Self Appraisal Form PM&DC

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FORMEDICAL ANDDENTALSCHOOLS
INPAKISTAN-2019
CONTENTS
1 Recognition Standards
2 Decision Rules
3 Methodology
This document describes the minimum requirements for a medical or dental college to operate
in Pakistan. The requirements highlighted in this document pertain to evaluation of a college’s
infrastructure and equipment adequacy for provision of medical education. This document
only deals with the initial inspection mandatory for recognition of a medical or dental college.
Along with the evaluation of a college on requirements highlighted in this document, the
college will also be surveyed on the standards for performance evaluation — which deals with
the quality of the process of delivery of education.
Requirements of this document are to be fulfilled by the medical and dental colleges at all
time during the operation. However, the evaluation of fulfilment of these requirements are
evaluated:
1. When a new medical or dental college apply for recognition by PMDC

2. When an existing medical or dental college apply for increase in number of students
3. By the order of the Evaluation Committee of PMDC pursuant to complaints or reports
received against any existing college
4. By a general order of the Evaluation Committee of PMDC
For new colleges, the inspection shall be carried out using requirements of this document as
well as for the performance evaluation accreditation framework.
PMDC Initial Recognition Framework 2

PMDC INITIAL RECOGNITION
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1. Recognition
Standards
Pakistan Standards for Initial Recognition of Medical and Dental Colleges
Recognition Standard 0: Pre-requisites

Recognition Standard 1: Infrastructure requirements
Recognition Standard 2: Equipment Requirements
Recognition Standard 3: Faculty and Staff requirements
Recognition Standard 4: Teaching Hospital Requirements
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Pre-Requisites
Legal Requirements
01. The college must be established in a building owned by the legal entity that is granted the
recognition or its parent entity.
02. The college must own minimum of 50% hospital beds.
03. The college must provide clinical education on 500 hospital beds per 100 students of
admission. Commented [WU1]: Must be Cllarfied
04. For the hospital beds that the college does not own, the college must have a valid and
current MoU with a third-party hospital.
0.5. For a public college, it has to be approved by the respective ministry of health. For a
private college, it must be registered as a company with Security and Exchange Commission
of Pakistan (SECP)
0.6. The college must have a working capital of minimum equivalent of number of students
over all sessions x one month fee of each student
0.7. The college must invest an equivalent amount of 1% of the total annual fee into an
endowment fund utilization of which shall be regulated by PMDC
0.8. The college must have its account audited on an annual basis and annual report made Commented [WU2]: Please Clarify that VC/ Dean/ Principle of
Medical College Operational Control of College account
available to PMDC
0.9. The hospital owned by the college must have its account audited on an annual basis and
annual report made available to PMDC
0.10. The college must have all its teaching hospitals within 25 km from the college or
within 30 minutes of travel time under normal traffic conditions
0.11. For private college, it must provide bank guarantee of PKR 30 Million
0.12. For private college, it must provide college guarantee of PKR 20 Million
0.13. For public college, its governance structure must be compliant with the government
regulations. For private college, its governance structure must be compliant with the
requirements of SECP.
0.14. The services offered by the hospital must be approved by the relevant authorities. E.g.
when radiology services must be approved by Pakistan Nuclear Regulatory Authority
(PNRA).

Recognition Standard 1: Infrastructure
College Covered Area
1.1. Total covered area of the teaching college must be at least 65,000 sq. ft.
1.2. The college must have a Learning Resource Centre with at least 12% of the covered
area of the college
1.3. The college must have an auditorium with at least 7% of the covered area of the
college
1.4. The college must have at least 4 lecture halls, all of which with at least 11% of the
covered area of the college
1.5. The college must have at least one demonstration / small group room for Anatomy,
Physiology, Biochemistry, Pharmacology, Pathology, Forensic Medicine and
Community medicine, all of which with at least 5% of the covered area of the college
1.6. The college must have two Common Rooms, one for boys and one for girls, combined
with at least 7% of the covered area of the college
1.7. The college must have a Day-Care Room with at least 3% of the covered area of the
college
1.8. The college must have a student’s cafeteria with at least 4% of the covered area of the
college
1.9. The college must have Administration Offices (comprising of Principal Office, Vice
Principal Office, Committee Room, Faculty Room, IT Department Room, Student
Section Office, Security Office, Waiting Area, Support Staff Offices, Finance Office,
Maintenance Office) with at least 4% of the covered area of the college
1.10. The college must have Anatomy Museum with at least 1% of the covered area of the
college
1.11. The college must have Dissection Hall with at least with at least 4% of the covered Commented [WU3]: 1 percent of college covered area is
sufficient for dissection hall
area of the college
1.12. The college must have Pathology Museum with at least 1% of the covered area of the
college
1.13. The college must have Forensic Medicine Museum with at least 1% of the covered
area of the college
1.14. The college must have at least 5 multi-purpose labs for Histology, Physiology,
Biochemistry, Pharmacology, Pathology I, II, III and Community Medicine with at
least 9% of the covered area of the college
1.15. The college must have Skill Development Lab with at least 1% of the covered area of
the college
1.16. The college must have Faculty Offices in each faculty (Basic Sciences Faculty Offices
inside college building) with at least 9% of the covered area of the college
1.17. The college must have adequate circulation spaces to meet emergency, safety and
disability requirements
1.18. Any associated dental college may utilize the same basic sciences laboratories and
lecture halls, provided separate adequate faculty is available

Seating Requirements
1.19. The college must have seating capacity for 20% of total student strength in Learning
Resource Centre
1.20. The college must have seating capacity of 75% of the total student strength in
auditorium
1.21. The college must have seating capacity of equivalent of student strength in each class
in each of the 4 Lecture Halls
1.22. The college must have seating capacity of 25 individuals in each of the 7
Demonstration / Small Group Rooms
1.23. The college must have seating capacity for 5% of total student strength in Common
Room for Boys
1.24. The college must have seating capacity for 5% of total student strength in Common
Room for Girls
1.25. The college must have seating capacity for 20% of total student strength in Students
Cafeteria
1.26. The college must have seating capacity for 30 individuals in Committee Room
1.27. The college must have seating capacity for 50 stools in Dissection Hall Commented [WU4]: Please Repharse
1.28. The college must have seating capacity of 50 students in each of the 5 multi-purpose
labs for Histology, Physiology, Biochemistry, Pharmacology, Pathology I, II, III and
Community Medicine Commented [WU5]: 35 students capacity of each lab is stuffient
1.29. The college must have separate workstation for each faculty member of Basic
Sciences inside college building, preferably separate offices for Associate Professors
and above.
Hostel Requirements
1.30. The college must have a boys’ hostel with at least covered area of 10,000 sq. ft. Commented [WU6]: 10 percent of mails students 20 percent ant
female students strength facility of hostels is sufficient
1.31. The boys’ hostel must have the capacity to house at least 20% of the total male student
strength
1.32. The college must have a girls’ hostel with at least covered area of 10,000 sq. ft.
1.33. The girls’ hostel must have the capacity to house at least 30% of the total female
student strength
1.34. The hostel must have television and internet access
1.35. The hostel must have indoor games facilities
Other Requirements
1.36. The college must be able to provide teaching in an environment with comfortable
room temperature (18 to 24 degrees Celsius) in lecture halls, demonstration areas,
laboratories and learning resource centres under conditions of full occupancy.
1.37. The college’s Learning Resource Centre must have functioning computers for 30% of Commented [WU7]: 20 percent seating capacity is enough
seating capacity with access on all computers of HEC and university’s digital library
1.38. The college must have Wi-Fi connectivity all across the campus, with access to every

student and faculty. Wi-Fi connectivity must allow access to HEC and university’s
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digital library.
1.39. The college must have at least one multi-sports ground as per the requirements of HEC.
1.40. The college must provide transport facility, either owned or hired, to at least 20% of the
total student strength
1.41. The college must provide transport facility, either owned or hired, to at least 30 faculty
members
1.42. The college must provide transport facility, either owned or hired, to at least 30 other
staff members
1.43. The college must provide to students a counselling cell, staffed with a clinical
psychologist
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Recognition Standard 2: Equipment
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College Laboratory Equipment Requirements
Anatomy Major Anatomy: (Dissection
hall)
Commented [WU8]: Please Delete optional , two cadavers /
prosecution / palatinate bodies should b mandatory
2.1. The college must have a facility of the cadaver.
2.2. The college must have at least two appropriate dissecting instruments for two cadavers
available, functional and in use. (Optional)
2.3. The college must have at least four operational full dissection tables available,
functional and in use.
2.4. The college must have at least twelve half dissection tables available, functional and in
use.
2.5. The college must have at least two Penta-head Multi -viewing Biological Microscope
available, functional and in use. Commented [WU9]: Please delete it is not required dissection
hall
Anatomy: (histology Laboratory)

2.6. The college must have at least two histology slide sets per hundred students available,
2.7. The college must have at least twenty binocular microscopes per hundred students
available, functional and in use.
2.8. The college must have at least one slide projecting microscope per hundred students
2.9. The college must have at least one large refrigerator per hundred students available,
Anatomy: (Museum)
2.10. The college must have at least two torsos (Male and Female) model per hundred
students available, functional and in use.
2.11. The college must have at least one cross sectional torso model per hundred students
2.12. The college must have at least five upper limbs (muscles, vessels, nerves and joints)
anatomical model per hundred students available, functional and in use.
2.13. The college must have at least five lower limbs (muscles, vessels, nerves and joints)
2.14. The college must have at least five head and neck (muscles, vessels, nerves and joints)
2.15. The college must have at least five special senses anatomical model per hundred
2.16. The college must have at least two brain anatomical model per hundred students
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2.17. The college must have at least one histology models per hundred students available,
2.18. The college must have at least one embryology models per hundred students available,
2.19. The college must have at least eight pelvis models per hundred students available,
2.20. The college must have at least four abdominal viscera models per hundred students
2.21. The college must have at least four liver models per hundred students available,
2.22. The college must have at least four kidney models per hundred students available,
2.23. The college must have at least four CVS models per hundred students available,
2.24. The college must have at least four respiratory system models per hundred students
2.25. The college must have at least hundred human’s loose bones per hundred students
2.26. The college must have at least two articulated skeletons per hundred students available,
2.27. The college must have at least two articulated vertebral column per hundred students
2.28. The college must have one anatomical chart of every system per hundred students
2.29. The college must have at least one cross sectional body model per hundred students
2.30. The college must have anatomy CDs available, functional and in use.
2.31. The college must have at least three histology slides set per hundred students available,
2.32. The college must have at least one embryology slides set per hundred available,
2.33. The college must have at least one neuro-anatomy slide set per hundred students
Anatomy (Minor)
Anatomy: (Dissection hall)

2.34. The college must have at least fifty stools set per hundred available, functional and in
use.
Anatomy: (histology laboratory)

2.35. The college must have at least one computers per 100 students with internet facility
2.36. The college must have at least one scanner per 100 students available, functional and in
use.
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2.37. The college must have at last one colour laser printer per 100 students available,
2.38. The college must have at least 35 stools per 100 students available, functional and in
use.
Anatomy: (Museum)
2.39. The college must have at least four multimedia per hundred students available, Commented [WU10]: One multimedia is enough in anatomy
measume
functional and in use for teaching purpose.
2.40. The college must have at least four multimedia per hundred students available,
2.41. The college must have at least five white boards per hundred students available,
2.42. The college must have at least one slide projecting microscope/Multi head microscope
per hundred students available, functional and in use for teaching purpose.
Physiology (Major)
2.43. The college must have at least fifteen sphygmomanometers per hundred students
2.44. The college must have at least ten microscope Binoculars per hundred students
2.45. The college must have at least twenty haemocytometers per hundred students
2.46. The college must have at least fifteen haemoglobin meters per hundred students
2.47. The college must have at least ten complete perimeters per hundred students available,
2.48. The college must have at least twenty-five ESR pipettes per hundred students
2.49. The college must have at least twenty percussion hammers per hundred students
2.50. The college must have at least two oxygen cylinders per hundred students available,
2.51. The college must have at least thirty clinical thermometers per hundred students
2.52. The college must have at least five student kymographs per hundred students
2.53. The college must have at least two ECG machines per 100 hundred students available,
2.54. The college must have at least one centrifuge machine per hundred students available,
2.55. The college must have at least five microhaematocrit reader per hundred students
2.56. The college must have at least one microhematocrit centrifuge per hundred students

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2.57. The college must have at least one vitallograph graph compact per hundred students
2.58. The college must have at least thirty stethoscopes per hundred students available,
2.59. The college must have at least two data acquisition system (power lab) per hundred Commented [WU11]: One powar lab id enough

2.60. The college must have at least one finger pulse oximeter per hundred students available,
2.61. The college must have at least one automated blood cell counter per hundred students
Physiology (Minor)
2.62. The college must have at least fifteen stop watches per hundred students available,
2.63. The college must have at least fifteen tuning forks of different frequencies per hundred
2.64. The college must have at least five vision E type charts/Snellen's charts per hundred
2.65. The college must have at least five Ishihara charts per hundred students available,
2.66. The college must have at least two weighting machines per hundred students available,
2.67. The college must have at least five Frog’s boards (Trays SS12s 10, Tray ELI 10,
dissecting forceps and plain scissors) per hundred students available, functional and in
use.
2.68. The college must have at least an audiometer available, functional and in use.
2.69. The college must have at least an examination coach available, functional and in use. Commented [WU12]: Correct spelling of examination couch
2.70. The college must have at least a fire extinguisher available, functional and in use.
2.71. The college must have at least a Jaeger's chart. Commented [WU13]: All red highlighted standards are not
required semi column should be deleted
2.72. The college must have at least a jesters of various volumes available, functional and in
use.
2.73. The college must have at least an ophthalmoscope.
2.74. The college must have at least a refrigerator.
2.75. The college must have at least a stethoscope (complete), with assembly available,
2.76. The college must have teaching microscope available, functional and in use.
2.77. The college must have torch available, functional and in use.
2.78. The college must have tourniquets available, functional and in use.
2.79. The college must have water bath available, functional and in use.
2.80. The college must have beaker 100ml available, functional and in use.
2.81. The college must have beaker 500ml available, functional and in use.
2.82. The college must have blood group tiles available, functional and in use.
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2.83. The college must have capillary tubes (heparinised) available, functionaland in use.
2.84. The college must have treadmill or aerometer cycle available, functional and in
2.85. use.
2.86. The college must have capillary tubes (heparinised) available, functionaland in use.
2.87. The college must have capillary tubes (plain) available, functional and in use.
2.88. The college must have centrifuge tubes with cock available, functional and in use.
2.89. The college must have EDTA tube available, functional and in use.
2.90. The college must have ESR pipette available, functional and in use.
2.91. The college must have glass rod available, functional and in use.
2.92. The college must have magnifying glass available, functional and in use.
2.93. The college must have sufficient microscope slides.
2.94. The college must have sufficient Petri dishes.
2.95. The college must have spirit lamp available, functional and in use.
2.96. The college must have thermometer available, functional and in use.
2.97. The college must have Win Trobe’s tubes available, functional and in use.
2.98. The college must have antisera A, B and D available, functional and in use.
2.99. The college must have cedar wood oil available, functional and in use.
2.100. The college must have distilled water available, functional and in use.
2.101. The college must have HCL.
2.102. The college must have Leishman’s stain available, functional and in use.
2.103. The college must have methylated spirit available, functional and in use.
2.104. The college must have platelet solution (Ree’s and Ecker’s solution) available,
2.105. The college must have pregnancy test kits available, functional and in use.
2.106. The college must have pregnancy strips available, functional and in use.
2.107. The college must have RBC solution available, functional and in use.
2.108. The college must have WBC solution available, functional and in use.
2.109. The college must have xylene available, functional and in use.
Biochemistry (Major)
2.110. The college must have at least two supertonic 20 per hundred students available,
2.111. The college must have at least two clinical PH meters per hundred students available,
2.112. The college must have at least one analytical photometer per hundred students
2.113. The college must have at least one large size incubator per hundred students available,
2.114. The college must have at least one electronic balance per hundred students available,
2.115. The college must have at least one thermal cycler per hundred students available,
2.116. The college must have at least one electrophoresis per hundred students available,

2.117. The college must have at least two glucometers per 2019
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Biochemistry (Minor)
2.118. The college must have at least one water distillation unit (operation china 10 Litres) per
hundred students available, functional and in use.
2.119. The college must have at least one electric water bath per hundred students available,
2.120. The college must have at least one electric water bath per hundred students available,
functional and in use.t all time
2.121. The college must have at least five stop watch per hundred students available,
2.122. The college must have at least one hot box oven per hundred students available,
Pharmacology (Major)
2.123. The college must have at least a respirator per hundred students available, functional Commented [WU14]: Not required , should be desalted
and in use.
2.124. The college must have at least complete polygraphs per hundred students available,
2.125. The college must have at least five audio-visual facility and experimental CD’s of
Pharmacology practical’s per hundred students available, functional and in use.
2.126. The college must have at least five BP apparatus per hundred students available,
2.127. The college must have at least five stethoscopes per hundred students available,
2.128. The college must have at least power laboratory per hundred students available,
2.129. The college must have at least two mannequins for demonstrating delivery of drugs
through different roots of administrations per hundred students available, functional and
in use.
Pharmacology (Major) Commented [WU15]: Duplication, should be deleted

2.130. The college must have at least a respirator per hundred students available, functional
and in use.
2.131. The college must have at least complete polygraphs per hundred students available,
2.132. The college must have at least five audio-visual facility and experimental CD’s of
Pharmacology practical’s per hundred students available, functional and in use.
2.133. The college must have at least five BP apparatus per hundred students available,
2.134. The college must have at least five stethoscopes per hundred students available,
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2.135. The college must have at least power laboratory per hundred students available,
2.136. The college must have at least two mannequins for demonstrating delivery of drugs
through different roots of administrations per hundred students available, functional
and in use.
Pharmacology (Minor)
2.137. The college must have at least five audio-visual facility and experiment CDs of Commented [WU16]: Not required
pharmacology practical’s per hundred students available, functional and in use

2.138. The college must have at least one electronic balance per hundred students available,
Pathology I and II (Major)
2.139. The college must have at least fifteen microscope binoculars per hundred students Commented [WU17]: 35 microscopes are recommended

2.140. The college must have at least one Microscope multi head (5 piece) per hundred
Pathology I and II (Minor)

2.141. The college must have at least four stain dropping bottles (250ml) per hundred
2.142. The college must have at least four wash bottles per hundred students available,
2.143. The college must have at least four adjustable staining racks per hundred students
2.144. The college must have at least two 14 cubic feet refrigerators per hundred students
2.145. The college must have at least a — 20 C deep freezer per hundred students available,
2.146. The college must have at least four glass beaker (Pyrex) 500 ml graduated per
2.147. The college must have at least four glass cylinder (Pyrex) 500 ml graduated per
2.148. The college must have at least four water stills per hundred students available, Commented [WU18]: Tow water stills are enough
2.149. The college must have at least one incubator 37 c large per hundred students
available, functional and in use.t all time.
2.150. The college must have at least one floating bath per hundred students available,
2.151. The college must have at least twenty Staining jars per hundred students available,
2.152. The college must have at least one automatic tissue processor per hundred students

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2.153. The college must have at least one embedding station per hundred students available,
2.154. The college must have at least one water Bath electric per hundred students available,
2.155. The college must have at least one paraffin embedding bath per hundred students
2.156. The college must have at least one oven-wax embedding (100 c) per hundred students
2.157. The college must have at least one Microtome per hundred students available,
2.158. The college must have at least one knife sharpener per hundred students available,
2.159. The college must have at least a large incubator per hundred students available,
Community Medicine (museum)
2.160. The college must have various models to educate students on various aspects of
primary and preventive healthcare as well as community health.
2.161. The college must have incinerator available, functional and in use.
2.162. The college must have four intra uterine devices available, functional and in use.
2.163. The college must have four combined oral contraceptive pills available, functional and
in use.
2.164. The college must have four injectable contraceptive available, functional and in use.
2.165. The college must have four contraceptive implants available, functional and in use.
2.166. The college must have hundred growth charts available, functional and in use.
2.167. The college must have ten mid upper arm circumference (MUAC) tapes available,
2.168. The college must have five weight Machine available, functional and in use.
2.169. The college must have three population pyramid vaccines available, functional and in
use.
2.170. The college must have three model of iceberg available, functional and in use.
2.171. The college must have five mercury sphygmomanometer available, functional and in
use.
2.172. The college must have five stadiometer available, functional and in use. Commented [WU19]: Not required
2.173. The college must have five Verniercalliper available, functional and in use.
Forensic medicine (Major)

2.174. The college must have at least one male and female skeleton available, functional and
in use.
2.175. The college must have at least twenty separate bones available, functional and in use.
2.176. The college must have at least twenty models available, functional and in use.
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2.177. The college must have at least thirty toxicological specimens available, functional and
in use.
2.178. The college must have at least twenty Slides (Toxicology and serology) available,
2.179. The college must have at least a routine equipment for serology laboratory available,
2.180. The college must have at least three binocular microscopes available, functional and in
use.
2.181. The college must have at least a manual Spectroscope available, functional and in use. Commented [WU20]: Not Required
2.182. The college must have two examination sets available, functional and in use.
2.183. The college must have at least sixty assault weapons available, functional and in use.
Forensic medicine (Minor)

2.184. The college must have at least twenty medico-legal x-rays slides and photography
Teaching Hospital(s) Equipment Requirements
Major Equipment
General Medicine
2.185. The hospital must have at least one defibrillator per hundred students available,
2.186. The hospital must have at least two ECG machine (Trippel Channel) per hundred
2.187. The hospital must have at least one video endoscopic system with upper and lower sets
per hundred students available, functional and in use.
2.188. The hospital must have at least one Trolley for endoscopes (Pak made) per hundred
2.189. The hospital must have at least one echo cardiograph 2D with colour doppler per
2.190. The hospital must have at least one ETT machine per hundred students available,
2.191. The hospital must have at least four complete nebulizers per hundred students available,
2.192. The hospital must have at least 10 BP apparatus per hundred students available,
2.193. The hospital must have at least 10 stethoscopes per hundred students available,
2.194. The hospital must have at least 4 pulse oximeters per hundred students available,
2.195. The hospital must have at least 6 glucometers per hundred students available, functional
and in use.
2.196. The hospital must have at least 2 cardiac monitors per hundred students available,

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2.197. The hospital must have at least 10 thermometers per hundred students available,
2.198. The hospital must have at least 3 torches per hundred students available, functional and
in use.
2.199. The hospital must have at least 3 measuring tapes per hundred students available,
2.200. The hospital must have at least 4 hammers per hundred students available, functional
and in use.
2.201. The hospital must have at least 2 tuning forks (128Hz) per hundred students available,
2.202. The hospital must have at least 5 examination couches per hundred students available,
Dermatology
2.203. The hospital must have at least 3 electrocautery machines per hundred students
2.204. The hospital must have at least 15 magnifying glasses with fluorescent lamps per
2.205. The hospital must have at least 3 wood lamps per hundred students available, functional
and in use.
2.206. The hospital must have at least 1 PUVA machine per hundred students available,
2.207. The hospital must have at least 1 UVB machine per hundred students available,
2.208. The hospital must have at least 3 liquid nitrogen cylinders for cryo per hundred students
2.209. The hospital must have at least 1 microscope with accessories per hundred students
2.210. The hospital must have at least 6 biopsy sets per hundred students available, functional
and in use.
2.211. The hospital must have at least 6 BP apparatus per hundred students available,
Surgery
2.212. The hospital must have at least 8 basic standard surgical sets per hundred students
2.213. The hospital must have at least 1 thoracic surgical set per hundred students available,
2.214. The hospital must have at least 1 vascular surgical set per hundred students available,
2.215. The hospital must have at least 1 paedsurg setsper hundred students available,
2.216. The hospital must have at least 1 plastic surgery set per hundred students available,
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2.217. The hospital must have at least 2 surgical diathermies (Monopolar and Bipolar)
machines per hundred students available, functional and in use.
2.218. The hospital must have at least 1 harmonic/Ligasure machine per hundred students
2.219. The hospital must have at least 2 fibre optic colonoscope (Diagnostic and therapeutic)
or flexible sigmoidoscope per hundred students available, functional and in use.
2.220. The hospital must have at least 2 rigid sigmoidoscope and proctoscope per hundred
2.221. The hospital must have at least 2 complete laparoscopic surgical sets per hundred
2.222. The hospital must have at least 1 microsurgical instrument set per hundred students
2.223. The hospital must have at least 1 transurethral resection of prostate surgical set per
2.224. The hospital must have at least 2 cystoscopes (diagnostic and therapeutic) per
2.225. The hospital must have at least one fibreopticoesophagoscope/gastroscopeper hundred
2.226. The hospital must have at least 1 fibre optic bronchoscope per hundred students
2.227. The hospital must have at least 1 portable X-ray machine, operation table, and
radiographic film cassette facilities e.g. for per operative cholangiogram. Image
intensifier with C-arm and double monitors per hundred students available, functional
and in use.
2.228. The hospital must have at least 3 suction machines per hundred students available,
2.229. The hospital must have at least 1 defibrillator per hundred students available,
Obstetrics and Gynaecology

2.230. The hospital must have at least 4 ultrasounds with linear, vaginal, section probes and
punctures per hundred students available, functional and in use.
2.231. The hospital must have at least 1 hysteroscope per hundred students available,
2.232. The hospital must have at least 1 colposcope per hundred students available,
2.233. The hospital must have at least 2 laparoscopic surgical sets with camera and monitors
2.234. The hospital must have at least 1 delivery table per hundred students available,
2.235. The hospital must have at least 10 examination tables per hundred students available,
2.236. The hospital must have at least 3 manual BP apparatus per hundred students available,
functional and in use.t all time?
2.237. The hospital must have at least 24 dyna-map (multi-para) per hundred students

