Goal 17: Partnerships for the Goals

Manipal Academy of Higher Education (MAHE) is committed to assessing sustainability literacy and knowledge as part of its ongoing quality assurance and compliance initiatives. Our institution conducts regular assessments to gauge sustainability practices and awareness, aligning with international standards such as ISO 9001, ISO 14000, and ISO 50001.

Specifically, MAHE conducts gap analyses and audits every six months internally and annually externally to identify areas for improvement and compliance with sustainability practices. Additionally, energy audits are conducted semi-annually internally and annually externally to monitor and optimize energy consumption.

To evaluate sustainability literacy and knowledge, MAHE employs a comprehensive approach similar to Sulitest TASK parameters. This includes regular gap analyses focused on sustainability awareness and education levels among stakeholders within the institution.

The insights gathered from these assessments contribute to the preparation of sustainability reports, providing a structured overview of MAHE's sustainability initiatives and areas for development. This commitment underscores MAHE's dedication to fostering sustainability practices and enhancing environmental literacy across our academic community.

Issue Date: 30/01/2023                                                                                              Revision Status: R5

EMS Objectives

EnMS Objectives – Targets defined annually

Integrated Manual

ISO 9001:2015

ISO 14001: 2015

ISO 50001:2018

Manipal Academy of Higher Education,

manipal.edu, Madhav Nagar,

Manipal- 576 104, Karnataka, India

Phone:  91 820 2571201 – 2571219

Fax:  91 820 2570062

Website: www.manipal.edu

Copy uploaded on: Intranet web portal – maheportal

Note: Black font color indicates applicability of all 3 standards (Q, E, EnMs). Green font indicates EMS applicability and blue font indicates EnMS applicability.

Table of Contents

Annexures:

Revision Status Record

INTRODUCTION:

MAHE was founded by Late Dr. TMA Pai (1898-1979) is also synonymous with excellence in higher education. Over 30,000 students from 57 different nations live, learn and play in the sprawling University town, nestled on a plateau in Karnataka’s Udupi district. It also has nearly 2600 faculty and almost 10000 other support and service staff, who cater to the various professional institutions in health sciences, engineering, management, communication and humanities which dot the Wi-Fi-enabled campus.

The University has off-campuses in Mangalore and Bangalore, and off-shore campuses in Dubai (UAE) and Melaka (Malaysia). The Mangalore campus offers medical, dental, and nursing programs. The Bangalore Campus offers programs in Regenerative Medicine. The Dubai campus offers programs in engineering, management and architecture, and the Melaka campus offers programs in medicine and dentistry.

Every institute has world class facilities and pedagogy, which are constantly reviewed and upgraded to reflect the latest trends and developments in higher education.

In Manipal, these include educational facilities like the Simulation Lab with computer driven Manikins, an Innovation Centre, one of Asia’s largest health sciences libraries, one of the world’s best anatomy museums, a business incubation centre and various other centers of excellence. Academic collaborations and twinning programs with several universities in the US, UK, Australia and other countries ensure that students get international exposure and expertise.

The MARENA, a massive indoor sports complex with five badminton courts, four squash courts, three tennis courts, a basketball court, a hi-tech gym and a walking track, reflects the university’s belief that a healthy mind needs a healthy body.

Part of the Manipal Group, the University is one of the top private University as ranked by NIRF, NAAC accredited (A Grade), listed prestigious THE & QS World, Asia BRICS and Emerging economic countries, ISO 9001:2015, ISO 14001: 2015 and ISO 50001:2018 certified.  

For more details refer the webpage www.manipal.edu .

The Manipal Group, a pioneer in higher education services with a 60-year-old legacy of excellence, also owns and operates campuses in Sikkim and Jaipur in India, and in Nepal, Malaysia, and Antigua, in the Caribbean.

Vision, Mission and Values of MAHE:

Vision

• Global leadership in human development, excellence in education and healthcare.

Mission

• Be the most preferred choice of students, faculty and industry

• Be in the top 10 in every discipline of education health sciences, engineering and management.

Manipal Values

• Integrity

• Transparency

• Quality

• Team work

• Execution with passion

• Humane touch

With above Vision, Mission and Values, MAHE is aspiring to become one of the top Universities in the world with continuously improving the thrust areas like Academic Excellence, Research, Internationalization and Employer Reputation

The purpose of Integrated Management System is 

• the ability to consistently provide products and services that meet customer and applicable statutory and regulatory requirements

• addressing risks and opportunities associated with its context and objectives 

• the ability to demonstrate conformity to specified IMS requirements 

The purpose of the Integrated Management System Manual is to define and describe the IMS, to define the responsibility and authority of the management personnel involved in the operation of the system, and to provide a general description of the requirements of the standard as they apply to MAHE. 

This manual is used internally to guide MAHE through the various requirements of the   ISO 9001:2015 (Quality), ISO 14001: 2015 (Environment) & ISO 50001:2018 (Energy) standard that must be met and maintained in order to ensure interested parties satisfaction, continual improvement and provide the necessary instructions.

4.0 Context of the University

4.1 Understanding the University (MAHE) and its Context 

MAHE shall determine and facilitate the external context either positive or negative factors or conditions for consideration like but not limited to customer, market, competitive, social, economic environments, legal and strategic direction of MAHE. 

The internal context will be facilitated related to knowledge and improve the overall performance of the University.

MAHE also determines external and internal issues that are relevant to the purpose and that affect its ability to achieve the intended outcomes of the integrated management system. 

Such issues shall include Quality performance, environmental aspects, Energy performance (Example: Energy Use, Consumption and Efficiency) being affected by or capable of affecting the overall processes of the University which relates to Health care & Education services. Allied services shall be considered while evaluating the Context. This performance are reviewed and monitored at various levels of operations of University, the relevance and appropriateness of the current performance indices shall be reviewed when New requirements, Change management processes are initiated.

Reference Documents: MAHE ISP 4-01

4.2 Understanding the Needs and expectations of interested parties 

MAHE has a process to identify, implemented the needs and expectations of the stakeholders which are relevant to the effectiveness of the integrated management Systems. At defined frequency there shall be a review and monitoring mechanism to validate the current needs and expectations are appropriate or it calls of any change to be initiated.

MAHE has ensured that applicable legal requirement and other requirements relevant, and those relating to the overall operations of the University, Environment related, Energy Efficiency, Use and their consumption is identified, applied, and implemented.

Appropriate access to the above requirements is defined across the processes to ensure effective implementation and compliance. There has been a constant effort to ensure that the above requirements are reviewed periodically for applicability and level of compliance.

The need and expectation of interested parties related to quality as well as Environment and energy is detailed in MAHE ISP 4-02 

Reference Documents: MAHE ISP 4-02

4.3 Determining the scope of the integrated management system 

While determining the scope of the quality management system following aspects are considered 

1. Internal and external issues 

2. Needs and expectations of relevant interested parties

3. The compliance obligation

4. University, institutions, hospitals, hostels, canteen, facilities, physical boundaries associated services and equipment 

5. Authority and ability to exercise control and influence 

The scope of the IMS (Q, E, EnMS) process of the University is specified in Annexure 4 R3 in this Manual

The organization shall apply all the requirements of this International Standard if they are applicable

within the determined scope of The Integrated Management System and is maintained as documented information. Necessary justification shall be defined if there is any exclusion when a requirement is not applicable which may only be claimed if the requirements determined as not being applicable do not affect the organization’s ability or responsibility to ensure the conformity of its products and services and the enhancement of intended outcomes [No energy related scope exclusion is sought inferring all energy types are included].  Appropriate personnel are made responsible and authorized to ensure the intended outcomes are achieved.

