The TQM Journal

The TQM Journal Emerald Article: External and internal quality audits in higher education Juha Kettunen

Article information: To cite this document: Juha Kettunen, (2012),"External and internal quality audits in higher education", The TQM Journal, Vol. 24 Iss: 6 pp. 518 - 528 Permanent link to this document: http://dx.doi.org/10.1108/17542731211270089 Downloaded on: 24-09-2012 References: This document contains references to 31 other documents To copy this document: [email protected]

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TQM 24,6

External and internal quality audits in higher education

518

Turku University of Applied Sciences, Turku, Finland

Juha Kettunen Received 29 May 2011 Revised 21 July 2011 Accepted 29 September 2011

The TQM Journal Vol. 24 No. 6, 2012 pp. 518-528 r Emerald Group Publishing Limited 1754-2731 DOI 10.1108/17542731211270089

Abstract Purpose – The purpose of this paper is to analyse the maintenance of the process-based quality assurance system in a higher education institution. Design/methodology/approach – The paper introduces the process management as the essential element of quality assurance in higher education and discusses the external quality audit of the quality assurance agency, extends the study to the quality management between the external audits and presents the procedure of internal quality audits. Finally, the results of the study are discussed and summarised. Action research methodology was adopted in this study. The paper shows that the process-based quality assurance system makes the organisation responsive, agile and enables the achievement of strategic objectives. Findings – The audit group must first evaluate the necessary improvements in the process. If no improvements are found, the quality deviations must be reported. The audit helps the institution take corrective actions to amend the process descriptions or maintain the processes. Originality/value – The paper shows that the necessary processes of a higher education institution can be systematically described and audited. Keywords Finland, Higher education, Process management, Auditing, Quality assurance Paper type Case study

1. Introduction The recent literature on quality assurance in higher education is focused on the planning and auditing of quality assurance systems, but the literature describing the maintenance of the quality assurance system after obtaining the desired certificate is meagre (Costes et al., 2008). Water (2000) defines maintenance as the control of the quality management which can be seen as the control system itself. Autonomous higher education institutions (HEIs) have an obligation to plan and implement their quality assurance systems. They typically include dissimilar descriptions of processes. The maintenance of the processes is an essential activity that can be carried out in a systematic manner. External quality assurance in the European higher education systems has developed tremendously in recent years. The main purpose of the quality assurance agencies is to support the development of the quality of HEIs. The quality assurance agencies have formally been recognised by public authorities in the European higher education area as agencies with responsibilities for external quality assurance (Costes et al., 2008). These agencies regularly perform external quality assurance as a core function. Each HEI is responsible for the design and implementation of its own quality assurance system. Certified systems, such as the ISO-norms, speak of external and internal auditing (ISO 19011, 2002; Hernandez, 2010). Because HEIs typically have no standardized quality assurance systems, they rather have value-added auditing (Dereli et al., 2007) to give assistance to the institution and the quality assurance agency. The auditing can be seen as part of the maintenance of the system. In an ideal case, the maintenance system is designed at the moment of implementation of the