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2.238. The hospital must have at least 3 pulse oximeters per hundred students available,
2.239. The hospital must have at least 6 baby weighing scales hundred students available,
2.240. The hospital must have at least 10 pinnard stethoscopes/fetoscopes per hundred students
2.241. The hospital must have at least 4 instrument sterilizers per hundred students available,
2.242. The hospital must have at least 2 sonicaid per hundred students available, functional
and in use.
2.243. The hospital must have at least 10 CTG machines per hundred students available,
2.244. The hospital must have at least 10 neonatal resuscitation trolley and heaters per hundred
2.245. The hospital must have at least 12 disposable delivery sets per hundred students?
2.246. The hospital must have at least 20 Cusco’s speculum per hundred students available,
2.247. The hospital must have at least 3 adult ambu bags and masks per hundred students
2.248. The hospital must have at least 20 Sims speculum per hundred students available,
2.249. The hospital must have at least 20 perineal/vaginal/cervical repair sets per hundred
2.250. The hospital must have at least 6 Caesarean section sets per hundred students available,
2.251. The hospital must have at least 6 dilatation and Evacuation sets (D&C) per hundred
2.252. The hospital must have at least 4 manual vacuum aspirators per hundred students
2.253. The hospital must have at least 6 vacuum ventuse cups per hundred students available,
2.254. The hospital must have at least 6 outlet forceps per hundred students available,
2.255. The hospital must have at least 6 infant laryngoscopes with spare bulbs per hundred
2.256. The hospital must have at least 6 suction machines per hundred students available,
2.257. The hospital must have at least 5 teaching dummies and anatomical pelvis models per
2.258. The hospital must have at least 2 dummies for pelvic examination per hundred students
2.259. The hospital must have at least 1 adequate equipment for family planning per hundred
19
Basic Surgery sets in main Operating Theatre
2.260. The hospital must have at least 1 sterilizer (>300L capacity) per hundred students
2.261. The hospital must have sufficient instrument boxes, scalpel handles of various sizes,
May-Heggar Needle holders of various sizes, artery forceps, Halstead (non-serrated
and curved ) various sizes, surgical dissecting scissors, metzembaum (Curved) of
various sizes, Kocher’s forceps (toothed, straight, haemostatic) of various sizes,
Probes of various sizes, Dissecting forceps with and without teeth of various sizes,
Haemostatic forceps (Collin and Chaput) of various sizes, towel clips and galipots of
various sizes for hundred students available, functional and in use.
2.262. The hospital must have Farabeuf retractors, short, self-retaining retractors for thoracic,
abdominal and minor procedures etc. per hundred students available, functional and in
use.
Out-Patient:
2.263. The hospital must have 1 stethoscope per clinic per hundred students available,
2.264. The hospital must have 1 fetal/paediatric stethoscope per respective clinics per
2.265. The hospital must have BP apparatus per clinic per hundred students available,
2.266. The hospital must have one thermometer (Oral/armpit) and sufficient rectal
thermometers per hundred students available, functional and in use.
2.267. The hospital must have light source (battery type), tongue depressors, tape measures
(Flexible, soft), Snellen chart (including for uneducated patients), hammers, head
mirrors/head lights, mirror laryngeal sets, otoscopes, and Collyer pelvimeters,
examination tables, per hundred students available, functional and in use.
2.268. The hospital must have laryngoscopes per hundred students available, functional and
in use.
2.269. The hospital must have stretchers (folding type) per hundred students available,
2.270. The hospital must have ambu bags for infants, paediatric patients and adult patients
2.271. The hospital must have suction machines per hundred students available, functional
and in use.
2.272. The hospital must have consumables like gloves, Endo tracheal tubes of various sizes,
IV cannulas of various sizes, masks etc. per hundred students available, functional and
in use.
Paediatrics Department
2.273. The hospital must have 1 weighing scale per hundred students available, functional
and in use.
2.274. The hospital must have 1 length/height measuring scale per hundred students
2.275. The hospital must have 2 ultrasonic nebulizers per hundred students available,
2.276. The hospital must have 1 paediatric ventilator per hundred students available,

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2.277. The hospital must have 1 neonatal ventilator per hundred students available,
2.278. The hospital must have 1 pulse oximeter per hundred students available, functional
and in use.
2.279. The hospital must have 3 infusion pump per hundred students available, functional
and in use.
2.280. The hospital must have 1 cardiac monitor per hundred students available, functional
and in use.
2.281. The hospital must have 1 transport incubator per hundred students available,
2.282. The hospital must have 1 neonatal resuscitator per hundred students available,
2.283. The hospital must have 1 low grade suction apparatus per hundred students available,
2.284. The hospital must have 1 resuscitator (infant/child), manual per hundred students
2.285. The hospital must have 1 suction machine (dual operation with tubes) per hundred
2.286. The hospital must have 2 otoscopes with infant diagnostic heads per hundred students
2.287. The hospital must have 2 forceps, splinter/repilation, and spring per hundred students
2.288. The hospital must have 2 paediatric nasal speculums per hundred students available,
2.289. The hospital must have 1 scale for infants per hundred students available, functional
and in use.
2.290. The hospital must have 1 height measuring scale for infants per hundred students
2.291. The hospital must have 6 oral/armpit thermometers per hundred students available,
2.292. The hospital must have 5 BP apparatus (new born, neonatal, paediatric, cuffs) per
Accident and Emergency Department

2.293. The hospital must have 2 beds with monitoring facilities per hundred students
2.294. The hospital must have 1 minor operating theatre per hundred students available,
2.295. The hospital must have 1 pharmacy in emergency area per hundred students available,
2.296. The hospital must have 1 facility for resuscitation including crash cart (Defibrillator)
and a cubicle for patient with central oxygen, suction and monitoring facilities stay per
hundred students available, functional and in use.(essential)
21
2.297. The hospital must have 1 anaesthesia machine with ventilator per hundred students
Operating Rooms
2.298. The hospital must have five fully equipped operating rooms available, functional and in
use.
2.299. The hospital must have appropriately furnished Pre-aesthesia area available, functional
and in use.
2.300. The hospital must have recovery area with central oxygen and suction and monitoring
facilities per hundred students available, functional and in use.
2.301. The hospital must have monitoring facilities per OR per hundred students available,
2.302. The hospital must have 1 image intensifier per hundred students available, functional
and in use.
2.303. The hospital must have facilities for resuscitation per hundred students available,
2.304. The hospital must have 5 anaesthesia work stations per hundred students available,
2.305. The hospital must have 1 diathermy machine per theatre (Monopolar and bipolar) per
2.306. The hospital must have adequate OT Waste disposal method per hundred students
Critical care beds with isolation facilities as a part of intensive care, coronary
care and neonatal care & HDU
2.307. The hospital must have ten medical ICU beds (Essential) available, functional and in
use.
2.308. The hospital must have ten surgical ICU beds (Mandatory) available, functional and in
use.
2.309. The hospital must have ten separate paediatric & neonatal intensive care beds available,
2.310. The hospital must have implementation of sanitation & isolation protocols available,
Central Sterilization and Storage Department

2.311. The hospital must have Instrument washing area available, functional and in use.
2.312. The hospital must have linen washing area available, functional and in use.
2.313. The hospital must have 1 washer and disinfector per hundred students available,
2.314. The hospital must have 2 steam autoclaves with 134 degrees’ temperature (500L) per
2.315. The hospital must have 1 Ethylene oxide/ Formaldehyde gas / plasma sterilizer per
2.316. The hospital must have 1 sealant machine per hundred students available, functional
and in use.

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2.317. The hospital must have chemical based high level disinfection/ sterilization facilities
2.318. The hospital must have storage and distribution counter per hundred students available,
2.319. The hospital must have separate path for collection of dirty linen and instruments
Radiology Services with all imaging modalities
X-Ray Machines:
2.320. The hospital must have 4 Fluoroscopy/image intensifiers (500mA) per hundred students
2.321. The hospital must have 1 stationary Bucky table (300mA) per hundred students
2.322. The hospital must have 1 stationary Bucky Stand (300mA) per hundred students
2.323. The hospital must have 1 portable X-ray (100mA) per hundred students available,
Ultrasound:
2.324. The hospital must have 2 probe grey scale (3.5 MHz) per hundred students available,
2.325. The hospital must have 2 probe portable grey scale (3.5 MHz) per hundred students
2.326. The hospital must have 1 colour Doppler (with multi frequency probes) per hundred
2.327. The hospital must have 2 biopsy probes per hundred students available, functional and
in use.
Other Equipment:
2.328. The hospital must have 1 CT scan 4/16/64/128/256) per hundred students available,
2.329. The hospital must have 1 MRI (1.5/3 tesla) per hundred students available, functional
and in use.
2.330. The hospital must have 1 mammography per hundred students available, functional and
in use.
2.331. The hospital must have per hundred students available, functional and in use.
2.332. The hospital must have 1 Orthopantomogram (OPG) per hundred students available,
Safety Equipment:
2.333. The hospital must have 7 lead aprons per hundred students available, functional and in
use.
2.334. The hospital must have 1 TLD per hundred students available, functional and in use.
23
2.335. The hospital must have 4 lead shields/partitions per hundred students available,
2.336. The hospital must have film badge/radiation detector per staff member and available,
Hospital Laboratory Services
Haematology Instrument:
2.337. The hospital must have 3/5 part automated differential counter per hundred students
2.338. The hospital must have 2 microscopes (1 with teaching head) per hundred students
2.339. The hospital must have 5 neubauer chambers per hundred students available, functional
and in use.
2.340. The hospital must have basic staining facilities including for reticulocytes per hundred
2.341. The hospital must have 1 fridge to keep samples per hundred students available,
2.342. The hospital must have plus >300 tests in 30 days
Blood Bank
2.343. The hospital must have 1 serofuge per hundred students available, functional and in use.
2.344. The hospital must have 1 agglutination viewer per hundred students available,
2.345. The hospital must have 1 blood bank fridge per hundred students available, functional
and in use.
2.346. The hospital must have 1 microscope and 1 water bath/heat block per hundred students
2.347. The hospital must have 1 platelet rotator with incubator per hundred students available,
2.348. The hospital must have 1 minus thirty-degree refrigerator for storage per hundred
2.349. The hospital must have >30 units of blood provided per month
Chemical Pathology:
2.350. The hospital must have 1 automated chemistry analyser per hundred students available,
2.351. The hospital must have 1 immuno-assay analyser per hundred students available,
2.352. The hospital must have 1 refractor-meter per hundred students available, functional and
in use.
2.353. The hospital must have 1 ion selective electrode per hundred students available,
2.354. The hospital must have 1 blood gas analyser (either in department or in ICU) per
2.355. The hospital must have 1 fridge and 1 minus eighty degree freezer for lab per hundred

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2.356. The hospital must have number of Tests > 1000 per month?
Microbiology:
2.357. The hospital must have 1 incubator (37 degrees) per hundred students available,
2.358. The hospital must have basic staining facilities per hundred students available,
2.359. The hospital must have 1 fridge per hundred students available, functional and in use.
2.360. The hospital must have 2 microscopes with teaching heads per hundred students
2.361. The hospital must have 1 safety hood per hundred students available, functional and in
use.
2.362. The hospital must have lab Reports more than 150/month
25
Recognition Standard 3: Faculty and Staff
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The requirements mentioned in this standard pertain to faculty and staff of the college. The
numbers written in this section relate to admission of a class of 100 students. For any other
number of admission class, the same ratio be applied.
General Requirements
3.1. The college must have faculty attendance of at least 70% verifiable through biometric
attendance
3.2. The college must have contracts with all faculty members, with remuneration clearly
specified
3.3. The college must be able to demonstrate payment of the remuneration to the faculty
members through banking channel every month for the last 12 months
Basic Sciences
Anatomy:
3.4. The college must have at least one Professor of Anatomy
3.5. The college must have at least one Associate Professor of Anatomy
3.6. The college must have at least two Assistant Professors of Anatomy
3.7. The college must have at least eight demonstrators of Anatomy, or equivalent number in Commented [WU21]:
case of integrated curriculum
3.8. The college must have at least two lab technicians / assistants of Anatomy Commented [WU22]: Only lab tecnications should be pointed
in all labs of medical college ,lab assistant are not required
3.9. The college must have at least two dissection hall attendants
3.10. The college must have at least one curator of anatomy museum
3.11. The college must have at least one computer operator in Anatomy Department Commented [WU23]: Insert
Physiology:
3.12. The college must have at least one Professor of Physiology
3.13. The college must have at least one Associate Professor of Physiology
3.14. The college must have at least two Assistant Professors of Physiology
3.15. The college must have at least eight demonstrators of Physiology, or equivalent number
in case of integrated curriculum
3.16. The college must have at least two lab technicians / assistants of Physiology Commented [WU24]: Only lab tecnications should be pointed
3.17. The college must have at least one computer operator in Physiology Department
3.18.
Biochemistry:
3.18. The college must have at least one Professor of Biochemistry
3.19. The college must have at least one Associate Professor of Biochemistry
3.20. The college must have at least two Assistant Professors of Biochemistry
3.21. The college must have at least six demonstrators of Biochemistry, or equivalent number
3.22. The college must have at least two lab technicians / assistants of Biochemistry
26
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3.23. The college must have at least one computer operator in Biochemistry Department
Commented [WU25]: Only lab tecnications should be pointed
Pharmacology:
3.24. The college must have at least one Professor of Pharmacology
3.25. The college must have at least one Associate Professor of Pharmacology
3.26. The college must have at least one Assistant Professor of Pharmacology
3.27. The college must have at least six demonstrators of Pharmacology, or equivalent number
3.28. The college must have at least one Pharmacists in Pharmacology
3.29. The college must have at least one lab technician / assistant of Pharmacology Commented [WU26]: Only lab technician should be pointed in
all labs of medical college ,lab assistant are not required
3.30. The college must have at least one computer operator in Pharmacology Department
Pathology:
3.31. The college must have at least one Professor of Pathology (Either in Histopathology,
Microbiology, Chemical Pathology or Haematology)
3.32. The college must have at least one Associate Professor of Histopathology
3.33. The college must have at least one Associate Professor of Microbiology
3.34. The college must have at least one Associate Professor of either Chemical Pathology or
Haematology
3.35. The college must have at least one Assistant Professor of Histopathology
3.36. The college must have at least one Assistant Professor of Microbiology
3.37. The college must have at least one Assistant Professor of Chemical Pathology
3.38. The college must have at least one Assistant Professor of Haematology
3.39. The college must have at least eight demonstrators of Pathology, or equivalent number in
case of integrated curriculum
3.40. The college must have at least four lab technicians / assistants of Pathology Commented [WU27]: Only lab tech should be pointed in all
labs of medical college ,lab assistant are not required
3.41. The college must have at least one curator of pathology museum
3.42. The college must have at least one computer operator in Pathology Department
Forensic Medicine:
3.43. The college must have at least one either Professor, Associate Professor or Assistant
Professor of Forensic Medicine
3.44. The college must have at least four demonstrators of Forensic Medicine, or equivalent
number in case of integrated curriculum
3.45. The college must have at least one lab technician / assistant of Forensic Medicine Commented [WU28]: Only lab technician should be pointed in
all labs of medical college ,lab assistant are not required
3.46. The college must have at least one computer operator in Forensic Medicine Department
Medical Education
3.47. The college must have at least one either Professor, Associate Professor or Assistant Commented [WU29]: Ina addition to HOD There should be one
secretary and 4 instructress / Coordinator in medical education
Professor of Medical Education department
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Public Health
3.49. The college must have at least one Professor of Community Medicine or Public Health
3.50. The college must have at least one Associate Professor of Community Medicine or
Public Health
3.51. The college must have at least two Assistant Professors of Community Medicine or
Public Health
3.52. The college must have at least four demonstrators of Community Medicine or Public
Health, or equivalent number in case of integrated curriculum
3.53. The college must have at least one male medical social worker
3.54. The college must have at least one female medical social worker
3.55. The college must have at least one social worker who is a qualified psychologist
3.56. The college must have at least one Family Medicine Specialist Commented [WU30]: At the level of instructors
3.57. The college must have at least one computer operator in Public Health Department
Clinical Sciences
General Medicine
3.58. The college must have at least two Professors of General Medicine
3.59. The college must have at least two Associate Professors of General Medicine
3.60. The college must have at least two Assistant Professors of General Medicine
General Surgery
3.61. The college must have at least two Professors of General Surgery
3.62. The college must have at least two Associate Professors of General Surgery
3.63. The college must have at least two Assistant Professors of General Surgery
Gynaecology
3.64. The college must have at least two Professors of Gynaecology
3.65. The college must have at least two Associate Professors of Gynaecology
3.66. The college must have at least two Assistant Professors of Gynaecology
Ophthalmology
3.67. The college must have at least one Professor of Ophthalmology
3.68. The college must have at least one Associate Professor of Ophthalmology
3.69. The college must have at least one Assistant Professor of Ophthalmology
ENT
3.70. The college must have at least one Professor of ENT
3.71. The college must have at least one Associate Professor of ENT
3.72. The college must have at least one Assistant Professor of ENT
Should be rephrased as 3 faculty members like Professor/Associate/Assistant Professor (1+1+1

or 1 + 2 )

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Paediatrics
3.73. The college must have at least one Professor of Paediatrics
3.74. The college must have at least one Associate Professor of Paediatrics
3.75. The college must have at least one Assistant Professor of Paediatrics
Orthopaedics
3.76. The college must have at least one Professor of Orthopaedics
3.77. The college must have at least one Associate Professor of Orthopaedics
3.78. The college must have at least one Assistant Professor of Orthopaedics
Should be rephrased as 3 faculty members like Professor/Associate/Assistant Professor (1+1+1

or 1 + 2 )
Psychiatry
3.79. The college must have at least one Professor of Psychiatry
3.80. The college must have at least one Associate Professor of Psychiatry
3.81. The college must have at least one Assistant Professor of Psychiatry
Should be rephrased as 3 faculty members like Professor/Associate/Assistant Professor (!+1+1

or 1 + 2 )
Dermatology
3.82. The college must have at least one Professor of Dermatology
3.83. The college must have at least one Associate Professor of Dermatology
3.84. The college must have at least one Assistant Professor of Dermatology
Not many dermatologists available. Should have 1 professor/associate professor/assistant

professor plus at least one Senior registrar
Cardiology
3.85. The college must have at least one faculty members Assistant Professor or above in
Cardiology
Neurology
Neurology
Pulmonology
Pulmonology
Nephrology
Nephrology
Gastroenterology
29
Gastroenterology
Medicine and Allied Specialty

either Rheumatology, Endocrinology, Oncology or Infectious Diseases
Accident and Emergency

3.91. The college must have at least one faculty member Assistant Professor or above; or one
consultant in Accident and Emergency

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^ir-.
Anaesthesia
3.92. The college must have at least one Professor of Anaesthesia
3.93. The college must have at least one Associate Professor of Anaesthesia
3.94. The college must have at least one Assistant Professor of Anaesthesia
Radiology
3.95. The college must have at least two faculty members Assistant Professor or above in
Radiology
Surgical and Allied Specialty

3.96. The college must have at least one faculty members Assistant Professor or above in of
in any two of the following specialties:
3.96.1. Cardiac Surgery
3.96.2. Neurosurgery
3.96.3. Paediatric Surgery
3.96.4. Thoracic Surgery
3.96.5. Urology
3.96.6. Plastic surgery
3.96.7. Maxillofacial Surgery
Support Departments
3.97. The college must have appropriately staffed Quality Assurance Cell
3.98. The college must have appropriately staffed IT Department
3.99. The college must have appropriately staffed Student Section
3.100. The college must have appropriately staffed Security Department
3.101. The college must have appropriately staffed Finance Department
3.102. The college must have appropriately staffed Maintenance Department
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Recognition Standard 4: Teaching Hospital
The requirements in this section pertain to admission of class of 100 students. For any other
number of students, similar ratios shall apply.
General
4.1. The college, if using a third-party hospital for teaching, must have a valid MoU with
hospital(s), which shall have not less than 10 years validity at the time of inspection.
4.2. The college must provide clinical teaching to students in a hospital with a functioning
Electronic Health Management Information System with capabilities of recording of:
4.2.1. Number of patient encounters in OPD
4.2.2. Number of admissions in IPD
4.2.3. Number of procedures in OPD
4.2.4. Number of procedures / surgeries in IPD
4.2.5. Type of procedures / surgeries in OPD and IPD
4.2.6. Calculating Length of Stay (LOS) in IPD
4.2.7. Bed Occupancy
4.2.8. Lab Tests Volume
4.2.9. Biometric Attendance
4.3. The teaching hospital must not charge any accommodation or consultation fees from the
patient on teaching beds (25% of total number of beds), while laboratory services,
medicine and supplies, if any, must only be charged from the patient on a no-profit
basis.
4.4. The college must provide to the clinical faculty a separate workstation or office
(preferred for Associate Professor or above)
Clinical Specialities and Beds
For a measureable element to be marked ‘met’, the bed has to be occupied by a patient of the
same specialty at the time of inspection and prior to inspection verified through the HMIS
data.
4.5. The hospital(s) must have Internal Medicine specialty with a minimum of 75 inpatient
beds
4.6. The hospital(s) must have Psychiatry specialty with a minimum of 5 inpatient beds
4.7. The hospital(s) must have Dermatology specialty with a minimum of 5 inpatient beds
4.8. The hospital(s) must have Cardiology specialty with a minimum of 5 inpatient beds
4.9. The hospital(s) must have a minimum of 5 CCU beds
4.10. The hospital(s) must have Neurology specialty with a minimum of 5 inpatient beds
4.11. The hospital(s) must have Pulmonology specialty with a minimum of 5 inpatient beds
4.12. The hospital(s) must have Nephrology specialty with a minimum of 5 inpatient beds
4.13. The hospital(s) must have a minimum of 5 dialysis chairs
4.14. The hospital(s) must have Gastroenterology specialty with a minimum of 5 inpatient
beds

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4.15. The hospital(s) must have Medical ICU with a minimum of 10 inpatient beds
4.16. The hospital(s) must have at least one of the following specialties with a minimum of 5
inpatient beds
4.16.1. Rheumatology
4.16.2. Endocrinology
4.16.3. Oncology
4.16.4. Infectious Diseases
50 beds may be distributed by the hospital(s) in any of the medicine and allied specialties
above.
4.17. The hospital(s) must have General Surgery specialty with a minimum of 75 inpatient
beds, excluding post-operative recovery beds
4.18. The hospital(s) must have Gynaecology and Obstetrics specialty with a minimum of 50
inpatient beds (including labour room)
4.19. The hospital(s) must have Ophthalmology specialty with a minimum of 15 inpatient beds
4.20. The hospital(s) must have Ear, Nose and Throat (ENT) specialty with a minimum of 15
inpatient beds
4.21. The hospital(s) must have Orthopaedics specialty with a minimum of 15 inpatient beds
4.22. The hospital(s) must have Anaesthesia specialty with a minimum of 10 Surgical ICU
beds
4.23. The hospital(s) must have at least two of the following specialties with a minimum of 10
inpatient beds each
4.23.1. Cardiac Surgery
4.23.2. Neurosurgery
4.23.3. Paediatric Surgery
4.23.4. Thoracic Surgery
4.23.5. Urology
4.23.6. Plastic Surgery
4.23.7. Maxillofacial Surgery
25 beds may be distributed by the hospital(s) in any of the surgery and allied specialties above.
4.24. The hospital(s) must have Paediatrics specialty with a minimum of 60 inpatient beds
4.25. The hospital(s) must have Accident and Emergency (A&E) specialty with a minimum of
10 beds
4.26. At least 10% of all inpatient beds (not including Medical ICU and Surgical ICU) must
have cardiac monitor with slandered pulse, BP, ECG and Oxygen Saturation.
Patient Load
Patient load is to be verified from the hospital’s HMIS.
33
Outpatient Load
4.27. The hospital(s) should have had minimum OPD of more than month 500 patients per
averaged for the past 12 months in General Medicine
averaged for the past 12 months in Psychiatry
averaged for the past 12 months in Dermatology
averaged for the past 12 months in Cardiology
averaged for the past 12 months in Neurology
averaged for the past 12 months in Gastroenterology
4.33. The hospital(s) should have had minimum of more than 150 patients per month seen
averaged for the past 12 months in Accident and Emergency
4.34. The hospital(s) should have had minimum OPD of more than 150 patients per month
averaged for the past 12 months in specialty identified in 3.90
averaged for the past 12 months in Paediatrics
averaged for the past 12 months in General Surgery
averaged for the past 12 months in ENT
averaged for the past 12 months in Ophthalmology
averaged for the past 12 months in Gynaecology and Obstetrics
averaged for the past 12 months in Orthopaedics
averaged for the past 12 months in each of the two specialties identified in 3.96
Inpatient
4.42. Total bed occupancy of the hospital should be at least 70% in the past 12 months.
4.43. In each of the specialty in the hospital, the bed occupancy should be at least 50% in the
past 12 months
Major and Minor Procedures

Major procedure is defined as a procedure performed under general anaesthesia. Minor procedure
is defined as a procedure performed under local or no anaesthesia.
4.44. The hospital(s) should have had minimum of 350 procedures performed in the past 12
months in General Medicine
months in Dermatology

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months in Cardiology
months in Neurology
months in Gastroenterology
months in Accident and Emergency
months in medicine and allied specialty identified in 3.90
4.51. The hospital(s) should have had minimum of 3500 minor procedures in the past 12
months in General Surgery
4.52. The hospital(s) should have had minimum of 1000 major procedures in the past 12
months in General Surgery
months in Anaesthesia
months in Anaesthesia
4.55. The hospital(s) should have had minimum of 250 procedures in the past 12 months in
ENT
Ophthalmology
months in Gynaecology and Obstetrics
months in Gynaecology and Obstetrics
Orthopaedics
4.60. The hospital(s) should have had minimum of 100 minor procedures in the past 12 months
in each of the two specialties identified in 3.96
4.61. The hospital(s) should have had minimum of 100 major procedures in the past 12 months
in each of the two specialties identified in 3.98
Lab volume
4.62. The hospital should have had more than an average of 300 haematology tests performed
every month, for the past twelve months
4.63. The hospital should have had more than an average of 30 units of blood provided by
blood bank per month, for the past twelve months
4.64. The hospital should have had more than an average of 1000 chemical pathology tests
performed every month, for the past twelve months
4.65. The hospital should have had more than an average of 150 microbiology tests performed
every month, for the past twelve months
4.66. The hospital should have had performed more than an average of 30 biopsies per month,
for the past twelve months
35
Facilities
4.67. Each of the hospital(s) must have hospital pharmacy, both for indoor and outdoor
patients
4.68. All the hospital pharmacies must have trained and qualified pharmacists, with minimum
qualification of Pharm D.
4.69. The hospital must have faculty workstations or offices for each of the faculty member.
4.70. The hospital(s) must have resuscitation area with all equipment
4.71. The hospital(s) must have 20 separate OPD rooms for specialties
4.72. The hospital(s) must have five designated areas / demonstration rooms in OPD for
teaching / evaluation of medical students
4.73. The hospital(s) must have five fully equipped operating rooms
4.74. The hospital(s) must have a Central Sterilization and Store Department (CSSD)
4.75. The hospital(s) must have a radiology department