1. Scope (Application)

Technical Scope: Refer Manual Annexure 4 R3 & SOP Annexure 2a, b, c (EnMs)

Geographical Scope: 

1. 1.2 Management responsibility

4.2.1 Top Management

Top management is committed to the development & implementation of the Energy Management System & to continually improve its effectiveness 

Towards the above 

1. Importance of energy management system and legal requirements has been communicated at various level of the University

2. Energy policy has been defined, established, implemented and maintained

3. Energy objectives and targets have  been established & reviewed  periodically  in management review meetings 

4. Energy management / technical team formed and Management representative appointed 

5. Scope and boundaries are identified to address the EnMS requirements 

6. The EnPls are established which are appropriate to the university

7. Energy performances are considered in long term planning, procurement. 

8. Energy performance results are measured and reported at determined intervals  

9. Management reviews are being conducted periodically to ensure its continued suitability, adequacy, effectiveness  of EnMS established & implemented

10. Adequate resources have been provided for all the activities of the University. They are periodically reviewed & resources augmented to improve the EnMS and the resulting energy performance

4.4 Quality Environment, Energy Management System & its processes

MAHE has established, documented, implemented and is maintaining Integrated Management System (IMS) complying with the requirements of ISO 9001: 2015, ISO  14001:2015, ISO 50001:2018  Manipal has also has a programme to continually improve the effectiveness of the IMS and through Internal Audits and Management Review Meetings

Manipal has implemented the following steps for establishing its IMS:

• Determination of the required inputs and the expected outputs from the processes through Process Interaction

• Determination of the sequence and interaction of processes

• Determination of the criteria and methods needed to ensure that both the operation and control of these processes are effective       

• Determination of the resources needed and ensure their availability

• Determination of the assignment of responsibilities and authorities for these processes which is addressed in the University Chart

• Determination of the risks and opportunities in accordance with the requirements of 6.1, and plan and implement the appropriate actions to address the risks is mentioned in each procedures

• Evaluation of the processes and implement any changes required to ensure that the processes achieve their intended results is done by the measuring and monitoring the process with respect to measurements

• Determination of the opportunities for improvement of the processes and the IMS through continual improvement programs

• When establishing and maintaining the IMS MAHE will consider the knowledge gained from needs and expectation, context of the University

MAHE has maintained documented information to the extent necessary to support the operation of processes and retain documented information to the extent necessary to have the confidence that the processes are being carried out as planned.

Reference Documents: IM ANNEX 2 

5.0 Leadership

5.1 Leadership and commitment

5.1.1 General

The top Management of MAHE shall demonstrate leadership and commitment with respect to the IMS by following the steps:

• Taking accountability of the effectiveness of the IMS through Internal Audit and Management Review Meeting within defined frequency

• Ensuring the technical scope and boundaries, IMS policy and IMS objectives, targets are established and are compatible with the strategic direction and the context of the University

• Ensuring that the quality policy is communicated, understood and applied throughout the University by sign boards and communicated in induction training

• Ensuring the integration of IMS requirements into the University’s business processes and effectively monitoring the change mechanism within the scope of the operations.

• Promoting awareness of the process approach and risk-based thinking by doing risk assessment as proactive approach

• Ensuring the availability of resources for the IMS

• Communicating to the employees about the importance of effective IMS and conforming the IMS requirements

• Ensuring the IMS achieves intended results by measuring the process objectives and targets

• Engaging, directing and supporting the employees to contribute for the effective IMS

• Promoting the continual improvement 

• Supporting other relevant management roles to demonstrate their leadership as it applies to their areas of responsibility 

• Ensuring Formation of teams (Energy) and actions plans for effective implementation of various programs

• Performance of the IMS is monitored, reviewed and verified for the appropriateness on a continuous basis 

Reference Documents: SOP 6-01 / ISP 9-01 & 02

5.1.2 Customer Focus

The top Management of MAHE shall demonstrate leadership and commitment with respect to customer focus by following:

• Ensuring the customer requirements and applicable statutory and regulatory requirements are determined , understood  and met as per the university standards and environmental related rules and regulations

• Ensuring the risks and opportunities that can affect the conformity related to stake holders and services and the ability to enhance customer satisfaction are determined and is addressed in the Risk assessment of each procedure

• Ensuring the focus on enhancing customer satisfaction is maintained. Customer satisfaction is measured once in a year

Reference Documents: Quality policy

5.2 Policy:

5.2.1 Establishing the policies

The management of MAHE has established, implemented and is maintaining the defined Quality, Environment & Energy Policy: 

Quality policy

MAHE aims to strengthen its unique value system through: 

• Providing value based higher education and healthcare services at par with International Standards; 

• Promoting Research and collaborations; 

• Meeting the societal objectives; 

• Enhancing the proficiency of its students ,staff  and faculty to achieve global competency through training and development; 

• Demonstrating continual quality improvement in all its academic, healthcare services and co-curricular activities through upgrading the delivery system, and sharing the best practices; 

• Exceeding the expectations of the beneficiaries, stakeholders and regulatory bodies. 

MAHE is committed to: 

• Delivering world class education and healthcare services by continuously improving the thrust areas like Academic Excellence, Research, Internationalization and Employer Reputation

• Complying with requirements of different stake holders including regulatory bodies.

Date: 12.12.17 Chancellor 

Top Management continually reviews the effectiveness of the Quality Management System and allocates necessary resources.

The Management reviews the quality policy at least once in a year for its continuing suitability and revises if necessary

5.2.2 Communicating the policy 

The policy is documented in section 5.2.1 of the MAHE IMS manual. The policy is communicated through display boards and understood within the University through trainings. The policy is made available to relevant interested parties, as appropriate thorough suitable means and medium.

Environment, Energy Policy:

MAHE (MAHE) endeavors to promote community welfare, environmental protection and efficient energy use to a level of performance that moves “beyond compliance”. Striving to set a benchmark on a National and International level for education, healthcare, environment and energy management. MAHE is committed to cleaner and greener campuses. To realize this vision, the University commits to:

• Institutionalize best practices, comply with applicable laws, regulations, and other recognized requirements related to environment and energy use and where practicable exceed them. 

• Preventing pollution by continually monitoring and improving its environmental and energy performance by provision of resources to achieve set objectives and targets

• Establish and maintain management systems to improve energy performance and to minimize harmful effects on environment, human health and safety 

• Promote use of clean, safe and energy efficient technologies in order to utilize natural resources efficiently 

• Encourage transparency and communication of its commitment to sustainable development, simultaneously increasing awareness amongst its stakeholders as well as the community at large 

• Foster education, research and information exchange on energy and environmental development to move toward global sustainability 

Manipal, 12.12.2017                                                                                                            Chancellor

Institutionalize best practices - Infers 

• supports the procurement of energy efficient products and services that impact energy performance

• supports design activities that consider energy performance improvement                  

5.3 University roles, responsibilities and authorities

MAHE University’s chart is shown in Annexure 1 of the Integrated Manual. The responsibilities and authorities are addressed in the Annexure1 (for energy management system) of the integrated Manual.

Reference Documents:

In order to ensure effective implementation of IMS, top management of MAHE has defined responsibility and authority of individuals and their inter-relationships. Functional Chart and detailed documentation of responsibility and authority.

Institutional / Departmental Committee:

• To ensure continuous quality improvement in their area of activity

• To assist Institutional MR / HOD in quality development initiatives

• To assist Institutional MR / HOD in identifying the area of activities and the documentation of process

Chairman/Head Committees: ( HOI/ HOD) 

• To ensure proper functioning of the respective committees

• To furnish action report of the committees to IMR for Management Review

• To ensure the decisions of the committees are informed to all concerned and actions taken are monitored

Board of Management:

Principal organ of Management of University, a compact and homogenous body enabling it promptly to take and implement well considered decision and effectively handle crisis. The body is the authority that supports the University in taking policy decision for the development of the University.

The role and responsibility of the Board of Management is detailed in MOA for MAHE with UGC on Jan 14^th 1994

Chancellor/Chairman:

Chancellor/Chairman by virtue of office shall be the Head of the University. The role, responsibility and authority of the Chancellor/Chairman is detailed in point 17 in MOA for MAHE with UGC on Jan 14^th 1994

Pro Chancellor:

Pro Chancellor by virtue of office shall be the functional head of the University.

Vice Chancellor: 

The role, responsibility and authority of the Vice Chancellor is detailed in point 18 in MOA for MAHE with UGC on Jan 14^th 1994. 

Pro Vice Chancellor:

Overall Administrative Supervisory Responsibility of the University for 

• Planning

• International Admissions

• University teaching departments

• Quality of services provided 

Registrar:

Overall Administrative Supervisory Responsibility of the University, Constitute Institutions and Associated Teaching Hospitals

Direct Administrative Responsibilities of the following departments 

• Human Resources

• Admission

• Public Relations

• Legal

• Organize the following Official Statutory Meetings as ex-officio member Secretary:

• Executive Committee Meeting

• Academic Senate

• Faculty Selection Committee Meeting both teaching / non-teaching

• Faculty promotions

The role and responsibility of the Registrar is detailed in point 20 in MOA of MAHE dated January 14, 1994

Director Finance:

The detailed role, responsibility and authority of Director Finance is detailed in point 21 in MOA of MAHE dated January 14, 1994. A brief about the same is presented below:

             The finance officer shall work under the supervision of the Vice Chancellor and is accountable to the     Board of Management. He shall play an advisory role and Ex-Officio member secretary of the Finance Committee. 

