2000-2-3Program Quality Assurance

Responsible Executive:
Vice President, Finance & Administration
Director, Quality Assurance
Issue Date:
January 18, 2018
Supersedes Date:
March 18, 2010
Last Review:
October 03, 2019
Last Revision:
October 03, 2019

Upon request, the college will provide a copy of this policy in an alternate format.

The purpose of the Quality Assurance Process is to ensure that College programs delivered to its students, clients and community are of a high and continuously improving quality. The Quality Assurance Process will contribute to the efficient and effective use of resources, and wise planning and budgeting.

Board policy requires that the College implement and continuously operate a comprehensive Quality Assurance Process.  The Process will be in compliance with the Minister’s Binding Directive, meet the requirements of the College Quality Assurance Audit Process (CQAAP) and serve the quality assurance needs of Lambton College.


  1. The Quality Assurance Process (Process) will be implemented by the President and overseen by the Quality Assurance Council (Council), which is appointed by and reports to the President. The Quality Assurance Office (Office) will operationalize the duties and functions of the Council
  2. The Process will cover all programs that lead to a Lambton College credential.  All programs regardless of means of delivery (e.g. online, in classroom) or delivery provider (e.g. Lambton College, licensee) will be part of and subject to the Process.  
  3. The Process will be continuous in nature.  All programs leading to a Lambton College credential will be subject to quality review on a continuous basis.
    1. A program delivered by Lambton College will undergo a Comprehensive Program Review every six years. In the third year between the comprehensive reviews, a program will complete a guided self-review resulting in a Triennial Review report to the Programs & Services Committee of the Board of Governors.
  4. The Process will be as objective as possible.  Whenever possible, a review will be based on quantitative data, objective measures and standards, and analysis and comment from disinterested parties and peers.
  5. The Process and individual reviews will be structured and conducted so as to be as efficient as possible.  It is important that the use of College resources be minimized and onerous demands on any department be avoided.
  6. Where an external accreditation process is available and undertaken, the QA Council may determine that the external accreditation process may wholly or partially replace the Comprehensive Program Review.
  7. Completion of Triennial Reports will be the responsibility of individual departments.  Support and guidance will be provided by the Quality Assurance Office.
  8. Comprehensive Program Reviews will be identified and scheduled by the Quality Assurance Office. This schedule will be presented to and approved by the Quality Assurance Council. Comprehensive Program Reviews will be conducted and supported by the Quality Assurance Office.
  9. New programs will be reviewed using the Triennial Report at the completion of the first iteration of the curriculum. The first Comprehensive Review will be scheduled one year later. The Implementation Report would be required from the dean, one year following the completion of the Comprehensive Review. After this initial period of review, the program would follow the standard Triennial Review and Comprehensive Review schedule.
  10. The Comprehensive Program Review and Triennial reports will include, where applicable, recommendations for quality improvement. 
  11. Implementation Reports will be prepared by the Dean responsible for the program describing the response to and the implementation of recommendations contained in the Comprehensive Program Review Report. Implementation Reports will be submitted to the Quality Assurance Office and the Quality Assurance Council One year after the completion of the Comprehensive Review.
  12. All program review reports and subsequent implementation report prepared for Lambton College delivered programs and submitted to the Council will be available in the Teaching & Learning Commons and available to the College community.  The Council will maintain on the QA website a current list of completed program reviews and a schedule of future program reviews. 
  13. Annually, the Council will report through the President to the Board on the Quality Assurance Process, describing reviews undertaken and completed, and the status of the recommendations contained in the reports of the previous year. This report will include both College and licensee-delivered programs, and will specifically identify them as such. This report will be posted to the Quality Assurance web page annually.


  1. The Quality Assurance Council is appointed by and reports to the President. The Council monitors the operations of the Quality Assurance Office, which implements the Quality Assurance Process. The Quality Assurance Office reports to the Vice-President, Finance & Administration.


  1. The President appoints the Quality Assurance Council, receives an annual report from the Council, ensures quality assurance recommendations are addressed, and reports annually to the Board on the Quality Assurance Process activities, findings and changes.