FRAMEWORK 2019
It
2. Decision Rules
Recognition evaluation is performed by inspectors appointed by PMDC to verify that a

college meets the infrastructure, equipment, faculty, staff and teaching hospital requirements.
In order for a college to qualify for recognition, the college must meet all of the standards as
per the following:
1. The college meets all the legal requirements

2. The college meets all the infrastructure requirements
3. The college meets at least 90% of equipment requirements Commented [WU31]: 90 PERCENT OF MAJOR EQIPMENT
requirement
4. The college meets at least 90% of the faculty requirements
5. The college meets at least 90% of the teaching hospital requirements
After satisfying all the above requirements, the college is recommended for a performance
evaluation, after which the college will be recognized by PMDC for admitting students to the
program.
For new colleges, applying to PMDC for recognition for the first time, a complete
performance evaluation may not be performed. Instead only components related to curriculum
design, assessment methods, faculty, institutional safety and hospital safety may be
performed. Full performance evaluation may be performed within 12 months of the start of
education in the college.
The decision rules for meeting the requirements outlined above are as:
Decision Rule Number 1 (Legal):

■ If all the legal requirements of college are verified to be met, the requirement for this
standard are deemed to be met.
■ If in any of the legal requirements are not met, the college will be deemed to have not
met the requirements of this standard.
Decision Rule Number 2 (Infrastructure):

■ If all the measurable elements of infrastructure of college are verified to be met, the
requirement for this standard are deemed to be met.
■ If in up to 10% of the measurable elements regarding infrastructure requirements are
not met, the college will be given 12 months to rectify the deficiency and the college
will be deemed to have provisionally met the requirements of the standard. Upon
rectification of the deficiency as verified by PMDC during onsite college visit, the
requirement for this standard are deemed to be met
37
■ If in more than 10% of measurable elements of the infrastructure compliance is not
met the college will be deemed to have not met the requirements of this standard.
Decision Rule Number 3 (Equipment):

■ If up to 90% of the measurable elements of equipment of college are verified to be
met, the requirement for this standard are deemed to be met.
■ If in up to 25% of the measurable elements regarding major equipment requirements
are not met, the college will be given 12 months to rectify the deficiency and the
college will be deemed to have provisionally met the requirements of the standard.
Upon rectification of the deficiency as verified by PMDC during onsite college visit,
the requirement for this standard are deemed to be met.
■ If in more than 25% of measurable elements of the major equipment compliance is not
■ If in any of the measurable elements, the equipment specified as ‘minor’ are not
available or functional, the college will be given 6 months to rectify the deficiency and
get it verified by PMDC
Decision Rule Number 4 (Faculty and Staff):

■ If up to 90% of the measurable elements of faculty of college are verified to be met,
the requirement for this standard are deemed to be met.
■ If in up to 25% of the measurable elements regarding faculty requirements are not
met, the college will be given 12 months to rectify the deficiency and the college will
be deemed to have provisionally met the requirements of the standard. Upon
rectification of the deficiency as verified by PMDC during onsite college visit, the
requirement for this standard are deemed to be met
■ If in more than 25% of measurable elements of the faculty and staff compliance is not
Decision Rule Number 5 (Teaching Hospital):

■ If any of the measurable elements of the section ‘General’ are found to be non-
compliant, the requirements of this standard are deemed to be not met.
■ If up to 90% of the measurable elements in sections other than ‘General’ of teaching
hospital are verified to be met, the requirement for this standard are deemed to be met.
■ If in up to 25% of the measurable elements regarding teaching hospital requirements
are not met, the college will be given 12 months to rectify the deficiency and the
college will be deemed to have provisionally met the requirements of the standard.
Upon rectification of the deficiency as verified by PMDC during onsite hospital visit,
the requirement for this standard are deemed to be met

FRAMEWORK 2019
■ If in more than 25% of measurable elements of the teaching hospital compliance is not
39
Methodology
Recognition Evaluation (Pre-requisite):

Recognition evaluation is performed to evaluate adherence of the college with the “PMDC
Standards for Recognition of Medical and Dental College” to ensure adequate and safe teaching
facilities are available for the students of the college. Recognition evaluation is carried out by
team of inspectors. Details of evaluation methodology are described in this document.
The process of evaluation is explained in detail as below:
Medical and Dental College’s Responsibilities

For a recognition inspection, the university with which the medical college is a constituent or
affiliated will conduct a self-evaluation based on the standards in this document based on data
of twelve-month period prior to the visit and submit the required copies to the Inspection Cell
at PMDC at least one month prior to the visit.
The Inspection Cell of PMDC shall select inspectors for the recognition evaluation survey at
least two weeks prior to the survey.
Inspection Coordinator
In preparation for the inspection visit, the dean should select a person to coordinate the logistics
of the visit. This person will serve as the liaison with the PMDC Inspection Cell about
preparations, scheduling and site visit arrangements.
Provision of a ‘Inspectors Room’ at the College

The team will require a dedicated room at the college. The room should have a furniture
enough to accommodate the team. It should, preferably, be close to the dean's office, so that
staff can control access and adjust the schedule as needed. The dean’s office should provide
any additional material the team may need in the room, including copies of selfevaluation
reports and any other documents requested by the team
The Inspection Schedule

The PMDC Inspection Cell in collaboration with the college and the team finalises the schedule
at least two weeks before the team arrives.
The administrators of clinical facilities should be advised that surveyors may be visiting patient
care units.

FRAMEWORK 2019
Typical Survey Plan
A typical inspection of a college consists of:
1. Infrastructure Evaluation: This evaluation is conducted by an architect appointed by

PMDC along with two civil technologists.
College Responsibility: For this evaluation, the medical and dental college is required
to submit a CAD drawing (in soft) of its layout to PMDC Quality and Accreditation
Cell. College shall also ensure that relevant engineers or technologists are available
during the site visit.
PMDC Responsibility: The appointed architect shall study the drawing and verify that
the drawing meets the requirements for covered area by the PMDC. In case, the
drawing meets the requirements of PMDC standards, architect and two civil
technologists will visit the college for one day and verify the actual building layout
with the CAD Drawings of the college.
Duration: Typical duration of this evaluation shall be one-day.
2. Equipment Evaluation: This evaluation is conducted by a team of a bio-medical

engineer and assisting quantity-surveyors to verify that the equipment required in
each section of the college is available. Basic Sciences faculty member as part of the
inspection team may assist in ascertaining the suitability of equipment in the
laboratory and Clinical Sciences faculty member as part of the inspection team may
assist in ascertaining the suitability of equipment in the hospital.
College Responsibility: For this evaluation, the college is required to submit self-
evaluation of the inventory of all equipment required by the standards. This includes
the equipment required in the teaching hospital. College shall also ensure that
relevant engineers or technologists at the college and hospital are available during the
visit
PMDC Responsibility: The appointed engineers and technologists shall study the self-
evaluation. In case, the self-evaluation meets the requirements of PMDC standards,
biomedical engineers and a quantity-surveyor shall verify all the medical equipment
in the college and teaching hospital.
Duration: Typical duration of this evaluation shall be two-days.
3. Faculty Evaluation: This evaluation is conducted by two inspectors appointed by

PMDC, one Health Professional Education Expert and one Health Institution
Management Expert.
College Responsibility: For this evaluation, it is the college’s responsibility to do a
selfevaluation of the basic sciences and clinical faculty of the college. It is also
college’s responsibility to ensure availability of head of department of each basic
science faculty during the evaluation visit.
PMDC Responsibility: The appointed inspectors shall review the list of faculty
submitted by the college before the visit. During the evaluation visit, the inspectors
will review faculty contract documents, speak to various faculty members and heads
of departments, and review curricular document to correlate faculty requirements to
education delivery.
Duration: Typical duration of this evaluation will be 0.5 days.
4. Hospital Evaluation: This evaluation is conducted by an inspector appointed by PMDC,
41
Hospital Management and Safety Expert.
College Responsibility: For this evaluation, it is the college’s responsibility to do a self-
evaluation of the meeting the requirements of the teaching hospital. It is also college’s
responsibility to ensure availability of hospital administration and any other relevant
documents or data during the visit.
PMDC Responsibility: The appointed inspector shall review the clinical facilities
during the hospital tour. The inspector shall ensure that all those clinical specialties that
are required are available in the teaching hospital(s). Moreover, the inspector shall
ensure that patient load is according to the minimum requirements of the standards.
Duration: Typical duration of this evaluation will be 1 day.
Surveyor Evaluation
Evaluation of the college layout submitted to PMDC to

Architect and Civil
actual — and comparing it with the space requirements of
Supervisors
PMDC
Biomedical Engineer and Evaluation all medical equipment requirements

Quantity Surveyor
Health Professional
Education Expert and Curriculum Evaluation/Faculty Evaluation/Student
Health Institution Evaluation
Management Expert
Hospital Management and

Teaching Hospital Evaluation/Medical College Safety Tour
Safety Expert
Basic Sciences Faculty

Basic Sciences-Medical College Facilities Evaluation
Member
Clinical Sciences
Hospital Equipment and Patient Load Evaluation
Faculty Member

FRAMEWORK
FORMEDICAL
ANDDENTALSCHOOLS
INPAKISTAN-2019
PMDC Accreditation Framework
2
1 CONTENTS
Standards
Evaluation Framework
Evaluation Process
3
Introduction
This document describes the different components of the accreditation framework for medical
and dental colleges in Pakistan.
This document has various sections that not only help evaluate medical and dental colleges in
Pakistan but also help the medical and dental colleges to improve the standard of education.
This accreditation framework reproduces the standards adopted and approved by Pakistan
Medical and Dental Council (PM&DC), developed in line with the standards prescribed by
World Federation of Medical Education (WFME).
This framework also highlights how the results of evaluation impact the functioning of
medical and dental colleges in Pakistan. Evaluation tools shall be developed by the Evaluation
Committee such that they ensure objectivity and transparency and are in line with the
requirements of the standards.
PMDC Accreditation Framework 4

Standards
Standard Pakistan Standards for Accreditation of Medical and Dental

Standard Colleges
Standard
1: Mission Statement 2: Outcomes
Standard
3: Institutional Autonomy and Academic Freedom
Standard
4: Curricular Organisation
Standard
5: Educational Contents
Standard
6: Curricular Management
Standard
7: Assessment
Standard
8: Student
Standard
9: Faculty
Standard
10: Program Evaluation and Continuous renewal 11: Governance, Services and
Standard
Resources 12: Research and Scholarship
5
Standard 1: Mission Statement
Essential Standards
A medical/dental college must have a written institutional mission statement, which:

1.1. is aligned with the vision of the university with which it is affiliated or of which
it is a constituent institution
1.2. demonstrates a clear institutional commitment to social accountability,
achievement of competencies and addresses the health needs of Pakistan
1.3. is developed with stakeholders’ participation (for example faculty members,
staff, students, university, health ministry officials)
1.4. is known to all stakeholders
Quality Standards
A medical/dental college should have a written institutional mission statement, which:

1.1s Aims at professional development and a commitment to life-long learning
Annotations
Mission
DEFINITION: Mission Statement: A characteristics of an ideal mission statement: Mission
statement must be:
1. Brief
2. Focused (towards the main targets of the institution)
3. Realistic
SAMPLE:
ABC medical college’s mission is to produce competent, research oriented doctors who can
serve the local and global communities equally adeptly and professionally.
Social Accountability
Social accountability of healthcare institutions is their responsibility towards the community
and their graduates. It is the responsibility of the medical/dental colleges and universities to
meet the health care needs of the country through provision of quality education, research and
service delivery. This service delivery is not restricted to the tertiary care teaching hospital but
these institutions should take ownership of defined populations (especially marginalized
populations) and improve the health status of those communities. This act of the
medical/dental colleges and universities should be documented with justification for the scope
of undertaken actions and a verification that anticipated outcomes and results have been

attained.
7
Standard 2: Outcomes
Essential Standards
The medical/dental college must develop outcomes that:

2.1 are in congruence with the mission of the institution
2.2 incorporate the knowledge, skills and professional behaviours that the students
will demonstrate upon graduation
2.3 are contextually appropriate for health care delivery in Pakistan.
2.4 have been developed in consultation with all stakeholders
2.5 are known to all stakeholders
2.6 are reviewed and revised in the light of program evaluation
Quality Standards
The medical/dental college should:
2.1s define the outcomes of the program which differentiates the institution from other similar
institutions
Annotation
Outcomes
1. Outcomes are statements of intention, just like objectives.
2. Outcomes provide a clear idea of what the learners are expected to do (perform) at the end
of the entire learning period (e.g. at the end of the MBBS/ BDS program). Hence, they
provide an overview (and not details) of what the learner is expected to do upon
completion of the education program in which he/ she is enrolled.
3. The number of outcomes is far less than the number of objectives. Usually outcomes
range between 5 to 7 for an extended program.
EXAMPLE: By the end of the (MBBS/ BDS) program, graduates will be able to:
• Manage common, non-critical conditions independently
• Assist in the management of critically ill patients
• Demonstrate professional, ethical and culturally-appropriate behaviour
• Advocate health promotion and disease prevention
• Work effectively in a health care team
• Demonstrate clear and efficient written and verbal communication abilities
Annotation for 2.2

Professionalism refers to ethical practices and behaviours as defined by the professions
including but not restricted to honesty, integrity, fairness and demeanour befitting a
medical/dental graduate.
8
Annotation for 2.1s
Outcomes are a set of statements which summarise the expected results at the end of the
educational program (MBBS/ BDS). Every institution must have a reason for existence. This
reason should be its unique feature which sets it apart from other institutions. An institution
may wish to lay emphasis on training its graduates within the community, or on providing
state-of-the-art high technology training via skills labs or aims at producing doctors’ adept at
practical research. Such unique features must be clear in the outcomes; such statements must
be present which help provide an identity to the program and to the institution.
9
Standard 3: Institutional Autonomy and Academic Freedom
Essential Standards
The medical/dental college must have institutional autonomy to:

3.1 formulate and implement policies to ensure smooth execution of its educational outcomes
3.2 develop a system for ensuring that the policies are implemented
3.3 allocate and appropriately use resources for implementation of the curriculum
Quality Standards
The medical/dental college should have institutional autonomy to:

3.1s select, design and implement its curriculum that is based on best evidence, medical/dental
education and meets the standards set by PM&DC.

Standard 4: Curricular Organisation
Essential Standards
The medical/dental college must:

4.1 have a curriculum aligned with the university vision, institutional mission and local and national
needs, for contextual relevance
4.2 clearly document the sequence of courses along with their rationale for the sequence
4.3 develop and implement a curriculum which meets the standards of PM&DC
4.4 develop and implement a curriculum which is outcome-based, patient-centred, community-
relevant, and promotes health and prevents diseases
4.5 encourage students to link concepts of basic and clinical disciplines
4.6 ensure that clinical sciences get at least half of the time of the undergraduate program
4.7 ensure systematic and organized learning in clinical settings
Quality Standards

4.1s incorporate a horizontally and vertically integrated curriculum.
4.2s incorporate innovative educational strategies such as self-directed learning,
independent learning, inter-professional learning, use of e-technology and simulations. 4.3s
have student-selected components (electives) as part of the curriculum
4.4s implement a curriculum which incorporates active learning as an integral educational
strategy
Annotations
• Active learning is any instructional strategy in which students are required to do

meaningful activities and think about their learning during the class in order to achieve
the session’s objectives.
• Educational strategy means teaching method or instructional method, for example lecture
or tutorial or small group discussion.
• Outcomes are statements describing what students can do at the end of the program
• Patient-centeredness keeps the curriculum focused around issues of the patient and not
around diseases. It aims to produce doctors who deal with patients as humans and not as
carriers of disease. It helps graduates provide holistic care to the patients.

Standard 6: Curricular Management
Essential Standards

5.1 ensure that educational content is decided in consensus by a group of relevant subject
experts including faculties of basic, clinical, behavioural and community health sciences
5.2 ensure that the content and its delivery are aligned with the competencies and/ or
outcomes agreed upon by the institution
5.3 ensure that the content that is taught and assessed is relevant to practice for a general
practitioner
5.4 have a document describing the content, extent and sequencing of courses and other components
of the curriculum (curricular map)
5.5 include the following along with the basic, clinical & community health sciences:
a. Behavioural sciences
b. Communication skills
c. Family medicine
d. Forensic medicine and toxicology
e. Islamiyat and Pakistan studies
f. Patient safety
g. Professionalism, medical and Islamic ethics
h. Research
i. Evidence-based medicine
j. Infection control
5.6 ensure that the curriculum includes applied basic sciences relevant to general practice
5.7 ensure that the students spend sufficient time in planned contact with patients in relevant clinical
settings
5.8 ensure that a representative from the department of medical education is present to facilitate the
process of content agreement
Quality Standards

5.1s include social sciences in their implemented curriculum in order to help students
understand how individuals interact with society as a whole and how individual behaviour
affects promotion of health and prevention of diseases
5.2s include topics like study skills, leadership, principles of management and medical
education/teaching strategies in the program
5.3s ensure that the students spend sufficient time in planned contact with patients and
community in relevant clinical and community settings

Standard 5: Educational Contents
Essential Standards
The medical / dental college must:

6.1 have a curriculum committee duly represented on the institutional organogram
6.2 have process of:
defined terms of reference (TORs) for the curriculum committee including the
a. planning, implementation and evaluation of the curriculum in order to ensure that

educational outcomes are achieved.
b. planning, implementation and evaluation of innovations in the curriculum
c. ensuring representation of at least one member from the Department of Medical
Education with a postgraduate qualification in medical education recognised by the
PM&DC
6.3 ensure that adequate supervision of learning experiences is provided throughout required
laboratory work, skills labs, chair-side teaching, clinical rotations and
field visits
6.4 develop study guides which clearly specify overall objectives of the course and terminal
objectives for every teaching session.
6.5 disseminate study guides to the students and faculty (preferably on-line as well)
13
Standard 7: Assessment
Assessment is an essential and integral part of educational process. Its outcome bears
importance for both students as well as for the faculty and institution. For students, its
importance lies in the fact that it affects the decisions of pass and fail, ranking, awards and
distinctions, and issue of transcripts. For the faculty, assessment provides the grounds for
substantiation of their teaching methodology and achievement of educational outcomes. For
the institution, it provides the essential and sound grounds for program evaluation and brings
forth important input for curriculum development and evolution.
Essential Standards
The medical / dental college must:

7.1 develop appropriate and contextual policies for assessment of students.
7.2 ensure that assessments cover knowledge, skills and attitudes
7.3 use a wide range of assessment methods
7.4 define a clear process of assessment
7.5 ensure that the assessment practices are compatible with educational outcomes and
instructional methods.
7.6 implement pre-, per- and post- exam quality assurance procedures in assessment by the
university with which the college if affiliated or is a constituent of
7.7 use external examiners to ensure fairness
7.8 use a system for appeal of results
7.9 ensure assessments are externally evaluated
Quality Standards
The medical / dental college should:

7.1s use standard setting methods for examination items
7.2s use integrated assessment instruments such as cluster MCQ’s, extended matching
questions
14
As consumers of institutional services, students are the most important stakeholder
group in higher education. The institutions must engage their students in the
management, delivery and evaluation of their services. They should be consulted, given
certain rights and responsibilities in all academic matters that concern them. This
section provides a set of essential (must) and quality (should) standards for
undergraduate medical/dental education in Pakistan.
Essential Standards

8.1 follow the admission policy in congruence with the national regulations/guidelines.
8.2 have student support programme addressing financial needs.
8.3 ensure that students have access to counselling to address their psychological,
academic and/ or career needs.
8.4 ensure confidentiality of students’ academic and medical records.
8.5 ensure student representation and appropriate participation in educational
committees and any committee where they can provide meaningful input.
8.6 have access to their records and appeal’s process in case of discrepancies.
8.7 have clear policies, funding, technical support and facilities regarding
co- curricular opportunities for the students.
8.8 have a policy and practice to systematically seek, analyse and respond to
student feedback about the processes and products of the educational
programmes.
8.9 provide access to preventive and therapeutic health services to all the students.
8.10 ensure a fair and formal process for taking any action that affects the
status of a student.
8.11 have policies and code of conduct that is known to all students.
8.12 have clearly defined transfer policy in line with the PM&DC regulations
Quality Standards

8.1s have infrastructure for disabled students.
8.2s provide scholarships/bursaries to students based on clearly defined criteria.
8.3s have student exchange mechanism regionally and internationally.
Annotations
Student support programme means loans schemes and debt management counselling to
address their financial needs.
Needy students means students who are on merit and can provide an evidence that they
do not have enough funds to continue their studies. The institutional academic council
15
Standard 8: Student
might define criteria and consider the cases on merit basis.

Academic counselling would include addressing questions related to the student’s choice of
selected components/electives
Career counselling would include guidance related to achieving their career goals and entry
into postgraduate programs
Confidentiality means available only to members of the faculty and administration on a need
to know basis. Laws concerning confidentiality of record need to be kept in view.
Committees include all educational, management and disciplinary committees. This includes
development of the mission and vision, policy guidelines, curriculum committees, academic
council and service delivery.
Areas of appeals include admission, attendance, assessment, promotion, demotion or

dismissal processes and products of the educational programmes means curriculum, teaching
and learning processes.
Fair and formal process includes timely notice of the impending action, disclosure of the
evidence on which the action would be based, an opportunity for the medical student to
respond and an opportunity to appeal
Status of student means that can affect his/her educational progression for example
admission, promotion, demotion, graduation or dismissal
Disability means any physical disability which may not affect his/her ability to actively
contribute as a member of healthcare team. The institutional medical team should decide it on
case to case basis.
Scholarships/bursaries mean reduction in fee or free education based on performance. The

institutional academic council might define some criteria and select on merit.
Transfer policy and exchange mechanisms means policies devised by the affiliating
university for transfer and student exchange in congruence with PM&DC guidelines.
17
Standard 9: Faculty
Essential Standards

9.1 ensure that the institution’s leadership is qualified by education, training and experience
9.2 have documented job description
9.3 have faculty recruitment, selection, promotion and retention policies based on the
policies/criterias provided by the PM&DC and universities’ statutory bodies.
9.4 have sufficient trained faculty to meet the medical educational needs as per PM&DC
regulations.
9.5 have faculty fulfilling its various roles
9.6 have faculty development program (FDP) with clear goals aligned with faculty and program
needs
9.7 have opportunities for national CME/CPD activities
Quality Standards

9.1s have the program for training the trainers
9.2s have evidence-based educational innovation in faculty development approaches 9.3s link
the annual appraisal/performance report (including research output) of faculty with their
promotion
9.4s provide opportunities for international CME/CPD activities

Standard 10: Program Evaluation and Continuous renewal
The evaluation of programs overlaps with quality assurance requirements of the Higher
Education Commission (HEC), that has mandated every higher education institute (HEI) to
adopt the quality assurance standards and procedures.
The PM&DC encourages the universities for ensuring quality assurance and compliance with
PM&DC and HEC standards.
Essential Standards

10.1 ensure processes and schedules for review and update of all academic activities through an
established mechanism of program evaluation.
10.2 regularly review results of evaluation and student assessments to ensure that the gaps
are adequately addressed in the curriculum in consultation with curricular committee.
10.3 allocate resources to address deficiencies and continuous renewal of programs.
10.4 have program evaluation in compliance with PM&DC accreditation standards
10.5 ensure that students, faculty and administration are involved in program evaluation.
10.6 have mechanism for curriculum monitoring and progressive improvements.
10.7 ensure that amendments based on results of program evaluation findings are
implemented and documented.
Annotations
Program evaluation: Gathering, analysis and interpretation of information, using valid and
reliable methods of data collection, from all components of the program. The process of
evaluation should serve to make judgments about its effectiveness in relation to the mission,
curriculum and intended educational outcomes.
Academic activities: These include all formal educational experiences of the learner during
his enrolment in the institute.
Gaps: This refers to deficiencies in the fulfilment of curricular standards as defined in

PM&DC standard 4.
Renewal of programs: This refers to modifications made in the program by incorporating

results of program evaluation.
Curriculum Monitoring: This implies supervising and proctoring processes of curricular

development and implementation.
19
Standard 11: Governance, Services and Resources
Essential Standards

11.1 have hierarchical system of academic governance.
11.2 have mechanisms for dissemination of all policies and procedures related to
governance, services and resources
11.3 have clear roles/authority of Dean and /or Principals and HOD’s as per PM&DC rules
11.4 have adequate and safe buildings and structures for medical/dental college, teaching
hospital and housing facilities as per PM&DC initial evaluation
11.5 have satisfactory and functional IT and library facilities
11.6 have adequate financial resources for institutional requirements
11.7 have fulfilled all legal requirements
11.8 have mechanisms for addressing disciplinary issues
11.9 have incorporated the principles of social accountability in the medical/dental college
11.10 have an established department of medical education
11.11 have health, fitness, faculty support and cafeteria facilities

NATIONAL ACCREDITATION FRAME WORK,
FOR MEDICAL ANO DEMTALSCHOOL IN PAMSUN -2019 vH
Standard 12: Research and Scholarship
Essential standards

12.1 have a research advisory committee that can facilitate faculty and students on research.
12.2 have research as an integral part of the curriculum.
12.3 provide opportunities for research to the students and faculty.
Quality standards

12.1s have a research cell led by an appropriately qualified faculty member and with adequate
support staff that can guide faculty and students on research.
12.2s demonstrate a commitment to continuing scholarly productivity.
12.3s provide opportunities for multi-disciplinary and applied research.
Annotations
Medical research and scholarship encompasses scientific research in basic, biomedical,

clinical, behavioural, public health, social sciences and health professionals education.
Medical scholarship means the academic attainment of advanced medical knowledge and
inquiry. It must meet these criteria: i) The work must be made public. Ii) The work must be
available for peer review and critique according to accepted standards. Iii) The work must be
able to be reproduced and built on by other scholars. The examples would include original
papers, systematic reviews, scoping review, meta-analysis, literature reviews, concept and
innovative papers, different publications such as short communications, teaching innovations,
developing course documents, developing and maintaining the online curricular documents,
and preparing teaching material and presenting it for peer- review.
The research component within the curriculum would be ensured by research activities
within the medical school itself or its affiliated institutions, and by the scholarship and
scientific competencies of the teaching staff.
Multi-disciplinary research would include any research beyond health sciences for example;
agriculture, engineering, computer sciences and IT (developing an App).
21
Framework
The accreditation framework of PM&DC separates pre-requisites for establishing a medical and
dental college from on-going evaluation of the quality of education being delivered. While the
pre-requisites are evaluated once, where either a college meets the requirements or not — the
performance evaluation is done at a frequency according to their category as defined in this
section to ensure quality of delivery of education. For clarification, different evaluations terms are
explained below:

A mandatory evaluation carried out to determine whether the college meets the basic / minimum
requirements to be recognized as a medical or dental college. Such evaluation is to be mandatorily
carried out prior to granting an institution recognition for the first time and to be carried out any
time by the Order of the Evaluation Committee pursuant to complaints or reports received against
any existing college or by a general order of the Evaluation Committee.
Performance Evaluation:
An evaluation carried out on a recurring basis to determine the quality of education being
imparted by the college and facilities offered to students towards improvement of quality of
education. This evaluation is done on at a frequency determined by the category of the college or
carried out any time by the Order of the Evaluation Committee pursuant to complaints or reports
received against any existing college or by a general order of the Evaluation Committee.
Performance Category:
Categories defined by the Council for placement of each recognized college pursuant to a
Performance Evaluation and the recommendation of the Evaluation Committee.
Categories shall be separately notified for Medical and Dental institutions and similarly for Public
and Private institutions.
A+ Category The following are Performance Categories:
Superb performance obtaining an evaluation score equal to or

A Category above 85%.
Excellent performance obtaining an evaluation score between
B Category 80% and 84%
Upper Mid-level performance obtaining an evaluation score between 70% and 79%.