quality assurance system or when the maintenance of a particular part has been started, but the maintenance should be designed not later than after the external audit based on the recommendations of the audit group. The purpose of this study is to analyse the internal and external auditing of processes to maintain the quality assurance system of an HEI. Process management is integral to the quality assurance system of the organisation ( Jeston and Nelis, 2006, 2008). The internal process auditing requires management, personnel and the target unit of the institution to continuously improve the processes or amend education, research and development and support services when corrective actions are needed. This study emphasises that HEIs should adopt procedures to maintain and develop their quality culture between the external evaluations. The purpose of institutional quality assurance is to ensure that the defined objectives can be achieved (Kettunen, 2008, 2011b). Quality, therefore, is the verified achievement of objectives. The quality assurance system produces information about how the institution and the extent to which its administrative units have succeeded in their activities. The information is used to improve the activities and ensure that the processes are reasonable and can be controlled. The quality assurance system communicates the outcomes and activities of the institution to the management, personnel, students and external stakeholders. The system enhances public confidence in the quality of education and other activities. The quality audit establishes the qualitative objectives set by the HEI for its own activities, and evaluates the procedures and processes that the HEI uses to maintain the quality of its education and other activities. Its purpose is to evaluate whether the quality assurance of the HEI works as intended, whether the quality assurance system produces useful and relevant information for the improvement of its operations and whether it results in effective improvement measures (Finnish Higher Education Evaluation Council, 2008). The study is organised as follows. Section 2 introduces the process management as the essential element of quality assurance in higher education. Section 3 discusses the external quality audit of the quality assurance agency. Section 4 extends the study to the quality management between the external audits and presents the procedure of internal quality audits. Finally, the results of the study are discussed and summarised in the concluding section. 2. Process management in the quality assurance The European Association for Quality Assurance (ENQA) in higher education disseminates information, experiences and good practices in the field of quality assurance in higher education to European quality assurance agencies, public authorities and HEIs. ENQA promotes European co-operation in the field of quality assurance in higher education in order to develop and share good practice in quality assurance and to foster the European dimension of quality assurance. The guidelines, requirements and membership criteria of ENQA have been described in the Standards and Guidelines for Quality Assurance in the European higher education area (ENQA, 2009). The FINHEEC the primary quality assurance agency in charge of evaluation of Finland’s universities and universities of applied sciences. According to the Universities Act and the Universities of Applied Sciences Act, the institutions are responsible for the evaluation of their education, research and other activities and the impact of those activities. The institutions participate in the external evaluation

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of their operation and quality assurance system on a regular basis and publish the findings of those evaluations. The institutional audits of all the Finnish higher educational institutions are undertaken by FINHEEC in six-year cycles. The institutional audits evaluate the quality assurance system of the institutions. The evaluation of centres of excellence undertaken on a regular basis is the other task, whose aim is to develop the quality of processes, evaluate the outcomes achieved and provide feedback for participating institutions (Kettunen, 2011a). The Finnish institutional quality audit does not evaluate the real outcomes of the HEIs. FINHEEC also undertakes thematic evaluations such as the national implementation of the Bologna Process. Action research methodology was adopted in this study, because it provides solutions of immediate relevance and generalised knowledge. According to Rowley (2003), action research generates insights that enhance the understanding, analysis and critical evaluation of theory. Action research encourages the use of concepts and models from theory as a lens through which sense can be developed about the organisation. Action research also helps researchers demonstrate analytical abilities in linking theory and practice. External and internal audits are the maintenance of the quality assurance system. The results and recommendations of external audits affect the design and implementation of internal audits, which are typically more thorough than the external audits. The external audits can result in the recommendation that the internal audits should be performed more frequently or be more attentive to certain shortcomings. When one process is improved, other processes may require scrutiny. This scrutinising can be seen as a maintenance activity. The internal auditing can be carried out on a continuous or periodical basis. If the result of an auditing violates the defined processes, maintenance has to be started. The processes are maintained and continuously improved following Deming’s (1986) Plan-Do-Check-Act sequence. At the first stage, the objectives for the activities are planned and defined and the processes are inspected. The plans are then implemented according to the process descriptions. The third stage is the evaluation of the achievement of objectives and the conformance to processes. If non-conformance is detected, it is reported along with the plan for corrective actions. Based on the result of the evaluation the processes are improved and approval is given to proceed with successive activities. Once the processes have been amended, all affected personnel are notified of the changes. It is clear that without an integrated system of process descriptions there will be no successful continuous improvement. Continuous improvement usually focuses on the improvement of existing processes, without inquiring into completely alternative ways of performing the tasks, for instance, integrating processes or eliminating unnecessary activities. Business process re-engineering is typically cross-functional and changes are typically larger in business process re-engineering. Usually continuous improvement provides incremental innovations but re-engineering is related to the strategic objectives and other goals of the organisation and produces radical innovations (Pereira and Aspinwall, 1997). The process approach of quality assurance means that the processes, their mutual interaction and management are inter-related. Integration is a way to make a whole, or to unify disparate activities or parts. Integration is more than the mere physical compatibility of equipment and components. An integrated system works in

