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Quality Assurance and Review Process Procedure

Policy Code: CG1248

Purpose
Scope
Definitions
Actions
Internal Quality Reviews
Internal Quality Audits
Plan and Schedule Quality Audits
Prepare to Conduct Internal Quality Audits
Conduct Quality Audits
Report on Quality Audits
Effectiveness of Action Taken in Response to Non-Conformances
Corrective Action Requests (CARs)
External Audits
Responsibilities
Policy Base
Associated Documents
Forms/Record Keeping
Implementation

Purpose

This procedure describes the planning, conduct and reporting of Internal Quality Audits and Reviews along with the monitoring of any actions required as an outcome.

Quality Audits and Reviews at the University of Ballarat are conducted at planned intervals to determine whether the policies, procedures and processes which form the foundation of the Quality Framework are effectively implemented and maintained. Quality Audits and Reviews also provide the opportunities for self reflection and identification of any potential opportunities for improvement.

Scope

This procedure is applicable to all Programs/Courses and operational processes of the University of Ballarat irrespective of their location of delivery or by whom they are being delivered.

Definitions

Term Definition
Audit Conclusion: The outcomes of an audit provided by the auditor/s after consideration of the audit objectives and all audit findings.
Audit Criteria: The policies, procedures and/or requirements the audit is measured against.
Auditee:  A person, School, Centre or Directorate that is being audited.
Audit Evidence: The records, statements of fact or other information which are relevant to the audit criteria and can be verified.
Audit Findings Results of the evaluation of the collected audit evidence against the audit criteria.
Audit Plan: Description of the activities and arrangements for an audit.
Audit Scope: Refers to the extent and boundaries of the audit process.
Audit/s: The systematic, independent and documented process for obtaining audit evidence and evaluating it objectively to determine the extent to which the audit criteria is fulfilled.
Corrective Action Request(CAR): A request that action is required to be taken to correct a non conformance.
External Audit: A Quality Audit conducted by an external party against legislative and/or regulatory requirements. e.g. ESOS, AQTF, VRQA etc.
Improvement Opportunity(IO): An observation made regarding potential improvement of a current activity to increase compliance with required processes.
Internal Quality Auditor: A person who is competent and authorised to perform quality audits. Internal audits are assigned to be undertaken by Quality Services.
Non Conformance / Non Compliance: An observation from evidence available does not comply with the practices required under the quality management system.
Quality Audit:  An objective, systematic, and documented process to verify that actual processes and records comply with the planned and/or documented arrangements established by the University. Also referred to as an 'Audit'.
Quality Committee: The process which evaluates the suitability, adequacy, and effectiveness of an organisation's quality management system, and looks for improvement opportunities.
Quality Framework: The system established by the University to assure the quality of its processes.
Quality Review: A review is a course of action that examines a particular activity or process, which may not have a set criteria and is undertaken for continuous improvement opportunities. It is not a quality control activity and is not measured against specific criteria, but can provide recommendations that may lead to improvement of an activity/process.
Root Cause Analysis:

It is a structured approach to identify the factors - physical, human and latent causes - that resulted in the non-conformance occuring. It is the true reason or basis as to why the non-conformance occurred. The root cause analysis is to be identified in order to prevent recurrence of the event in the future.

In order to improve the system effectively, the root cause of problems must be addressed not merely the proximate cause of the problem. The use of Root Cause Analysis is an attempt to find the definitive problem rather than viewing a symptom as the cause. A solution that will improve the system more effectively can be developed to address the issue rather than the symptom.

Examples of the basis elements of root cause are:

  • No or poor procedures
  • Lack of staff training
  • Poor communication
  • Lack of Resources / Poor Resources
  • Environment

Actions

Internal Quality Reviews

The purpose of reviews is the assurance of quality and as an essential mechanism for quality enhancement and are conducted at the University of Ballarat to ensure that these goals are met.

The principles and steps involved in the undertaking of reviews is similar to those of an internal quality audit, the main difference being that a review may result in recommendations for consideration and not corrective action requests.