C Category
Mid-level performance obtaining an evaluation score between
D Category 60% and 69%.
All newly recognized or any existing colleges, obtaining
F Category
performance evaluation score between 50% and 59%.
Performance evaluation score less than 50%
Evaluation Frequency
Colleges will be evaluated at the following frequency

Category Evaluation Frequency
A+ Category Every 3 years
A Category Every 3 years
B Category Every 2 years
C Category Every 1 year
D Category Every 1 year
F Category Upon Meeting the Requirements
Achievement & Upgradation System

Performance Evaluations shall be carried out as per the categorization of college. A private
college placed in a given Performance Category shall have the following prescribed method to
upgrade to the next category and consequent penalties for failing to achieve improvement.
Category Period Penalty
One year period granted to achieve Failure to achieve results in
D Category
Category C. stopping further admissions
Failure to achieve results in de-

Two consecutive year mandatory period to recognition and transfer of
improve to Category C. students to a higher category
college.
23
Failure to achieve results in pre-
One year period granted to achieve suspension warning and
C Category
Category B. reduction in allocated seats by
20%.
Two-year consecutive mandatory period to Failure to achieve results in
improve to Category B. stopping further admissions.
Failure to achieve results in de-
Three-year consecutive mandatory period recognition and transfer of
to improve to Category B. students to a higher category
college.
Public colleges shall be correspondingly categorized based on performance for public knowledge
and provincial governments advised to seek improvement.
Demotion
A college failing to achieve the minimum score for the category it was existing in would be
demoted to the category below.
Incentive Plan
The incentives for the medical and dental colleges based on their categories are:
Permission to increase students by
Category Fee not to be regulated under batches of 50 every three-year, subject
A+ maximum cap. to conduct of Recognition Evaluation
to determine enhancement of capacity.

batches of 50 every three years subject
Fee not to be regulated under
Category A to conduct of Recognition Evaluation
maximum cap.
to determine enhancement of capacity.
batches of 25 every three years subject
to conduct of Recognition Evaluation
Fee capped to a maximum of
Category B to determine enhancement of capacity.
1,200,000 per year per student.

Category C No increase of students allowed.
1,050,000 per year per student.

Category D No increase of students allowed.
950,000 per year per student.

NATIONAL ACCREDITATION FRAME WORK
rOR MEDICAL ANO DENTAL SCHOOL IN PAKISTAN - 2019
Method

Recognition evaluation is performed to evaluate adherence of the college with the “PM&DC
Initial Inspection Proforma” to ensure adequate and safe teaching facilities are available for the
students of the college. Recognition evaluation is carried out by a team of inspectors. Details of
evaluation methodology are described in the respective guides.
Performance Evaluation (On-Going)

The ongoing evaluation of a medical or dental college is carried out by a team comprising of
inspectors from PM&DC of professional categories including health professional education
expert, health institution management expert and a hospital management and safety expert.
Certificate of compliance with the pre-requisites on all aspects of the initial inspection is to be
provided by the medical and dental college leadership. Inspection team will randomly check at
least three items from any section of the initial inspection during the survey.
The process of evaluation is explained in detail as below:
Medical and Dental College’s Responsibilities

For an evaluation survey, the university with which the medical college is a constituent of or
affiliated with will conduct an evaluation on the same tool as prescribed in this accreditation
framework and prepare the appropriate information required for the survey during the twelve-
month period prior to the survey and submit the required copies to the Quality and Accreditation
Cell at PM&DC at least one month prior to the survey. The medical college shall provide a
certificate of compliance with the pre-requisites on all aspects of the initial inspection to be
provided by the college leadership. The university or college can take help from the PMDC’s
Guidelines for Implementation of Accreditation Standards for Medical and Dental Colleges.
The Quality and Accreditation Cell of PMDC shall select surveyors for the performance
evaluation survey at least two weeks prior to the survey. The profiles of the team members shall
be sent to the dean’s office at medical college one week before the survey.
Survey Coordinator
In preparation for the survey visit, the dean should select a person to coordinate the logistics of
the visit. This person will serve as the liaison with the PMDC Quality and Accreditation Cell
regarding preparations, scheduling and site visit arrangements.
25
Provision of a ‘Surveyors Room’ at the College
The team will require a dedicated room at the college. The room should have furniture suitable to
accommodate the team. It should, preferably, be close to the dean's office, so that staff can control
access and adjust the schedule as needed. The dean’s office should provide any additional
material the team may need in the room, including copies of selfevaluation reports and any other
documents requested by the team, such as course evaluations, syllabi, etc.
Student Involvement in the Survey

Survey team will meet with students. Students shall be selected randomly so that they may
provide truly representative student input. The survey team will seek student opinions about a
variety of topics, including the quality and adequacy of the educational programme, student
academic and personal counselling, health service, financial aid, and the role of students in
academic policy and feedback. Students may also serve as guides in the visits to the library,
classrooms, laboratories, learning centres, and clinical facilities. The confidentiality of the student
feedback shall be maintained by the team to ensure no repercussions against the students
involved.
The Visit Schedule

The PMDC Quality and Accreditation Cell in collaboration with the college and the team, shall
finalise the schedule at least two weeks before the team arrives.
The administrators of clinical facilities should be advised that surveyors may be visiting patient
care units. Student guides may conduct the tours.
Exit Conference/ Survey Report

Before departing, the team chair will give the dean and the executive (vice-chancellor, president,
etc.) a printed summary report, which contains the score of the proforma, to be signed by the
dean. In case of successful accreditation, PMDC shall issue certificate of accreditation after the
approval of the Evaluation Committee and Council, the category that the college got classified
into, and list the medical college and its category on its website. In case of any dispute in the
report, the dean’s office may communicate with the PMDC’s Quality and Accreditation Cell.
Typical Survey Plan
A typical survey of a college shall consist of:
1. Leadership Session: All three surveyors meet the leadership to get an overview of the
college, any changes from the last survey, get an overview by the college leadership on
continued compliance with legal requirements, details of MoUs with any teaching
hospitals, etc.
2. Medical College Management Session: A session conducted by the Institutional

Management Expert with discussion on management and resources of the college

including organisational relationships of college with university and teaching
hospital(s), organisation of staff, interaction of dean with college’s governance
organisation, councils, committees and academic departments, financial status and
projections, research programmes and funding, and the status of facilities for
education, research and patient care. Adequacy of finances for the achievement of the
college’s missions are discussed; recent financial trends and projections for various
revenue sources, financial health of and market conditions for the clinical services are
also reviewed with the leadership of the college.
3. Curricular Organization and Curricular Management Session: Session conducted

by the Health Professional Education expert with the relevant leadership of the
medical college to review educational objectives, outcome measures and how they are
integrated throughout the curriculum. The session also focuses on curriculum design,
content coverage, and methods of teaching and evaluation of student performance.
Evidence of implementation of curriculum is also reviewed.
Next the Health Professional Education expert will discuss with the relevant
leadership of the medical college that constitute the curriculum committee to review
Curriculum management and programme evaluation. The session also focuses on
discussion of the system for implementation and management of the curriculum;
adequacy of resources and authority for the educational programme and its
management; and methods for evaluating the effectiveness of the educational
programme and evidence of success in achieving objectives. Evidence of effective
management is reviewed.
4. Infrastructure Tour: This tour is conducted by the Architect. The focus of this tour
is to evaluate adequacy of infrastructure in terms of space, seating requirements,
hostel and other facilities for medical education. The architect will review the map
(CAD) and will ensure that the infrastructure is in alignment with the drawings and its
corroboration with PMDC requirements.
5. Biomedical Equipment Tour: This tour is conducted by the Biomedical Engineer.

The focus of this tour is to evaluate adequacy of equipment and relevant material
required for provision of appropriate medical education.
6. Medical College Safety Tour: This tour shall focus on the safety of systems in the
medical education. The safety focus shall remain on fire safety, general safety,
disaster preparedness, hazardous material, infection prevention and control and safety
of water systems.
7. Student Session: This session is conducted with students by the Institutional

Management Expert for discussion of students’ personal, academic, career and
financial counselling system in the college, financial aid; health services; infection
control education and counselling; student perspective of curriculum, teaching, and
evaluation/grading; students’ role and perceived value of student input in academic
planning, implementation and evaluation. The session shall also review the
27
effectiveness of academic counselling, policies and procedures for student
advancement and graduation and for disciplinary actions; review standards of conduct
and policies for addressing student mistreatment, career guidance strategies; advanced
and sub-specialty clerkships/clinical experiences and electives for rounding out
clinical education of the students.
8. Faculty Session: This session focuses on interaction with faculty other than the
leadership already interacted with. The session focuses on discussion of notable
achievements and ongoing challenges in individual courses and clerkships/clinical
experiences; contributions of individual courses and clerkships/clinical experiences in
achieving institution’s educational objectives; adequacy of resources for education,
and availability of faculty to participate in teaching. There will also be a discussion
on faculty appointment, promotion policies, and faculty development opportunities,
effectiveness of faculty governance, faculty compensation and incentives, and
opportunities for collegial interaction among faculty.
9. Medical College Facilities Tour: Tour conducted by the Institutional Management

Expert Tour of clinical learning facilities including inspection of lecture halls, small
group classrooms, labs and study areas used for pre-clinical education of the students.
Visit of library and computer learning facilities. Visit of basic sciences department to
review successes and ongoing challenges in the administrative functioning of
departments; adequacy of resources for research, scholarship, teaching; and
departmental support for faculty and graduate programmes. Visiting and meetings
with heads of those departments that offer the major required clerkships/clinical
experiences. Discussions to include successes and ongoing challenges in
administrative functioning of departments; adequacy of resources for all missions
(clinical, research, scholarship, teaching); departmental support for faculty and
students; balancing of clinical and academic demands on faculty. Institutional tour
will include the hostel facilities and may be divided into multiple sessions throughout
the survey.
10. Hospital Facilities and Safety Tour: This tour is conducted by the Hospital
Management and Safety Expert. The focus of this tour is to evaluate adequacy and
safety of hospital facilities for clinical training. The safety focus shall remain on fire
safety, general safety, disaster preparedness, hazardous material, infection prevention
and control and safety of water systems. 1
1 Hospital Clinical Tour: This tour is conducted by the Clinical Sciences Medical
Expert. The focus of this tour is to evaluate adequacy and safety of hospital facilities
for clinical training. The focus shall not be on the documentation in the medical
record or the care provision in the hospital.

29
A typical agenda of the evaluation survey is:
0900 0930 1000 1030 1100 1130 1200 1230 1300 1330 1400 1430 1500 1530
0930 1000 1030 1100 1130 1200 1230 1300 1330 1400 1430 1500 1530 1600
CD
Infrastructure College infrastructure
Q.
O
Tour verification
O C (College)
> Biomedical Equipment College equipment
>4
CO Tour verification
CD c
> CD (Hospital)
CD
'c Q
Prayer
Curriculum, Break
>4
.Q
Curriculum Student Session
ttJO c Management
c o
■4—1
CD CD (College)
CD
c
CD
CO
CD Medical College Medical College Safety
Management Session Tour
0900 0930 1000 1030 1100 1130 1200 1230 1300 1330 1400 1430 1500 1530
0930 1000 1030 1100 1130 1200 1230 1300 1330 1400 1430 1500 1530 1600
Infrastructure
Tour (Medical
College)
Biomedical Equipment
Tour
(Medical College)
Medical College Facilities
Tour Follow-ups as needed
Prayer
Break & Closing Session
Faculty Session Hospital Clinical
Tour
Medical College Facilities
Tour
Hospital Facilities and Safety

Tour

Medical College Management Session
Purpose
A session conducted by the Institutional Management Expert with discussion on management and
resources of the college including organizational relationships of college with university and teaching
hospital(s); organization of staff; interaction of dean with college’s governance organization, councils,
committees and academic departments; Financial status and projections; Research programs and funding;
and the status of facilities for education, research and patient care. Adequacy of finances for the
achievement of the school’s missions are discussed; recent financial trends and projections for various
revenue sources are also reviewed with the leadership of the college.
Location
Dean’s Office or Committee Room
College Participants
■ Dean of the college
■ Finance Manager or equivalent of the college
■ Representation from the university with which the college is affiliated or is a constituent college
of
■ Leadership of the teaching hospital
Surveyor(s)
Institutional Management Expert
Standards/Issues Addressed
■ Standard 3: Institutional Autonomy and Academic Freedom (3.1 to 3.3)
■ Standard 8: Student (8.1 and 8.10)
■ Standard 9: Faculty (9.6, 9.7) and (9.4s)
Documents/Materials Needed
■ Medical College ownership document (or parallel)
■ Ownership evidence of Hospital beds
■ MOU of non-owned beds (If applicable)
■ SECP registration (if applicable)
■ Financial statement reflecting Working capital
■ Budget document
■ Annual audited financial reports
■ Evidence of utilization of FDP funds
■ Organogram of the college and relationship with the university
■ ToRs of curriculum committee
■ College’s faculty development program
How to Evaluate
To evaluate the compliance to relevant standards, review the documents provided by the college. Based
on the review, conduct a leadership interview session with the following list of questions answered:
Medical College Management Session
Compliance
Q
Evaluation Question
# Not
Yes No
Applicable

1. Has the medical college been established in a building owned
by the legal entity that has been granted the recognition?
(Ownership document)
Has the medical college ownership of at least 50% of the Yes
2. hospital beds?
(Ownership document)
Yes
3. Is the total student to bed ratio as per PMDC guidelines?
(500 beds per 100 students)
N/A
4. Does the medical college have the college must have a valid
and current contract with a third-party hospital for at least 5
years at the time of inspection(If applicable)
For a For a public college, it has to be approved by the
relevant ministry. For a private college, it must be
5. registered as a company with Security and Exchange
Commission of Pakistan (SECP) or other applicable
approvals such as:
a. a)Body corporate registered under the relevant laws of

companies or societies or trust.
b. Federal Government or Provincial Government
or Local Government.
c. Pakistan University
d. Public religious or charitable trust registered
under relevant law
Does the medical college have a minimum working capital 
6.. equivalent of no. of students x one month fee of each
student?
Does the college invest equivalent of 1% of the total annual 
7. fee into an endowment fund, utilization of which is regulated
a. Body corporate registered under the relevant laws of
by PMDC?
companies or societies or trust
Does the college have its account audited by a third party? 
8. (Report to be submitted to PMDC)
b. Federal Government or Provincial Government or Local

Government
c. Pakistan University
P a g e 71 | 175
The hospital owned by the college must have its 
9 account audited on an annual basis and annual report
made available to PMDC
Are all the teaching hospitals within 25KM of the medical 
10. college premises?
(under 30 min of travel under normal traffic conditions)
Does the college have a bank guarantee of PKR 30 N/A
11.
million?
Does the collage provide bank guarantee of PKR 20 N/A
12.
million for teaching hospital?
Does the public college’s governance structure compliant N/A
13.
with government regulations? (If applicable)
Does the private college’s governance structure compliant N/A
14.
with SECP regulations? If applicable)
15.
Does the college have a standardized budget development 
process?
(If yes) Is the budget development process collaborative 
16. and takes into account the requirements of curriculum
delivery from the faculty?

17.
Does the budget have resources allocated for co- curricular
activities, minimum of PKR 10,000 per student per year
Does the budget have resources allocated for faculty 
18. development program for national CPD, minimum of PKR
25,000 per faculty per year?
Does the budget have resources allocated for international 
19. CPD for faculty, minimum of equivalent USD 25,000?
Does the budget have resources for financial support of 

20. students, with minimum 5% students getting 25%
discounts?
21.
Does the budget have resources allocated for financial 
support of 1% students studying free of cost?
Does the budget correlate with the audited accounts of the 
22. previous year — taking into account the number of
students?
23.
Are HR policies developed, applicable to the college staff? 
24. Is there admission policy developed? 
25.
Is the admission policy in line with national regulations? 
26. Is there a mechanism to ensure that the vision of the

university and the mission of the college remain aligned?
27.
Is there a mechanism at the hospital’s end to ensure 
adequacy of clinical facilities for the program?
28.
Are all graduates given opportunity to medical students for 
house job in the hospital?
29. Is there a structured hierarchy defined for the institution?


(organogram of the institution and of various departments)
Is there a structured process to disseminate policies 
30. developed by the institutional leadership related to
governance, services and resources?
Are the roles and authorities of the Dean and or Principal 
31. clearly defined in his/her job description which are in
alignment with PMDC regulations?
Are the roles and authorities of the Head of departments 
32. clearly defined in his/her job description which are in
alignment with PMDC regulations?
Are the legal requirements related to medical institution 
33. fulfilled at the primary survey and are still valid?
34.
Is there an established mechanism to address disciplinary 
issues?
35.
Has the institution incorporated principles of social 
accountability in its program?
36.
Is there a department of medical education at the 
institution?
37.
Is there a process to allow females to take maternity 
leaves?
38.
Is there a process to ensure health needs of faculty are met? 
39. Is there a structured program to ensure fitness of faculty? 
40.
Is there a structured program to support socioeconomic 
needs of the faculty members?
Yes
Use the rest of the session to clarify any queries regarding the functioning of the medical school —
including information needed for subsequent sessions.
P a g e 73 | 175
Curricular Organization and Curricular Management
Session
Purpose
This session is conducted by the Health Professional Education expert with the relevant leadership of the
medical college to review educational objectives, outcome measures and how they are integrated
throughout the curriculum. The session also focuses on curriculum design, content coverage, and methods
of teaching and evaluation of student performance. Evidence of implementation of curriculum is
reviewed.
The scope of this session covers relevant leadership of the medical college that constitute the curriculum
committee to review curriculum management and program evaluation and discussion of the system for
implementation and management of the curriculum, adequacy of resources and authority for the
educational program and its management, and methods for evaluating the effectiveness of the educational
program and evidence of success in achieving objectives. Evidence of effective management is reviewed.
Location
College Committee Room
Members of the curriculum committee
Surveyor(s)
Health Professional Education expert
■ Standard 1: Mission Statement (1.1 and 1.2)
■ Standard 2: Outcomes
■ Standard 4: Curricular Organization
■ Standard 5: Educational Contents
■ Standard 6: Curricular Management
■ Standard 10: Program Evaluation and Continuous Renewal (10.5)
■ Document outlining mission of the institution
■ Document outlining vision of the university
■ Organogram of the institution reflecting curriculum committee
■ Terms of reference of the Curriculum Committee including its structure
■ Minutes of meeting reflecting discussion on curriculum and how the changes are made based on
feedback and evaluation by the various stakeholders
■ Curriculum Document
■ College’s policy on electives for students and record of student selected electives
■ College’s study guides
■ Program Feedback
■ Program evaluation results
■ List of all current or previous (last 12 months) research projects
What Will Occur
The surveyor(s) would like to look at the development methodology, structure, implementation, and
review and feedback integration mechanism of the curriculum. Curriculum committee structure and
its TORs shall also be discussed in this session. The surveyor will engage in discussion with the
curriculum committee members and will request evidence against standards based on the
questionnaire given below.
How to Evaluate
To evaluate the compliance to relevant standards, review the documents provided by the college.
Based on the review, conduct a Curricular Organization/management interview session with the
following list of questions answered:
Curriculum Organization and Management
Compliance
Sr. Surveyor Question
Yes No Not
Applicable
1
Are the curricular outcomes developed in alignment with 
the mission statement of the institution?
2
Are the curricular outcomes developed in alignment with 
the university vision?
Are the curricular outcomes developed with the 
3 involvement of students? (Evidence of involvement e.g.
meeting minutes, feedback, etc.)
Was faculty involved in development of curricular 
4 outcomes? (Evidence of involvement e.g. meeting
minutes, feedback, etc.)
5
Are the curricular outcomes developed with the 
involvement of other stakeholders as applicable?
6
Do the outcomes of curricular document address 
knowledge, skill and attitude?
7 Are outcomes of curricular documents evident in 
institution’s prospectus and/or websites?
8 Are local diseases and health problems of Pakistan 
prioritized in the curriculum?
9
Are the results of review incorporated or addressed in 
curriculum?
10
Is the program reviewed at least once every two years or 
earlier as needed?
11
Are the internal review findings shared with the 
stakeholders?
P a g e 75 | 175
12 
Are innovative learning strategies being implemented?
13
Is there representation of basic sciences on the curricular 
committee?
14 Is there representation of clinical sciences on the 
curricular committee?
15
Is there representation of behavioral sciences on the 
16
Is there representation of community medicine on the 
Is there representation of medical education with a post 
17 graduate qualification recognized by PM&DC on the
18 Are social sciences included in the curricular document? 
19
Are study skills included in the curricular document? 
20 Is leadership included in the curricular document? 
21
Are principles of management included in the curricular 
document?
22
Are principles of medical education included in the 
curricular document?
23
Are teaching strategies included in the curricular 
document?
24
Is the curricular document structurally aligned with the 
PM&DC curriculum guidelines?
Are there ancillary aides such as mannequins, models, 
videos, libraries, simulators, simulated patients or other
25
such methodologies employed to ensure early clinical
experience?
26
Are pre-clinical subjects taught with clinical relevance 
(case scenarios etc.)?
27
Are small group discussion session used as a learning 
strategy?
28 Are community visits arranged for the students? 
Do the clinical sciences carry at least half of the 
29 weightage of curriculum? (Credit hours and trainings
etc.)
30 Is the curricular document designed to address 
knowledge needs of subjects/topics?
31 Is the curricular document designed to address skills 

needs of subjects/topics?
32 Is the curricular document designed to address attitude 
needs of subjects/topics?
33 Are the lectures interactive? 
34 Is the curriculum horizontally integrated? 
35 Is the curriculum vertically integrated? 

Are there opportunities for students for self- directed or 
36 independent learning such as online lectures, video
tutorials, etc.?
Are electives (student selected components) essential part 
37
of the curriculum?
Are clinical rotations/clerkships scheduled for each of the 
38
clinical subjects?
Is there sufficient evidence to ensure that competencies 
39 are addressing the outcomes identified by the
organization?
Does the curriculum structure address knowledge, skills 
40
and attitude required by a general practitioner?
41
Is there a curricular committee structure evident in the 
organogram of the organization?
42
Are the Terms of Reference documented for the 
Do the TORs include; 
a. planning, implementation and evaluation of
43
the curriculum in order to ensure that educational
outcomes are achieved?
44 b. planning, implementation and evaluation of
innovations in the curriculum?
c. ensuring representation of at least one
member from the Department of medical education with
45
a post graduate qualification recognized by ?PM&DC in
medical education recognized by the PM&DC
46 Is there evidence of implementation of the TORs through 

various meeting minutes?
Is the learning being supervised throughout the 
47 curriculum management as evident by the schedules of
the teachers, lab staff etc.?
Are the study guides developed clearly mentioning the 
48 overall objectives of the course and terminal objectives
of each teaching session?
P a g e 77 | 175
49 Are the study guides disseminated to the students? 
50 Are the study guides disseminated to the faculty? 