Director Students Affairs:

The detailed role, responsibility and authority of Director Student Affairs is detailed in point 23 in MOA of MAHE dated January 14, 1994. A brief about the same is presented below: 

The director is responsible for the student welfare activities and will supervise the setting up and implementation of guidelines and procedures for function of hostels, student counseling, health and other nonacademic matters.

Director General Services:

The detailed role, responsibility and authority of Director General Services is detailed in point 24 in MOA of MAHE dated January 14, 1994. A brief about the same is presented below:

The Director shall be responsible for the supervision and maintenance of campus services including establishment of procedures for functioning of physical plant, grounds, security, transport, maintenance and support services.

Director Quality: 

Top management has appointed Director Quality to oversee the entire quality initiatives across MAHE. Who shall demonstrate leadership and commitment with respect to the quality management system by:

• taking accountability for the effectiveness of the quality management system;

• ensuring that the quality policy and quality objectives are established for the quality management

• ensuring the integration of the quality management system requirements into the organization’s

• business processes;

• promoting the use of the process approach and risk-based thinking;

• ensuring that the quality management system achieves its intended results;

• promoting improvement

Management Representative / Energy Manager 

Top Management of MAHE has appointed Manager  with appropriate skills and competence who irrespective of other responsibilities, has the responsibility and authority to 

• Ensure the EnMS is established, implemented, maintained and continually improved in accordance with energy management standard activities

• Identify persons authorized by an appropriate level of management to work with the management representative in support of energy management activities 

• Report to top management on energy performance 

• Report to top management on the performance of the EnMS 

• Ensure that the planning of energy management activities is designed to support the university energy policy

• Define and communicate responsibilities and authorities in order to facilitate effective energy management 

• Determine criteria and methods needed to ensure that both the operation and control of EnMS are effective 

• Promote awareness of the energy policy and objectives at all levels of the University 

  For details relating to Energy management team and Energy technical team formation letter.

In addition, the job responsibilities are available in the concerned Department for all the above post. All positions in the University are defined in the respective documents for Job Responsibility for each department.

Other Committees:

(Various Committees functioning in University are Institutional Purchase Committee,  Board of Management, Executive Committee, Academic Senate, Core Committee For Quality, Management Review Committee, Planning and Monitoring Committee, Finance Committee, Faculty Selection Committee, Board Of Studies,  Grievance Committee, Examination Committee, Question Paper Selection Committee, Personal Seeing Committee, Examination Grievances Committee,  Malpractice Committee, Selection Of Examiners Committee, Selection Committee For Non-Teaching Staff, Selection Committee For Non-Teaching Technical Staff, Non-Teaching Staff Promotion Committee, Cultural Co-Ordination Committee, Sports Council Committee, Hostel Management Committee, PhD Registration Committee, PhD Guideship Committee, General Services Committee, Student Affairs Committee, Fee Fixation Committee, Endowment Fund Committee, Sexual Harassment Committee, University Research Cell, Scientific Advisory Committee, Quality Advisory Committee, Ethics Committee)

The formation and selection of members is decided by top management, HOI/HOD and duties of such committees are described in specific circulars released by University from time to time.

In addition, Institutional committees are constituted on need basis and documented at the respective institutions.

The list of the committees, its functioning, chairman, Objectives etc are available with the respective standard Management Representative.

Reference Documents: IM ANNEX 1 ORG STRUCTURE

6.0 PLANNING

6.1 Actions to address risks and opportunities

6.1.1    When planning for the Integrated management system (Quality, Environment and energy), MAHE has considered the

• issues referred to in standard clause 4.1,  

• requirements referred to in standard clause 4.2, 

• scope of the IMS  

and determine the risks and opportunities that need to be addressed to:

• Give assurance that the Integrated management system can achieve its intended result/outcomes

• Enhance desirable effects, Enhance performance 

• Planning is consistent with the IMS Policy  

• Prevent, or reduce, undesired effects including the potential for external environmental conditions to affect the organization;

• Achieve improvement 

MAHE has established procedures to include risk assessment, Environmental aspects, Compliance obligations, Planning action and emergency preparedness which are effectively implemented across all the processes 

6.1.2   MAHE shall plan actions to address these risks and opportunities and how to integrate and implement the actions into its Integrated management system processes and evaluate the effectiveness of these actions 

Actions taken to address risks and opportunities will be proportionate to the potential impact on the conformity of stake holders and services 

6.1.2 Environmental aspects 

Environment aspects as applicable to MAHE is captured in this section. Where procedures are defined for their implementation, a reference to such procedure is also provided in relation to the elements in SOP 6-02

6.1.3 compliance obligation (E)

It is understood by the University that during the course of its day to day operations processes and activities it has to identify recognize and comply with several statutory and regulatory requirements, which impose certain discipline, norms and guidelines, which shall be complied with in relation to environmental interactions. Methodology of identifying, understanding, access and compliance to such legal and other requirements (LOR) is explained in SOP-09-03

6.1.4 Planning action (E) 

     MAHE shall plan to take actions to address its significant environmental aspects, compliance obligations, risk and opportunities identified, plan to integrate and implement the actions into environmental management system processes and evaluate the effectiveness of these actions. When planning these actions team shall consider the technological options and the financial, operational and business requirements

Reference Documents: SOP 6-02

6.2 Objectives and planning to achieve them

6.2.1 MAHE has established and defined the objectives at relevant functions / levels which is consistent with the defined policy, is monitored and measurable, is relevant to conformity of products & services and is communicated. The objectives are reviewed & updated periodically. While defining the objectives, applicable requirements such as various regulatory/statutory, those relevant to the conformity of services and enhancement of stakeholder’s satisfaction is addressed.

While defining the objectives of energy management system in addition to the above listed requirements Significant energy Uses and opportunities to improve the energy performance are also  considered.

6.2.2 The University shall determine the resources required, responsible person, timeline for completion, evaluation of results to achieve the overall IMS objectives and retain documented information.

Reference Documents: Annexure 5 - Objectives

6.3 Planning of changes (Q)

When there is a need for change in the QMS , MAHE carry out the change in a planned and systematic manner

MAHE also consider the following:

• The purpose of the change and any of its potential consequences

• The integrity of the QMS

• The availability of resources

• The allocation and re-allocation of responsibilities and authorities

Reference Documents: ISP 8-02

6.3 Energy review 

MAHE has defined a process for energy review, methodology and criteria. The energy review has been documented and maintained and retained accordingly.  To develop the energy review MAHE shall

• Analyze energy use and consumption based on measurement and other data that is to identify current energy sources, evaluate past and present energy use and consumption 

• Based on the analysis of energy use and consumption, identify the areas of significant energy use 

• Identify facilities, equipment, systems, processes and personnel working for or on behalf of the university that affects significant energy use and consumption 

• Based on other relevant variables affecting significant energy uses, determine the current energy performance of facilities, equipment, systems and processes related to identified significant energy uses and estimate future energy use and consumption. determine prioritize and record the opportunities for improving energy performance 

• Energy review are updated once in six months as well as in response to major changes in facilities, equipment, systems, energy using processes

  Ref SOP: Planning Policy, Objective & targets, Energy planning & Review SOP 6-02

6.4. Energy performance indicator

MAHE has determined EnPIs which are relevant for monitoring and measuring energy performance, reviewed and or compared with the baselines as appropriate.  These indicators are used to demonstrate and enable Improvements in the energy performances.

Methodology for determining and updating EnPI has been documented. Energy performance which significantly affects the intended results are used to revisit the EnPIs . The performances are reviewed once in six months and recorded.

Ref SOP: Planning Policy, Objective & targets, Energy planning & Review SOP 6-02

6.5 Energy baselines -EnB(s)

Energy baseline established using information in the initial energy review, considering a suitable data period.

MAHE has considered and evaluated data indicating relevant variables that significantly affect energy performance, accordingly normalization of the EnPI value(s) and corresponding EnB(s) shall be carry out.

