The purpose of this document is to describe the various audit processes for UL support departments 1 and to outline the detailed procedure for conducting QMS (inter-department audits). Audits are a reliable mechanism through which the effectiveness of a Quality Management System (QMS) is systematically reviewed for the benefit of the department. An audit is a valuable tool that also allows a department to evaluate its own processes to assure the continual improvement of its QMS. The audits can occur in a number of ways, each with a different emphasis and involving different groups of people but the principle remains the same – to verify that documented procedures are being followed and to promote continual improvement. The overriding priority of the audit process is to assist departments in taking full advantage of the benefits of the QMS. The spirit of the process is supportive rather than inspectoral.
The Quality Support Unit has overall responsibility for this process.
There are currently four types of audit. For the purpose of this process, the following terms will apply:
 Internal Audit / Self-Assessment: Under the UL Guidelines for Quality Management Systems, each support department is required to conduct annual internal audits/self-assessments. Each department must document an Internal Audit Process and schedule an annual audit of all QMS and key business processes. Outcomes from these audits were incorporated into the department’s quality improvement action plan. Each department is responsible for their own audit process.
 QMS Audit: The purpose of the process is to ensure that all components of the quality management system are audited for compliance with the UL framework and for continual improvement. It allows for a sharing of best practice and a focus on inter-department collaboration. Prior to the review, the
QSU will schedule inter-department audits of the QMS. Audits are conducted using auditors from within the department under review and also trained auditors from other departments. The audits are scheduled by the Quality Officer in the QSU, who has overall responsibility for the process. A record is kept by the QSU of all trained auditors. The audit schedule for each department outlines details of the QMS and business processes to be audited, the assigned auditor and the date of the audit. Assigned auditors prepare checklists prior to the audit, based on the process to be audited.
Upon completion of each audit, the auditor sends the audit report to the Quality Officer, who combines all individual reports into a comprehensive audit report for the department.
Recommendations for improvement are then entered into the department’s Quality Improvement
Action Plan. (See Section 1 below for further details.)
 Gap Analysis Audit: This is an audit conducted by the Quality Support Unit (QSU), typically one year prior to the department’s Quality Review. The QMS Benchmark documented is used to ascertain the department’s progress to date in developing their QMS and to identify areas which need to be improved. The outcome of this gap analysis audit can be a very valuable first step in preparation for the quality review. (See Section 2 for further details.)
1 Department can mean department, unit or section.
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 Quality Review Process: This is effectively an audit of the QMS conducted by the Quality Review
Group on a 7-year cycle. The review process is designed to fulfil the requirements of the legislation in line with the Irish Universities Association (IUA) and Quality and Qualifications Ireland (QQI) policies and agreements.
1.1 Selection and Training of Quality Auditors
Support departments in UL are encouraged to have a number of trained quality auditors. Each department is required to nominate at least two members of staff to form a panel of QMS (interdepartment) auditors. Nominations will be requested by the QSU prior to each cycle of quality reviews.
The QSU will maintain a register of auditors and quality team leaders.
Auditor training is scheduled by the Quality Support Unit as required.
1.2 Role and Responsibilities of Auditors participating in QMS Audits
During the review cycle, auditors will be required to participate in the QMS audit of at least one other support department in UL. The audit schedule will be compiled by the QSU and communicated to the panel of auditors. QMS audits will be conducted annually, throughout the 7-year cycle. Typically auditors can expect to be involved in one QMS audit of another department each year. Auditors may also be asked to participate as a reviewer in the quality review of another support department. This requires a commitment of no more than 4 days within the 7-year review cycle.
Typically each auditor can expect to be called upon to:

Participate in QMS reviews of their own department

Assist with a QMS review of another department

Participate as a reviewer during a quality review of another department
Such activities outside one’s own department should rarely exceed 4 days per year and would normally be just 1-2 days per annum.
1.3 Confidentiality
Auditors must exhibit the highest level of professional objectivity and discretion in gathering, evaluating, and communicating information about the activity or process being audited. Complete confidentiality must be maintained at all times. Auditors must make a balanced assessment of all the relevant circumstances and not be unduly influenced by their own interests or by others when documenting the audit findings and writing the audit report.
1.4 The Audit Schedule
QMS audits are scheduled by the Quality Officer (in consultation with departmental quality team leaders).
Requests for participation are sent by the Quality Officer to the auditor panel. The audit schedule for each department outlines details of the QMS and business processes to be audited, the assigned auditor and the date of the audit. A full schedule of QMS audits will be maintained by the QSU.
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1.5 Preparing for the Audit

The Quality Officer will meet with the departmental quality team leader approximately one month before the audit, for planning purposes. In consultation with the quality team leader, the Quality
Officer will select a minimum of 2 auditors from the panel to assist in the audit. A minimum of two auditors from the department will also be used.

The quality team leader will provide all relevant documentation to the Quality Officer (Quality
Manual, procedures & supporting documentation) approximately 3 weeks before the audit.
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The Quality Officer will meet with the nominated auditors to pass on the documentation and discuss roles to be performed during the audit (at least 2 weeks before the audit).

Individual auditors will then liaise with the process owners to schedule preferred dates/times for the audit. Auditors should also familiarise themselves with the Auditing Process and the UL ‘ Quality
Management System – Standard Framework for Support Departments .’

Auditor(s) will use the documented procedures provided by the department to prepare a list of questions to be used during the audit. Sample questions are available on the QSU website which may be used as a reference guide. It is important that all elements of the quality management system as well as the individual departmental procedures are included in the list. Auditors should ensure that the QMS principles are evident throughout the key business processes (e.g. leadership, customer focus, involve all staff, continual improvement, etc.).

