Quality Assurance & Formal Program Review Policy

Quality Assurance & Formal Program Review Policy
DepartmentAcademic/Centre for Academic Quality
Creation DateJuly 17, 2020
Approval DateJuly 20, 2020
Effective DateSeptember 8, 2020

Organizational Scope

The Policy applies to all full-time and part-time programs offered in The Michener Institute of Education at UHN (“Michener”).


This policy ensures the content and delivery of programs for which a credential is awarded within Michener are responsive, current and relevant in meeting employer, community, student and government needs.  To support this, Michener is committed to embedding an evidence-informed quality assurance process to ensure continuous quality improvement (CQI) in all educational programs.  This and the Formal Program Review provide CQI processes to improve Michener courses and programs through an ongoing cycle of monitoring, reflecting and improving.


Accreditation: an ongoing assessment process and official recognition of a health education program against the minimum standards required to ensure that graduating students can deliver safe, high-quality care at entry to practice.

Accreditation Survey: an off-site and on-site accreditation review

Continuous Quality Improvement (CQI): a systematic process to improve courses and programs through an ongoing cycle of monitoring, reviewing and improving using real time documentation of program performance.

Formal Program Review: an internally driven comprehensive and in-depth reflection on program metrics, program content and delivery, academic services, as well as progress on recommended action plans.  A Formal Program Review may also include an external review.

Labour Market Analysis: the process of identifying the appropriate labor market for various types of positions e.g. surveying the market to determine the workforce requirements locally, provincially and nationally; salaries that are being paid for like positions; and identifying  market  trends including compensation practices.

Postsecondary Education Quality Assessment Board (PEQAB): an Ontario agency that makes recommendations to the Minister of Colleges and Universities of Ontario on applications for ministerial consent under the terms of the Post-secondary Education Choice and Excellence Act, 2000. Ministerial consent is required by all public or private degree-granting organizations, either for profit or non-profit, based inside or outside the province, to offer all or part of a degree program in Ontario. It is also required by all private organizations in Ontario, either for profit or non-profit, and by all Ontario public organizations not empowered to grant degrees by Ontario statute to offer all or part of degree programs.

Quality Assurance Review: an annual review of program data in the context of comparator programs and trend information including application and enrolment numbers, student and graduate satisfaction, graduation and retention, program learning outcomes and program advisory committee activity.

University of Toronto Quality Assurance Process (UTQAP): an Ontario Universities Council on Quality Assurance approved process assigning the responsibility for academic standards, quality assurance and program improvement, in the first instance, to universities themselves. The University of Toronto’s approach to quality assurance is built on two primary indicators of academic excellence:  (1) the quality of the scholarship and research of faculty and (2) the success with which that scholarship and research is brought to bear on the achievement of Degree-Level Expectations


All Michener programs will conduct a Formal Program Review at least every six years and an annual Quality Assurance Review. In accordance with PEQAB requirements, the first Formal Program Review will occur prior to submitting a request for renewal of Ministerial consent. Subsequent Formal Program Reviews will be conducted where feasible, in the year prior to accreditation. Frequency may change as required by regulatory bodies, accreditation recommendations or other external drivers. Program labour market analysis will occur in conjunction with Formal Program Reviews as required by the Ministry of Health through its transfer payment agreement with Michener. Annual Quality Assurance reviews allow for ongoing evaluation and quality improvement of programs. Both review processes apply to all diploma, undergraduate and graduate degree programs offered by Michener, and to degree programs that are offered by Michener with other institutions including all joint, multidisciplinary, interdisciplinary, multi-site and inter-institutional programs.

The comprehensiveness of Formal Program Reviews for certificate, diploma and degree programs may vary based on the requirements identified above or to align with relevant standards, such as the Postsecondary Education Quality Assessment Board (PEQAB) requirements for degree programs, provincial standards for diploma programs and national competency profiles.

The Quality Assurance and Formal Program Reviews are not waived because of other recently conducted external reviews, such as an accreditation or processes required by other institutions where programs are offered jointly, e.g. UTQAP. Reviews of academic programs for professional accreditation bodies form part of collegial self-regulatory systems intended to ensure that mutually agreed-upon threshold standards of quality are maintained in new and existing programs. Such reviews may serve different purposes than those required by Michener. In some cases, however an accreditation, PEQAB or UTQAP process, may be used in conjunction with Michener’s internal review processes, if the mandates of the externally driven reviews are closely aligned and any deficits can be easily identified through a gap analysis and remedied.

The review of an academic program can be completed singularly, or where appropriate program clusters may be reviewed together.

Program External Evaluation Review Committee

The Formal Program Review process will include a report from a Program External Evaluation Review (PEER) Committee.  The PEER Committee will consist of senior academic peers, both scholars and administrators, with relevant expertise external and internal to Michener.  The Senior Director, Academic Programs is responsible for the selection of the external review committee in consultation with the program(s) to be reviewed.  All reviewers are approved by the Principal and Executive Vice-President, Education.  The Michener member will be from outside of the program under review with no conflict of interest.  The PEER Committee will be composed of at least two external reviewers qualified by discipline and experience to review the program(s).  The PEER Committee process will include: 1) an off-site review of materials provided by Michener; 2) an on-site visit; and 3) the self-study report, undertaken with student input, and submitted as part of the Formal Review Process by the Program Review Team.  The on-site visit will include a tour of the facilities as well as the opportunity to conduct interviews with key program stakeholders, including faculty and students.  The summation of this review will be provided in a report to the Senior Director, Academic Programs, the Principal, and the Executive Vice-President Education. Michener will prepare a formal response to the PEER Committee’s report. The PEER Committee’s report, and Michener’s response, will be housed in the Centre for Academic Quality as well as with the Academic Chair of the program(s).

Institutional Authority

The Senior Director, Academic Operations and Quality is responsible for the oversight of the Michener Quality Assurance Process and ensuring that the Quality Assurance Review and Formal Program Review process is applied in a manner that conforms to Michener’s quality assurance principles and requirements.

The Senior Director, Academic Programs is responsible for ensuring that annual quality assurance reviews of academic programs are undertaken. Where quality concerns are raised, the Senior Director, Academic Programs monitors the timely implementation of improvements in conjunction with the Academic Chair.

The Senior Director, Learning, Innovation and Research is responsible for the oversight of data collection, analysis and reporting in a manner that conforms with established institutional policies and processes established through the Applied Educational Research Department.  The Senior Director ensures the quality of methodology, data collection strategies, analytic approaches and program evaluation criteria.

Associated Documentation

Postsecondary Education Quality Assessment Board Manual for Public Organizations: 2019

Quality Assurance and Formal Program Review Procedure

Quality Assurance Review Core Elements & Process

Quality Assurance and Formal Program Review Flow Chart

Revision History

Date Reviewer Change(s) Made
July 17, 2020 Sydney Redpath, Fiona Cherryman, Ann Russell New policy introduced to capture work already in place but not formally defined in policy.