Policy on Policies

Title

University of North Carolina at Chapel Hill Policy on Policies

Introduction

Purpose

The University of North Carolina at Chapel Hill (“UNC-Chapel Hill” or “University”) Policy on Policies (“Policy Framework”) is intended to:

• Formalizing the process by which Policies, Standards, and Procedures (“Policy Documents”) are developed, approved, reviewed, published, updated, communicated, and retired ("Policy Management");
• Shift the University to a more proactive policy development and risk management model;
• Promote consistency, efficiency, and transparency in University Policy Management; and
• Reflect best practice in higher education Policy Management.

Scope

This Policy applies to all University Units.

Policy

Interpretation Guidance

The University Policy Officer, PRC Chair, Policy Liaisons, and Issuing Officers have the authority to interpret and apply the Policy on Policies and related Procedures to their own Policy Documents in a practical and common-sense manner. However, they cannot make substantive changes to University Policy Documents outside their scope of authority without proper approval from University officers who are responsible for such decisions.

Creating New Policy Documents

To maintain a useful and quality policy repository, a Unit should only create a new policy if the policy accomplishes the following (see Image 1):

• helps the University/Unit address internal and/or external organizational problems,
• has a Unit responsible for ongoing maintenance of the policy, and
• follows the University formatting criteria.

Mandatory Criteria for Writing New University Policy Documents

Every University and Unit Policy Document must have a single Issuing Officer, even if multiple Units have some interest or stake in the document.

All new University Policy Documents must meet the following formatting criteria:

• Be documented in writing;
• Comply with the Style Guide published by the Office of Ethics and Policy; and
• Use the latest templates provided by the Office of Ethics and Policy unless the Office of Ethics and Policy grants the Unit an exception; see Style Guide Exemptions section below for more details about possible exceptions;
• Reduce structural barriers identified in the Policy Equity Audit (gendered language, high reading levels, extensive jargon, negative statements, and digital accessibility); and
• Comply with any relevant governing laws and regulations.

These criteria ensure all University Policy Documents have a consistent, accessible format that is easy to understand for audiences with a wide range of backgrounds and education levels.

Recommended Criteria for Writing New University or Unit Policy Documents

The decision to create a new University or Unit Policy Document is ultimately up to the Unit responsible for administering the Policy. According to Dehart-Davis, the best practice is to write Policy Documents that address "significant organizational problems with reasonably clear causes."¹ Organizational problems can be internal (e.g., bad behavior, human error) or external (e.g., regulation, public opinion, or liability).

Units should write Policy Documents in response to organizational problems that occur repeatedly and/or are consequential. According to Dehart-Davis, Units should not write Policy Documents "in response to extreme events, to a handful of people, or even to a particular employee."²

The Office of Ethics and Policy does not require, but strongly recommends, Units format their Unit Policy Documents according to the University Policy criteria.

Restrictions on Creating Unit Policy Documents

Units must not create Unit Policy Documents when prohibited from doing so by an existing Board of Trustees, Board of Governors, UNC System, or University Policy.

Units must not create Policy Documents that are less restrictive than existing University Policies. However, Units may create Unit Policy Documents that are more restrictive than University Policy Documents.

If a University Policy Document is created or updated and is more restrictive than an existing Unit Policy Document, the University Policy Document is the controlling version.

Reviewing and Updating Existing Policy Documents

To maintain a current and accurate policy repository, a Unit must regularly complete a comprehensive review of all policies for which they are responsible for both accuracy of content and to ensure the policy documents follow the same University formatting criteria as required for the creation of new policy documents. See Image 2.

University Policy Documents

Review Interval

Issuing Officers or their designee(s) must complete a comprehensive review of each of their University Policy Documents at least every three (3) years, however an annual one (1) year review is the default to ensure policies remain current and accurate.

Mandatory Review of Existing University Policy Documents

Units must ensure all existing University Policy Documents meet the same criteria as new University Policy Documents when the content undergoes its next revision unless the Office of Ethics and Policy grants an exemption in writing per this Policy.