A template for the audit checklist is available as a form on the QSU website.
The following information should be included on all audit checklists: o Date of audit o Name of the auditors o Name of the department being audited and the auditee(s) o Previous audit findings (where applicable)
1.6 The Actual Audit
Typically an audit of a process will take approximately 1 hour.
Opening Meeting: Introductions should be made during the opening meeting and the auditor(s) should outline the structure and scope of the audit and emphasise that it is the department’s process and not the person that is being audited.
The Audit Trail: Auditors should bring a copy of the procedures they are auditing along with the prepared questions on their checklist. The following should be discussed during the audit:
 Show me how….(objective evidence);
 Ascertain whether the procedure is effective, reliable and efficient;
 Invite auditees to make suggestions for improvement;
 Ensure QMS principles are evident throughout all business processes.
Closing Meeting: Before the audit concludes, review the main issues arising from the audit. Reach consensus of opinion (among the auditors) regarding what is and is not an issue. Only audit findings that have been agreed should be included in the audit report. Auditors should acknowledge the time given by the department and the support and assistance given during the audit.
1.7 Following an Audit
On completion of the audit, it is the responsibility of the auditor to ensure completion of the audit report.
The audit report should clearly outline any recommendations for improvement resulting from the audit.
These will have previously been discussed at the closing meeting. A template for the Audit Report is available as a form on the QSU website .
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This report is sent electronically to the Quality Officer, normally within 48 hours of the audit, and a copy is sent to the process owner (auditee). Upon receipt of all audit reports, the Quality Officer will compile a comprehensive report and send to the Director of the Department and Quality Team Leader. Action items arising from the audit are recorded by the department and included in their quality improvement action plan.
The schedule of Quality Reviews (2013-2016) for support departments is published on the QSU website .
Approximately 12 months before their review date, the QSU will contact each department and arrange for a
Gap Analysis audit to be conducted. The QMS Benchmark document will be used to ascertain the department's progress to date under each of the goals of the framework. It is also used to outline areas which need further improvement.
Prior to the review, the QSU will schedule inter-department audits of the QMS. Audits are conducted using auditors from within the department under review and also trained auditors from other departments. The audits are scheduled by the Quality Officer in the QSU, who has overall responsibility for the process. A record is kept by the QSU of all trained auditors.
The audit schedule for each department outlines details of the QMS and business processes to be audited, the assigned auditor and the date of the audit. Assigned auditors prepare checklists prior to the audit, based on the process to be audited. Upon completion of each audit, the auditor sends the audit report to the
Quality Officer, who combines all individual reports into a comprehensive audit report for the department.
Recommendations for improvement are then entered into the department’s Quality Improvement Action
Plan.
The Quality Review Process for support departments comprises the following three key stages:
1.
A thorough, soul-searching, self-evaluation exercise by the department’s quality team, leading to an analytical 30-page self-assessment report (SAR).
2.
A visit by a group of reviewers – the Quality Review Group (QRG) – who study the SAR prior to their arrival and then spend three days at UL during which they meet the department under review, their partners and stakeholders. The focus of this review is conformance of the department QMS with the UL Quality Management System Standard Framework. The reviewers will want to see evidence that key processes are well documented and routinely audited and improved. The department’s quality improvement plan will be used as evidence to show that issues are identified, recorded and resolved. This review leads to the development of a concise report by the QRG, which is read back to the department at the conclusion of the visit, presented to Executive
Committee and published on the UL website.
3.
Follow-up activities:

The QRG finalises the report.

Executive Committee considers the QRG report The QRG report is published on the Quality Support
Unit website The QRG report is presented to Governing Authority (GA Strategic Planning and QA
Committee – GASPQA)

The department creates a Quality Improvement Action Plan.

Progress is reviewed at least annually.
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In preparation for the review, each department must have a designated quality team and an appointed quality team leader. Full details of the quality review process for support departments are available on the
QSU website .
The following documents are relevant to this process:

QMS Benchmark document;

Register of auditors and quality team leaders;

Audit Schedule

Quality Management System – Standard Framework for Support Departments;

Audit Checklist Template;

Audit Report Template;

Quality Review Process for Support Departments;

Gap Analysis Report Template.
The following audit records are held:

Self-Audits: These records are held by the department for a minimum of three years.

QMS Audits: QMS audit records and audit paper trails are held by the department for a period of at least 3 years. Copy audit reports are also maintained by the Quality Support Unit.

Gap Analysis: Gap Analysis records are held by the Quality Support Unit for a period of at least 7 years (retain until superseded to comply with the University Records Management Policy ).

Quality Reviews: Records are held by the Quality Support Unit for a period of at least 7 years (retain until superseded to comply with the University Records Management Policy).
Evaluation of process effectiveness is carried out using feedback from the panel of trained auditors and also by the audit process itself.
Revision No. Date Approved by: Details of Change Process Owner
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ART / KOM
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Oct ‘13
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Gary Walsh
Initial Release
Minor edits
Major review to differentiate between different types of audits
Slight modification to procedure layout to conform to standard template
Modified following feedback from QMS auditor training session and Library audits.
Modified to include UL logo – requirement for
UL web policy
Re-write of procedure to provide more clarification.
Quality Support Unit
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Kim O’Mahony
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Figure 1: Overview of Quality Audit Process
Self-Audit
- Arranged by QSU
- Panel of auditors
- Inter-departmental auditing
- Annual audit schedule
- Arranged by QSU
- 12 months prior to review
- Uses QMS Benchmark document
- Comprehensive report to department
- Continually updated
- Reviewed during QMS audits