Traditional curriculum: Does the Anatomy curriculum
(including embryology, histology, gross anatomy etc.)
51 include 500 dedicated hours of study? Integrated system:
Is Anatomy (including embryology, histology, gross
anatomy etc.) content being covered during comparable
hours (500) of teaching?
Traditional curriculum: Does the Physiology curriculum 
include 500 dedicated hours of study? Integrated system:
52
Is Physiology content being covered during comparable
Traditional curriculum: Does the Biochemistry 
curriculum include 200 dedicated hours of study?
53
Integrated system: Is Biochemistry content being covered
during comparable hours (200) of teaching?
Traditional curriculum: Does the Pharmacology 
54
Integrated system: Is Pharmacology content being
covered during comparable hours (300) of teaching?
Traditional curriculum: Does the Pathology curriculum 
(including general pathology, special pathology,
hematology, parasitology, etc.) include
500 dedicated hours of study?
55
Integrated system: Is Pathology (including general
pathology, special pathology, hematology, parasitology,
etc.) Content being covered during comparable hours
(500) of teaching?

Traditional curriculum: Does the Forensic Medicine
56 curriculum include 100 dedicated hours of study?
Integrated system: Is Forensic Medicine content being
Traditional curriculum: Does the ENT curriculum 
include 150 dedicated hours of study?
57
Integrated system: Is ENT content being covered during
comparable hours (150) of teaching?

58 Traditional curriculum: Does the Eye/Ophthalmology
Integrated system: Is Eye/Ophthalmology content being
Traditional curriculum: Does the Gynecology and 
Obstetrics curriculum include 300 dedicated hours of
59 study?
Integrated system: Is Gynecology and Obstetrics content
being covered during comparable hours (300) of
teaching?
Traditional curriculum: Does the Public Health 
60
Integrated system: Is Public Health content being

Traditional curriculum: Does the Research Methodology
and Evidence based Medicine curriculum include 120
61
dedicated hours of study? Integrated system: Is Research
Methodology and Evidence based content being covered
Traditional curriculum: Does the General Surgery 
62
Integrated system: Is General Surgery content being
Traditional curriculum: Does the Anesthesiology and 
Critical Care curriculum include 50 dedicated hours of
study?
63
Integrated system: Is Anesthesiology and Critical
Care content being covered during comparable hours
(50) of teaching?
Traditional curriculum: Does the Orthopedics and 
Traumatology curriculum include 100 dedicated hours of
study?
64
Integrated system: Is Orthopedics and
Traumatology content being covered during comparable
Traditional curriculum: Do minimum of two specialties, 
from the surgical specialties listed below, include 150
dedicated hours of study?
• Cardiac Surgery.
• Neurosurgery.
• Pediatric Surgery
65
• Thoracic Surgery
• Urology
• Plastic surgery
Integrated system: Does minimum of two from list above
have content being covered during comparable hours
(150) of teaching?
Extra marks for more hours in each of the following 
66 specialties:
• Cardiac Surgery
P a g e 79 | 175
• Neurosurgery
• Pediatric Surgery
• Urology
• Plastic surgery
• Spinal Surgery
• Urology
• Maxillofacial Surgery
• Colorectal Surgery
• Hepatobiliary Surgery
• Surgical Oncology
• Endocrine Surgery
• Bariatric Surgery
• Pediatric Cardiac Surgery
Integrated system: Are extra marks allotted for more
hours in each of the above mentioned specialties.

Traditional curriculum: Does the General Medicine
Integrated system: Is General Medicine content being
Traditional curriculum: Does the Family Medicine 
68
Integrated system: Is Family Medicine content being
Traditional curriculum: Does the Psychiatry curriculum 
69
Is Psychiatry content being covered during comparable

Traditional curriculum: Does the Emergency Medicine
70
Integrated system: Is Emergency Medicine content being
Traditional curriculum: Does the Dermatology 
71
Integrated system: Is Dermatology content being covered
Traditional curriculum: Does the Cardiology curriculum 
72
Is Cardiology content being covered during comparable
Traditional curriculum: Does the Neurology curriculum 
73 include 50 dedicated hours of study? Integrated system:
Is Neurology content being covered during comparable
Traditional curriculum: Does the Pulmonology 
Integrated system: Is Pulmonology content being covered
Traditional curriculum: Does the Nephrology curriculum 
75
Is Nephrology content being covered during comparable

Traditional curriculum: Does the Gastroenterology
Integrated system: Is Gastroenterology content being
Traditional curriculum: Does the Pediatrics curriculum 
77
Is Pediatrics content being covered during comparable
Traditional curriculum: Does the Islamiyat curriculum 
78
Is Islamiyat content being covered during comparable
Traditional curriculum: Does the Pakistan Studies 
79
Integrated system: Is Pakistan Studies content being

Traditional curriculum: Does the Behavioral
Sciences and professionalism (components listed below)
80 a. Communication Skills
b. Medical Ethics
c. Professionalism
d. Leadership and Management
Integrated system: Is Behavioral Science content being
Traditional curriculum: Does the specialized medical 
subjects (mentioned below) curriculum include 200
• Pediatric Cardiology
• Neonatology
81 • Endocrinology
• Rheumatology
• Stroke Medicine
• Medical Oncology
• Clinical Hematology
• Geriatrics
P a g e 81 | 175
• Acute Medicine
Integrated system: Are specialized medical subjects
mentioned above being covered during comparable hours
(200) of teaching?
Traditional curriculum: Does the Patient Safety 
82
Integrated system: Is Patient Safety content being

Traditional curriculum: Does the Infection Control
Integrated system: Is Infection Control content being

Traditional curriculum: Does the Self-Directed Learning
Integrated system: Does Self-Directed Learning have 500
Is the curriculum spanning over a total of about
85 6000 credit hours? 
Is there a mechanism to receive feedback about the 
86
curriculum from students?
Is there a mechanism to receive feedback about the 
87
curriculum from faculty?
88 Is there a mechanism to integrate student feedback into 
the curriculum? (Evidence of changes made)?
Is there a mechanism to integrate faculty feedback into 
89
the curriculum? (Evidence of changes made)?
Does the unit provide learning opportunities that are over 
90 and above the PMDC requirements and are
commendable in terms of Faculty requirements?
commendable in terms of Equipment?
commendable in terms of Innovative teaching
methodologies?
Assessment
Compliance
Sr. Surveyor Question
Yes No Not
Applicable
1 Is the assessment structured to assess the knowledge of 
students on the subject?
2 Is the assessment structured to assess the skills of students on 
the subject?
3 Is the assessment structured to assess the attitude of students 
on the subject?
4
Does the Continuous internal assessment carry 20-40% of 
overall weightage?
5 Does the Final external assessment carry 60-80% of overall 
weightage?

6 Is there a method to ensure that assessment methodologies are
in alignment with Table of Specifications (TOS)?
7 Are there assessment methodologies defined? 
8 Are there any formative methodologies for assessment? 
9 Are there summative methodologies for assessment? 
10 Are Multiple choice questions part of assessment? 
11 Are Short Answer Questions used as an assessment tool? 
12 Are short Essay questions used as an assessment tool? 
13
Are Objective Structured Practical Exam (OSPE) part of 
assessment in the non-clinical years?
14
Are Objective Structured Clinical Exam (OSCE) part of 
assessment in the clinical years?
15 Are portfolios/log books used as part of assessment? 
Does the assessment consists of Mini-Clinical Evaluation 
16 Exercise (Mini-Cex) or Work Placed based assessment in
clinical years?
17 
Are short cases part of the assessment in the clinical years?
18 
Are long cases part of the assessment in the clinical years?
P a g e 83 | 175
19 Are simulated patients and standardized patients, part of 
assessment?
20
Is there a mechanism to take student feedback on assessment 
strategies?
21
Is there a mechanism to take teacher feedback on assessment 
strategies?
22 Is the student feedback communicated to faculty? 
23
Is the feedback utilized to improve assessment 
methodologies?
Does the unit provide learning opportunities that are over and 
24 above the PMDC requirements and are commendable in terms
of Faculty requirements?
of Equipment?

Does the unit provide learning opportunities that are over and
26
above the PMDC requirements and are commendable in terms
of Innovative teaching methodologies?
of Faculty requirements?
of Equipment?

29
above the PMDC requirements and are commendable in terms
of Innovative teaching methodologies?
30
Are there any pre-assessment quality assurance procedure in 
place?
31 Are there any per-assessment quality assurance procedure in 
place?
32 Are there any post-assessment quality assurance procedure in 

place?
Infrastructure Tour
Purpose
This tour is conducted by the Architect. The focus of this tour is to evaluate adequacy of infrastructure in
terms of space, seating requirements, hostel and other facilities for medical education. The architect will
review the map (CAD) and will ensure that the infrastructure is in alignment with the drawings and its
corroboration with PMDC requirements.
Location
All facility areas.
Tour Participants
■ One representative from administration
■ One representative from project team (if available)
Surveyor(s)
Architect
■ CAD Map of the facility

■ Seating plan of the facility
■ Hostel facilities design
What Will Occur

The surveyor(s) will visit the hospital to ensure that the infrastructure is sufficient and adequately spaced
to meet the needs of the students, faculty and other staff. Visit will cover IPD, OPD, OR and critical areas
including other operational areas/units of the facility in general. These visits will include comparison of
map/drawings to the actual structure.
How to Prepare
To evaluate the compliance to relevant standards, review the documents provided by the college. Based on
the review, conduct an infrastructure tour/session with the following list of questions answered:
P a g e 85 | 175
Infrastructure Tour
Compliance
Q# Evaluation Question
Yes No Not
Applicable
College Covered Area
1.
Total covered area of the teaching college must be at least 72,000 
sq. ft.
2.
The medical college should be a purpose-built building
separate from the hospital

2.
The college must have a Learning Resource Centre with at least 
7% of the covered area of the college
3.
The college must have an auditorium with at least 7% of the 
covered area of the college.
4. The college must have at least 5 lecture halls, all of which


with at least 10% of the covered area of the college.
The college must have at least 5 demonstration / small 
5. group rooms with at least 2.5% of the covered area of the
college
6.
The college must have two Common Rooms, one for boys and
one for girls, combined with at least 5% of the covered area of

the college
Under
7. The college must have a Day-Care Room with at least 1% of the Constr
covered area of the college. uction
8.
The college must have a student’s cafeteria with at least 1.5% of 
the covered area of the college.
The college must have Administration Offices (comprising of


Principal Office, Vice Principal Office, Committee Room, Faculty
9.
Room, IT Department Room, Student Section Office, Security Office,
Waiting Area, Support Staff Offices, Finance Office, Maintenance
Office) with at least 3% of the covered area of the college
10. The college must have Anatomy Museum with at least 0.5% of 
the covered area of the college
11.
The college must have Dissection Hall with at least with at least 
2% of the covered area of the college
12.
The college must have Pathology Museum with at least 1% of 
the covered area of the college.
The college must have Forensic Medicine Museum with at least 
0.5% of the covered area of the college
The college must have at least 5 multi-purpose labs for
Histology, Physiology, Biochemistry, Pharmacology, Pathology

13. and Community Medicine with at least 9% of the covered area of
the college.
15.
The college must have Skill Development Lab with at least 1% of 
the covered area of the college
16.
The college must have Faculty Offices in each faculty (Basic
Sciences Faculty Offices inside college building) with at least 5%

of the covered area of the college
17.
The college must have adequate circulation spaces to meet 
emergency, safety and disability requirements
18.
Any associated dental college may utilize the same basic sciences
laboratories and lecture halls, provided separate adequate faculty

is available
Seating Requirements
19. The college must have seating capacity for 20% of total student 
strength in Learning Resource Centre for the 5 years tenure
20.
The college must have seating capacity of 60% of the total 
student strength in auditorium for the 5 years tenure
21.
The college must have seating capacity of equivalent of student
strength in each class in each of the 5 Lecture Halls

22. The college must have seating capacity of 25 individuals in each


of the 5 Demonstration / Small Group Rooms
23.
The college must have seating capacity for 5% of total male 
student strength in Common Room for Boys for the 5 years tenure
24 The college must have seating capacity for 5% of total female 

student strength in Common Room for Girls for the 5 years tenure
25 The college must have seating capacity for 20% of total student 
strength in Students Cafeteria
26
The college must have seating capacity for 30 individuals in 
Committee Room
27
The college must have seating capacity for 50 students in
Dissection Hall

The college must have seating capacity of 50 students in each of


28
the 5 multi-purpose labs for Histology, Physiology, Biochemistry,
Pharmacology, Pathology I, II, III and Community Medicine
The college must have separate workstation for each faculty
member of Basic Sciences inside college building, preferably

29
separate offices for Associate Professors and above.
Hostel Requirements
P a g e 87 | 175
30
The college must have a boys’ student hostel with at least
covered area of 10,000 sq. ft. and a male house officers

hostel of 5000 sq ft
31
The boys’ hostel must have the capacity to house at least 
20% of the total male student strength

32 The college must have a girls’ hostel with at least covered
area of 10,000 sq. ft. a girls’. and a female house officers
hostel of 5000 sq ft
33
The girls’ hostel must have the capacity to house at least 
30% of the total female student strength
34 The hostel must have television and internet access 
35 The hostel must have indoor games facilities 
Other Requirements
The college must be able to provide teaching in an 

environment with comfortable room temperature (18 to 26
36 degrees Celsius) in lecture halls, demonstration areas,
laboratories and learning resource centres under conditions
of full occupancy.
The college’s Learning Resource Centre must have
functioning computers for 30% of seating capacity with

37
access on all computers of HEC and university’s digital
library
The college must have Wi-Fi connectivity all across the
campus, with access to every student and faculty. Wi-Fi

37
connectivity must allow access to HEC and university’s
digital library.
38 The college must have at least one multi-sports ground as 
per the requirements of HEC.
39 The college must provide transport facility, either owned or


hired, to at least 20% of the total student strength
40 The college must provide transport facility, either owned or 

hired, to at least 30 faculty members
41
The college must provide transport facility, either owned or
hired, to at least 30 other staff members

The college must provide to students a counseling cell,
staffed with a clinical psychologist

Biomedical Tour
Purpose
This tour is conducted by the Biomedical Engineer. The focus of this tour is to evaluate adequacy of equipment and
relevant material required for provision of appropriate medical education.
Location
All facility areas (Medical College and Hospital)
Tour Participants
■ One representative from biomedical department
Surveyor(s)
Biomedical Engineer
■ Periodic Preventive Maintenance Schedule (PPM) Schedule

■ Machine/equipment Logs
■ Per machine log book
■ Downtime Report
What Will Occur

The surveyor(s) will visit the medical college and the hospital to ensure they are available in adequate numbers, are
functional and are in use. Equipment inventory will be audited and the log of machines will be checked for their
quality control.
How to Prepare
To evaluate the compliance to relevant standards, review the documents provided by the college. Based on
the review, conduct a comprehensive tour of the hospital to verify its equipment’s. On Day two college
tour, remember to conduct a paired tour with basic sciences nominee to ensure that educational material
mentioned in checklist is close to what is required by PMDC.
P a g e 89 | 175
Biomedical Equipment Session
Compliance
Not
Yes No Applicabl
e
Anatomy: (Dissection Hall)
1.
Does the college have a facility of cadavers

2.
Does the college have at least two appropriate dissecting instruments 
for two cadavers
or equivalent ? available? (Optional)
3.
Does the college have at least four operational full dissection tables
available?

Does the college have at least At least 50 stool sets available,
functional and in use. At least twelve half dissection tables available

4.
under active use at all times?
Anatomy: (histology Laboratory)
5.
Does the college have at least two histology slide sets per hundred
students available under active use at all times?

6 Does the college have at least fifteen binocular microscopes per 
hundred students available under active use at all times?
7 at least one slide projecting microscope/ one penta-head Multi - 
viewing Biological Microscope available, functional and in use
8
Does the college have at least one large refrigerator per hundred

9.
at least one computer with internet facility available, functional
and in use. (Optional)

10.
at least one scanner available, functional and in use. (Optional 
11.
at least one colour laser printer available, functional and in 
use. (Optional)
Anatomy: (Museum)
12 At least one Male torso model available, functional and in use. 

13 At least one cross sectional torso model available, functional and in 
use. (optional)
Does the college always have at least five upper limb (muscles,
14. vessels, nerves and joints) anatomical model per hundred students

available?
Does the college always have at least five lower limb (muscles,
3 2 not
available
available?
Does the college always have at least four head and neck (muscles,

available?
17. Does the college always have at least five special senses anatomical 
model per hundred students available?
18.
Does the college always have at least four brain anatomical model per 
hundred students available?
Does the college always have at least one histology models per ?
19.
20.
Does the college always have at least one embryology models per

21.
Does the college always have at least five pelvis models per hundred
students available?

22. Does the college always have at least four abdominal viscera models 
per hundred students available?
Does the college always have at least four liver models per hundred 1 3
23. deficient
students available?
24.
Does the college always have at least four kidney models per hundred
students available?

25.
Does the college always have at least three CVS models per hundred
students available?

Does the college always have at least four respiratory system models 1 3
26 deficient
27
Does the college always have at least hundred human’s loose bones per 
28
Does the college always have at least two articulated skeletons per 
29 Does the college always have at least one articulated vertebral column 
30 At least one multimedia available, functional and in use.
31
Does the college always have at least one cross sectional body model 
32
Does the college always assorted anatomy CDs available,
functional and in use under active use at all times?

33
At least two white boards available, functional and in use for teaching
purpose.

34 At least one Female torso model available, functional and in use. 
P a g e 91 | 175
Physiology (Major)
35 Does the college have at least fifteen sphygmomanometers per hundred 
36 Does the college have at least ten microscope Binoculars per hundred 
37 Does the college have at least twenty haemocytometers per hundred 
38 Does the college have at least fifteen hemoglobin meters per hundred 
39 Does the college have at least ten complete perimeters per hundred 
40 Does the college have at least twenty-five ESR pipettes per hundred 
41 Does the college have at least twenty percussion hammers per hundred 
42 Does the college have at least two oxygen cylinders per hundred 
43 Does the college have at least thirty clinical thermometers per hundred 
44 Does the college have at least five student kymographs per hundred 
45
Does the college have at least two ECG machines per 100 hundred 
46 Does the college have at least one centrifuge machine per hundred 
47 Does the college have at least five micro hematocrit reader per hundred  Acquisition
under process
48 Does the college have at least one micro hematocrit centrifuge per  Research Lab
49 Does the college have at least thirty stethoscopes per hundred students 
available under active use at all times?
50 Does the college have at least two data acquisition system (power lab) 
per hundred students available under active use at all times?
51
Does the college have at least one finger pulse oximeter per hundred

Physiology (Minor)
52
Does the college have at least fifteen stop watches per hundred

53
Does the college have at least fifteen tuning forks of different
frequencies per hundred students available under active use at all

times?
54 Does the college have at least five vision E type charts/Snellen’s charts 
per hundred students available under active use at all times?
55 Does the college have at least five Ichihara charts per hundred students 
56
Does the college have at least two weighting machines per hundred

57
Does the college have at least an audiometer available under active use
at all times?
 Acquisition
under process
58 Does the college have at least an examination coach available under 
active use at all times?
59 Does the college have at least a fire extinguisher available under active 
use at all times?
60
Does the college have at least a jaeger's chart per under active use at all
times?

61 Does the college have at least an ophthalmoscope per under active use 
at all times?
Does the college have at least a refrigerator per under active use at all Yes Available in
62 Research Lab
times?
P a g e 93 | 175
63 Does the college have at least a stethoscope (complete),with assembly

64
Does the college have assorted torches available under active use at all times?

65 Does the college have assorted tourniquets available under active use at all 
times?
66 Does the college have at least a water bath available under active use at all  Available in
research lab
times?
67
Does the college have at least a beaker 100ml available under active use at all
times?

68
Does the college have at least a beaker 500ml available under active use at all
times?

69
Does the college have at least a blood group tiles available under active use at
all times?

70 Does the college have at least a capillary tubes ( heparinized) available under 
71 Does the college have at least one treadmill or aerometer cycle available 
72 Does the college have assorted capillary tubes ( heparinized) available under 
73 Does the college have assorted centrifuge tube with cock available under 
74
Does the college have at least a EDTA tube available under active use at all
times?

75 Does the college have assorted ESR pipette available under active use at all 
times?
76 Does the college have at least a glass rod available under active use at all 
times?
77
Does the college have at least a magnifying glass available under active use at
all times?

78
Does the college have assorted microscope slides under active use at all
times?

79 Does the college have assorted Petri dish under active use at all times? 
80 Does the college have at least a spirit lamp available under active use at all 
times?
81 Does the college have at least a thermometer available under active use at all 
times?
82
Does the college have at least a Wintrobe's tubes available under active use at
all times?

83 Does the college have antisera A,B and D available under active use at 
all times?
84 Does the college have cedar wood oil available under active use at all 
times?
Does the college have distilled water available under active use at all
85 times? 
86 Does the college have HCL available under active use at all times? 
87
Does the college have Leishman’s stain available under active use at
all times?

88
Does the college have methylated spirit available under active use at
all times?

Does the college have platelet solution( Ree's and Ecker's solution)
89 available under active use at all times? 
Does the college have pregnancy test kits available under active use at
90 all times? 
91 Does the college have pregnancy strips available under active use at all 
times?
92
Does the college have RBC solution available under active use at all
times?

93 Does the college have WBC solution available under active use at all 
times?
94 Does the college have xylene available under active use at all times? 
Biochemistry (Major)
95
Does the college have at least two clinical PH meters per hundred

96
Does the college have at least one large size incubator per hundred

97 Does the college have at least one electronic balance per hundred 
students available under active use at all times.?
98 Does the college have at least one thermal cycler per hundred students 
99 Does the college have at least one electrophoresis per hundred students 
100
Does the college have at least two glucometers per hundred students

101 a bench top centrifuge 
101. At least 1x Microlab functional, available and in use
1

10.2 At least 10x microscopes functional, available and in use 
103 At least 1x Refrigerator functional, available and in use 
Biochemistry (Minor)
P a g e 95 | 175
Does the college have at least one water distillation unit (operation 
104 china 10 Liters) per hundred students available under active use at
all times?
105
Does the college have at least one electric water bath per hundred 
106
Does the college have at least five stop watch per hundred students 
107
Does the college have at least one hot box oven per hundred 
Pharmacology (Major)
108
at least three audio-visual facility and assorted experimental 
CDs for pharmacology practical’s available, functional and
in use. two BP apparatus available, functional and in use.
109
at least 
at least two stethoscopes available, functional and in use
110 and 10 kymographs, functional and in use. 
Pharmacology (Minor)
at least one electronic balance available, functional and in 
111 use.
Pathology I and II (Major)
112 Does the college have at least fifteen microscope binoculars per 
113 Does the college have at least one Microscope multi head (5 piece) per 
Pathology I and II (Minor)

114 Does the college have at least four stain dropping bottles (250ml) per 
115 Does the college have at least four wash bottles per hundred students 
116 Does the college have at least four adjustable staining racks per 
117 Does the college have at least two 14 cubic feet refrigerators per 
118 Does the college have at least a -120 C deep freezer per hundred 
119 Does the college have at least four glass beaker (Pyrex) 500 ml 
graduated per hundred students available under active use at all times?
120 Does the college have at least four glass cylinder (Pyrex) 500 ml 
graduated per hundred students available under active use at all times?
121 Does the college have at least four water stills per hundred students 
122 Does the college have at least one incubator 37 c large per hundred 
students available under active use at all time?
123 Does the college have at least one floating bath per hundred students 
124 Does the college have at least twenty Staining jars per hundred students 
125 Does the college have at least one automatic tissue processor per 
Does the college have at least one embedding station per hundred
126 students available under active use at all times? 
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127 Does the college have at least one water Bath electric per hundred 
128 Does the college have at least one paraffin embedding bath per hundred 
129 Does the college have at least one oven-wax embedding (100 c) per 
130 Does the college have at least one Microtome per hundred students 
131 Does the college have at least one knife sharpener per hundred students 
132 Does the college have at least a large incubator per hundred students 
Community Medicine (museum)

The department must use digital technology in the form of Images,
133 Illustrations,Infographics and power point slides on primary healthcare

and community and preventive medicine.
134 At least one multimedia projector or LED and onecomputers for


display of images, illustrations, video clips and /or power point slides.
135 One computer for research software 
136
at least 5 Images / Illustrations or power point slides of each of 
the following Categories:
 Ice berg phenomena of the disease 

 Pustule eruption in small pox and chicken pox 
 Lifecycle of malaria parasite (P.vivax and Falciparum) 
 Xerosis (conjunctival) in vitamin A deficiency 
 Lead line on gum 
 Cutaneous Leishmaniasis, Ulcers on forearm and head 
 Tick 
 Flea 
 Sand Fly 
 House Fly 
 Aedes Agypti mosquito 
 Anopheles mosquito 
 Population Pyramid 
 Coal Miners Lung 
 Snow storm silicosis (lung) 
 Ground Glass Anthracosis (lung 
 Bleeding Gums 
 Rickets 
 Poliomyelitis 
 Measles 
 Vaccine Vile Monitor 

159
 Dental Fluorosis 
 Spot maps 
 Bar Charts 
 Histograms

 Frequency Polygon 
 Normal Distribution Curve 
 Marasmus / Kwashiorkor 
 Functioning of incinerator 
 Food pyramid 
 Sustainable development Goals 
137 At least following models
 1 x Septic tank 
 1 x Water filtration plant 
 5 x mid arm circumference (MUAC)tapes 
 Various contraceptive devices and oral pills 
 50 x Growth charts 
 50 x antenatal charts 
 3 x measuring tapes and 3 x weighing machines for
BMI calculation

 10x water purification tablets 

 1 x water testing kit for chlorine 
 3 x EPI vaccines 
138 Following soft wares fully functional and in use forResearch
methods
 SPSS latest version 
 Microsoft Excel 
 Epi info 
 WHO Sample size calculator 
 One of the Reference Managers (Endnote X7 or 
Mendeley)
Forensic medicine (Major)

139 Does the college have at least one male and female skeleton 
140 Does the college have at least fifteen separate bones available 
141 Does the college have at least twenty models available under active 
use at all times?
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142 Does the college have at least fifteen toxicological specimens 
143 at least 5 simple hand held magnifying glass available, ?
144
. Does the college have at least three binocular microscopes
available under active use at all times?.