A review involves the review of a process and does not have a set criteria. It is a continuous improvement activity - not a quality control activity.

Both reviews and internal quality audits follow the same basic principle that the review/audit process must be:

  • Evidence based
  • Efficient
  • Rigorous
  • Transparent
  • Objective

As with internal quality audits, reviews must have a purpose.  They must have the potential to lead to meaningful and worthwhile change; and where change is not the outcome, they must provide assurance the current University practice is appropriate.

Key activities related to continuous improvement within the University may be potentially subject to review.  A review will be initiated as a result of a specific trigger, such as:

  • Identification of risk, strategic need/opportunity, concern about performance on the basis of regular performance monitoring, benchmarking, previous reviews or other evidence
  • Major organisational or external environmental change, posing risks or creating opportunities
  • new and emerging regulatory or legislative requirements
  • a planned cycle as part of the internal quality audit schedule.

The review process must include:

  • A statement of the scope and/or terms of reference (including reference to any specific trigger for the review and to any relevant goal or strategy)
  • Defined responsibilities for initiation and carriage
  • A specific but realistic timeframe
  • Relevant external standards and benchmarks
  • Reference to relevant performance indicators or other data
  • Reference stakeholder data
  • External stakeholder input where appropriate
  • Methodology
  • Approval by the Quality Committee.

Internal quality reviews are planned and scheduled as per the Internal Quality Audit process. Refer to Plan and Schedule of Quality Audits.

Internal Quality Audits

Plan and Schedule Quality Audits

Prepare to Conduct Quality Audits

Conduct Quality Audits

Report on Quality Audits

Effectiveness of Action Taken in Response to Non Conformances

Corrective Action Requests (CARs)

To ensure that the internal quality audit process provide useful outcomes based on evidence, the following principles must be adhered to by all Internal Quality Auditors. At all times the Internal Quality Auditor will demonstrate:

  1. Ethical conduct through the demonstration of integrity, confidentiality and discretion;
  2. Fair presentation through the obligation to report truthfully and accurately;
  3. Due professional care through the application of diligence and fair judgement in auditing,
  4. Independence - The Internal Quality Auditor must be independent of the activity being audited and free from bias and conflict of interest.
  5. Objectiveness - The Internal Quality Auditor must maintain an objective state of mind and ensure the audit findings and conclusions are based only on the audit evidence.
  6. Evidence-based approach - Audit evidence must be verifiable and based on samples of information available.

Plan and Schedule Quality Audits

  STEPS WHO IS RESPONSIBLE? COMMENTS
1.

Develop an Internal Quality Audit Plan on an annual basis.

The Audit Plan should be finalised by the end of January for the remainder of the year. The Audit Plan is subject to change from time to time as circumstances require.

A methodology for conducting audits should be considered and decided at this time. For instance, a particular focus may be used (ie focus on a particular element of compliance requirement) or a new methodology may be implemented.

 Quality Services
  • The Plan is developed taking into account:
  • Non conformances and improvement opportunities identified during previous audits, whether conducted by an internal or external party;
  • Preparation required for forthcoming regulatory audits (ASQA, TEQSA, ISO, IE);
  • Representation of all delivery modes;
  • Representation of all campuses and teaching sites;
  • Risk Analysis completed taking into account specific risk criteria;
  • Procedures specifically required by ISO 9001:2008, ASQA,TEQSA, VRQA (VCAL) Standards or other standards as required;
  • The need to verify the effectivess of completed corrective actions;
  • Numbers of students enrolled in programs or courses (specific risk criteria);
  • Other relevant factors as required, ie items affecting the VET or Higher Education sectors.
2. Approve Audit Plan Quality Committee. The Internal Quality Plan is forwarded to the Quality Committee for approval.
3. Based on the Audit Plan above, a detailed Audit Schedule should be constructed. Quality Services The Internal Quality Schedule is forwarded to the Quality Committee for approval.
4. Develop the Audit methodology specific to the type of Audit/Review occurring. Quality Services The methodology should be discussed and confirmed.
5. Assigned trained internal auditor/s to conduct the audit/s. Quality Services Auditors cannot be assigned to audit their own department.