 EnB(s) shall be revised when EnPI(s) no longer reflect the MAHE’s energy performance, there has been major changes to the static factors and/or according to a pre-determined method. Appropriate information of EnB(s), relevant variable data and modifications to EnB(s) as documented information are retained.

Reference Documents: SOP 6-02

6.6 Planning for collection of energy data

MAHE shall ensure that key characteristics of its University operations affecting energy performance are identified, measured, monitored and analyzed at planned intervals. A data Collection Plan appropriate to the size, complexity, resources and the measuring equipment’s has been put in place. The Plan shall indicate the source of data collection, frequency of data collection and who will be responsible for data collection, such details are retained as documented information. Data collection relates to those that are relevant variables to SEU’s, Energy Consumption related to SEU’s and operational criteria related to SEU’s, Static factors, data specified in action plan as a minimum. The data so collected shall be reviewed and updated by concerned authorities at defined intervals as appropriate.

Equipment’s used for Monitoring and measuring key characteristics shall be accurate and repeatability ensured. Documented information establishing the accuracy and repeatability is retained.

 7.0 SUPPORT

7.1 Resources  (Q & E)

7.1.1 General

MAHE has established system to determine and provide the resources needed in terms of international standards, workspace etc which are necessary to establish, implement, maintain and continually improve the IMS. MAHE shall also consider:

• The capabilities of, and constraints on the existing internal resources

• The required needs obtained from the external providers

Reference Documents: SOP 7-02

7.1.2 People (Q)

MAHE has established system to provide the persons necessary for the effective implementation of IMS and for the operation and control of its processes in order to consistently meet customer, statutory and regulatory requirements

Reference Documents: ISP 7-03

7.1.3 Infrastructure (Q)

MAHE shall determine, provide and maintain the infrastructure necessary for the operation of its processes and to achieve conformity of services

Reference Documents:  SOP 7-02

7.1.4 Environment for the operation of processes (Q)

MAHE has determined, provided and maintained the environment necessary for the operation of its processes and to achieve conformity of services through regular monitoring as appropriate

Reference Documents: SOP 7-02

7.1.5 Monitoring and measuring resources (Q)

7.1.5.1 General 

MAHE has determined and provided the resources needed to ensure valid and reliable monitoring and measuring results which is used to verify the conformity of services to the requirements, ensuring is done through calibration and maintenance of equipments

It also ensures the resources provided:

• Are suitable for the specific type of monitoring and measurement activities being undertaken

• Are maintained to ensure their continued fitness for its purpose

MAHE shall retain the documented information like maintenance records, calibration certificates as evidence of fitness for purpose of monitoring and measurement resources

Reference Documents: SOP 9-02

7.1.5.2 Measurement traceability (Q)

In addition MAHE also traces the measurement results for providing confidence in the validity of the results and measuring equipment is:

• Verified or calibrated at specific intervals or prior to use against measurement standards traceable to international or national measurement standards, when no such standards exist, the basis used for calibration or verification is retained as documented information addressed in the calibration procedure

• Identified in order to determine their calibration status with the calibration sticker

• Safeguarded for adjustments, damage or deterioration that would invalidate the calibration status and subsequent measurement results

MAHE determine, if the validity of previous measurement results has been adversely affected when measuring equipment is found to be unfit for its intended purpose, and MAHE takes appropriate corrective actions as necessary

Reference Documents: Agreement with outsourced activity

7.1.6 University knowledge (Q)

MAHE determines the knowledge necessary for the operation of its processes and to achieve conformity of services. This knowledge shall be maintained and made available to the extent necessary though knowledge bank in server which is accessible to all employees of MAHE

When addressing changing needs and trends, MAHE shall consider its current knowledge and determine how to acquire or access the necessary additional knowledge and required updates

University knowledge includes information like intellectual property and lesson learnt. To obtain knowledge MAHE has considered the internal sources like capturing undocumented knowledge and experience of topical experts within MAHE and external sources like standards, conferences, gathering knowledge from customers or external providers

Reference Documents: Knowledge Bank in MAHE Portal

7.2 Competence 

MAHE has ensured that any person working for or on its behalf related to significant energy uses, are competent based on appropriate education, training skills or experience 

MAHE has defined job descriptions for all functions and levels affecting conformity to stake holder’s requirements. Based on this, MAHE:

• Determine the necessary competence of person doing work under its control that affects the performance and effectiveness of the IMS

• Ensure that these persons are competent on the basis of appropriate education, training or experience

• If necessary take actions (training need identification through competency matrix review) to acquire the necessary competence, and evaluate the effectiveness of the actions taken

• Retain the appropriate documented information (Records) like Competency matrix, skill matrix and On Job Training card as evidence of competence

Reference Documents: Competency Matrix – Skill Matrix

7.3 Awareness

MAHE is strongly creating awareness to its employees working under the control of MAHE about IMS policy, relevant IMS objectives, the implications of not conforming to the IMS requirements and their contribution to the effectiveness of the IMS, including the benefits of improved performance through training

Top management strongly believes in upgrading the competency of the personnel in line with changing requirements which is critical for success. Hence it has established the systems for 

• Identifying the development / training needs wherever required for personnel performing a task on or behalf of the University particularly whose work affects conformity to service requirement / having an impact on significant aspects, significant energy use.

• Arranging training or other actions to satisfy the above identified needs.

• MAHE also makes persons working for it or on its behalf aware of the following:

  a) The importance of environmental / energy policy and procedures and with the requirements of the environmental / energy management system,

  b) The significant environmental aspects, significant energy uses and related actual or potential impacts associated with their work, and the environmental benefits of improved performance (Quality, Energy, Environment, Financial, and Safety).

  c) Their roles and responsibilities in achieving conformity with the requirements of the Environmental Management system, Energy management system and

  d) The impact, actual or potential with respect to energy use and consumption of their activities and how their activities and behavior contribute the achievement of energy objectives and targets and the potential consequences or implications of departure from specified procedures.

• Evaluating the effectiveness of the training and action taken.

• Necessary records related to education qualification, experience, training and skills are maintained.

Reference Documents: ISP 7-04

7.4 Communication

Reference documents mentioned after every section and the Level 3 documents define the communication needs and processes within the University. The management ensures that communication and information dissemination do take place regarding various issues of cross-functional nature and impacting the IMS including vision & mission statements, quality policy, quality objectives etc.

The communication data may be public, private and official. The modes of communication may be through management reviews, cross functional team meetings, internal audits, analysis and discussions of findings of customer feedback, monitoring and measurement of processes and service, analysis of data, corrective actions, continual improvement projects, mail, internal circulars, telephones / mobiles, public notice boards. 

1. Communication is recognized as a key element of functioning in the University due to multiple variability involved in factors such as people, processes, operations, machines etc.  Duly recognizing the need for appropriate communication, essential system is devised which this document addresses for both internal & external communication in relation to general activities as also EMS and EnMS in particular.

   1. Responsibility of ensuring adherence to this is with all concerned for their day-to-day activities.  However, specific responsibility of External communication in relation to LOR EMS and EnMS is with DGS and EE.

   2. A process has been defined in which people or personnel across all walks of the University operation are encouraged to initiate, suggest improvement programs. 

   3. MAHE shall establish and implement a process by which any person(s) doing work under the University control can make comments or suggest improvements to the EnMS and to energy performance. The organization shall consider retaining documented information of the suggested improvements.

MAHE ensures that Information (data) provided or communicated is consistent and dependable.

2.0 PROCEDURE STEPS 

2.1 INTERNAL COMMAHENICATION: Following tables serves as the procedure 

2.2 External Communication 

2.2.1 External communications are both inward and outward and will be with Regulatory bodies such as CPCB, KSPCB, MOEF, CEIG, MESCOM Local authorities or with interested parties who include non-government groups, general public. Such communications range from structured like consents, periodic returns, and correspondences to unstructured and un-defined communications such as general complaints / requirements from local public. Following table provides a methodology of its receipt and disposal as also responsibility for such communication. Responsibility and methodology of receiving, documenting and reporting to relevant communication from external parties are covered in this table below

External Communication: Outward (MAHE, Manipal to outside agencies)

External Communication: Inward (from outside agencies)

2.2.2 Concerned HOI/MS ensures communication channels and related equipment, gadgets. Intercom, mobiles, alarm, public address system, notice board, intranet and internet are always well maintained and in a fit condition for use. 