conjunction with previously incompatible elements. An interacted system requires accurate information by each activity on a timely basis and without asking in the format required by activities (Nookabadi and Middle, 2006). Integration is the task of improving the performance of large and complex collection of internal processes by managing the interactions among the people involved in those processes. An essential feature of the integrated system is the focus on improving the co-ordination among interacting individuals, organisational units and processes. All the processes of a system must work together for the entire system to function as a whole. An integrated system is representative of how an organisation is structured and how each process is related to other processes either indirectly or directly forming a total system. 3. External quality audits The organisations that aim to increase their efficiency identify and manage numerous interrelated processes. Quality standards are typically based on the process approach. For example, the ISO 9001 standard envisages and calls for process management in the first few sections. It is thus normal practice to find organisations with documents containing process map, flow diagrams and other process descriptions that guide people to perform their tasks (Owen and Raj, 2003; Tague, 2004; Object Management Group, 2007). Based on the premise of process-based quality assurance, the Turku University of Applied Sciences (TUAS) has identified its processes. The experts of the institution have drawn extensive and inter-related flow charts and written process cards that cover the core and support processes. Most of the Finnish HEIs have described only a small number of processes, but the process notations are not equal. The processes of HEIs need to be relatively stable but reviewed when there are any important changes. To avoid frequent changes, the process descriptions should be rather general and avoid excessive detail. The quality manager of the institution typically takes responsibility to prepare for the external audits. The quality manager organises seminars, where the principles of quality assurance are promoted and good practices are shared within the personnel. These seminars are also used to train managers, personnel and students to perform the quality audits. The quality manager, the members of the quality team and the topmanagement participate actively in key seminars in order to lead and remain apprised of the latest developments of quality assurance. The HEI produces a self-evaluation report, which is the written description of the institution and its quality assurance system (Bozo et al., 2009). The basic information includes the description of strategic management and quality assurance (Kettunen, 2011b), but it also includes information on processes, management, faculties, students and related matters. Each institution also collects institutional evidence about the functioning of the quality assurance system. The amount of evidence may be one or two folders comprising several hundred pages. The members of the audit group are provided with the usernames and passwords to the necessary information systems of the institution. The audit group is given sufficient time to study the self-evaluation report prior to the site visit. An additional in-depth briefing is arranged by the quality assurance agency in preparation of the site visit. The audit visit of three days to the TUAS was in October 2009. On the first day, the audit group met separately with the top- and middle management, teachers, research and development, support services, students and partners. The second day consisted of

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site visits to faculties and thematic interviews with personnel administration, language education and the support services of branches. The third day was spent continuing the thematic interviews with communication and marketing activities. The quality audits usually also include a random target of an interesting topic or tours of the campus and facilities. Finally the audit group interviewed the top-management a second time and gave the preliminary feedback of the audit results. In case of nonconformity the management should immediately take corrections, corrective actions or preventive actions (ISO 9001, 2000). The closing seminar was arranged for the management and personnel of the TUAS in February 2010. The audit group presented the recommendations, which were discussed at the seminar. The auditing procedure and the recommendations of the audit group were published by FINHEEC in the audit report (Hintsanen et al., 2010). The TUAS clearly passed the audit, which is not necessarily obvious, because many institutions have had re-audits. Some of the recommendations of the audit group were implemented at once but others were included in the 2011 or later action plans. Table I describes the audit targets and the conclusions made by the audit groups about the strengths, good practices and weaknesses of the quality assurance systems of Finnish HEIs in 2005-2008. Audit targets two o four and six are directly related to the internal processes of the institution. It can be seen that 52 per cent of the weaknesses are directly linked with the quality assurance of processes, but indirectly the processes have larger importance in quality assurance. Therefore the institutions Audit targets