Prepare to Conduct Internal Quality Audits

  STEPS WHO IS RESPONSIBLE? COMMENTS
1. Read the relevant information that apply to the process/program being audited. Quality Services The information could be in the form of a policy, procedure, guideline and forms or relevant legislation, regulations or standards.
2. Establish contact with the Dean and Deputy Dean / Head of Department of the specific School and Department / Director / Manager of process being audited to inform them of the intention to conduct an audit within their area. Quality Services
  • Refer to Email Template 1.
3.

Establish contact with the Auditee and arrange a time to conduct the audit.

 Quality Services

Advise:

  • Objective, scope and criteria of the audit,
  • Timelines for conducting audit.

Negotiate a mutually convenient date and time.

Advise the auditee the amount of time required to conduct the audit.

  • Refer to Email Template 2
4.

Send out Preparation for Audit Preparation Checklist (if applicable) to assist the auditee in their preparation.

Include the Internal Quality Auditing Procedure for the auditee's information.

 Quality Services

Audit Preparation Checklists to be developed by Quality Services when preparing the pre-audit documentation.

  • Refer to Email Template 3.

Conduct Quality Audits

  STEPS WHO IS RESPONSIBLE? COMMENTS
1. Commence the Audit with an opening meeting. Quality Services This may be a short discussion at the beginning of the audit. The objective of this is to outline the scope of the audit and the process the audit will follow. The Auditee should be asked if they have any questions they require answering prior to commencing the actual audit.
2. Conduct audit. Quality Services

Refer to:

  • Relevant checklists.
  • Documents required to be completed and available in accordance with a specific UB Policy and Procedure,
  • Information provided by the auditee prior to the audit meeting.
  • Copies of relevant procedures and standards.
  • Previous audit results.

Note: These documents will vary significantly depending on the area being audited.
3.

Close the audit meeting by summarising the audit findings and discuss outcomes / observations arising from the audit with auditee.

Indicate a time-frame in which the auditee will receive the audit report.

 Quality Services

Provide feedback to the auditee and include details of any:

  • Good practice /good ideas observed,
  • Non Conformances, the subsequent Corrective Actions and the requirement to ensure their effectiveness,
  • Improvement opportunities,

Report on Quality Audits

  STEPS WHO IS RESPONSIBLE? COMMENTS
1. Complete internal quality audit report within five (5) working days. Quality Services This includes identification of Improvement Opportunities and Non Conformances.
2. Send internal quality audit report to Auditee asking them to read the document and advise of any inaccuracies Quality Services / Auditee

The auditee is to return the draft with any changes to Quality Services within 5 working days.

  • Refer to Email Template 4.
3. Finalise internal quality audit report including any changes/comments from auditee. Quality Services  
4. Log identified CARs and IOs onto the CAR & IO Database. Quality Services
  • Non conformances are issued with an individual ID number.
5. Complete CAR Summary Form and forward together with the completed audit report noting non-conformances and improvement opportunities to the Auditee with a copy to the relevant Dean / Deputy Dean / Head of Department / Associate Dean (Learning & Teaching) / Program Co-ordinator / Manager and Auditors. Quality Services / Auditee
  • Electronic copies of audit reports to be maintained by Quality Services.
  • Refer to Associate Documents - Forms to access the CAR Summary Form Template.
  • Nominate a date within 2 weeks for the Auditee to complete the CAR Summary Form and return to Quality Services.
  • For Internal Audits - only non-conformances are to be addressed, although it is recommended that improvement opportunities are given careful consideration by the Deputy Dean / Associate Dean (Learning & Teaching) and Auditee. (IOs are listed with the Internal Audit Report).
  • Refer to Email Template 5.
6. Auditee to forward completed CAR Summary Form to Quality Services by the nominated 2 week date. Auditee / Quality Services

Auditee to complete the following on the CAR Summary Form:

  • Root Cause Analysis (What has caused the non-conformance to occur?) - Column 3
  • Proposed Action (What corrective action will be taken to address the non-conformance and prevent the root cause from re-occurring?) - Column 4, and
  • Proposed Time-line for Completion of Action (Suggested completion date within 4 weeks).
  • The Root Cause Analysis, Proposed Action and Proposed Time-line to address the corrective action are logged onto the CAR and IO Database.