Mandatory Assessment Criteria

Units conducting a comprehensive review of a University Policy Document must ensure each University Policy Document:

• Complies with any relevant governing laws and regulations;
• Complies with the Style Guide published by the Office of Ethics and Policy;
• Use the latest templates provided by the Office of Ethics and Policy unless the Office of Ethics and Policy grants the Unit an exception; see Style Guide Exemptions section below for more details about possible exceptions;
• Reduces structural barriers identified in the Policy Equity Audit (gendered language, high reading levels, extensive jargon, negative statements, and digital accessibility); and
• Contains updated contact information, links to related documents or information, names of Units, and related non-substantive content.

Technical Corrections

Technical corrections to address typos, broken hyperlinks, etc. do not require the issuing Unit to initiate a comprehensive review or revision.

Unit Policy Documents

The Office of Ethics and Policy does not require, but strongly recommends, that Units develop, publish, and follow similar review intervals and criteria for University Policy Documents.

Approving Policy Document Drafts

All draft University and Unit Policy Documents must follow the approval steps outlined in the University's Procedure for Policy Management.

Publishing Policy Documents

University Policy Documents

Electronic University Policy Repository

All University Policy Documents must be published by the Office of Ethics and Policy in the electronic University Policy Repository.

Duplicate University Policy Documents

The Office of Ethics and Policy does not require, but strongly recommends, that Units not publish duplicate copies of Policy Documents (in electronic or hardcopy formats) outside the electronic University Policy Repository unless required to do so by an external legal or regulatory body.

Unit Policy Documents

The Office of Ethics and Policy does not require, but strongly recommends, that Units also publish their Unit Policy Documents in the electronic University Policy Repository to help create a comprehensive resource of all Policy Documents at the University.

Conflict Between Versions of Policy Documents Published in the Electronic University Policy Repository and Any Other Version

If there is a difference between the version of a University or Unit Policy Document in the electronic University Policy Repository and any other version, the version in the electronic University Policy Repository is the authoritative version.

Linking to Policy Documents Published in the Electronic University Policy Repository

If a University Unit mentions a University or Unit Policy Document in any written or electronic communication (such as websites, newsletters, social media posts, presentations, or printed materials), the University Unit must provide a link to that Policy Document in the electronic University Policy Repository. This ensures that anyone looking for Policy Documents can always access the most up-to-date version.

Retiring Policy Documents

A University or Unit Policy Document may need to be retired, instead of updated, as operational or regulatory requirements evolve.

University Policy Documents

Units must follow the process listed in the University Procedure for Policy Management to retire a University Policy Document.

Unit Policy Documents

Unit Heads may retire any Unit Policy Document and may use any process acceptable to the Unit that complies with the University’s Records Management Policy.

Roles and Responsibilities

University Chancellor

The University Chancellor is responsible for oversight of all University Policy Documents. The Chancellor has delegated the management of University Policy Documents to the Office of Ethics and Policy.

The Chancellor retains the right to determine exceptions, appoint permanent or ad-hoc committees for review or approval, or otherwise act to ensure Policies are aligned with the University’s mission.

Director of the Office of Ethics and Policy

The Director of the Office of Ethics and Policy designates Units requiring a Policy Liaison, maintains a list of those Units and Policy Liaisons, and coordinates with Unit leaders to facilitate the selection of an appropriate staff or faculty member to serve as a Policy Liaison.

The Director of the Office of Ethics and Policy serves as the University Policy Officer. In that role, they may, in consultation with the PRC Chair, request that the Vice Chancellor of Institutional Integrity and Risk Management (IIRM VC) convene the Executive Policy Approval Committee (EPAC) to review any new University Policy Document or any proposed update to an existing University Policy Document that meets either of the following criteria:

• If the Unit does not accept substantive feedback from PRC and that failure to accept feedback creates Institutional Risk for the University; or
• If the content of the University Policy Document creates extraordinary Institutional Risk for the University.

In the event that the Director position is vacant, the Associate Director of the Office of Ethics and Policy will perform the responsibilities ascribed to the Director in this section.