Table I. Strengths, good practices and weaknesses of the quality assurance systems of Finnish HEIs in 2005-2008

1. Definition of the objectives, functions, actors and responsibilities of the quality assurance system as well as the respective documentation 2. The comprehensiveness and effectiveness of the quality assurance procedures and structures related to the basic mission Degree education Research/research and development Interaction with and impact on society as well as regional development co-operation Support services (such as library and information services, career and recruitment services, and international services) Staff recruitment and development 3. Interface between the quality assurance system and the management and steering of operations 4. Participation of personnel, students and external stakeholders in quality assurance 5. Relevance of, and access to, the information generated by the quality assurance system Within the HEI From the perspective of the external stakeholders of the HEI 6. Monitoring, evaluation and continuous improvement of the quality assurance system 7. The quality assurance system as a whole Total

Strengths

Good practice

Weaknesses

19

10

23

13 9

18 7

19 6

2

3

10

5 7

9 5

1 8

10

5

15

10

13

18

4

7

22

0

0

8

2 22 103

0 7 84

5 24 159

should pay more attention to process management. When institutions and their quality assurance systems mature over time the auditing should be focused more on the processes and objectives moving away from compliance auditing but at the same time making sure that all regulatory and statutory requirements are met (Pollit et al., 2002). One of the main problems is the insufficient comprehensiveness of the quality assurance procedures. The quality assurance does not cover all the detailed processes of the institution. Moitus (2009) points out that attention of audit groups is focused on specific institution-specific targets, which may lead to weaknesses in other targets. The Finnish evidence indicates that 29 per cent of the re-audits are related to the quality assurance as a whole and 35 per cent are directly related to internal processes and the continuous improvement. The other main reasons that an HEI would fail the quality audit are the inadequate documentation and information generated by the quality assurance system. 4. Internal quality audits The quality assurance system of the TUAS has identified and developed processes across the organisation. The processes are described in flow charts, process cards and detailed documents that the institution places in its intranet (Chase, 1998; Lari, 2002; Chin et al., 2004; Haraburda, 1999; Hussain et al., 2009). The sequence and interaction among the processes are determined. The institution has also determined the necessary criteria and methods of assuring that both the operation and control of these processes are adequate. It has also ensured the auditing and continuous improvement of these processes. The personnel of the institution are expected to act in accordance with the established processes. The external quality audit of the TUAS recommended the systematic auditing of internal processes. The internal quality audits support the usability of process descriptions and development of processes (Hintsanen et al., 2010). The internal audits show potential, because they produce information about the functioning of the quality assurance system and the necessary improvements of processes. The internal quality audits are targeted only to the processes and are therefore only part of the quality assurance system which includes many other procedures (Kettunen, 2010). The internal audit is a procedure to evaluate the described internal processes of the institution according to the annual action plan based on the general two- to three-year plan. The audit group prepares the auditing documents and comprises the members of management, personnel and students who have passed the training for internal auditing. The Rector’s decision includes the purpose of auditing, the main topics, the stipulations where processes are based, the timetable, chairman and auditors. Traditional compliance-based audits are shifting towards performance-based audits. A cross-functional audit group is essential for performance-based internal quality audits. It is a team of dedicated people with different functional expertise working towards a common goal. The success of the cross-functional audit groups depends upon the support of top-management and the competence of the group how to audit against the process descriptions. Empirical results by Milena and Rusjan (2010) show that internal audits contribute to the achievement of business goals and that internal audits have positive effects on business performance. The internal audit can suggest ways to improve the processes to increase efficiency. It is necessary to evaluate how critical operations function to achieve the objectives and meet the customer needs. Auditing also identifies the procedures that do not work as planned and documented in the process descriptions. Consequently, the