NOTE: If the CAR Summary Form has not been forwarded to Quality Services within the nominated timeframe, the Escalation Process will be followed.
7. Monitor Non conformances and IOs and progress of proposed action / response. Quality Services
  • Progress of Corrective Actions Requested will be monitored and reported to the Quality Committee.
8. All audit results will be reported to the Quality Committee on a quarterly basis. Quality Services

The Audit Results Report will include:

  • trends
  • status of Corrective Action Requests (CARs)
  • any recommendations
  • any commendations / best practices

Note: Non-conformances and Improvement Opportunities are not monitored on an individual basis. Trends are reported to the Quality Committee for discussion and system wide resolution.

Effectiveness of Action Taken in Response to Non-Conformances

  STEPS WHO IS RESPONSIBLE? COMMENTS
1.

Quality Services will contact the Deputy Dean / Associate Dean (Learning & Teaching) and Auditee of the School/Section/Directorate/Centre responsible for addressing the non conformance by the agreed date

OR

The Deputy Dean / Associate Dean (Learning & Teaching) and Auditee of the School/Section/Directorate/Centre responsible for addressing the non conformance will inform Quality Services when the agreed corrective action/s is/are being progressed and forward evidence.

 School/Section/Directorate/Centre Evidence may be either in hardcopy or electronic. Direct contact by email should be made with Quality Services to advise them of the completion of this step.
2.

The status of CARs will be determined by conducting a follow up audit or sighting evidence of the proposed action.

The Deputy Dean / Associate Dean (Learning & Teaching) and Auditee must also provide evidence in evaluating the effectiveness of the proposed action.

 Quality Services

Follow-up audits/review of evidence are conducted to verify the effectiveness of actions taken;

  • has the proposed action effectively solved the issue arising from the CAR, and
  • will the proposed action effectively prevent future occurrences?

Note: There is a requirement to validate the effectiveness of the corrective action in a timely manner.
3. Report the results of follow-up audit/review of evidence to the relevant Dean / Deputy Dean / Associate Dean (Learning & Teaching). Quality Services.

If corrective action has been implemented and evaluated to be effective in correcting the issue originally identified, then the CAR will be completed and CLOSED.

If action has not been effective, negotiate with relevant Deputy Dean / Associate Dean (Learning & Teaching) / Auditee the further actions required to resolve the issue and update progress of CAR to EXTENDED on Database.

NOTE: The CAR or IO will NOT be closed until the effectiveness of the action has been evaluated and evidence of evaluation has been shown.

Corrective Action Requests (CARs)

Escalation Process - Provision of Root Cause Analysis, Proposed Action & Proposed Time-line Information
Escalation Process - Completion of Proposed Actions / Evaluation on Effectiveness of Actions

It is the responsibility of Management relevant to the area being audited to ensure any corrective action requests (CARs) are responded to in a timely manner to ensure the removal of any non conformances and their root cause. Refer to Steps 2-7 as stipulated in Report on Quality Audits.