2.3 The Management of MAHE, Manipal has, for the present, decided not to disclose significant environmental aspects to the public. 

2.4 Top Management periodically reviews the effectiveness of communication with IMR & HOI/MS related to both internal and external communications during each MRM & deficiencies found during such review will be appropriately addressed.

Reference Documents: SOP 7-04

7.5 Documentation requirement/Documented Information 

7.5.1 General / 7.5.2 Creating and updating 

The Integrated Management System documentation at University includes: 

Documentation Structure in three levels – level I, II, III. These levels are related to –

•  Integrated Manual ( Level I ): This is an Apex Document of IMS reviewed and approved by the Top Management of MAHE capturing its commitment in the form of –Documented statements of Quality , Environment & Energy policy and Objectives Integrated Manual at University describes the overall policy guidelines of the QMS , EMS, EnMS and gives reference of the detailed procedures. Documentation is structured as in Table 1 List of Integrated System Procedures is given in Table 2.
• Integrated System Procedures (Level II): Standard specifies establishment, implementation and maintenance of several procedures as part of IMS. Effectiveness of such procedures is well felt only when they are documented, since they –
  • Ensure that the activity is undertaken consistently;
  • Ensure proper communication, besides being an effective tool for training  
  • Prevent adverse consequences of not having such procedures; A list of Level II procedures are provided in the Table 2 below.
• (Level III): Standard operating Procedures, Operational Control Procedures, Emergency Response Procedures, Environmental Legal Register, Energy Legal Register, Data Sheets, objectives and job description. These are specific documents, which are related to how an activity is performed consequently.

Formats & Records:

These provide evidence of implementation of IMS besides capturing vital data / information which when subjected to analysis; provide trends / signals for appropriate decision and action Vice Chancellor is the authority for review and approval of the Integrated Manual and its revision. 

Director Quality & Compliance is responsible for preparation, issue, distribution and control of Integrated Manual and its revision. The details of the documentation structure and the quality system procedures are given in tables in the following pages.

Table 1: structure of integrated system documentation

Table 2: structure of integrated system procedures

Integrated Manual:

1. Integrated Manual at University describes the overall policy guidelines of the IMS and gives reference of the detailed procedures.
2. Documentation is structured in 3 levels system as in Table 1
3. List of Integrated System Procedures is given in Table 2
4. The description of the interaction between the processes of the Integrated Management system is given in Annexure 2.

7.5.3 Control of Documented Information:

1. General:

University has established processes for control of documents to ensure that relevant documents are available at the required locations.

2. The control includes: Identification of the documents including their current revision status
   • Review of documents and data for adequacy and their approval by authorized persons prior to their release for use.
   • Issue of approved documents and data to relevant users
   • Removal of obsolete documents from the user location.
   • Maintenance of master list or equivalent to identify the current revision status of document and data issued
   • Process to be followed in case of revision of these documents.
   • Periodically review and update the documents as necessary
3. Document control of activities of approval, issue and change/modification are carried out as per procedure SOP 7-01
4. Documents of external origin applicable to University are identified necessary for planning and operation are  indexed, identified, distribution controlled and updated as per procedure SOP 7-01
5. User departments ensure:
   • Accessibility to pertinent issue of appropriate documents to personnel at locations where the activity of Integrated Management System is performed
   • Removal and disposal of obsolete documents from all points of use

6. For document stored/are in electronic media, adequate controls are ensured with appropriate Access, virus controls and back-up methods. Any printout of these documents taken without the permission of IMR is treated as UNCONTROLLED COPY
7. All medical documents / records are controlled as per Hospital policy.

Reference document: SOP 7-01: Control of Documents

CONTROL OF RECORDS:

1. General:

University has defined the system for establishing and maintenance of records to provide evidence of conformity to requirements and effectiveness of the Energy Management systems. The process of control of records includes:

2. Identification, collection, indexing, access, filing, storage, maintenance and disposition of Records. The retention period of all records are specified.
3. Records are identified to the services / activity involved and ensured to remain legible, readily identifiable and retrievable. It is ensured that the documents are traced to the services / activities.
4. All records are stored in areas having adequate protection against deterioration, damage and loss
5. Whenever required contractually, records are made available to the customer or their representative.

Reference document: SOP 7-05

4.5.4.2 / 4.6.5  Control of documents (EnMS) / Control of records / 7.5.3  Control of documented information (Q&E)

7.5.3.1 The external and internal documents are controlled as addressed in procedure of control of documented information. All documents shall be available in soft copy in “read only form” with a password control available with MR in the server and in hard copy with master copy seal available with MR. These will be distributed to different departments through “Issue Control Register” with a controlled copy seal, sign and issue date. The documented information from external origin is identified and controlled by IMR

7.5.3.2 MAHE shall address the activities through the procedure Control of documented information which includes distribution, access, retrieval, use and control of changes. Storage, preservation, retention and disposition is addressed in the Control of records SOP 7-05

The documented information of external origin determined by MAHE necessary for the planning and operation of IMS shall be identified as appropriate and be controlled SOP 7-01

Also documented information retained as evidence of conformity shall be protected from unintended alterations by uploading the same in the intranet portal of MAHE by Director Quality

MAHE shall establish and maintain records to demonstrate conformity to the requirement of EnMS & energy performance results achieved. For detail  Control of records refer SOP 7-05 and annexure – 01 R0

Reference Documents: SOP 7-05, 7-01 & ISP 7-01

8.0 Operation

8.1 Operational planning and control

University has established processes for systematic planning of service realization. The process involves academic process and patient care process at respective institutions including anti ragging policy. Academic activities include admission process for constituent institutions, planning and conducting examinations, evaluation, declaration of result and awarding certificates.

In addition to the above, procedure for identifying environmental aspects of the above activities and evaluation of significant aspects is developed as below.

Clear delegation of responsibilities for the above are identified.

Compliance to applicable statutory and regulatory requirements is also taken into account during the service realization. Allocation of resources, monitoring of the status of the service realization on periodic basis also form the part of planning of services requirements.

Processes are also established for introduction of new courses as documented in ISP-08-06.

List of the reference documents are listed below:

Reference Document:

Curriculum (Syllabus Book)

Unit Plan / Lesson Plan

Clinical Postings – Where ever applicable.

Evaluation Plan

Selection and Evaluation of Vendors (Hospital, MAHE)

Assessment of Vendors, Vendor Rating records (Hospital, MAHE)

Purchasing Process of Pharmacy

8.1 Operational Planning and control

MAHE has planned, implemented and controlled the process, related to the SEUs, which are needed to meet requirements identified and to implement the actions determined in risk assessment planning. These are ensured by means of the following

• Establishing, Implementing and setting criteria for the effective operation and maintenance of (facility, Equipments, System) energy using processes. In absence of the defined process and criteria can lead to a significant deviation from intended energy performance
• Operating and maintaining facilities, processes, systems and equipment in accordance with operational criteria
• Appropriate communication of the operational controls to the team working for or on behalf of the university
• keeping documented information to the extent necessary to have confidence that the processes have been carried out as planned.

Any planned changes and unintended changes are reviewed for its consequences and impact, necessary actions to mitigate any adverse effects are initiated duly documented

Significant Energy Use processes are adequately controlled which includes processes that are outsourced

8.2 Requirements for services

8.2.1 Customer communication

Customer communication system for Continuous improvement of healthcare activity and shall include:

• Customer feedback including customer complaints
• Customer information sources like patient information booklet.

University invites applications from the prospective students giving clearly the admission process including hostel facility and the eligibility criteria.

The detailed processes are defined for ascertaining the eligibility of the applicant against criteria through review of application, entrance tests and others.

Processes are also defined for counseling and formal admission of the eligible applicant to the courses.

University makes use of well-defined communication channels for communication with prospective students, student, their guardian and others.

These include website, prospectus, brochures, emails, reports, mark cards and others University has also established process for receipt of feedback including complaints from students, guardians and other interested parties.

Service realization processes detail about the communication with students and other interested parties.