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internal auditing has two main parts. The auditing identifies the achievement of objectives and the improvement of processes to avoid operational risks as part of the quality assurance system. One of the ethical principles of the quality audit is its objectivity, which means that the observations and conclusion are based on oral or written evidence. The auditors are disinterested observers. Another principle is independence, which means that the auditors do not audit any process for which they are responsible and that they have no affiliation with the target unit. The auditors must have sufficient and adequate qualification and experience. The planning and procedure of auditing are systematic and consequential. The audit uses proven methods to ensure the reliability and validity of data. The auditing pays attention to all essential matters. Figure 1 describes the essential elements of the internal quality audit at the TUAS. The quality manager takes the main responsibility of the quality audits and prepares the action plan of the quality auditing for the period of two to three years and presents the plan for the Rector and management team. The Rector of the institution supervises the preparation of the auditing and approves the action plan of auditing based on the proposal made by the quality manager. The audit visits start with the opening session, where the chairman of the audit group describes the purpose of auditing, procedure and timetable for the target unit. The opening session is followed by the site visits. The audit group plans the themes and questions of the site visits. The visits comprise individual or group interviews depending on the nature of the process. The audit group does not collect only oral evidence, but also written documentation about the functioning of the processes. It is necessary to focus first on process management in auditing and look for improvements in the process. If improvements are not found, the audit group should Quality audit of processes Management group

Contributes the action plan of auditing

Coordinates the improved process

Rector

Quality manager

Target unit

Process owner

Figure 1. The procedure of internal quality audit

Audit group

Supervises the action plan of auditing

Approves the action plan of auditing

Prepares the action plan of auditing

Plans the auditing

Approves the improved process

Prepares the improved process

Approves the audit report

Prepares the audit report

Summary meeting of audit

Audit visits

Improves the process Yes

Yes Improved process

No

Quality deviation

No

look for the quality deviations. There is no reason to look at the quality deviations if the process is flawed. The audit group makes two important decisions in this order: (1)

(2)

Improved process: the audit group may observe necessary improvements in the process. The need for improvement can come from management, personnel or emerge from the student or customer feedback. The audit group makes a conclusion that the amended processes can be managed and performed more efficiently and they can produce better outcomes. In such a case, the process owner and the process team should improve the process. The improvements can be incremental or lead to the radical re-engineering of processes. Quality deviations: the audit group may observe quality deviations, which is a case where the actual process deviates substantially from the described process and the risks of deviation with respect to the achievement of objectives and customer services exceed the acceptable level. The manager and the target unit should take corrective action corresponding to the agreed and approved process description.

The results of the audit are prepared for the summary meeting of audit and presented to the management and personnel of the target unit. The results include good practice, suggested improvements in the process and quality deviations, which are presented, discussed and specified in the meeting. The purpose of the collaborative summary meeting is to effect improvements in the processes, action and disseminate good practice. If the process is improved, the quality manager prepares and submits the improved process description for the management team, which coordinates the process descriptions of the institution. The audit group and quality manager prepare a written audit report. The members of the audit group have different themes during the site visits. The audit group and the target unit write feedback from the auditing to the audit report. The feedback to the audit group is used to evaluate and improve the procedure of the internal quality audit. Finally, the Rector approves the improved process and the audit report. 5. Conclusions HEIs have an obligation to plan and implement their quality assurance systems, but the autonomous institutions typically have no specifications as regards the structure and contents of the system. That allows HEIs to develop the systems and procedures that are consistent with their own strategic and operational objectives and requirements. The autonomy allows the use of external support to audit the quality assurance systems and to select the internal procedures of quality assurance. This study found the evidence of the process management as a mechanism to describe, maintain and improve the quality assurance system of an HEI. The systematic procedure of external audits and internal process audits to maintain processes promote the continuous improvement of the institution. If the processes are not known, they cannot be managed in a systematic way. The process descriptions evolve through collaborative planning, implementation, auditing and continuous improvement. According to the evidence, the weaknesses found in the external audits of the quality assurance systems are mainly related to process management. The process management has not yet attained a strong position in higher education even though it is widely used by private companies. The most prominent weaknesses of the quality assurance can be found in education, but there are challenges also in the outreach and

