6.2 Cyclical Audit: Process

6.2.1     Pre-orientation and briefing details

This in-person half-day briefing occurs in the year prior to a university’s scheduled Cyclical Audit (see the Schedule of Audits). The Quality Assurance Secretariat and a member of the Audit Team provides an orientation on what to expect from the Cyclical Audit to the Key Contact and any other relevant stakeholder(s) (such as key staff members, Deans, the committee(s) responsible for quality assurance, etc.).

6.2.2     Assignment of auditors

Normally three auditors, selected from the Audit Committee’s membership by the Quality Assurance Secretariat, conduct a Cyclical Audit. These auditors will be at arm’s length from the university undergoing the audit. Members of the Quality Assurance Secretariat accompany the auditors on their site visit and constitute the remainder of the Audit Team.

6.2.3     Institutional self-study

Each university presents and assesses its quality assurance processes, including challenges and opportunities, within its own institutional context. This occurs through an institutional quality assurance self-study (see suggested template). The self-study is prepared and submitted to the Quality Assurance Secretariat in advance of the desk audit and forms the foundation of the Cyclical Audit. The self-study will pay particular attention to any issues flagged in the previous audit.

6.2.4     Selection of the sample of quality assurance activities for audit

The Audit Team independently selects a sample of programs for audit that represents the New Program Approval Protocol (normally two examples of new programs developed under this Protocol) and the Cyclical Program Review Protocol (normally three or four examples of programs that have undergone a Cyclical Program Review) described in this Framework. Where appropriate, the Audit Team may look at the Record of Substitution or Addition compiled for programs that are also subject to accreditation (see Section 5.5).

Programs that have undergone the Expedited Protocol and/or the Protocol for Major Modifications (Program Renewal and Significant Change) will not normally be subject to audit.

A small sample of new programs still in development and/or cyclical program reviews that are still in progress may also be selected, in consultation with the university. If so, documentation associated with these in-progress quality assurance processes will not be required for submission for audit. Instead, the auditors will ask to meet with the program representatives to gain a better understanding of current quality assurance practices in the institution (see Guidance).

Specific areas of focus may also be added to the audit when an immediately previous audit has documented causes for concern (see “Cause for Concern” below) or when the Quality Council so requests. The University will be informed of the specific areas of focus in the letter from the Quality Assurance Secretariat that also details the programs selected for audit. The university itself may also request that specific programs and/or quality assurance elements be audited.

The auditors may consider, in addition to the required documentation, any additional elements and related documentation stipulated by the university in its IQAP.

6.2.5     Desk audit[1] of the university’s quality assurance practices

In preparation for a scheduled on-site visit, the auditors undertake a desk audit of the university’s quality assurance practices. Using the university’s self-study and records of the sampled programs, together with associated documents, this audit tests whether the university’s practice is in compliance with its IQAP, as ratified by the Quality Council.[2] In addition, the audit will note any misalignment of its IQAP with the QAF.

It is essential that the auditors have access to all relevant documents and information to ensure they have a clear understanding of the university’s practices. The desk audit serves to raise specific issues and questions to be pursued during the on-site visit and to facilitate an effective and efficient audit.

The documentation to be submitted for audit will include:

  1. The relevant documents and other information related to the programs selected for audit, as requested by the Audit Team;
  2. The record of any revisions of the university’s IQAP, as ratified by the Quality Council; and
  3. The annual report of any minor revisions of the university’s IQAP that did not require Quality Council re-ratification.

Universities may provide any additional documents at their discretion.

During the desk audit, the auditors will also determine whether the university’s web-based publication of the Executive Summaries, and subsequent reports on the implementation of the review recommendations for the programs included in the current audit, meet the requirements of Framework Section 5.4.1.

The auditors undertake to preserve the confidentiality required for all documentation and communications and to meet all applicable requirements of the Freedom of Information and Protection of Privacy Act (FIPPA).

6.2.6     Site Visit

After the desk audit, auditors normally visit the university over two or three days. The principal purpose of the on-site visit is for the auditors to get a sufficiently complete and accurate understanding of the university’s application of its IQAP in its pursuit of continuous improvement of its programs. Further, the site visit will serve to answer questions and address information gaps that arose during the desk audit and assess the degree to which the institution’s quality assurance practices contribute to continuous improvement of its programs.

In the course of the site visit, the auditors speak with the university’s senior academic leadership including those who the IQAP identifies as having important roles in the QA process. The auditors also meet with representatives from those programs selected for audit, students, and representatives of units that play an important role in ensuring program quality and success. These include, but are not limited to, the Library, Teaching and Learning Services, Institutional Research, Instructional Media, and other technical support service representatives. The university, in consultation with the auditors, establishes the program and schedule for these interviews prior to the site visit.

6.2.7     Audit Report

Following the conduct of an audit, the auditors prepare a report that will be considered “draft” until it is approved by the Quality Council. The report, which is to be suitable for subsequent publication, comments on the institution’s commitment to the culture of engagement with quality assurance and continuous improvement and will:

  1. Describe the audit methodology and the verification steps used;
  2. Comment on the institutional self-study submitted for audit;
  3. Describe whether the university’s practice is in compliance with its IQAP as ratified by the Quality Council, on the basis of the programs selected for audit;
  4. Note any misalignment of its IQAP with the QAF;
  5. Respond to any areas the auditors were asked to pay particular attention to;
  6. Identify and record any notably effective policies or practices revealed in the course of the audit of the sampled programs; and
  7. Comment on the approach that the university has taken to ensuring continuous improvement in quality assurance through the implementation of the outcomes of cyclical program reviews and the monitoring of new programs.