  1. The Council oversees and is responsible for the Quality Assurance Process.  The Council will:
    1. ensure compliance with the Quality Assurance policy,
    2. identify and recommend resources for the Quality Assurance Process,
    3. advise and affirm the actions of the Quality Assurance Office,
    4. affirm the programs or program clusters to be reviewed as identified by the Quality Assurance Office,
    5. confirm the review calendar,
    6. report annually to the President and Board on the Quality Assurance process, findings and implementation. 
  2. The Council will consist of four representatives from faculty and two from each of the other employee groups, as recommended by each group, and be chaired by the Vice-President, Administration & Finance.

Quality Assurance Office

  1. The Office conducts the Quality Assurance Process for the College for all College-delivered programs, supports the Council in its operations, oversees the QA Processes enacted by the International Department for licensees, acts as a liaison between the Council and the departments undergoing review, and provides support to the departments for the reviews.
  2. The Office will:
    1. provide operational support to the Council,
    2. coordinate the activities of the Council,
    3. provide liaison between the Council and departments regarding reviews,
    4. conduct, lead and support program reviews through
      • the formation of the review teams,
      • the organization and support of review meetings,
      • the identification, modification and implementation of research techniques and tools for program reviews,
      • the collation, computation and summary of research findings,
      • the leading and chairing of the program reviews and review meetings,
      • the writing of program review reports, 
    5. prepare program review reports, to the satisfaction of the review team, to be presented to the Council,
    6. prepare the annual report, and any other requested reports, for the Council. 

Program Reviews

Triennial Program Review

The purpose of the triennial review is to determine if all of the components that are prerequisite to the delivery of a quality program are in place and being used.

  1. Triennially, the Program Curriculum Committee for each program will review the documentation, structure and delivery of the program using the checklists and the template provided by the Quality Assurance Office. 
  2. The department will review the annual performance indicators to determine if the program is meeting operational expectations and identify any early warnings of program shortcomings. Performance indicators are maintained and distributed by the Quality Assurance Office.
  3. If components are not in place, performance expectations are not being met or shortcomings are otherwise identified, the department will develop a strategy(s) to be part of the annual operational plan in order to address the issues.
  4. The department, through its dean, will report to the Programs & Services Committee of the Board, using the supplied report template, on its findings and any recommendations for improvement. These recommendations should be addressed in the next operational plan for the program.
  5. The triennial report will include a report on the implementation of the recommendations contained in the previous triennial and comprehensive program review reports.
  6. Each triennial report will also be used as the basis for the program department triennial report and presentation to the Programs and Services Committee of the Board.

Comprehensive Program Review

The purpose of the Comprehensive Review is to complete a thorough, comprehensive and detailed review of an academic program, or cluster of programs, in order to determine if the program is operating in an effective and efficient manner, providing a high quality program of study and learning experience to the students, and in compliance with all requirements and standards of the College, Ministry and any relevant professional or regulatory bodies. 

  1. The Quality Assurance Office will identify the programs or program clusters to be reviewed and determine the schedule for the reviews so that all programs within the College will be reviewed on a six-year schedule, and all programs delivered by a licensee site will be reviewed on a three-year schedule. The Quality Assurance Council will affirm the programs or program clusters to be reviewed and the review schedule.
  2. The Quality Assurance Office, in conjunction with the program department, will assemble the review team.  The review team will consist of:
    1. one or two faculty members, including the coordinator, from the program,
    2. one or two faculty members from an unrelated program or department,
    3. two or three individuals external to the College who will be chosen for their expertise or experience in the field or their position as an (potential) employer of program graduates,
    4. one graduate of the program with no current affiliation to the program,
    5. one or two current program students in their final year of study.
  3. The Office will appoint a chair to the review and will provide research, writing and administrative support to the review team. 
  4. The team will address the items and questions provided to it by the Council and any other items or questions that it deems relevant before or during the review.
  5. The review will be completed within four months with the delivery of a report, which will include recommendations for quality improvement, to the Council.
  6. One year later, the Dean of the program will report to the Council on the implementation of the recommendations.
  7. Once received and approved by the Council, the Implementation Report will be provided to the President and the Board of Governors - via the report to the Board - and then forwarded to the Review Team members.

Quality Assurance at Licensee Schools 

  1.  The College Dean responsible for the contractual relationship with a licensee (hereinafter "the College Dean") will be responsible for the Lambton Quality Assurance Process as it applies to the licensee in accordance with this policy.