Escalation Process - Provision of Root Cause Analysis, Proposed Action & Proposed Time-line Information

If the response providing the Root Cause Analysis, Proposed Action and Proposed Time-line (Steps 2-6) are not received by Quality Services within the stipulated time-frame, the following escalation process will be initiated:

  STEPS WHO IS RESPONSIBLE? COMMENTS
1. Corrective Action Request Summary Form sent from Quality Services to Auditee and Deputy Dean. Quality Services
  • Auditee/Deputy Dean are provided Instructions on the Corrective Action Request process within the Corrective Action Request (CAR) Summary Form.
  • A response is required within 2 weeks.
2. If a response is not received within 2 weeks (response date as stipulated in Step 1 of Instructions), the CAR will be escalated via a memorandum forwarded by the Director, Planning Quality & Review to the Dean of the School. Quality Services
  • A response is required within 1 week.
  • Refer to Email Template 6 and Memorandum Template.
3. If a response is not received within 1 week, the CAR will be escalated with correspondence forwarded from the Deputy Vice-Chancellor, Learning and Quality to the relevant SDVC or DVC or officer for action. Quality Services
  • A response is required immediately.
  • Refer to Email Template 7 and Memorandum Template.

Escalation Process - Completion of Proposed Actions / Evaluation on Effectiveness of Actions

It is expected that the Proposed Action/s and the Evaluation of the Effectiveness of the Action/s will be completed in a timely manner (eg. one to six month time-frame).

The "Proposed Time-line for Completion of Action" is the stated time-frame in which the Proposed Action and the Evaluation on the Effectiveness of that Action is to be completed. Once this time-frame has expired, Quality Services will contact the area/staff responsible and ask to view evidence in support of the proposed action.

If the Proposed Action and Effectiveness of the Action and supporting evidence is not completed within that timeframe, the following escalation process will be initiated:

  STEPS WHO IS RESPONSIBLE? COMMENTS
1. Quality Services to contact the area/staff responsible, after the stated Proposed Time-line for Completion of Action, in order to view evidence relating to the Proposed Action/s and the Evaluation in the Effectiveness of the Action/s. Quality Services  
2. If the Proposed Action, the Effectiveness of the Proposed Action and supporting evidence is not completed by the stated time-frame, the CAR will be escalated via a memorandum forwarded by the Director, Planning Quality & Review to the Dean of the School. Quality Services

A response is required within 1 week.

Refer to Email Template 8 and Memorandum Template.
3. If a response is not received within 1 week, the CAR will be escalated with correspondence forwarded from the Deputy Vice-Chancellor, Learning and Quality to the relevant SDVC or DVC. Quality Services

A response is required immediately.

Refer to Email Template 9 and Memorandum Template.

External Audits

The process for Corrective Action Requests and Improvement Opportunities resulting from External Audits conducted at the University of Ballarat will be undertaken as per the Internal Quality Audit process.

However, for External Audits, all Non-Conformances and Improvement Opportunities will be monitored on an individual basis.

Responsibilities

  • Manager - Quality, Surveys and Records has responsibility for the maintenance of this procedure.
  • Specific responsibilities are included under Actions.

Policy Base

  • ISO 9001:2008 Quality Management Systems - requirements
  • ISO 19011:2002(E) Guidelines for quality and/or environmental management systems auditing

Associated Documents

Forms

Forms/Record Keeping

Title Location Responsible Officer Minimum Retention Period
Internal Quality Audit Schedule Planning, Quality & Review Section Quality Services Located within L:Drive and archived once administrative use is concluded.
Quality Audit Checklists and Reports Planning, Quality & Review Section Quality Services Located within L:Drive and archived once administrative use is concluded.
CAR and IO database Planning, Quality & Review Section Quality Services Located within L:Drive and archived once administrative use is concluded.
CAR and IO Status Reports Planning, Quality & Review Section Quality Services Located within L:Drive and archived once administrative use is concluded.

Implementation

The Internal Quality Auditing Procedure will be implemented throughout the University of Ballarat via:

  1. an Announcement Notice under ‘UB News’ on the ‘UB Homepage’ website and through the University of Ballarat Policy - ‘Recently Approved Documents’ webpage to alert the University-wide community of the approved Procedure; and
  2. inclusion on the University of Ballarat Policy Central website;
  3. the schedule and other relevant internal quality audit and review information placed on Quality @ UB website;
  4. the amended procedure implemented by Quality Services for the 2013 Audit Process, and
  5. the amended procedure to be used when training Auditors within the organisation.
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