The report shall not contain any confidential information.

A separate addendum provides the university with detailed findings related to the audited programs. This addendum is not subject to publication.

The report may include findings in the form of:

Suggestions, which are forward-looking, and are made by auditors when they identify opportunities for the university to strengthen its quality assurance practices. Suggestions do not convey any mandatory obligations and sometimes are the means for conveying the auditors’ province-wide experience in identifying good, and even on occasion, best, practices. Universities are under no obligation to implement or otherwise respond to the auditors’ suggestions, though they are encouraged to do so.

Recommendations, which are recorded in the auditors’ report when they have identified failures to comply with the IQAP and/or there is misalignment between the IQAP and the required elements of the Quality Assurance Framework. The university must address these recommendations in its response to the auditors’ report.

Causes for concern, which are potential structural and/or systemic weaknesses in quality assurance practices (for example, inadequate follow-up monitoring, as called for in Framework Section 5.4.1 d)) or a failure to make the relevant implementation reports to the appropriate statutory authorities (as called for in Framework Section 5.4.2). Causes for Concern require that the university take the steps specified in the report and/or by the Quality Council to remedy the situation.

The Audit Report includes recommendations that the Quality Council take one or more of the following steps, as appropriate:

  1. Direct specific attention by the auditors to the issue(s) within the subsequent audit, as provided for in Framework Section 6.2.4;
  2. Schedule a larger selection of programs for the university’s next audit;
  3. Require a Focused Audit
  4. Adjust the degree of oversight and any associated requirements for more or less oversight (see Guidance);
  5. Require a Follow-up Response Report, with a recommended timeframe for submission; and/or
  6. Any other action that is deemed appropriate.

Ultimately, the Audit Report includes an assessment of the overall performance of the university and contains recommendations to the Quality Council, as appropriate, based on that assessment.

See also “Remedies Available” in Part One.

6.2.8     Disposition of the Audit Report

The Quality Assurance Secretariat submits the Audit Report to the Audit Committee for consideration. Once the Audit Committee is satisfied with the Report, it makes a conditional recommendation to the Quality Council for approval of the Report, subject only to minor revisions resulting from the fact checking stage described below.

The Quality Assurance Secretariat provides a copy to the university’s “authoritative contact” identified in Framework Section 1.2, for fact checking. This consultation is intended to ensure that the report does not contain errors or omissions of fact but not to discuss the substance or findings of the report.

That authority submits its report on the factual accuracy of the draft report within 30 days. If needed, the authority can request an extension of this deadline by contacting the Quality Assurance Secretariat and providing a rationale for the request. This response becomes part of the official record and the audit team may use it to revise their report. However, the university’s fact checking response will not be published on the Quality Council’s website. When substantive changes are required, the draft report will be taken back to the Audit Committee.

The Chair of the Audit Committee takes the Audit Committee’s recommendation for approval of the report to the Quality Council.

The Council either accepts the report, or refers it back to the Audit Committee for modification.

6.2.9     Transmittal of the Audit Report

Upon approval by the Quality Council, the Quality Assurance Secretariat sends the approved report to the university with an indication of the timing for any required follow-up.

6.2.10   Publication of main audit findings

The Quality Assurance Secretariat publishes the approved report of the overall findings, absent the addendum that details the findings related to the audited programs, together with a record of the recommendations on the Quality Council’s website. The university will also publish the report (absent the previously specified addendum) on its website.

6.2.11   Institutional Follow-up Response Report

When a Follow-up Response Report is required (as per Section 6.2.7 v)), the university will submit the Report within the specified timeframe, detailing the steps it has taken to address the recommendations and/or Cause(s) for Concern.

If the Audit Team is satisfied with the university’s Follow-up Response Report, it drafts a report on the sufficiency of the response. The auditors’ report, suitable for publication, is then submitted to the Audit Committee for consideration.

If the Audit Team is not satisfied with the institutional response, the Audit Team will consult with the institution, through the Quality Assurance Secretariat, to ensure the follow-up response is modified to satisfy the requirements of the Audit Report. In so doing, the institution will be asked to make any necessary changes to the follow-up response within a specified timeframe. The Audit Committee submits a recommendation to the Quality Council to accept the university’s follow-up response and associated auditors’ report.

See also “Remedies Available” in Part One.

6.2.12   Web publication of follow-up report

The Quality Assurance Secretariat publishes the Follow-up Response Report and the auditors’ report on the scope and adequacy of the university’s response on the Quality Council website and sends a copy to the university for publication on its website.

6.2.13   Additional reporting requirements

A report on all audit-related activity is provided to OCAV, COU and MCU through the Quality Council’s Annual Report.


[1] A desk audit is a limited-scope, off-site examination of the relevant documents and records by the auditors. [2] Changes to the institution’s process and practices within the eight-year cycle are to be expected. The test of the conformity of practice with process will always be made against the ratified Institutional Quality Assurance Process applying at the time of the conduct of the review.