Quality Assurance Process 

  1. The College Dean shall establish, document and implement a Quality Assurance Process that defines requirements and expectations, and monitors the licensee's program delivery. For each licensee, the Quality Assurance Process shall
    1. encompass all programs delivered by the licensee that lead to a Lambton College credential;
    2. encompass all aspects of the Lambton College credential programs, including program structure, curriculum delivery, and all student support services and campus services delivered, or expected to be delivered, to the students in the program;
    3. be consistent with and substantially reflect the operating principles and processes of the Lambton College Quality Assurance program;
    4. establish a process to regularly review measures of program and campus success, e.g. student satisfaction, co-op placement rates, graduation rate, etc.;
    5. monitor the currency and completeness of program documentation, including program curriculum, course outlines, and student records;
    6. require the production, to established standards, and central storage of a course portfolio at the completion of the delivery of each course section and ensure the regular review of the portfolios by a subject matter or pedagogical expert. 

Program Reviews 

  1. The College Dean shall oversee regular comprehensive program reviews and ensure the licensee conducts regular program self-reviews that
    1. meet or exceed the frequency of and expectations for the same reviews at Lambton College;
    2. produce explicit, published recommendations for improvements to the programs and services. 
  2. The College Dean shall produce a regular report on the licensee's implementation of the recommendations in the program review reports.
  3. The College Dean shall receive and review all program comprehensive and self-review reports for thoroughness and equivalence to the respective reviews conducted at Lambton College.

Quality Assurance Office 

  1. The Lambton College Quality Assurance Office shall
    1. periodically formally review the Quality Assurance Process for each licensee, and report on such to the Council,
    2. apply the same Quality Assurance expectations and standards to the Lambton College credential programs delivered at licensee sites as programs delivered at Lambton College.
  2. The Quality Assurance Office will review all comprehensive program review reports for thoroughness and equivalence to the respective reviews conducted at Lambton College.
    1. If the Office or the College Dean finds the Report or process to be incomplete or unsatisfactory, the Office or the Dean will return the report to the International Department or the author, respectively, for the identified shortcomings to be addressed and the report resubmitted; or the Office may choose to undertake its own review of the licensee-delivered program.
    2. If the Office is satisfied with the review process and report, then the report will be presented to the Council via the Quality Assurance Office for its consideration and acceptance with subsequent forwarding to the President and Board, or its rejection of the report and return of it to the Office.
  3. The Quality Assurance Office shall receive and review all reports on the implementation of recommendations contained in a program review reports.
    1. If the Office finds a report to be deficient, it will return the report with the requirement that the deficiencies in the report be addressed for re-submission and re-consideration.
    2. When the Office accepts an implementation report, that report shall then be presented to the Council for approval, filed with the President and Board and included in the annual report to the Board.
  4. Site visit audits of licensees shall be the responsibility of the College Dean.
    1. In no case shall the time between site audits of a licensee exceed three years.
    2. During a site audit, the QA auditor will meet with licensee management, to audit the operations for the purpose of gaining an understanding of all aspects of the Lambton College credential programs, e.g. structure, documentation, delivery, student satisfaction, etc., and an program and campus services that exist or should exist to ensure the quality of the programs and the student experience.
    3. The site audit shall result in a formal written report to the College Dean and Quality Assurance Council describing the audit process undertaken, findings, the auditor's opinion and recommendations for quality improvement, which shall be forwarded to the Dean for the licensee to undertake.
    4. The site audit report shall be presented to the Quality Assurance Council, which shall fill the report with the Office of the President and Board, and forward the report to the responsible Lambton College Dean for consideration and communication to the licensee for follow-up.
    5. One year after receiving the site audit report from the Council, the licensee shall provide to the College Dean a report on the status of the implementation of the recommendations contained in the site audit report, which the Dean shall forward to the Council.
    6. The recommendation implementation report shall be received and reviewed by the Quality Assurance Council, which shall file the report with the Office of the President and the Board. 

Reporting on Quality Assurance at Licensee Site

  1. The Quality Assurance Council, in its annual report to the President and Board, shall report specifically and separately on QA activities and results pertaining to the licensee's delivery of Lambton College programs.

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