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engagement of the institutions in their region, and in personnel recruitment, research and development. The process descriptions typically cover the core processes of the institution including education, research and development. Even though most HEIs have some type of process description, the comprehensiveness and elaborateness of processes are still serious challenges. The experiences from the TUAS show that all the processes of the institution can be systematically described and audited so that they can be maintained and continuously improved. The internal quality audit may observe necessary improvements in the processes or quality deviations. The primary focus of the internal quality audit should be process management and process improvements. If process improvements are found, the process owner should plan and describe the process with the process team. If no process improvements are found, the audit of quality deviations is on a steady foundation. If the actual process deviates substantially from the process description, the manager and organisational unit should take corrective action. References Bozo, D., Damian, R., de la Rosa Gonza´lez, C., Helle, E., Imoda, F., Kohler, A., Papazoglou, V.J., Rauret Dalmau, G. and Shopov, T. (2009), “Current trends in European quality assurance”, ENQA Workshop Report No. 8, ENQA, Helsinki, available at: www.enqa.eu/files/ENQA_ wr8_current_trends_final.pdf (accessed 17 May 2011). Chase, N. (1998), “Case studies: intranet eases quality-manual headaches”, Quality, Vol. 37 No. 10, pp. 48-51. Chin, S., Kyungrai, K. and Yea-Sang, K. (2004), “A process-based quality management information system”, Automation in Construction, Vol. 13 No. 2, pp. 241-59. Costes, N., Crozier, F., Cullen, P., Grifoll, J., Harris, N., Helle, E., Hopbach, A., Keka¨la¨inen, H., Knezevic, B., Sits, T. and Sohm, K. (2008), “Quality procedures in the European higher education area and beyond – second ENQA survey”, ENQA Occasional Papers No. 14, ENQA, Helsinki, available at: www.enqa.eu/files/ENQA%20Occasional%20 papers%2014.pdf (accessed 17 May 2011). Deming, W.E. (1986), Out of The Crisis, MIT Center for Advanced Engineering Study, Cambridge, MA. Dereli, T., Baykasog˘lu, A. and Das¸, G.S. (2007), “Fuzzy quality-team formation for value added auditing: a case study”, Journal of Engineering and Technology Management, Vol. 24 No. 4, pp. 366-94. European Association for Quality Assurance (ENQA) (2009), “Standards and guidelines for quality assurance in the European higher education area”, European Association for Quality Assurance in Higher Education, Helsinki, available at: www.enqa.eu/files/ ESG_3edition%20(2).pdf (accessed 20 July 2011). Finnish Higher Education Evaluation Council (2008), “Audits of quality assurance systems of Finnish higher education institutions, audit manual for 2008-2011”, publications of the Finnish Higher Education Evaluation Council 10:2007, Tammer-Paino Oy, Tampere, available at: www.kka.fi/files/147/KKA_1007.pdf (accessed 17 May 2011). Haraburda, S.S. (1999), “Building a quality, intranet-based document management system”, Plant Engineering, Vol. 53 No. 11, pp. 34-40. Hernandez, H. (2010), “Quality audit as a driver for compliance to ISO 9001:2008 standards”, The TQM Journal, Vol. 22 No. 4, pp. 454-66. Hintsanen, V., Luukka, M.R., Lounasmeri, T., Majander, M., Renvall, J., Holopainen, H. and Hiltunen, K. (2010), “Audit of the quality assurance system of Turku University of Applied

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About the author Juha Kettunen is the Rector of the Turku University of Applied Sciences in Finland and Adjunct Professor of the University of Jyva¨skyla¨ in Finland. He was previously the Director of the Vantaa Institute for Continuing Education of the University of Helsinki and Director of the Advanced Management Education Centre of the University of Jyva¨skyla¨. He holds a PhD from the University of Bristol in the UK, a DSc (Economics and Business Administration) from the University of Jyva¨skyla¨ in Finland and a DSc (Technology) from the University of Oulu in Finland.

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