145 at least 2 ultraviolet lamps for examinations of stains, available, ?
146 one autopsy examination sets available, functional and in use. ?
147
Does the college have at least ten assault weapons available under

Forensic medicine (Minor)
148 Does the college have at least ten medico-legal x-rays slides and 
photography available under active use at all times?
Teaching Hospital(s) Equipment
Requirements
General Medicine
149 Does the hospital have at least one defibrillator per hundred 
students available and functioning at all times?
150 Does the hospital have at least two ECG machine (Triple Channel) 
per hundred students available and functioning at all times?
151
Does the hospital have at least one video endoscopic system with
upper and lower sets per hundred students available and

functioning at all times?
152 Does the hospital have at least one Trolley for endoscopes (Pak 
made) per hundred students available and functioning at all times?
153
Does the hospital have at least one echo cardiograph 2D with color 
Doppler per hundred students available and functioning at all
times?
154 Does the hospital have at least one ETT machine per hundred 
155 Does the hospital have at least four complete nebulizers per 
hundred students available and functioning at all times?
156 Does the hospital have at least 10 BP apparatus per hundred students available 
and functioning at all times?
157 Does the hospital have at least 10 stethoscopes per hundred students available

158 Does the hospital have at least 4 pulse oximeters per hundred students

available and functioning at all times?
159 Does the hospital have at least 6 glucometers per hundred students available

160 Does the hospital have at least 2 cardiac monitors per hundred students

161 Does the hospital have at least 10 thermometers per hundred students 
162 Does the hospital have at least 3 torches per hundred students available and 
163 Does the hospital have at least 3 measuring tapes per hundred students 
164 Does the hospital have at least 4 hammers per hundred students available and 
165 Does the hospital have at least 2 tuning forks (128Hz) per hundred students 
166 Does the hospital have at least 5 examination couches per hundred students 
Dermatology
167 Does the hospital have at least 3 electrocautery machines per hundred students 
168 Does the hospital have at least 15 magnifying glasses with fluorescent lamps 
169 Does the hospital have at least 3 wood lamps per hundred students available 
170 Does the hospital have at least 1 PUVA machine per hundred students 
171 Does the hospital have at least 1 UVB machine per hundred students available 
172 Does the hospital have at least 3 liquid nitrogen cylinders for cryo per 
173 Does the hospital have at least 1 microscope with accessories per hundred 
174 Does the hospital have at least 6 biopsy sets per hundred students available 
175 Does the hospital have at least 6 BP apparatus per hundred students available 
Surgery
P a g e 101 | 175
176 Does the hospital have at least 8 basic standard surgical sets per hundred 
177 Does the hospital have at least 1 thoracic surgical set per hundred students 
178 Does the hospital have at least 1 vascular surgical set per hundred students 
178 Does the hospital have at least 1 pediatric surgery sets per hundred students 
179 Does the hospital have at least 1 plastic surgery set per hundred students 
180 Does the hospital have at least 2 surgical diathermies (Monopolar and

Bipolar) machines per hundred students available and functioning at all times?
181 Does the hospital have at least 1 harmonic/Ligasure machine per hundred 
182
Does the hospital have at least 1 fiber optic colonoscope (Diagnostic and
therapeutic) or flexible sigmoidoscope per hundred students available and

183 Does the hospital have at least 2 rigid sigmoidoscope and proctoscope per 
184 Does the hospital have at least 1 complete laparoscopic surgical sets per 
185 Does the hospital have at least 1 microsurgical instrument set per hundred 
186 Does the hospital have at least 1 Transurethral resection of prostate surgical 
set per hundred students available and functioning at all times?
187
Does the hospital have at least 1 cystoscopes (diagnostic and therapeutic) per

188 Does the hospital have at least one fiber optic oesophagoscope/gastroscope

189 Does the hospital have at least 1 fiber optic bronchoscope per hundred 
Does the hospital have at least 1 portable X-ray machine, operation table, and
radiographic film cassette facilities e.g. for per operative cholangiogram?

190
Image intensifier with C-arm and double monitors per hundred students
191 Does the hospital have at least 3 suction machines per hundred students 
192 Does the hospital have at least 1 defibrillator per hundred students available 
Obstetrics and Gynecology

193
Does the hospital have at least 4 ultrasounds with linear, vaginal, section
probes and punctures per hundred students available and functioning at all

times?
194 Does the hospital have at least 1 hysteroscope per hundred students available 
195 Does the hospital have at least 2 colposcope per hundred students available 
196 Does the hospital have at least 1 laparoscopic surgical sets with camera and

monitors per hundred students available and functioning at all times?
197 Does the hospital have at least 4 delivery table per hundred students available 
198 Does the hospital have at least 10 examination tables per hundred students 
200 Does the hospital have at least 6 manual BP apparatus per hundred students 
available and functioning at all time?
201 Does the hospital have at least 8 dyna-map (multi-para) per hundred students 
available and functioning at all times
202 Does the hospital have at least 6 pulse oximeters per hundred students 
203 Does the hospital have at least 4 baby weighing scales hundred students 
204 Does the hospital have at least 10 Pinnard stethoscopes/fetoscopes per 

205 Does the hospital have at least 4 instrument sterilizers per hundred students 
206 Does the hospital have at least 2 sonic aid per hundred students available and 
207 Does the hospital have at least 4 CTG machines per hundred students 
208 Does the hospital have at least 4 neonatal resuscitation trolley and heaters per 
209
Does the hospital have at least 12 disposable delivery sets per hundred
students?

210 Does the hospital have at least 20 Cusco’s speculum per hundred students 
211 Does the hospital have at least 3 adult ambu bags and masks per hundred 
212 Does the hospital have at least 20 Sims speculum per hundred students 
213 Does the hospital have at least 10 perineal/vaginal/cervical repair sets per 
214 Does the hospital have at least 8 Caesarean section sets per hundred students 
215 Does the hospital have at least 5 dilatation and Evacuation sets (D&C) per 
216 Does the hospital have at least 6 manual vacuum aspirators per hundred 
P a g e 103 | 175
216 Does the hospital have at least 6 vacuum ventuse cups per hundred students 
217 Does the hospital have at least 6 outlet forceps per hundred students available 
218 Does the hospital have at least 6 infant laryngoscopes with spare bulbs per 
220 Does the hospital have at least 6 suction machines per hundred students 
221
Does the hospital have at least 4 teaching dummies and anatomical pelvis
models per hundred students available and functioning at all times?

222 Does the hospital have at least 2 dummies for pelvic examination per hundred 
students available and functioning at all times.
223 Does the hospital have at least 1 adequate equipment for family planning per 
Basic Surgery Sets in main Operating Theatre

224 Does the hospital have at least 1 sterilizer (>300L capacity) per hundred 
Does the hospital have sufficient instrument boxes, scalpel handles of various

sizes, May-Heggar Needle holders of various sizes, artery forceps, Halstead
(non-serrated and curved ) various sizes, surgical dissecting scissors,
225 metzembaum (Curved) of various sizes, Kocher’s forceps (toothed, straight,
hemostatic) of various sizes, Probes of various sizes, Dissecting forceps with
and without teeth of various sizes, Hemostatic forceps (Collin and Chaput) of
various sizes, towel clips and galipots of various sizes for hundred students
226
Does the hospital have Farabeuf retractors, short, self-retaining retractors for
thoracic, abdominal and minor procedures etc. per hundred students available

Out-Patient:
227 Does the hospital have 1 stethoscope per clinic per hundred students available 
228 Does the hospital have 1 fetal/pediatric stethoscope per respective clinics per 
229 Does the hospital have BP apparatus per clinic per hundred students available 
230
Does the hospital have one thermometer (Oral/armpit) and sufficient rectal
thermometers per hundred students available and functioning at all times

Does the hospital have light source (battery type), tongue depressors, tape 
measures (Flexible, soft), Snellen chart (including for uneducated patients),
231 hammers, head mirrors/head lights, mirror laryngeal sets, otoscopes, and
Collyer pelvimeters, examination tables, per hundred students available and
232 Does the hospital have laryngoscopes per hundred students available and 
233 Does the hospital have stretchers (folding type) per hundred students 
234 Does the hospital have ambu bags for infants, pediatric patients and adult

patients per hundred students available and functioning at all times?
235 Does the hospital have suction machines per hundred students available and 
236
Does the hospital have consumables like gloves, Endo tracheal tubes of
various sizes, IV cannulas of various sizes, masks etc. per hundred students

Pediatrics Department
237 Does the hospital have 1 weighing scale per hundred students available and 
238 Does the hospital have 1 length/height measuring scale per hundred students
 Need length &
height measuring
scale falahee
239 Does the hospital have 2 ultrasonic nebulizers per hundred students available 
240 Does the hospital have 1 pediatric ventilator per hundred students available 
241 Does the hospital have 1 neonatal ventilator per hundred students available 
242 Does the hospital have 1 pulse oximeter per hundred students available and 
243 Does the hospital have 3 infusion pump per hundred students available and 
244 Does the hospital have 1 cardiac monitor per hundred students available and 
245 Does the hospital have 1 transport incubator per hundred students available 
246 Does the hospital have 1 neonatal resuscitator per hundred students available 
247 Does the hospital have 1 low grade suction apparatus per hundred students 
248 Does the hospital have 1 resuscitator (infant/child), manual per hundred 
249 Does the hospital have 1 suction machine (dual operation with tubes) per 
250 Does the hospital have 2 otoscopes with infant diagnostic heads per hundred 
251
Does the hospital have 2 forceps, splinter/repilation, spring per hundred 
P a g e 105 | 175
252 Does the hospital have 2 pediatric nasal speculums per hundred 
253 Does the hospital have 1 scale for infants per hundred students  Need 1
length
scale for
254 Does the hospital have 1 height measuring scale for infants per  Need
infants
height
measuring
255 Does the hospital have 6 oral/armpit thermometers per hundred  scale
256
Does the hospital have 5 BP apparatus (new born, neonatal,
pediatric, cuffs) per hundred students available and functioning at

all times?
257
Does the hospital have one paediatric BLS mannequin
?
Accident and Emergency Department

258 Does the hospital have 2 beds with monitoring facilities per 
259 Does the hospital have 1 minor operating theatre per hundred 
260 Does the hospital have 1 pharmacy in emergency area per

Does the hospital have 1 facility for resuscitation including crash 
261 cart (Defibrillator) and a cubicle for patient with central oxygen,
suction and monitoring facilities stay per hundred students
available and functioning at all times?(essential)
Operating Rooms
262 Does the hospital have five fully equipped operating rooms 
263 Does the hospital have appropriately furnished Pre-anesthesia area 
264
Does the hospital have recovery area with central oxygen and
suction and monitoring facilities per hundred students available and

265 Does the hospital have monitoring facilities per OR per hundred 
266 Does the hospital have 1 image intensifier per hundred students 
267 Does the hospital have facilities for resuscitation per hundred 
268 Does the hospital have 5 anesthesia work stations per hundred 
269
Does the hospital have 1 diathermy machine per theatre
(Monopolar and bipolar) per hundred students available and

270 Does the hospital have adequate OT Waste disposal method per hundred 
Critical care beds with isolation facilities as a part of intensive care,
coronary care and neonatal care & HDU
271 Does the hospital have ten medical ICU beds (Essential) available and 
272 Does the hospital have ten surgical ICU beds (Mandatory) available and 
273 Does the hospital have ten separate pediatric & neonatal intensive care beds 
274 Does the hospital have implementation of sanitation & isolation protocols 
Central Sterilization and Storage Department

275 Does the hospital have Instrument washing area available and functioning at 
all times?
276 Does the hospital have linen washing area available and functioning at all 
times?
277 Does the hospital have 1 washer and disinfector per hundred students available 
Does the hospital have 2 steam autoclaves with 134 degrees’ temperature
278 (500L) per hundred students available and functioning at all times?

279 Does the hospital have 1 Ethylene oxide/ Formaldehyde gas / plasma sterilizer 
280 Does the hospital have 1 sealant machine per hundred students available and 
281 Does the hospital have chemical based high level disinfection/sterilization

facilities per hundred students available and functioning at all times?
282 Does the hospital have storage and distribution counter per hundred students 
283 Does the hospital have separate path for collection of dirty linen and 
instruments available and functioning at all times?
Radiology Services with all imaging modalities

X-Ray Machines:
284 Does the hospital have 1 Fluoroscopy/image intensifiers (500mA) per hundred 
285 Does the hospital have 1 stationary Bucky table (300mA) per hundred students 
P a g e 107 | 175
?
286 Does the hospital have 1 stationary Bucky Stand (300mA) per hundred
287 Does the hospital have 1 portable X-ray (100mA) per hundred students
Ultrasound:
288 Does the hospital have 2 probe grey scale (3.5 MHz) per hundred students
289 Does the hospital have 2 probe portable grey scale (3.5 MHz) per hundred
290 Does the hospital have 1 color Doppler (with multi frequency probes) per
291 Does the hospital have 2 biopsy probes per hundred students available and
Other Equipment:
292 Does the hospital have 1 CT scan and 16 slices per hundred students available
293 Does the hospital have 1 MRI (1.5/3 tesla) per hundred students available and
294 Does the hospital have 1 mammography per hundred students available and
295 Does the hospital have 1 Orthopantomogram (OPG) per hundred students
Safety Equipment:
296 Does the hospital have 7 lead aprons per hundred students available and
297 Does the hospital have 2 TLD per hundred students available and functioning
at all times?
298 Does the hospital have 4 lead shields/partitions per hundred students available
299 Does the hospital have 1 film badge/radiation detector per staff member and
Hospital Laboratory Services

Hematology Instrument:
300 Does the hospital have 3/5 part automated differential counter per hundred 
301 Does the hospital have 2 microscopes (1 with teaching head) per hundred 
302 Does the hospital have basic staining facilities including for reticulocytes per

303 Does the hospital have 1 fridge to keep samples per hundred students 
Blood Bank
304 Does the hospital have 1 serofuge per hundred students available and 
305 Does the hospital have 1 agglutination viewer per hundred students available 
306 Does the hospital have 1 blood bank fridge per hundred students available 
307 Does the hospital have 1 microscope and 1 water bath/heat block per hundred 
308 Does the hospital have 1 platelet rotator with incubator per hundred students 
309 Does the hospital have 1 minus thirty-degree refrigerator for storage per 
Chemical Pathology:
310 Does the hospital have 1 automated chemistry analyzer per hundred students 
311 Does the hospital have 1 immuno-assay analyzer per hundred students 
312 
1 electrolyte analyser available, functional and in use.
313 Does the hospital have 1 blood gas analyzer (either in department or in ICU) 
314 Does the hospital have 1 fridge and 1 minus twenty degree freezer for lab per 
Micro biology:
315 Does the hospital have 1 incubator (37 degrees) per hundred students 
P a g e 109 | 175
316 Does the hospital have basic staining facilities per hundred students available 
317 Does the hospital have 1 fridge per hundred students available and 
318 Does the hospital have 2 microscopes with teaching heads per hundred 
319 Does the hospital have 1 safety hood per hundred students available and 
Documentation Review
320 
Is the preventive maintenance/calibration plan being carried out periodically?
321 Is the record of preventive maintenance/calibration being maintained? 

322 Is the record of repair maintenance being maintained? 
323 Is the record of down time being maintained? 
324 Are there any master calibrators available? 
325 Are the master calibrators calibrated? 
Are the training certificates of person dedicated for calibration of medical
326 devices available? 
327 Is the record of service/maintenance reports of rental/contractual equipment 
maintained?
328 Is dedicated/separate workshop for repairing/maintenance of BM equipment 

available?
329 Is sufficient BM staff for repair/maintenance with reference to the number of 

beds/equipment available?
Is proper training of end user being done at the time of installation? 
(attendance list of trainings)
330 Is daily and weekly self-test list of Defibrillators available? 
Ophthalmology Department
2.25 1 Autorefracto/Keratometer available, functional and inuse. 
6
2.25 1 Ultrasound A-scan bio-meter available, functional and 
7. inuse.
2.25 1 Ultrasound B-scan available, functional and in use 
8.
2.25 1 Keratometer (automated) available, functional and in use. 
9.
2.26 . 1 Application Tonometer available, functionaland in use. 
0
2.26 . 1 Phacoemulsification unit available, functional and in use. 
1
2.26 1 Slitlamp with applanation tonometer available, functionaland 
2 in use.
2.26 2.263. 1 Prism bar (Horizontal) available, functional and in use. 
3
2.26 2.264. 1 Lensometer manual available, functional and in use. 
4
2.26 1 Operating microscope available, functional and in use. 
5
2.26 . 1 indirect ophthalmoscope available, functional and in use. 
6
2.26 1 direct ophthalmoscope available, functional and in use. 
7
2.26 . 1 Retinoscope available, functional and in use. 
8
1 Tiral lens set with trial frame available, functional and inuse 
2.27 . 1 Prism bar (vertical) available, functionaland in use. 
0
2.27 1 Manualvisual field analyzer Bjerrum screen 
1 available,functional and in use.
2.27 1 Automated visual field analyzer Bjerrum screen available, 
2 functional and in use
2.27
3
1 electrosurgical diathermy unit (Mono/Biploar) 
available,functional and in use
2.27 1 Portable surgical light available, functional and in use.
4

P a g e 111 | 175
ENT Department
2.27 1 OPD instrument set available, functional and in use. 
5.
2.27 1 Auroscope available, functional and in use. 
6
2.27 1 Ultrasound B-scan available, functional and in use. 
7.
2.27 . 1 microscope for O.T available, functional and in use. 
8
2.27 . 1 rigid endoscopes with all accessories available, 
9 functionaland in use.
2.28 . 1 Audiometer available, functional and in use. 
0
2.28 . 1 Impedance Audiometer available, functional and in use. 
1
2.28 . 1 BERA available, functional and in use. 
2
2.28 1 Minor OT dressing/Examination set available, 
3. functionaland in use
2.28 . 1 General Set for OT available, functional and in use. 
4
2.28 1 Microscope instrument set for maxioidectormy 
5. available,functional and in use.
2.28 . 1 Microscope instrument set for tympanoplasty 
6 available,functional and in use
2.28 . 1 Microscope instrument set for Stapedectomy 
7 available,functional and in use.
2.28 1 Set for tonsillectomy available, functional and in use. 
8.
2.28 1 Set for Rhinoplasty available, functional and in use. 
9.
2.29 1 Set for FESS available, functional and in use. 
0.
2.29 1 Air Drill with all accessories available, functional and in 
1. use.
Medical College Safety Tour
Purpose
This tour is conducted by the Hospital Management and Safety Expert. The focus of this tour is to evaluate adequacy
and safety of medical college facilities for clinical training. The tour will focus on the safety of systems in the
medical education and shall cover fire safety, general safety, disaster preparedness, hazardous material, infection
prevention and control and safety of water systems.
Location
All facility areas.
Tour Participants
■ One relevant safety representative
■ One representative from department managing medical equipment
■ Representation from IT
■ Department Heads and representatives’ availability at their respective sites
Surveyor(s)
Hospital Management and Safety Expert
Recognition Standard 1: Infrastructure requirements 2 Standard 11:
Governance, Services and Resources (11.4, 11.11)
■ Facility Map
■ Fire, Safety & Security Program documents
■ Utilities Management Plan
■ Hazardous Material & Waste Management Plan
■ Emergency Preparedness and Evacuation Plan
■ Infection Control and Prevention Program
■ Infrastructure plans to meet needs of persons with disabilities
■ IT Resource Center details
■ Library/Digital Resource Center details (including list of subscriptions)
What Will Occur

The surveyor(s) will visit the facility to ensure that the infrastructure is sufficient and adequately equipped to meet
the needs of the students, faculty and other staff. Visit will cover various operational areas of the institution. These
visits will include on site interviews with the relevant departmental heads regarding the routine functioning of their
operations, any challenges faced, fire safety plans, emergency preparedness plans, infection control plans and others
to validate their execution through evidence as and when required. During the tour, the surveyor will also ensu re
provision of internet and Wi-Fi services throughout the facility from the perspective of students and faculty.
2
Refer to initial inspection guide
P a g e 113 | 175
How to Prepare
The institution should identify the participants in this session and develop and implement various plans as mentioned
above. The institution should identify the progress against those plans in the relevant committees and maintain
updated records showcasing their progress.
Medical College Safety Tour

Surveyor Question Compliance
Q#
Hostels Yes No Not
Applicable
1 Are the students satisfied with the male hostel’s facilities? 

2 Are the students satisfied with the female hostel’s facilities? 
■■
3 Are the students/faculty/staff satisfied with the cafeteria?
Fire Protection!
4 Does the organization have a documented fire safety and evacuation 

plan?
5 Does the fire safety plan has training schedule for staff, faculty and 
students?
6 Does the fire safety plan mention an oversight by a designated 

person?
7 Does the fire safety plan identify high risk/fire-prone areas? 

8
Does the fire safety plan address the risks identified in high risk
areas?

9 
Does the institute have a designated and trained fire response team?
10 Does the institute conduct a mock fire evacuation drill? 

11 Does the institute have a designated assembly area? 
12
Are students/faculty aware of the designated assembly area and
alternative fire exits?

13 Are portable fire extinguishers available in every department? 
14 Are staff and students aware about the location and use of fire 
extinguishers?
15 Are evacuation maps displayed at the department/floor? 

16 Are emergency exits unobstructed and clear at all times? 
17 Are Illuminated exit signs displayed at exit doors? 
Safety and Security
18 Does the institute have slip resistant strips on stairs?  =

19 Are grip bars available with stairs to avoid falls? 
20 In case of elevators, are safety mechanisms (emergency alarm, 
maximum load, emergency number) displayed?
21 Are all electrical wires secured (connectors used to connect wires 

instead of tapes)
Has the organization taken remedial steps to address fire risks for
22 vulnerable areas? (Lab, generator room, server room, store, record

room)
23 
Are security guards available at entrance and aware of his duties?
24 Are Institutions entrance secured and walls protected from outside 

intruders?
25 Is first aid kit available to cater to students/faculty needs? 

26
Are bar grips available in washrooms for disabled/old age persons?

27 Are ramps available or other measures taken to ensure ease of 
=
transportation for disabled persons?
Hazardous Material & Waste Management Program
28 Does the institution have a documented waste management 

program?
29 Is infectious waste being segregated appropriately through color 

coded bags? (e.g. red, yellow, blue)
30 Is temporary waste storage facility available? 

31 Is infectious waste being properly incinerated/disposed of within 24 
hours of generation?
32 Is inventory of hazardous material (chemical) maintained 

throughout the facility?
33 Are all chemicals labelled based on a hazardous tag? E.g. 

(toxic, corrosive, irritant, flammable)
34 
Are all chemicals stored properly according to optimal temperature?
35 
Is spill kit available to manage chemical/infectious/mercury spill?
P a g e 115 | 175
36 Are all relevant staff aware about risks of chemicals? 
37 Do all staff wear appropriate Personnel Protective Equipment PPEs

during work? (e.g. gloves, masks, gowns, eye shield as applicable)
38 Is Material Safety Data Sheet MSDS maintained for all chemicals? 

Utility Management
39 Are alternate sources of energy available in case of power failure to

cater to the institution’s needs?
 =
40 Is a facility map available? 
41 Is drinking water being tested quarterly? 
IT, Library and Learning Resource Center
42 Is IT server room secured from unauthorized access?  =

43 Is backup data being saved periodically at other locations? (avoid 
loss of data in case of fire)
44 Are fire measures being taken to avoid fire incidents? 
45 Is proper temperature being maintained as required by server 
rooms?
46 Is Wi-Fi internet available throughout the campus for 

students/faculty with adequate speed?
Are there sufficient educational resources in library to cater to need
47 of the student? 
=
(Online subscriptions, journal subscriptions etc.)
Infection Control and Prevention Program
48 
Is there a documented infection control program in the institution?
49 Is there a mechanism to ensure safety of staff, faculty while


handling biological materials like cadavers and items in animal lab?
50 Is there a mandatory Hepatitis B vaccination policy for all health 

care workers and students?
51 Are floors clean? 

52 Are horizontal surfaces clean? 
53 Is dust found in high places? 
54 Are ceiling tiles not discolored, wet, missing or damaged? 
55

Is there evidence of rodents, cockroaches, flies and mosquitoes?
56 Is pest control done regularly and safely by a certified pest control 

company?
57 Is linen clean? 
58 Is there a needle stick injury policy? 
59 Are sharp containers adequately available? 
60 Are sharp containers not overfilled (over three fourths)? 
61 Is patient/lab equipment clean? 
Are hand hygiene posters and Isolation Precaution signs present at
62 appropriate sites as needed for contact, droplet, and airborne

precautions?
63 
Is hand soap available in all hand washing stations/bathrooms?
64 Are alcohol rubs available at point of patient care with functioning 

dispensers?
65 Are eye wash stations or appropriate alternatives available in areas


where splash of bodily fluid/hazardous material is expected?
66 Are disposable latex gloves available whenever needed for handling 

bloody and body fluids or for contact precautions?
Are gowns adequately available when splashing anticipated or for
67 contact precautions? 
P a g e 117 | 175
Student Session
Purpose
This session is conducted with students for discussion regarding students’ personal, academic, career
and financial counseling system in the college, financial aid, health services, infection control
education and counseling, student perspective of curriculum, teaching, and evaluation/grading;
students’ role and to assess perceived value of student input in academic planning, implementation,
evaluation.
The session shall also review effectiveness of academic counseling, policies and procedures for
student advancement and graduation and for disciplinary actions, review standards of conduct and
policies for addressing student mistreatment, career guidance strategies, advanced and subspecialty
clerkships/clinical experiences and electives for rounding out clinical education of the students.
Location
College Committee Room
At least 10 students, with representation of all five years of the program. No faculty or administration
representation in the session. Equal representation of male and female students.
At least 4 current house officers.