Reference Documents: SOP 7-04

8.2 Emergency preparedness and response (E)

MAHE established, implemented and maintained the process needed to prepare for and respond to potential emergency situation identified for detail refer procedure SOP 8-06

MAHE shall

1. Prepare to respond by planning actions to prevent or mitigate adverse environmental impact from emergency situation
2. Respond to actual emergency situations
3. Take action to prevent or mitigate the consequences of emergency situations appropriate to the magnitude of the emergency and the potential environmental impact
4. Periodically test the planned response actions where practicable
5. Periodically review and revise the process and planned response actions in particular after the occurrence of emergency situation or tests
6. Provide relevant information and training related to emergency preparedness and response as appropriate ,to relevant interested parties

8.2:  Design

Identifying opportunities for the improvement of energy performance at the earliest stages of design and throughout the entire design process typically yields the best results.

This approach can avoid frequent barriers to appropriate energy performance, such as oversized equipment, over specified systems and the use of inefficient technology. The opportunity to overcome these barriers narrows as the design progresses. The design process should seek to optimize energy performance by evaluating a range of options that minimizes energy consumption and meets system needs.

MAHE has a well-established process to define the design aspects at the initial stages of the projects and maintenance .As a basic input design of new, modified and renovated facilities, Equipment’s , systems and processes which have significant impact on the Energy performance over the planned or expected operating lifetime.

Where applicable, the results of the energy performance consideration shall be incorporated into specification, design and procurement activities. MAHE shall retain documented information of the design activities related to energy performance

Reference document: ISP-08-03

8.2.2 Determining the requirements for services

Institutions offering Health care shall also determine the requirements applicable to patients which include

• Admission procedure,
• Diagnosis process.
• Consent from patient/patient representative before clinical procedure.
• Discharge Procedure/post Discharge procedure
• Contract review activities applicable for outsourced activity implied need of customer but necessary for known/intended use
• Statutory/regulatory requirements.
• Other requirements considered necessary by the University

Customer requirements are understood, adequately defined and documented. Before accepting any patients, they shall review to ensure that patient fulfills the required treatment consent.

Reference Documents: As mentioned above

8.2.3 Review of the requirements for services

8.2.3.1
MAHE shall ensure that it has the ability to meet the requirements for services that need to be offered to customers. MAHE shall conduct review before committing to serve to the customers which includes the following:

• Requirements specified by the patient or student , including the requirements for service and post-service activities is obtained through relevant required consent
• Requirements not stated by the patient or student but necessary for the process specified or intended use (if known)
• Additional statutory and regulatory requirements applicable to the services as per government rules and regulations

8.2.3.2  
Educational and Hospitals shall retain documented information on the result of the review and also any new requirements for services

Reference Documents: ISP 8-06

8.2.4 Changes to requirements for services

University has established processes for identifying the changing requirements of students and patients, including industry and societal requirements. This process also includes introducing new courses and patient care/treatment methodologies to meet such requirements.  The existing courses may also be updated in order to meet the above requirements. The applicable statutory and regulatory requirements are also taken into consideration while introduction of new courses or treatment methodologies and or update the existing ones. The details of the courses and their eligibility criteria are published in the web site as well as through prospectus.

Details about patient care and cost estimate of the treatment, estimated days of stay and such other details are discussed prior to beginning of treatment with the patient/patient relatives.

8.3 Design and development of products and services

8.3.1 General / 8.3.2 Design and development planning

University follows a well-defined process for the development of curriculum including the evaluation scheme for new courses. The process for updating / or modification in the curriculum including evaluation scheme for existing courses, has also been defined. The process includes systematic planning of development activities gathering the necessary input for development from various sources including statutory requirement including their review for adequacy, review for developmental output verification and validation of developmental output. The records at each stage are maintained.

The minimum requirements as per the statutory guidelines are demonstrated below

Even though the minimum requirements are prescribed the university has established a process for design and development of curriculum to meet industry and students requirements. This is continuously monitored and verified whether it meets the purpose through Board of studies meeting held at a frequency of at least twice a year.

The detailed process for new courses is explained in the ISP -08-06. The overall representation of the detailed curriculum design and development is described in ISP -08-06.

Design planning

The process of design planning identifies different stages, the responsibility of faculty to this process at each stage and the means of verifying the design of curriculum.

Planning will also identify the availability of the faculty to deliver the designed curriculum.

The overall responsibility of Board of Studies at the University is Deputy Registrar –Academics (Health Sciences) for Medical Courses and Deputy Registrar - Academics (Technical) for Technical & other courses.

The Chairman of the respective Board of studies is the responsible person for design and development of curriculum of that subject / course.

The Registrar is the overall responsible authority for Design and development of curriculum.

Followed by approval from Academic Senate.

Reference Documents: ISP -08-06.

8.3.3 Design and development inputs

The input used for the design shall consider the following

• Market need in terms of curriculum contents
• Overall goals of the program
• Regulatory norms
• Expectations of stakeholders
• Faculty experience
• Knowledge to be taught
• Method of evaluation
• Teaching methodology
• Faculty competence
• Bench mark with other university
• In case of twinning / Credit transfer programs inputs from Partner University
• Information derived from previous similar experience or actions taken
• Potential consequences of failure due to the nature of the services

The input shall be in the documented format (STN 140)

Reference Documents: ISP -08-06.

8.3.4 Design and development controls

MAHE have applied controls to the design and development activities which ensure the following:

• The results to be achieved are defined
• Reviews are conducted to evaluate the ability of results to meet design and development requirements
• Verification activities are conducted to ensure that the design and development outputs have met the input requirements
• Validation is conducted to ensure that the resulting product is capable of meeting requirements for the specified application or known intended use
• Any necessary actions are taken on problems determined during the reviews or verification and validation
• Documented information of all the above activities are retained

Reference Documents: ISP 8-06

8.3.5 Design and development outputs

The design output shall be the complete course curriculum (New and Revised) including requirements for implementing the course.

Reference Documents: ISP 8-06

8.3.6 Design and development changes

MAHE shall identify, review and control the changes made during changes of curriculum of syllabus, or subsequently, to the extent necessary to ensure that there is no adverse impact on conformity to requirements.

The documented information on design and development changes, results of reviews, authorization of the changes and the actions taken to prevent adverse impacts are retained.

Reference Documents: ISP 8-06

8.4 Control of externally provided processes, products and services

8.4.1 General

Director Purchase is responsible for the purchasing process which includes control of the outsourced processes.

Detailed process has been defined for evaluation and selection of vendors, sub-contractors and their reevaluation, rating based on their performance.

It is ensured that purchasing information is provided in full to the vendors / service providers in the form of purchase orders / contracts.

The purchase orders / contracts are reviewed for completeness by the competent authorities before their release.

Detailed process has been defined to verify the product / service provided to the vendors to ensure that the same conforms to the requirements. Authority for the verification is defined in the process.

The department communicates MAHE policy & requirements on EMS / EnMS during the stages of vendor identification, registration, and purchase process and supplier performance assessment.

Reference document:  Purchase Manual of University

Purchasing Process for Kasturba Hospital /TMA Pai Hospital, Udupi/ Karkala

The authority to sanction the capital budget is with Purchase Committee of MAHE. Any Purchase requirements of  Rs. 2 lakhs and beyond will be approved by Central Purchase Committee of Manipal Health System under General Manager (Procurement, Manipal Health System and of less than Rs. 2 lakhs will be approved by Purchase Committee of Kasturba Hospital, under MS&COO, Kasturba Hospital, Manipal.

Bio-medical/Patient care equipment’s are maintained by outsourced agent following stipulated norms of ECRI / manufacturer’s guidelines on case to case basis.  Calibration, maintenance and asset management of Engineering and Utilities (MAHE, Manipal) and outsourced agent assist Engineering and Utilities (MAHE, Manipal) and outsourced agent assist engineering in calibration and maintenance of few areas like weighing scale, BP Apparatus etc. 

Reference Documents: SOP 8-02

8.4.2 Type and extent of control of external provision

In determining the type and extent of control of external provision of products and services, MAHE consider the following:

• The potential impact of the externally provided processes, products and services on the University’s ability to consistently meet customer and applicable statutory and regulatory requirements.
• The perceived effectiveness of the controls applied by the external provider.

MAHE has established, implemented and verification done by respective team activities necessary to ensure the externally provided processes, products and services do not adversely affect the MAHE’s ability to consistently deliver conforming services to its stake holders.

For the outsourced processes or functions the scope of the MAHE’s IMS will remain the same and it will consider the above and define both the controls it intends to apply to the external provider and those it intends to apply to the resulting process output.

