMC faculties engage in research and publication activities. CMC organizes national/ international conferences and seminars where college faculties involve in paper presentations. Students also get to participate in such workshops/ conferences. Besides, students have compulsory provision of graduate research projects guided by college faculties which is expected to link the teaching and research. Faculty promotion policy adheres to the rule of promotion based on count of research publication in various indexed journals; it also encourages the faculties to combine research and teaching.

 

14.  Have you observed any positive outcomes of combination of teaching and research?       

Yes, with combination of research and teaching, students’ learning capacities have been enhanced. The rate of pass percentage of graduates have increased. Faculties’ capacity of research and teaching has strengthened. It has also increased the reputation of CMC.

 

15. Provide institution specific other innovations which have contributed to its growth and development.

CMC recently has developed an innovative learning method for MBBS, BDS and other students in which video conference of various procedures and surgeries are networked in classrooms whereby students directly learn the procedures and live operation from OT. It has been transmitted through projectors to classroom. Additionally, CMC has launched Hybrid International Emergency Medicine (HIEM) program to the interested  MBBS students.  HIEM is the first collaborative international Emergency Medicine (EM) training developed in the UK, in which trainees will go through 4 years of training (1st and 4th year in Nepal and 2nd and 3rd year training in the UK). HIEM training is recognized by RCEM-UK, and trainees on successful completion of the process will be able to work as specialists.

 

CRITERION 2: CURRICULAR ASPECTS

16.  Is there any provision for ensuring   consistency of teaching and learning with the academic goals and objectives of the institution?

Yes, CMC has developed a Teaching Protocol and all the faculties and staffs are advised to follow the guidelines of the Protocol so that the consistency of teaching and learning activities be ensured with coherence of academic goals of the institution. Weekly academic team meeting is conducted to discuss the issues related to teaching learning activities. Additionally, departmental meets, academic meets of the faculties with academic directors and principal help to ensure the coherence of teaching and learning with organizational goals.

 

 

17.  Are programs flexible enough to offer students the following benefits?

Yes, Clinical posting of Nursing and MBBS students are scheduled as per the student convenience. In addition, community field postings are kept considering weather condition for example most of the field posting are scheduled in summer and winter seasons avoiding rainy season. Regards horizontal mobility, CMC follows the rules and regulations of University, Thus we don’t have horizontal mobility of programs.  The institution offers some elective courses to students in UG and PG courses. For example, the students that joined in Master of Nursing program have elective options in the courses offered in Psychiatric  Nursing, Women's Health Nursing, Pediatric Nursing, etc.

 

 

18. Indicate the efforts to promote quality of education with provision of skills transfer among the students such as

 

Yes, the students have provision of learning and skill transfer through clinical posting, internship program, computer training, and language classes for communicative skills, and they play important role in group works like class presentations, camps, field visits etc. MBBS students have to complete their one and half year in internship while they take participation in clinical practices with senior doctors. Moreover, they should do mandatory research projects and other activities in a team and independently. Students in para medical courses also need to participate in community and field works, hospital clinical and others for better skill transfer. 

 

 

19.  Are there any additional focused programs and electives offered by the institution?

     

Yes, CMC has offered a focused program called Hybrid International Emergency Medicine (HIEM) course of four years duration. The course is designed by QiMET UK.  Trainees will follow Royal College of Emergency Medicine (RCEM) curriculum and Fellowship in Quality improvement (FQim) modules as part of the training. At the end of the training process, trainees will sit for Member of Royal College of Emergency Medicine MRCEM exam, will receive two qualifications (MRCEM and FQim).The degree of MRCEM will be awarded by Royal College of Emergency Medicine. The degree of FQim will be awarded by International Academy of Medical Leadership (IAML). HIEM training is recognized by RCEM-UK, Currently, the first batch of six students have started their second year in UK and the Second Batch of students have joined in the program at CMC. Additionally, students are offered language classes like Occupational English Test, IELTS, PTE, Communication skills training etc. to promote their language skills.  

 

20.  Has the institution taken any initiative to contribute/feedback to the curriculum of the university? Give evidence with the examples of last 4-5 years

Yes, CMC has forwarded Feedbacks and Suggestions to Institute Of Medicine (IOM), Tribhuvan University (TU) as regards to curriculum development and revision, by formulating a committee for curriculum review. This committee has submitted reports to IOM, TU for revision in curriculum.  

 

21.  Is there any mechanism to obtain feedback from academic peers and employers?

Yes, During Departmental Meetings, Faculties share their experiences and ideas to improve the class room performances and give feedbacks for improvement in examination and curriculum.  

 

22.  Give details of institution-industry-neighborhood networks if any? 

Yes, CMC has MOU contract with various organizations for upgrading its industry and community networks. CMC has been constantly involved in industry neighborhood networks as it provides free hospitalization and medication for residents of Chitwan Manaw Sewa Ashram, and free consultation and services for geriatric patients from Devghat Dharmartha Hospital. CMC runs specialty service at Baghauda Hospital, Madi, in collaboration with Madi Municipality and has tied up with Nepal Red Cross Society for Blood transfusion unit at CMC. CMC is also tied up with government for health delivery under PPP Model. CMC has network with Sunrise Bank which provides banking services like ATM inside the CMC premises.  CMC has network with other health posts and health centers to extend its scope of services. For example, it has been providing frequent health checkup programs to the dwellers of Ratnanagar area in association with Bakulahar Hospital, Tandi, Chitwan. Similarly, students frequently participate with community and neighborhoods for different health related awareness program and camps. Futher, students of Bachelors in Pharmacy visit various pharmaceutical company as a part of their curriculum.  

 

 

23.  Does the institution inculcate civic responsibilities among the students? Give brief explanation in terms of activities

Yes, CMC strives to inculcate civic- responsibility among students through various activities. For example, college offered food donation to the psychiatric patients sheltered in Chitwan Manav Shewa Ashram. Students from Master of Nursing, Psychiatric Department involved in the various civic responsibility program. Students are encouraged to participate in programs like Art of Living, Meditation etc. for boosting their moral value. Various programs are designed to engage the students to support the society. As part of civic responsibility, CMC engages the students in the following activities regularly.

  1. Food Donation Program
  2. Blood Donation
  3. Traffic Controlling
  4. Awareness against drugs abuses
  5. Awareness about saving the environment -Save the Life
  6. Awareness for the Sanitation

 

 

24.  What are the efforts of the institution towards all-round personality development of the learners? Give brief explanation in terms of activities.

 

 

For overall personality development of learners, CMC arranges various programs like extracurricular activities, sports, cultural programs, debate and quiz competition, graduation program, college annual day etc. Students are encouraged to participate in all of these programs. CMC organizes games and sports competition. It also organizes workshops/seminars and panel discussions for all-rounded development of our students. Outstanding students in games and sports are given incentives like financial and fringe benefits.  

 

25.  What are the practices of the institution to impart moral and ethical value-based education? Give examples of some practices

 

Yes, CMC has practices to impart moral and value-based education among students through various activities and guest classes. For example, CMC had arranged Art of Living Session for students of CMC  and interested students participated in the session. CMC celebrates the “Guru Purnima”, “Saraswoti Puja”  that helps students in inculcating civic education.