Surveyor(s)
Institutional Management Expert
■ Standard 1: Mission Statement (1.3 and 1.4)
■ Standard 4: Curricular Organization (4.3s)
■ Standard 6: Curricular Management (6.5)
■ Standard 8: Students (8.1 to 8.12) and (8.1s to 8.3s)
■ Standard 10: Program Evaluation and Continuous Renewal (10.5)
■ Standard 12: Research and Scholarship (12.1 and 12.3) and (12.1s)
■ Document outlining mission of the institution
■ Minutes of meeting reflecting discussion on mission of institution, involving students
■ College’s policy on electives for students
■ College’s study guides
■ College’s student financial support policy
■ Meeting minutes of curriculum committee reflecting student participation
■ College’s grievance policy
■ College’s code of conduct
■ Program evaluation results
■ List of all current or previous (last 12 months) research projects
What Will Occur
The surveyor(s) would like to look at the quality and safety issues at the laboratory services.
How to Evaluate
Document Review
To evaluate standards relevant to students, review the list of documents given above in order to
answer the questions below:
Student Session
Compliance
Yes No Not
Applicable
1.
Is there a college policy for students regarding electives 
(student selected component)?
2.
Is there a financial support policy / program available? 
3.
Does the policy have clearly defined criteria for 
scholarships / bursaries?
4.
Does the criteria include 5% of students getting
25% waiver on fee?

5.
Does the criteria include no fee for 1% of students, who 
are not related to the owners of the college?
6.
Is there evidence of disbursement of financial support in 
line with the policy?
7.
Is there a policy for access to academic and medical 
record of students?
8.
Is there a policy for co-curricular opportunities for 
students?
9.
Is there a policy for student feedback of the educational 
programs?
10.
Is there a policy for fair and formal process for taking 
any action that affects the status of a student?
11.
(Ifyes) Does the process include notice of impending 
action?
12.
(Ifyes) Does the process include disclosure of evidence on 
which action would be based?
13.
(Ifyes) Does the process include opportunity for the 
student to respond?
P a g e 119 | 175
14. (Ifyes) Does the process include an appeal process? 

15. Is there an evidence of implementation of the policy?
(Review case of demotion or dismissal)
16. Is a code of conduct document developed? 

17. Is a transfer policy developed? 
18. 
(Ifyes) Is the policy in line with PM&DC regulations?
Is there evidence of implementation of the policy? 
19. ((Review preferably two transfer cases — out of the college and
into the college)
Is there evidence of student participation in program 
evaluation?
20.
((Review meeting minutes or IEC report of university which
includes the program under review — MBBS/BDS)
21. and above the PMDC requirements and are commendable
in terms of Faculty requirements?
in terms of Equipment?
and above the PMDC requirements and are commendable
23.
in terms of Innovative teaching methodologies?
Based on the review, conduct a student interview session with the following list of questions
answered. For a ‘Yes’, at least 7 out of students should answer the question appropriately.
Student Interview Session
Compliance
Yes No Not
Applicable
1. Are the students aware of the mission statement of the

college or are able to retrieve it from appropriate
document?
2. Do the students understand the procedure for electives

(student selected components) and that it is in line with the
college policy?
3. Are study guides disseminated to the students? 
4.
Are students aware of the financial support program / 
policy?
6.
Do the students participate in the education committees of 
the college?
7.
Do the students have opportunities, funding and technical 
support for co-curricular activities?
8.
Do the students provide feedback on the education 
programs?
9.
(Ifyes) Is the student feedback taken on a defined interval as 
per policy?
10.
Do the students have access to preventative health 
services?
11.
Do the students have access to therapeutic health services? 
Do the students have knowledge about the grievance 
12. process for situations which affect the status of the
student?
13.
Are the students aware of the code of conduct
document?

14.
Are the students aware of the exchange program (regional 
and international) of the college?
15.
Are the students aware of the research advisory 
committee?
P a g e 121 | 175
16.
Do the students have knowledge of the research 
opportunities available to them?
17.
Do the students have knowledge of the infection 
prevention and control protocols?

18. Do the students have knowledge of the fire or emergency
drills that were previously arranged in the college?
19. 
Are there adequate facilities in the hospital for house job?
in terms of Faculty requirements?
in terms of Equipment?
and above the PMDC requirements and are commendable
22.
in terms of Innovative teaching methodologies?
Faculty Session
Purpose
This session focuses on interaction with faculty other than the leadership already interacted with. This session focuses
on discussion of notable achievements and ongoing challenges in individual courses and clerkships/clinical
experiences in achieving institute’s educational objectives; adequacy of resources for education, and availability of
faculty to participate in teaching.
This session will also include discussion on faculty appointment, promotion policies, and faculty development
opportunities, effectiveness of faculty governance, faculty compensation and incentives, and opportunities for collegial
interaction among faculty.
Location
At the discretion of medical college leadership inside the facility.
Faculty Participants
• One representative from each of basic sciences (Professor/Associate professor)
• One demonstrator from basic sciences and one from clinical sciences
• One representative from each of major clinical divisions (Professor/Associate Professor)
• Three department heads or faculty members with multiple roles
• Other (2-3) faculty members, at the discretion of the college
Surveyor(s)
Health Institutional Management Expert
Collaborative involvement of the faculty of medical college for medical students as required in the following standards
from the following chapters:
■ Standard 1: Mission (1.3 and 1.4)

■ Standard 2: Outcomes (2.4, 2.5 and 2.1s)
■ Standard 6: Curricular Management (6.3 and 6.4)
■ Standard 7: Assessment (7.3, 7.6 and 7.7)
■ Standard 9: Faculty (9.1 to 9.7)
■ Standard 9: Faculty (9.1s to 9.4s)
■ Standard 10: Program Evaluation and Continuous renewal (10.5)
■ Standard 11: Governance, Services and Resources (11.11)
■ Standard 12: Research and Scholarship (12.1, 12.3 and12.1s)
■ All related documents (as listed in required documents for day 1 of survey)
■ Mission statement document
■ List of faculty members
■ Departmental staffing plans
■ Faculty health records
■ Research advisory committee minutes indicating facilitation to faculty
■ Internal assessment and external assessment records (20:80 Rule)
■ Staff faculty files of participants as requested above
■ Job descriptions of various hierarchical tiers of faculty
■ Faculty training and development plan and records
■ Criteria for faculty recruitment, selection, promotion and retention
■ Financial trail of all faculty salary disbursements of previous 6 months
■ Faculty CME/CPD log of previous 12 months
P a g e 123 | 175
■ Biometric attendance of faculty (Minimum requirement >70%)
What Will Occur

The surveyor(s) will ask questions related to the direction of the medical college, its mission, curriculum
development and implementation, integration of outcomes into the program, methodologies of assessment,
involvement and support in research and assessment of health plan for the faculty.
The surveyor will assess compliance with the standards as listed above. During the session, the surveyor will also
identify issues that he or she will pursue in later survey activities.
The surveyor(s) will ask questions related to criteria for recruitment, selection, and promotion of faculty and the
plans in place for retention, methodologies in place for faculty development, financial disbursement of faculty, and
CME/CPD logs of the faculty.
The surveyor(s) will assess compliance with the standards as listed above. During the session, the surveyor(s) will
also identify issues that he or she will pursue in later survey activities.
How to Prepare
The institution should identify the participants in this session. Although the faculty should be familiar with all the
standards, the faculty should read closely the standards mentioned prior to survey. In preparation for this session, it
would be useful to turn the standards into questions. Mock discussions could then be conducted with participants so
they feel more comfortable with possible questions.
Faculty Session
Compliance
Not
Yes No
Applicable
1.
Is the mission developed with the involvement of the faculty
members?

(If applicable)
2.
Are the faculty members aware of the institutional vision?

3.
Is there a day care center to support faculty members?

4.
Are maternity leaves part of HR policy?

5.
Are psycho-social services available to cater the faculty needs?

6. Is there any financial support system to cater the faculty needs? 
7. Were curricular objectives developed with involvement of the

faculty members? (TORs or MOMs of curricular committee)
8.
Do the faculty members have access to study guides? (Online or 
hard copies etc.)
9.
Are the faculty members aware of the process to provide
feedback on curriculum?

10.
Are the departmental staffing plans of basic sciences in alignment
with PM&DC requirements?

11. Are the departmental staffing plans, of other clinical and non-

clinical sciences, in alignment with PM&DC requirements?
12.
Are the notable achievements of faculty acknowledged? (awards,
incentives etc.)

Is there a mechanism to document or communicate any ongoing
13. challenges in teaching or training on individual courses as faced

by the faculty members?
Is there a mechanism to ensure that these challenges are
14. addressed? 
15. Is there a process to ensure involvement of faculty in research?

(list of ongoing research projects involving faculty members)
16.
Is there a process to ensure that the health needs of the faculty are
met? (check the staff health plan)

Is there a structured faculty development program (FDP)?
17. (opportunities for training and development of staff at various

levels of the organization)
18.
Is there a process to ensure that the faculty members are involved
in continuous medical education?

Is there an institutional budget allocated for faculty to attend

19.
national and international educational trainings? (evidence of
international trainings and budget allocated in the past 12 months)
20.
Is there a mechanism to ensure effectiveness of faculty
governance? (feedback from faculty etc./ 360 feedback)

21.
Is there a policy and an established mechanism to ensure faculty
retention? (evidence of implementation)

Is there a policy and an established mechanism to ensure faculty
promotion that is in alignment with PM&DC staff selection and

22.
promotion criteria? (evidence of
implementation)
23.
Is there a mechanism implemented for faculty performance
evaluation and reporting?

24
Is the faculty appraisal/performance report linked to promotion?

What is the financial structure in place for financial disbursement


25
of the faculty? (request trail of salary transactions for a period of
last 6 months for random 5 faculty members)
P a g e 125 | 175
Are the job descriptions of the faculty members documented? (see

26
job description in staff files for Professor, Assoc. Professor, Asst.
Professor and Demonstrator etc. as applicable)
27
Are the faculty members aware of their job descriptions?

28
Are the faculty members engaged in multiple roles which are
evident from their job descriptions?

29
Is the head of the institution qualified by education, training and
experience in accordance with the PM&DC guidelines (add

guidelines here)?
30 above the PMDC requirements and are commendable in terms of

Faculty requirements?

Equipment?

Innovative teaching methodologies?
Medical Institution Staffing Section: (To be filled bvPMDC coordinator before the survey)
The inspector will request 5 random faculty files from the faculty list to interview the
faculty and to assess the file for;
1. Contract
2. Financial Disbursement
3. Attendance
4. Appraisals
Basic Sciences
Anatomy
30 The college must have at least one Professor of Anatomy 

31 The college must have at least one Associate Professor of 
Anatomy
32 The college must have at least two Assistant Professors of 

Anatomy
33
The college must have at least six demonstrators of Anatomy, or
equivalent number in case of integrated curriculum

34 The college must have at least two lab technicians / assistants of 

Anatomy
35
The college must have at least two dissection hall attendants

36 The college must have at least one curator of anatomy museum

37 The college must have at least one computer operator in Anatomy 
Department
Physiology:
38 The college must have at least one Professor of Physiology 

Physiology

Physiology
The college must have at least six demonstrators of Physiology,
41 or equivalent number in case of integrated curriculum

42 The college must have at least two lab technicians / assistants of 

Physiology
43 The college must have at least one computer operator in 

Physiology Department
at least one storekeeper in Physiology Department
44
Biochemistry:
44 The college must have at least one Professor of 

Biochemistry

Biochemistry

Biochemistry
47
The college must have at least four demonstrators of
Biochemistry, or equivalent number in case of integrated

curriculum
48 The college must have at least 1 lab technicians / assistants of 

Biochemistry

Biochemistry Department.
50 At least one storekeeper in Biochemistry Department
Pharmacology:
at least one Professor of Pharmacology yes(August 01,

50 2019 onwa
rd)
51 at least one Associate Professor of Pharmacology or above 
52 
at least one Assistant Professor of Pharmacology or above
at least five demonstrators of Pharmacology, or equivalent
53 number in case of integrated curriculum

54 at least one Pharmacists in Pharmacology
55
at least one lab technician / assistant of Pharmacology

P a g e 127 | 175
56 
at least one computer operator in Pharmacology Department
57 at least one storekeeper in Pharmacology Department
Pathology
at least two Professors of Pathology and 2 Associate Professors of 

57 Pathology (So as to cover all four disciplines namely
Histopathology, Microbiology, Chemical Pathology or
Haematology)
58
The college must have at least one assistant Professor of
Histopathology or above

59 The college must have at least one one assistant Professor of 
Microbiology or above
60 The college must have at least one at least one one assistant 
Professor of either Chemical Pathology or above
61
The college must have at least six demonstrators of Pathology, or
equivalent number in case of integrated curriculum

62 The college must have at least four lab technicians / assistants of 
Pathology
63 The college must have at least one curator of pathology museum 
Pathology Department
65 at least one storekeeper in Pathology Department
Forensic Medicine
66 The college must have at least one Professor or associate 

professor and one assistant Professor of forensic Medicine
67 The college must have at least three demonstrators of forensic 

medicine, or equivalent number in case of integrated curriculum
68 The college must have at least one lab technicians / assistants of 

Forensic Medicine
69
The college must have at least one computer operator in Forensic
Medicine Department

The college must have at least one storekeeper in Forensic
70
Medicine Department
Medical Education
71
The college must have at least one either Professor, 
Associate Professor or Assistant Professor of Medical Education
Public Health/Community Medicine

72 The college must have at least one Professor of Community 
Medicine or Public Health.

Community Medicine or Public Health.

Community Medicine or Public Health
75 At least five demonstrators of Community Medicine, orequivalent 

number in case of integrated curriculum
76 At least one social worker who is a qualified clinicalpsychologist 

and additionally responsible for student and faculty counseling
77 At least one statistician 

77 At least one computer operator in Community Medicine 
Clinical Sciences
General Medicine
79
The college must have at least two Professors of General
Medicine.

80
The college must have at least two Associate Professors of
General Medicine

81
The college must have at least two Assistant Professors of
General Medicine

82
At least 2 Senior Registrars/ Speciality Registrars of
GeneralMedicine or above

83 At least 4 Residents/ Medical Officers of General Medicine 
General Surgery
82 
The college must have at least two Professors of General Surgery
83 The college must have at least two Associate Professors of 

General Surgery

General Surgery
85 At least 2 Senior Registrars/ Speciality Registrars of 

GeneralSurgery or above
86 At least 4 Residents/ Medical Officers of General Surgery 
Gynaecology
85 
The college must have at least one Professors of Gynaecology
P a g e 129 | 175
86 The college must have at least two Associate Professors of 
Gynaecology

Gynaecology
At least 2 Senior Registrars/ Speciality Registrars of Ob/Gyneor 
above

At least 4 Residents/ Medical Officers of Ob/Gyne
Ophthalmology
88 
The college must have at least one Professor of Ophthalmology

Ophthalmology
90 The college must have at least one Assistant Professor of 
Ophthalmology
91
at least 1 Senior Registrars/ Specialty Registrars of
Ophthalmology or above

92
at least 3 Residents/ Medical Officers of Ophthalmology

ENT
91 The college must have at least one Professor of ENT 

92
The college must have at least one Associate Professor of ENT

93
The college must have at least one Assistant Professor of ENT

At least 1 Senior Registrars/ Speciality Registrars of ENT
orabove

At least 3 Residents/ Medical Officers of ENT

Pediatrics
94 The college must have at least one Professor of Paediatrics 

95
The college must have at least one Associate Professor of
Paediatrics.

96
The college must have at least one Assistant Professor of
Paediatrics

At least 1 Senior Registrars/ Speciality Registrars of
Paediatricsor above

At least 4 Residents/ Medical Officers of Paediatrics
Orthopaedics
97
The college must have At least one Professor or Associate
Professor of Orthopaedics 
98 The college must have At least one Assistant Professor or Senior 
Registrar/ SpecialtyRegistrar of Orthopaedics or above
99 The college must have At least 2 Residents/ Medical Officers of

Orthopaedics
Psychiatry
100
The college must have At least one Professor or
Associate Professor or Assistant Professor of 
Psychiatry.
101 The college must have At least 1 Residents/ Medical Officers of
Psychiatry

Dermatology
103
The college must have at least one Professor or
Associate Professor or Assistant Professor of 
Dermatology
105 The college must have at least 1 Residents/ Medical 
Officers of Dermatology
Cardiology P a g e 131 | 175
Yes
106 The college must have at least one faculty members
Assistant Professor or above in Cardiology
The college must have at least 1 Residents/ Medical Officers of
Cardiology
Pulmonology
The college must have at least one faculty member Assistant

Professor or above in Pulmonology
At least 1 Resident/ Medical Officers of Pulmonology
Nephrology
109 The college must have at least one faculty members 

Assistant Professor or above in Nephrology
The college must have at least 1 Resident/ Medical Officers of
Pulmonology
Gastroenterology
110 The college must have at least one faculty members 

Assistant Professor or above in Gastroenterology
At least 1 Residents/ Medical Officers of Gastroenterology
Medicine and Allied Specialty
The college must have at least one faculty member Assistant

Professor or above in either Clinical Haematology,

111 Rheumatology, Endocrinology, Oncology, Infectious Diseases,
Geriatrics or Neurology.
Accident and Emergency
The college must have at least one faculty member

112 Assistant Professor or above; or one consultant in Accident and

Emergency
1 casualty medical officers per shift
Anaesthesia
113
The college must have at least one Professor or one Associate
Professor ofAnaesthesia

115
The college must have Assistant Professor or Senior
Registrar/SpecialtyRegistrar of Anaesthesia or above

Radiology
The college must have at least one Professor or Associate 

Professor of Radiology
The college must have at least one Assistant Professor of
116 Radiology or above 
The college must have at least 1 Residents / Medical
Officers of Radiology
Surgical and Allied Specialty
The college must have at least one faculty members
117 Assistant Professor or above in of in any two of the following
 P a g e 133 | 175
specialties: and at least one resident/medical officer in the opted
allied surgical specialty:
1. Cardiac Surgery
2. Neurosurgery
3. Paediatric Surgery
4. Thoracic Surgery
5. Urology
6. Plastic surgery
7. Maxillofacial Surgery
Support Departments
Library managed by one librarian andone deputy librarian
The college must have appropriately staffed Quality Assurance

Cell

The college must have appropriately staffed IT Department 
The college must have appropriately staffed Student
Section

The college must have appropriately staffed Security Department 
The college must have appropriately staffed Finance Department 
The college must have appropriately staffed Maintenance
Department

Medical College Facilities Tour
Purpose
This tour is conducted by the Basic Sciences Expert on clinical learning facilities including inspection of lecture halls,
small group classrooms, labs, and study areas used for pre- clinical education of the students. It would comprise of:
■ Visit to library and computer learning facilities.
■ Visit of basic sciences department to review successes and ongoing challenges in administrative functioning of
departments; adequacy of resources for research, scholarship, teaching; and departmental support for faculty and
graduate programs.
■ Visiting and meetings with heads of those departments that offer the major required clerkships/clinical
experiences. Discussions to include successes and ongoing challenges in administrative functioning of
departments; adequacy of resources for all missions (clinical, research, scholarship, teaching); departmental
support for faculty and students; balancing of clinical and academic demands on faculty. Institutional tour will
include the hostel facilities and may be divided into multiple sessions throughout the survey.
Location
All facility areas.
Tour Participants
■ One representative from department managing medical equipment
■ Representation from IT
■ Department Heads and representatives’ availability at their respective sites
Surveyor(s)
Basic Sciences Expert
Recognition Standard 1: Infrastructure requirements Standard 11:
Governance, Services and Resources (11.4, 11.11)
■ Institutional Map
■ Departmental organograms/staff structure
■ Skill lab timetable
■ Timetables of basic science labs and museums available in their respective units which may include;
o Physiology Lab o Biochemistry
Lab o Histopathology Lab o
Dissection Hall o Pharmacology Lab
o Pathology Lab o Forensic
medicine lab/museum
o Museums of basic sciences
■ Small group discussion timetables
■ IT Resource Center details
Library/Digital Resource Center details (including list of subscriptions)
Research plan and activity log
P a g e 135 | 175
What Will Occur
The surveyor(s) will visit the facility to ensure that the infrastructure is sufficient and adequately equipped to meet the
needs of the students, faculty and other staff. Visit will cover various operational areas of the institution. These visits
will include on site interviews with the relevant departmental heads regarding the routine functioning of their
operations, any challenges faced, fire safety plans, emergency preparedness plans, infection control plans and others
to validate their execution through evidence as and when required. During the tour, the surveyor will also ensure
provision of internet and Wi-Fi services throughout the facility from the perspective of students and faculty.
How to Prepare
The institution should identify the participants in this session and develop and implement various plans as mentioned
above. The institution should identify the progress against those plans in the relevant committees and maintain
updated records showcasing their progress.
Medical College Facilities Tour

Surveyor Question Compliance
Q# Not
Physiology Applicable
Yes No
1 The physiology department structure is defined. 

2 The head of department is aware of his/her responsibilities. 
3 The head of department is aware of current departmental challenges. 
4 There is a structured time-table for students of various classes. (Small group 
discussions, Laboratory etc.)
5
There is a structured allocation of faculty to cover the student schedules.

6 There is structured duty roster of staff including lab technicians to provide 
technical and clerical support.
7 The lab is well equipped to cater to needs of the students. 

8 The students are comfortable with the study environment. 
9 The students feel adequacy of resources in the physiology lab. 
10 The students feel adequacy of resources in library. 
Biochemistry
The biochemistry department structure is defined. 

1

5

There is structured duty roster of staff including lab technicians to provide To Be
6 Determined
To Be
7 The lab is well equipped to cater to needs of the students. Determined
To Be
8 The students are comfortable with the study environment. Determined
Resource
9 The students feel adequacy of resources in the biochemistry lab.
Issue

Anatomy
1 The Anatomy department structure is defined. 

discussions, Laboratory, Dissection Hall etc.)
5


To be
8 The students are comfortable with the study environment.
Determined
The students feel adequacy of resources in the anatomy museum, and To be
9 Determined
dissection hall etc.
To be
10 The students feel adequacy of resources in library. Determined
P a g e 137 | 175
Pharmacology
The pharmacology department structure is defined. 

1

5


9 The students feel adequacy of resources in the pharmacology lab. 
Pathology
1 The pathology department structure is defined. 

5


9 The students feel adequacy of resources in the pathology lab. 
Forensic Medicine
The Forensic Medicine department structure is defined. 

1

5


9 
The students feel adequacy of resources in the Forensic Medicine museum.

Skill Lab
There is a person responsible for the skill lab who is aware of his/her

1
responsibilities.
2 The person responsible is aware of current departmental challenges. 



7 The students feel adequacy of resources in the skill lab. 
P a g e 139 | 175
Hospital Facilities and Safety Tour
Purpose
This tour is conducted by the Hospital Management and Safety Expert. The focus of this tour is to evaluate adequacy
and safety of hospital facilities necessary to maintain the essentials of quality and patient safety.
Location
All facility areas.
Tour Participants
■ One representative from safety department
■ One representative from biomedical department/equipment technician
Surveyor(s)
Hospital Management & Safety Expert
Standard 11: Governance, Services and Resources (11.4)
■ MIS generated data of;

o Hospital bed distribution per clinical specialty
o Hospital Bed occupancy data per clinical specialty for last 12 months (Month-wise) o
ALOS per clinical specialty for last 12 months (Month-wise)
o List of procedures (Major and Minor) performed in IPD per clinical specialty for last 12 months (month-
wise)
o List of procedures (Major and Minor) performed in OPD per clinical specialty for last 12 months
(month-wise)
o List of Top diagnosis and their frequencies (20 per major clinical specialty and 10 per subspecialties)
o Lab volume (major services data, month-wise)
o Summary of Financial statement of 25% beds allocated for teaching o Summary of Financial statement
of 75% rest of the beds
■ Facility map
■ Fire and safety plan
■ Utility plan
■ Waste management plan
■ Emergency preparedness and evacuation plan
■ Hazardous material program
■ Infection control and prevention program
What Will Occur

The surveyor(s) will visit the hospital to ensure that the infrastructure is sufficient and adequately equipped to meet the
needs of the students, faculty and other staff. Visit will cover IPD, OPD, OR and critical areas including other
operational areas/units. These visits will include on-site interviews with the relevant departmental/unit heads regarding
the routine functioning of their operations, any challenges faced, fire safety plans, utility plans,
emergency preparedness plans, biomedical equipment plans, infection control plans and others to validate their
execution through evidence as and when required.
How to Prepare
The hospital should identify the participants in this session and develop and implement various plans as mentioned
above. The hospital should identify the progress against those plans in the relevant committees and maintain updated
records showcasing their progress.
Administrative session
Compliance
Q # Surveyor Question Not
Yes No Applicable
Initial Inspection
Does the hospital have its account audited by a third party?


1
(Report to be submitted to PMDC)
2
Is there 70% biometric attendance of all faculty, staff of the hospital?

Is there evidence that the patients admitted on 25% of beds (allocated
for teaching) are not charged for accommodation and consultation?

4
Is there evidence that the patients admitted on 25% of beds (allocated

for teaching) are charged for Medications, diagnostic services (Lab,

radiology) and therapeutic services (procedures) etc. are at cost price
5
(not for profit)?
6
Does the hospital have Internal Medicine specialty with a minimum of
50 inpatient beds?

7
Does the hospital have Psychiatry specialty with a minimum of 5
inpatient beds?

8
Does the hospital have Dermatology specialty with a minimum of 5
inpatient beds?

9
Does the hospital have Cardiology specialty with a minimum of
5 inpatient beds? 
10 Does the hospital have a minimum of 5 CCU beds? 
Does the hospital have Neurology specialty with a minimum of 5 Yes
11
inpatient beds?
12 Does the hospital have Pulmonology specialty with a minimum 
P a g e 141 | 175
of 5 inpatient beds?
13
Does the hospital have Nephrology specialty with a minimum of
5 inpatient beds? 
14 Does the hospital have a minimum of 5 dialysis chairs?

15
Does the hospital have Gastroenterology specialty with a minimum of
5 inpatient beds?

16
Does the hospital have Medical ICU with a minimum of 10 inpatient
beds?

Does the hospital have at least one of the following specialties with a
minimum of 5 inpatient beds
• Rheumatology
• Endocrinology
• Oncology
17
• Infectious Diseases
• Clinical Haematology,
• Geriatrics
• Neurology
80 beds may be distributed bv the hospitalfs) in any of the
medicine and allied specialties above.
Does the hospital have General Surgery specialty with a minimum of

75 inpatient beds, excluding post-operative recovery beds?