Reference Documents: Annexure 3

8.4.3 Information for external providers

MAHE provides adequate purchasing information to external providers including applicable requirements as follows:

• The products and services to be provided or the processes to be performed on behalf of the University.
• Approval or release of products and services, methods, processes or equipment. – Test reports from suppliers
• Competence of personnel with necessary qualification.
• Their interactions with the University’s IMS.
• The control and monitoring of the external provider’s performance is applied by MAHE.
• Verification activities that MAHE or its customer (in case) intends to perform at the external provider’s premises. – supplier evaluation or re-evaluation

Reference Documents: University Purchase manual

8.3 Procurement  

MAHE has defined and documented energy purchasing specifications as applicable for effective energy use. When procuring energy services, products and equipment that have, or can have an impact on significant energy use. The purchase team in consultation with the projects and electrical department shall inform suppliers about the evaluation criteria which includes energy performance.

Energy core team establish and implement the criteria for assessing energy use, consumption and efficiency over the planned or operating lifetime when procuring energy using products, equipment and services which are expected to have a significant impact on the university energy performance

The technical specifications relating to the energy performance of procured equipment and services & Purchase of energy is communicated to the external providers at the time of tender and bidding or enquiry stage as applicable.

MAHE:

8.5.1
Service provision (Academic activities, admissions, examinations and awarding degrees) by University are carried out under controlled condition in the form of

• Defining service characteristics and requirements and made known to the constituent institutions.
• Providing necessary information required for the service provision at the right time and right place
• Periodical monitoring of activities of the constituent institutions
• Providing necessary resources
• Detailed processes are defined for each of the major processes

Product controls are applicable to:

• Activities carried out at OPD, ward areas, ICUs, Operation Theatres, Postoperative wards, casualty etc.

• Diagnostic units

• Ambulance service

• Utility activities and central Sterile supplier activity

• Billing activity

• Medical Records department activity

• Maintenance activities

Procedures have been established for all process control activities.




Reference Document: Respective DPs in Knowledge bank &nbpsFor adequate control following are ensured:




-Provision of work instruction where absence of such work instruction would cause adverse effect to quality

- Provision of suitable equipment for all activities

- Provision of suitable work areas/environment at all service delivery areas

-Compliance with appropriate procedure, requirement and quality plan

-Monitoring and control service delivery characteristics and effectives/treatment

- Approval of medical procedure and equipment before implementation

- Periodic maintenance of services delivery equipment

8.5.2 Identification and traceability

Detailed processes are defined for identification of the services provided and the associated products. These includes: Patient care, courses, subjects, examinations records, staff, students and others.

Reference document: SOP 8-04, Procedure for product/service identification and traceability

Traceability records are maintained for each student/patient and contains records such  as Admission records, academic records, progress notes, examinations records, marks card, results, certificate and others

For Hospitals

• Identification of products stored at Pharmacy- stock/sales, material- purchase/ stores, diagnostic units

• Identification of work areas

• Identification of Hospital staff

• Identification of patients

Head of Department of Pharmacy, Purchase/stores, diagnostic services, Medical Records Department are responsible for identification of activities. Medical Records department Head is responsible for traceability of Medical Records.

Method of identification of product, work areas, hospital staff and patient are detailed: SOP 8-04.

Traceability records are maintained for each patient and contain records including as applicable:

• Admission records

• Records of investigation

• Informed consent

• Procedure undergone

• Progress notes

• Operation notes

• Discharge summary etc.

8.5.3 Property belonging to customers or external providers

Customer property includes: 

• Marks card submitted by students at the time of admission (10+2 / UG)

• Patient records 

• Student details submitted at the time of admission 

• Student answer sheets

• Student degrees (till claimed) 

Detailed process has been defined to identify storage and protection of the documents and records received from students/ patients during admission, course duration/treatment process and examination. It is ensured that confidentiality of these documents is very well protected.  

Hospital related:

Customer property such as test/diagnostic/investigation- diagnosis are maintained in Medical Records. Confidentiality of the records are ensured to safe guard patient information. The documents are disclosed only under special circumstances like written request by patient, summons from Court of Law and for case reference by the Doctor. All medical records are stored and safe guarded in the hospital from destructions. If any customer property lost, damaged or otherwise found to be unsuitable for use, the hospital shall report this to the customer and maintain records. 

8.5.4 Preservation

Detailed processes have been defined for the proper preservation of the products / information associated with service delivery at academic and examination divisions. Processes are also defined for the proper preservation of the products associated with the support processes such as maintenance, automobiles and others.

These include proper identification, issues and receipt under authorization, preservation to avoid damage and others

Applicable to:

• Materials received in Purchase dept / Central stores.

• All records and documents related to Students/Institutions

• Other items and materials received

Appropriate methods of authorizing receipt to and delivery from storage areas have been established.

         Hospital related

Applicable to:

• Pharmacy items and materials received.

• Other items and materials received.

• Items handled at diagnostic units.

• Disposable items.

• Handling items at CSSD, wards, ICUs, OTs and other patient care areas.

Appropriate methods are employed with adequate equipment’s during all stages of service to patients. 

Adequate stages are provided to prevent damage or deterioration of items.

Appropriate methods of authorizing receipt to and delivery from storage areas have been established.

Measures like environment control, periodic checking of shelf life of products and checking of control of condition of products stored for long period have been established.

Condition of product stored for more than specified period of time is assessed and revalidated prior to use.

Reference Documents: Inventory Management 

8.5.5 Post-delivery activities

MAHE shall meet the requirements for the post-service activities associated with the services provided. In determining the extent of post service activities that are required, MAHE consider the following:

• The risks associated with the services.

• The nature, use and intended lifetime of the services.

• Customer feedback.

• Statutory and regulatory requirements.

Note: Post service actions include actions under, contractual obligations such as maintenance services, and supplementary services such as recycling or final disposal.

8.5.6 Control of changes

MAHE shall review and control unplanned changes (Deviation for temporary change) essential for production or service provision to the extent necessary to ensure continuing conformity with specified requirements.

 MAHE retain documented information describing the results of the review of changes, the personnel authorizing the changes and necessary actions. 

Reference Documents: ISP 8-02

8.6 Release of products and services

MAHE has implemented the planned arrangements at appropriate stages to verify that service requirements have been met. Evidence of conformity with the acceptance criteria is retained.

The release of the services to the student or patient will not proceed until the planned arrangements for the verification of conformity have been satisfactorily completed, unless otherwise approved by the relevant authority. Documented information shall provide traceability to the person authorizing release of services for students or patient.

Reference Documents: Discharge summary / Degree certificate

8.7 Control of non-conforming process outputs, products and services

Detailed processes are defined for the control of non-conforming services that are identified during the monitoring of the services delivery process. The customers’ complaints and feedback are also the sources for identification of the non-conforming product / services

The control aspect includes 

In case of Malpractice & failed students, action as per University Policy.

Hospitals

Applicable to:

• Handling of Nonconformance in pharmacy, materials (purchase and store)

• Non-conformance identified in various functional areas

• Concerned HODs held responsible to take necessary action on non-conformance

Controls of Non-conformances on items received:

• Items received are identified by authorized personnel during verification as detailed under sub clauses 8.2.3 and 8.2.4 of this manual.

• Non-conformances are recorded and actions taken may be rejected or accepted as it is with concession.

Control of Non-Conformances in service areas:

• Non-conformances received in each service areas are identified

• Immediate corrective/preventive actions are taken depending on nature of Non-conformances

• Time standards have been established for various service areas

• Deviations from these are recorded for identifying suitable preventive actions

• Non conformances addressed against Hospital infection guidelines.     

Reference Document:

SOP 8-05: Control of Non-conforming products/service:

SOP- 07-02: Employee Health and Safety

Identification of proper corrective preventive actions so as to avoid recurrence of the same. Appropriate records are maintained. 

Procedure for Identification of Emergency situations to mitigate the same is detailed in SOP 8-06 

9. Performance Evaluation

9.1 Monitoring, measurement, analysis and evaluation

9.1.1 General

MAHE shall determine the following:

• What needs to be monitored and measured?

• The methods of monitoring, measurement, analysis and evaluation, as applicable, to ensure valid results.

• When the monitoring and measuring shall be performed.

• When the results from monitoring and measurement shall be analyzed and evaluated.

MAHE ensures that monitoring and measurement activities are implemented in accordance with the determined requirements and shall retain appropriate documented information as evidence of the results. 

MAHE shall evaluate the quality performance and the effectiveness of the IMS. 

The organization shall determine for energy performance and the EnMS:

a) what needs to be monitored and measured, including at a minimum the following key characteristics:

1) the effectiveness of the action plans in achieving objectives and energy targets;

2) EnPI(s);

3) operation of SEUs;

4) actual versus expected energy consumption;

b) the methods for monitoring, measurement, analysis and evaluation, as applicable, to ensure valid results;

c) when the monitoring and measurement shall be performed;

d) when the results from monitoring and measurement shall be analyzed and evaluated.

MAHE shall evaluate its energy performance and the effectiveness of the EnMS.

Improvement in energy performance shall be evaluated by comparing EnPI value(s) against the corresponding EnB(s).

MAHE shall investigate and respond to significant deviations in energy performance and shall retain documented information on the results of the investigation and response. Documented information on the results from monitoring and measurement shall be retained appropriately.




Reference Documents: SOP 9-01




• Customer satisfaction




Beneficiary satisfaction is one of the measuring tools for quality of service provided by University. The effectiveness of Integrated Management System is assessed on an ongoing basis through measurement of customer satisfaction including positive / negative feedback and complaints, customer data on delivered service quality, by way of feedback forms.





9.1.2 Evaluation of compliance with legal requirements & other requirements (EMS, EnMS)

 

Methodology of evaluation of compliance implemented and maintained to the applicable legal and other requirements related to environmental and energy management which the University subscribes is addressed in SOP 09-03. Maintain knowledge and understanding of the compliance status and retain documented information as evidence of the compliance evaluation result.




Reference Documents: SOP-09-02




9.1.3 Monitoring, Measurement, Analysis and evaluation




MAHE shall analyze and evaluate appropriate data and information arising from monitoring, measurement and other sources.




The output of analysis and evaluation is used to:

• Demonstrate conformity of services to requirements.

• Assess and enhance customer satisfaction.

• Ensure conformity and effectiveness of IMS.

• Demonstrate that planning has been successfully implemented.

• Assess the performance of processes.

• Assess the performance of external provider (supplier).

• Determine the need or opportunities for improvements within the IMS.

It also serves as the input to the Management review.

Reference Documents: SOP 9-01




9.2.1 Internal audit of the IMS




Internal audits are conducted on periodical basis by competent internal auditors to determine whether the IMS (Quality, Environmental and Energy management system) confirms to the requirements and its implementation and maintenance status.

Detailed process has been defined covering the audit planning, auditor selection criteria and audit reporting and determination and implementation of actions based on the audit finding. Previous audit findings will also be used as one of the criteria for scheduling audits.

The audit finding is reviewed during the Management reviews at institutional levels, university departmental level and unresolved NCs may be referred to the MAHE Senior MRM. 




Reference Documents: ISP-09-01: Internal Audit




9.2.2 MAHE has taken following steps on internal audit:

• Plan, establish, implement and maintain an audit program defining the frequency, methods, planning requirements, responsibilities and reporting considering the quality objectives, the importance of the processes concerned, customer feedback, changes impacting on the university and the results of previous audits.

• Define the audit criteria and scope of the audit.

• Select auditors and conduct audits to ensure objectivity and impartiality of the audit process.

• Ensuring the results of audits is reported to relevant management.

• Taking necessary correction and corrective actions without any undue delay.

• Retaining the documented information as evidence of the implementation of the audit programme and the audit results 




Reference Documents: ISP-09-01

 

9.3 Management 




9.3.1 General




The top management of MAHE reviews the University's IMS at defined intervals, once in 6 months, to ensure its continuing suitability, adequacy and effectiveness. 




Reference Documents: Management review – ISP-09-02




9.3.1 Management review inputs 




Assessment of the IMS is based on the review of information inputs to management review. These inputs include the following:




• The status of actions from previous management reviews & Review of IMS policy

• Changes in external and internal issues relevant to Quality & Environmental management including its strategic direction.

• Information on performance, including trends and indicators for nonconformities and corrective actions, extent to which objectives have been met; monitoring and measurement of results; audit results; customer satisfaction and feedback from relevant interested parties; internal and external issues concerning relevant interested parties; performance of external providers ; adequacy of resources  for maintaining an effective IMS; process performance and conformity of products and services.

• The effectiveness of actions taken to address risks and opportunities.

• The needs and expectations of interested parties,

• Fulfillment of its compliance obligations

• Review of current and projected energy performance, EnPIs, Significant environmental aspects

• New potential opportunities for continual improvement.




Reference Documents: Management review – ISP-09-02




9.3.3 Management review outputs




The output from the management review shall include all decisions and action plans related to:

• Continual improvement opportunities.

• Changes to the IMS.

• Resource needs. 

• Conclusion on the continuing suitability, adequacy and effectiveness of the environmental management system

• Decisions related to continual improvement opportunities

• Decisions related to any need for changes to the EMS including resources

• Actions if needed when environmental objectives have not been achieved

• Any implications for the strategic direction of the university




Reference Documents: Management review –  ISP-09-02




10. Improvement




10.1 General

MAHE shall determine and select opportunities for improvement and implement necessary actions to meet customer requirements and to enhance customer satisfaction. This shall include:




• Improving processes to prevent nonconformities.

• Improving products and services to meet known and predicted requirements.

• Improving IMS results.




Reference Documents: Internal audit analysis and MRM




10.1/ 10.2 Non conformity and corrective action




10.2.1 
When nonconformity occurs, including the customer complaints, MAHE shall:




• React to the nonconformity, as applicable; take action to control and correct it and deal with the consequences.

• Evaluate the need for action to eliminate the cause of the nonconformity, in order that it does not recur or occur elsewhere, by; reviewing the nonconformity, determining the causes of the nonconformity and determining if similar nonconformities exist or could potentially occur.

• Implement any action needed.

• Review the effectiveness of any corrective action taken.

• Make changes to the IMS, if necessary.




Corrective actions taken shall be appropriate to the effects of the nonconformities encountered.




10.2.2 
MAHE shall retain the documented information as evidence of; the nature of the nonconformities and any actions taken and the results of corrective action.




Correction, corrective action and preventive action




Documented procedures are established to analyze the nature and root cause of problem and proposed action/plan to correct them from recurring. Suitable review methods are also adopted to ensure the effectiveness of the corrective actions. The corrective actions initiated are appropriate to the effects of the non-conformances encountered

Corrective actions are taken on the following:




• Customer complaints

• Non-conformance during receipt of items 

• Non-conformances identified at various functional areas

• Non-conformances at Internal Audit

• Delay against IMS objectives established.

 

Corrective actions and preventive actions shall be appropriate to the magnitude of the actual or potential problems and the energy performance consequences encountered 

 

Concerned HODs/In-charge are responsible for taking corrective actions and assessment of effectiveness. PC / respective HOI/MS are responsible for taking preventive actions.




Customer complaints or interested parties are received through suggestion boxes/ feedback forms/telephone/complaint registers recorded and necessary effective actions are taken by PC, VC, Registrar and respective HOIs/MS in addition to the concerned Committee in the University / institute/hospital. Corrective actions are taken for Non-conformance product/services after analysis of procedure, work instruction and related documents. The actions are recorded. Corrective actions on non-conformance observed during Internal Quality Audit are as detailed in section 9.2 internal audit 




Periodically preventive action meetings are conducted formally and informally to analyze:




• Customer complaints

• Non-conformance during receipt of items 

• Non-conformances identified at various functional areas

• Non-conformances at Internal Audits




Analysis is carried out using trends, procedures, work instructions and other related documents.

Preventive actions are planned and implemented. Controls are exercised to ensure that actions are effective. 

Procedures, work instructions and related documents are revised if necessary. Results of preventive actions are reviewed for effectiveness in Management Review meeting




Reference Documents: Online audit report




10.3 Continual Improvement




MAHE shall continually improve the suitability, adequacy and effectiveness of the IMS.

MAHE consider the outputs of analysis and evaluation and outputs from management review, to confirm if there are areas of underperformance or opportunities for continual improvement.

If applicable, MAHE shall select and utilize applicable tools and methodologies for investigation of the causes of underperformance and for supporting continual improvement.