18
Does the hospital have Gynecology and Obstetrics specialty with a

19 minimum of 70 inpatient beds (including labor room)?
Does the hospital have Ophthalmology specialty with a minimum of 15

20
inpatient beds?
Does the hospital have Ear, Nose and Throat (ENT) specialty with a
21 minimum of 15 inpatient beds?
22
Does the hospital have Orthopedics specialty with a minimum of 15
inpatient beds?

23
Does the e hospital have Anesthesia specialty with a minimum of 10
Surgical ICU beds?

Does the hospital have at least two of the following specialties with a
minimum of 10 inpatient beds each

• Cardiac Surgery
• Neurosurgery
24 • Paediatric Surgery
• Urology
• Plastic surgery
• Maxillofacial Surgery
P a g e 143 | 175
25 beds may be distributed bv the hospitalfs) in any of the
surgery and allied specialties above.
Does the hospital have Pediatrics specialty with a minimum of
25 60 inpatient beds?
26
Does the hospital have Accident and Emergency (A&E) specialty with 
a minimum of 10 beds?
Does the hospital have at least 5% of all inpatient beds (not including
Medical ICU and Surgical ICU) having cardiac monitor with slandered

27
pulse, BP, ECG and Oxygen Saturation?
Outpatient Load

Does the hospital have minimum OPD of more than 1500 patients per
28
month averaged for the past 12 months in General Medicine?
Outpatient Load

29
month averaged for the past 12 months in
Psychiatry?
Outpatient Load

30
month averaged for the past 12 months in Dermatology?
Outpatient Load

31
Cardiology?
Outpatient Load
Does the hospital have Minimum OPD of more than 150 patients
permonth averaged for the past 12 months in each nephrology and
pulmonology
Outpatient Load

33
month averaged for the past 12 months in Gastroenterology?
Outpatient Load

Does the hospital have minimum of more than 150 patients per month
34
seen averaged for the past 12 months in Accident and Emergency?
Outpatient Load

35
month averaged for the past 12 months in specialty identified in opted
elective allied medical specialty
Outpatient Load

36
Pediatrics?
Outpatient Load

37
month averaged for the past 12 months in General Surgery?
Outpatient Load

38 Does the hospital have minimum OPD of more than 250 patients per
month averaged for the past 12 months in ENT?
Outpatient Load

39
month averaged for the past 12 months in Ophthalmology?
Outpatient Load

40
Gynecology and Obstetrics?
Outpatient Load
41
month averaged for the past 12 months in Orthopedics?
Outpatient Load
42
month averaged for the past 12 months in each of the two opted
elective allied surgical specialities
Inpatient

43 Is total bed occupancy of the hospital at least 70% in the past 12
months?
45 Inpatient

In each of the specialty in the hospital, has the bed occupancy
P a g e 145 | 175
been at least 50% in the past 12 months?

46 Does the hospital have a minimum of 350 procedures performed in the
past 12 months in General Medicine?


past 12 months in Dermatology?


past 12 months in Cardiology?
49 Does the hospital have a Minimum of 200 procedures performed in the

past 12 months in each nephrology and pulmonology.


past 12 months in Gastroenterology?


past 12 months in Accident and Emergency?


Does the hospital have a minimum of 150 procedures performed in the
52
past 12 months in medicine and allied opted elective medical
specialty?


53 Does the hospital have a minimum of 3500 minor procedures in the
past 12 months in General Surgery?


54 Does the hospital have a minimum of 1000 major procedures in the
past 12 months in General Surgery?


past 12 months in Anesthesia?
56 Major and Minor Procedures


Does the hospital have a minimum of 2000 major procedures in
P a g e 147 | 175
the past 12 months in Anesthesia?
57 Does the hospital have minimum of 250 procedures in the past

12 months in ENT?
58 Does the hospital have a minimum of 250 procedures in the past 12

months in Ophthalmology?


past 12 months in Gynecology and Obstetrics?


60 Does the hospital have a minimum of 2000 major procedures in the
past 12 months in Gynecology and Obstetrics?


61 Does the hospital have a minimum of 250 procedures in the past 12
months in Orthopedics?


Does the hospital have a minimum of 100 minor procedures in the past
62
12 months in each of the each of the two opted elective surgical
specialities.


63 Does the hospital have minimum of 100 major procedures in the past
12 months in each of the two opted elective surgical specialities.
Lab volume

64 Does the hospital have more than an average of 300 hematology tests
performed every month, in the past twelve months?
Lab volume

More than an average of 300 hematology tests performed every month,
for the past twelve months
Lab volume

Does the hospital have more than an average of 30 units of blood
65
provided by blood bank per month, in the past twelve months?
Lab volume

Does the hospital have more than an average of 1000 chemical
66
pathology tests performed every month, in the past twelve months?
P a g e 149 | 175
Lab volume 
67 Does the hospital have more than an average of 150 microbiology tests
performed every month, in the past twelve months?
Lab volume

68 Does the hospital have performed more than an average of 30 biopsies
per month, in the past twelve months?
Facilities

69 Does the hospital have hospital pharmacy, both for indoor and outdoor
patients?
Facilities

70 Do all the hospital pharmacies have trained and qualified pharmacists,
with minimum qualification of Pharm D?
Facilities

71 Does the hospital have faculty workstations or offices for Associate
Professor and above ?
Facilities

72 Does the hospital have resuscitation area with all necessary equipment?
73
Facilities

Does the hospital have 20 separate OPD rooms for specialties?
Facilities

74 Does the hospital have Five designated areas / demonstration rooms in
OPD / IPD forteaching / evaluation of medical students
Facilities
76

Does the hospital have five fully equipped operating rooms?
76
Facilities

Does the hospital have a radiology department?
Fire Safety

Does the hospital have a documented fire safety and evacuation plan?
77 Does the fire safety plan include training schedule for staff, faculty and 
students?
80 
Does the fire safety plan mention oversight by a designated person?
81 Does the fire safety plan identify high risk/fire-prone areas? 

82 Does the fire safety plan address the risks identified in high risk areas? 
83 
Does the hospital have a designated and trained fire response team?
84 Does the hospital conduct mock fire evacuation drill? 

85 Does the hospital have a designated assembly area? 
86
Are students/faculty aware of the designated assembly area and
alternative fire exits?

87 Are portable fire extinguishers available at suitable locations? (at least 
one in every ward)
88 Are staff and students aware of the location and handling of fire 
extinguishers?
89 
Are evacuation maps displayed prominently at the department/floor?
90 Are emergency exits unobstructed and clear at all times? 

91 Are illuminated exit signs displayed at exit doors? 
Safety and Security
92 Does the institute have slip resistant strips on stairs? 

93 Are grip bars available with stairs to avoid falls? 
94 In case of elevators, are safety instructions (emergency alarm, 
maximum load, emergency number) displayed?
95 Are all electrical wires secured (connectors used to connect wires 

instead of tapes)?
96
Has the organization taken remedial steps to address fire risks for
vulnerable areas? (Lab, generator room, server room, store, record

room)
97 Are access restrictions in place for identified vulnerable areas ( labs,


mortuary, management offices, warehouse, and data rooms)?
98 
Are security guards available at entrance and aware of their duties?
99
Are hospital’s entrances secured and walls protected from outside
intruders?

P a g e 151 | 175
100 Are first aid kits available to cater to students/faculty needs? 
101 
Are bar grips available in washrooms for disabled/old age persons?
102 Are ramps available or other measures taken to ensure ease of 

transportation for disabled persons?
103 Are the staff in radiology department using dosimeters/TLD? 

104 Is there a log of radiation exposure being maintained for all staff? 
Emergency Plan
105 Are mock emergency drills conducted?
106 Are dedicated internal telephone numbers for fire, security and other
emergencies identified and displayed?
Waste Management
107
Does the hospital have a documented waste management program?
108 Is infectious waste being segregated appropriately through color coded

bags? (e.g. red, yellow, blue)
109 Is temporary waste storage facility available?
110 Is infectious waste being properly incinerated/disposed of within 24

hours of generation?
111 Is inventory of hazardous material (chemical) maintained throughout

the facility?
112 Are all chemicals labelled based on a hazardous tag? E.g. (toxic,
corrosive, irritant, flammable)
113
Are all chemicals stored properly according to optimal temperature?
114
Is spill kit available to manage chemical/infectious/mercury spill?
115 Is all relevant staff aware of risks of chemicals?
116 Does all staff wear appropriate Personnel Protective Equipment PPEs
during work? (e.g. gloves, masks, gowns, eye shield as applicable)
Are Material Safety Data Sheet MSDS maintained for all chemicals?
117
118
Is the nuclear waste being handled safely using lead boxes? (if
applicable)
Biomedical Gases Safety

119 Are the biomedical gases being handled safely?
120 Are the persons responsible for handling gas control valves in the ORs
and other critical areas adequately trained?
121 Is there a mechanism in place to ensure the supply of correct

biomedical gas from the designated port?
Utilities Management
122 Are alternate sources of energy available in case of power failure to

cater to the hospital’s needs?
123 Is a facility map available?
124
Is drinking waste water being tested quarterly?
IT|
d
Is Wi-Fi internet available for students/faculty with adequate speed
throughout the hospital?
Infection Control 1
126

Is there a documented infection control program in the institution?
127 Is there a mechanism to ensure safety of staff and faculty while

handling biological materials like cadavers and items in animal lab?
128 Is there a mandatory Hepatitis B vaccination policy for all health care 
workers and students?
129 Are floors clean? 

130 Are horizontal surfaces clean? 
131 Is dust found in high places? 
132 Are ceiling tiles not discolored, wet, missing or damaged? 
133 Is there evidence of rodents, cockroaches, flies or mosquitoes?
134 Is pest control done regularly and safely by a certified pest control 
company?
135 Is the linen clean? 

136 Is there a needle stick injury policy? 
137 Are sharp containers adequately available? 
P a g e 153 | 175
138 Are sharp containers not overfilled (over three fourths)? 
139 Is patient/lab equipment clean? 
Are hand hygiene posters and Isolation Precaution signs displayed at
140 appropriate sites as needed for contact, droplet, and airborne

precautions?
141 Is hand soap available in all hand washing stations/bathrooms? 

142 Are alcohol rubs available at point of patient care with functioning 
dispensers?
143 Are eye wash stations or appropriate alternatives available in areas


where splash of bodily fluid/hazardous material is expected?
144 Are disposable latex gloves available whenever needed for handling 
blood and body fluids or for contact precautions?
145 Are gowns adequately available when splashing is anticipated or for 

contact precautions?
146 Are hand washing facilities available for all staff? 

147 
Are patients with pulmonary TB placed in a separate single room?
NA
148 Is negative pressure or correct ventilation maintained in a single room
for TB patients?
Are patients with MDR organisms placed on Contact
149 Precautions?

150
Are adequate supplies and PPE available in Isolation areas?

151
Are patients’ bathrooms clean?

152
Are soap and paper towels available in each bathroom?

153
Is patient equipment clean?

154 Are patient specimens handled correctly and transported safely? 
Hospital Clinical Tour
Purpose
This tour is conducted by the Clinical Sciences Medical Expert. The focus of this tour is to evaluate the adequacy and
safety of hospital facilities for clinical training. The focus shall not be on the documentation in the medical record or the
care provision in the hospital.
Location
All facility areas.
Tour Participants
■ One representative from each clinical department in their respective units
Surveyor(s)
Clinical Sciences Medical Expert
Standard 11: Governance, Services and Resources (11.4)
■ Clinical Rotation Plan & Schedules

■ Student Logs
■ Case mix per department
■ Facility Map
■ Infection Control and Prevention Program
What Will Occur

The surveyor(s) will visit the hospital to ensure that the infrastructure is sufficient and adequately equipped to meet the
needs of the students, faculty and other staff. Visit will cover IPD, OPD, OR and critical areas including other
operational areas/units. These visits will include on site interviews with the relevant departmental/unit heads regarding
the routine functioning of their operations, any challenges faced, and appropriate utilization of operations and
infrastructure to ensure patients are being treated for a maximized learning experience for students.
How to Prepare
The hospital should identify the participants in this session and develop and implement various plans as ment ioned
above. The hospital should identify the progress against those plans in the relevant committees and maintain updated
records showcasing their progress.
P a g e 155 | 175
Emergency Department
Compliance
Q# Surveyor Question
Not
Yes No
Applicable
1 Does the hospital have an operational emergency department working 

24 hour a day, 7 days a week?
2 Does the hospital have 10 functional beds allocated for emergency 

care?
3 Is the emergency department easily accessible to patients? 

4 Does the hospital define a patient prioritization process? (triage) 
5
Does the EMERGENCY DEPARTMENT have a clearly defined
hierarchical structure?

6 Is the EMERGENCY DEPARTMENT head aware of his/her 
responsibilities?
7
Is there a timetable for students for clinical rotation/clerkship in
EMERGENCY DEPARTMENT?

8 Does the hospital have an orientation program for students? 
9 Does the provided orientation program cover principles of infection 
control?
10 Does the provided orientation program cover the fire and safety 
prevention guidelines?
11 Does the hospital provide unit specific orientation to the students? 

12 Is the learning supervised to ensure patient and student safety? 
13 Are the students comfortable with the learning experience provided in 
the EMERGENCY DEPARTMENT?
14
Is the student to supervisor ratio appropriate in the EMERGENCY
DEPARTMENT?

15 Are the students being trained on the skills identified for their

respective year of medical education as identified in the study guides?
16 Do the student logs support the provision of training? 

17
Does the EMERGENCY DEPARTMENT define and measure upper
limit of patient stay in the EMERGENCY DEPARTMENT?

18
Are relevant quality indicators identified and monitored by the 
department?
19 Are there any physician/staff with valid ACLS certification? 
20 Are there any physician/staff with valid PALS certification? 
21 Are there any physician/staff with valid ATLS certification? 
22
Is there a designated procedure room for the EMERGENCY
DEPARTMENT?

23 Are there appropriate resuscitation services available in the 
EMERGENCY DEPARTMENT?
24
Does the unit provide learning opportunities that are over and above
the PMDC requirements and are commendable in terms of Faculty

requirements?
25 Does the unit provide learning opportunities that are over and above

the PMDC requirements and are commendable in terms of Equipment?
26
the PMDC requirements and are commendable in terms of Innovative

teaching methodologies?
Medical Ward
27 Does the hospital have a fully functional medical ward? 

28 Does the hospital have 75 beds allocated for medical ward? 
29
Is the medical ward covered by sufficient trained physicians, nurses
and other staff 24/7, as evident by duty roster of the unit?

30 
Does the Medical unit have a clearly defined hierarchical structure?
31 Is the Medical unit head aware of his/her responsibilities? 

32
Is there a timetable for students for clinical rotation/clerkship in the
Medical Unit?

33 Does the hospital provide unit specific orientation to the students?

34
Is the learning supervised to ensure patient and student safety? 
the Medical Unit?
36 Are the student study guides available and implemented? 

37 Are the students trained on the skills identified for their respective year

of medical education as identified in the study guides?
Yes
P a g e 157 | 175
39 Is the student to supervisor ratio appropriate? 
40 Does the department define and measure patient length of stay? 
41 Are there relevant quality indicators identified and monitored by the 
department?

43 Is there a designated procedure room? 
45 Are there appropriate resuscitation services available? 
46 
Does the hospital ensure privacy and confidentiality of the patient?
47

requirements?

49

Surgical Ward
50 Does the hospital have a fully functional surgical ward? 

51 Does the hospital have 75 beds allocated for surgical ward excluding 
recovery room beds?
52 Is the ward covered by sufficient trained physicians, nurses and other 

staff 24/7, as evident by duty roster of the unit?
53 Does the unit have a clearly defined hierarchical structure? 

54 Is the unit head aware of his/her responsibilities? 
55
Is there a timetable for students for clinical rotation/clerkship in Unit?

56
Does the hospital provide unit specific orientation to the students?

the unit?


64 Are relevant quality indicators identified and monitored by the 
department?
65 Are there any physician/staff with valid ATLS certification? 

67 Are appropriate resuscitation services available? 
68 
69

requirements?

71

Obstetrics and Gynecology
72
Does the hospital have a fully functional OBGYN ward? 
73 Does the hospital have 50 beds allocated for the ward (including labor 
room beds)?


77

78

P a g e 159 | 175
the Unit?



87 Are there relevant quality indicators identified and monitored by the 
department?
88 Are there any physician/staff with valid NRP certification? 

89 Is there a designated procedure room?
90 Are there appropriate resuscitation services available?
91
92 the PMDC requirements and are commendable in terms of Faculty
requirements?
94 the PMDC requirements and are commendable in terms of Innovative
Orthopedics
95 Does the hospital have a fully functional orthopedics ward? 

96 Does the hospital have 15 beds allocated for the ward? 

100 Is there a timetable for students for clinical rotation/clerkship in Unit? 
the Unit?



department?
110 Are there any physician/staff with valid ATLS certification?

113 

requirements?


Nephrology/Pulmonology/Gastroenterology/Cardiology (choose any one)
117
Does the hospital have a fully functional ward? 
P a g e 161 | 175
123 

the Unit?



department?

135 

requirements?


Urology/Neurosurgery/Cardiothoracic/ Plastic Surgery (choose any one) 1
139 Does the hospital have a fully functional ward? 


144

the Unit?
148
Are the student study guides available and implemented? 
149
Are the students being trained on the skills identified for their

150
Do the student logs support the provision of training? 
151
Is the student to supervisor ratio appropriate? 
152
Does the department define and measure patient length of stay? 
153 Are relevant quality indicators identified and monitored by the

department?
154
Are there any physician/staff with valid ACLS certification? 
155
Is there a designated procedure room? 
156
Are appropriate resuscitation services available? 
157


requirements?
159


P a g e 163 | 175
Pediatrics and Neonatology
161 Does the hospital have a fully functional ward?
162 Does the hospital have 60 beds allocated for the ward?
163 Is the ward covered by sufficient trained physicians, nurses and other
164
Does the unit has a clearly defined hierarchal structure?
165
Is the unit head aware of his/her responsibilities?
166 Is there a timetable for students for clinical rotation/clerkship in Unit?
168 Is the learning supervised to ensure patient and student safety?
169 Are the students comfortable with the learning experience provided in
the Unit?
170
Are the student study guides available and implemented?
171
172
Do the student logs support the provision of training?
173
Is the student to supervisor ratio appropriate?
174
Does the department defines and measures patient length of stay?
department?
176 Are there any physician/staff with valid PALS/NRP certification?
177
Is there a designated procedure room?
178
Are appropriate resuscitation services available?
179
requirements?
181
Medical ICU (MICU)
183
Does the hospital have a fully functional MICU? 
184
Does the hospital have 10 beds allocated for the unit? 
185 Is the unit covered by sufficient trained physicians, nurses and other

186 Does the unit have a clearly defined hierarchal structure? 

187
Is the unit head aware of his/her responsibilities? 

190

the Unit?
192
193
Are the students trained on the skills identified for their respective year

194
195
196
Does the department define and measure patient length of stay? 

department?
198
Are there any physician/staff with valid ACLS certification? 
199
Is there a designated procedure room? 
P a g e 165 | 175
201 

requirements?
203


Surgical ICU (SICU)
205
Does the hospital have a fully functional SICU? 
206 Does the hospital have 10 beds allocated for the unit? 


209

the Unit?
214
215
Are the students trained on the skills identified for their respective year


217
218 
Does the department defines and measures patient length of stay?

department?
220
Are there any physician/staff with valid ATLS certification? 
223


requirements?
225


Pediatric ICU (PICU)/ Neonatal ICU (NICU) (choose any one)
227
Does the hospital have a fully functional PICU/NICU?
229
Does the unit have a clearly defined hierarchal structure?
230
Is the unit head aware of his/her responsibilities?
233
Is the learning supervised to ensure patient and student safety?
the Unit?
235
Are the student study guides available and implemented?
236
Are the students be trained on the skills identified for their respective
year of medical education as identified in the study guides?
237
Do the student logs support the provision of training?
238
Is the student to supervisor ratio appropriate?
239
Does the department define and measure patient length of stay?

department?
P a g e 167 | 175
241
Are there any physician/staff with valid PALS/NRP certification?
242
Is there a designated procedure room?
243
Are appropriate resuscitation services available?
244
requirements?
246
Operating Suite (including recovery room)
248
Does the hospital have a fully functional 5 operating rooms? 
249
Does the hospital have functional recovery room beds? 

staff, as evident by duty roster of the unit?
251
Does the unit have a clearly defined hierarchal structure? 
252


255
256
Are the students comfortable with the learning experience provided in 
the Unit?
257
258

259
department?
263
Are there any physician/staff with valid ATLS certification?
264
Are appropriate resuscitation services available? 
265


requirements?
267


ENT , Ophthalmology, (choose any one)
269 Does the hospital have a fully functional ENT / Ophthalmology unit?

270
Does the hospital have 15 beds allocated for the unit? 

272
Does the unit have a clearly defined hierarchal structure? 
273


276

the Unit?
278
279

P a g e 169 | 175

department?
284 Are there any physician/staff with valid advanced life support
certification?

285
Is there a designated procedure room for the unit? 
287


requirements?
289


Development Credits
Special Guidance:
■ Dr. Aamir Bilal (Chairman Evaluation Committee)
■ Dr. Arshad Javed (Vice Chancellor KMU)
■ Gen. Saleem Rana (Principal Army Medical College)
■ Dr. Zeeshan Bin Ishtiaque (Shifa International Hospital)
Core Team:
■ Mr. Taimoor shah (Healthcare Quality and Accreditation
Expert)
■ Dr. Abdul Wahab Hassan (Healthcare Quality Expert)
■ Mr. Umar Amjad (Hospital Management Expert)
Technical Reviewers and Valuable Inputs:

■ Dr. Riffat Shafi (Professor of Physiology and Medical Education)
■ Dr. Umar Farooq (Dean Ayub Medical Teaching Institute)
■ Dr. Shehla Baqi (Dow Medical College)
■ Dr. Muslim Khan (Khyber College of Medicine)
■ Brig. Iqbal Khakwani (Basic Sciences)
■ Mr. Ali Raza (Member PMDC)
■ Dr. Sami Saeed (Fauji Foundation Medical College)
■ Dr. Rashid Mahmood (Rehman Medical Institute)
■ Dr. Maqbol Ilahi (Rehman Medical Institute)
■ Dr. Amjad Naseem (Fauji Foundation Medical College)
■ Dr. Dawar Majeed (Fauji Foundation Medical College)
■ Dr. Usman Mehboob (Khyber Medical University)
■ Dr. Muhammad Noor (Medical Education)
■ Mr. Usman Ali (Biomedical Engineer)
■ Mr. Shujaat (Biomedical Engineer)
■ Mr. Hassan Jan (Architect)
■ Mr. Jameel (Electrical Engineer)
Support Team:
■ Mr. Umar Farooq (Clinical Quality Expert)
■ Ms. Arooj Ishtiaq (Management Quality Expert)
■ Ms. Kholood Abid Janjua (Sr. Research Analyst)
■ Dr. Sabih Qazi (Quality Specialist)
P a g e 171 | 175

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Self Appraisal Form PM&amp;DC

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1

1. When a new medical or dental college apply for recognition by PMDC

PMDC Initial Recognition Framework 2

Pakistan Standards for Initial Recognition of Medical and Dental Colleges

Recognition Standard 0: Pre-requisites

PMDC Initial Recognition Framework 4

College Covered Area

PMDC Initial Recognition Framework 5

PMDC Initial Recognition Framework 6

College Laboratory Equipment Requirements

Anatomy Major Anatomy: (Dissection

Anatomy: (histology Laboratory)

Anatomy: (Dissection hall)

Anatomy: (histology laboratory)

PMDC Initial Recognition Framework 10

available, functional and in use.

students available, functional and in use.

PMDC Initial Recognition Framework 12

Pharmacology (Major) Commented [WU15]: Duplication, should be deleted

pharmacology practical’s per hundred students available, functional and in use

Pathology I and II (Major)

available, functional and in use.

Pathology I and II (Minor)

PMDC Initial Recognition Framework 14

Community Medicine (museum)

Forensic medicine (Major)

Forensic medicine (Minor)

Teaching Hospital(s) Equipment Requirements

PMDC Initial Recognition Framework 16

Obstetrics and Gynaecology

PMDC Initial Recognition Framework 18

PMDC Initial Recognition Framework 20

Accident and Emergency Department

Central Sterilization and Storage Department

PMDC Initial Recognition Framework 22

Radiology Services with all imaging modalities

Hospital Laboratory Services

PMDC Initial Recognition Framework 24

students available, functional and in use.

Should be rephrased as 3 faculty members like Professor/Associate/Assistant Professor (1+1+1

PMDC Initial Recognition Framework 28

Should be rephrased as 3 faculty members like Professor/Associate/Assistant Professor (1+1+1

Should be rephrased as 3 faculty members like Professor/Associate/Assistant Professor (!+1+1

Not many dermatologists available. Should have 1 professor/associate professor/assistant

Medicine and Allied Specialty

Accident and Emergency

PMDC Initial Recognition Framework 30

Surgical and Allied Specialty

Clinical Specialities and Beds

PMDC Initial Recognition Framework 32

Major and Minor Procedures

PMDC Initial Recognition Framework 34

PMDC Initial Recognition Framework 36

Recognition evaluation is performed by inspectors appointed by PMDC to verify that a

1. The college meets all the legal requirements

Decision Rule Number 1 (Legal):

Decision Rule Number 2 (Infrastructure):

Decision Rule Number 3 (Equipment):

Decision Rule Number 4 (Faculty and Staff):

Decision Rule Number 5 (Teaching Hospital):

PMDC Initial Recognition Framework 38

Recognition Evaluation (Pre-requisite):

The process of evaluation is explained in detail as below:

Medical and Dental College’s Responsibilities

Self Appraisal Form PM&DC

Self Appraisal Form PM&DC