Associate Director of the Office of Ethics and Policy

The Associate Director of the Office of Ethics and Policy serves as the University Policy Review Committee (PRC) Chair. In that role, they are responsible for the following:

Scheduling PRC meetings;

• Inviting all relevant stakeholders to PRC meetings;
• Preparing PRC meeting agendas that may include time for topical discussions as requested by PRC liaisons;
• Sharing those agendas with all relevant stakeholders at least one (1) week before the PRC meeting to ensure ensuring Policy Liaisons can formulate thoughtful, substantive feedback prior to the PRC meeting, and solicit similar feedback from their Unit stakeholders prior to the PRC meeting;
• Moderating the discussion during PRC meetings;
• Taking notes, or appointing someone to take notes, during PRC meetings; and
• Posting PRC meeting agendas and notes on the Office of Ethics and Policy website following each PRC meeting.

Beyond the minimum criteria defined in this Policy Framework and in the University Procedure for Policy Management, the Associate Director of the Office of Ethics and Policy may opt to add reviewers, public meetings, or other ad-hoc processes as they deem appropriate to ensure that all Policy Documents adopted are well-considered and reflect the University’s aspirations and mission.

Policy Analyst (Office of Ethics and Policy)

The Policy Analyst oversees the publication, day-to-day coordination, and review of Policy Documents in alignment with the Policy Framework. The Policy Analyst may at their discretion and with agreement of the appropriate Policy Liaison and Issuing Officer or their designee, change the formatting of Policy Documents, including migrating them into the official University templates, without initiating a comprehensive policy review.

University Unit Heads

Unit heads are responsible for all policy documents under their purview. Individuals allowed to be Unit Heads for University Policy Documents are:

• The Chancellor,
• The Provost
• The Provost’s direct reports,
• Vice Chancellors,
• Deans,
• The Director of Athletics, or
• The Director of Internal Audit.

If an Issuing Officer changes roles or leaves the University, the Unit Head of the Unit responsible for managing the document, or that person's designee, must immediately select either a new Issuing Officer or an individual in the Unit to manage the document in the interim while a new Issuing Officer is being selected.

Issuing Officers

An Issuing Officer is an individual authorized to issue or create policy documents within their University Unit. Issuing Officers for University Policy Documents may be Unit Heads or their designees.

Individuals allowed to be Issuing Officers for Unit Policy Documents are anyone the issuing Unit Head selects based on any criteria the Unit Head deems appropriate, including themselves.

If the Unit Head is the Issuing Officer and they are changing roles or leaving the University, the Unit’s next-highest ranked individual in that Unit (e.g., Associate Vice Chancellor, Executive Vice Dean, etc.) automatically serves as the interim Issuing Officer until an interim Unit Head is appointed.

Policy Review Committee

PRC membership, authority, and responsibilities are defined in the PRC Charter published on the Office of Ethics and Policy website.

Policy Liaisons

Policy Liaisons responsibilities are defined in the PRC Charter published on the Office of Ethics and Policy website.

Beyond the minimum criteria defined in this Policy Framework and in the University Procedure for Policy Management, Policy Liaisons may opt to add reviewers, public meetings, or other ad-hoc processes as they deem appropriate to ensure that all Policy Documents adopted are well-considered and reflect the University's aspirations and mission.

Unrepresented Units

University Units with no designated Policy Liaison may designate any full-time staff member responsible for Policy management to work with the Office of Ethics and Policy. The Office of Ethics and Policy and PRC must facilitate and assist these Units as needed to ensure access to the Policy Management process and coordination with University Policy activities.

Executive Policy Approval Committee (EPAC)

EPAC is a committee that can be called into action following a request by the University Policy Officer and provides the first round of heightened review following the routine review by the PRC.

Membership

The EPAC is composed of a subset of the Chancellor's Cabinet, including:

• Human Resources and Equal Opportunity and Compliance;
• Finance and Operations;
• Office of University Counsel;
• Office of the Provost, and
• Other representatives as designated by the Chancellor.

Responsibilities

When tasked by the University Policy Officer, the EPAC may consult with the:

• Unit Head,
• University Policy Officer,
• PRC Chair,
• University General Counsel,
• IIRM VC,
• University Communications,
• Respective designees, and/or
• Other relevant stakeholders.

After this consultation, EPAC may take one of three actions:

• Send the University Policy in question back to PRC for additional review, along with a list of specific topics or areas of research to consider;
• Authorize the approval of the University Policy; or
• Elevate the University Policy to consideration by the Chancellor's Cabinet.

EPAC may elevate a University Policy for the Chancellor’s Cabinet review if, after consultation with the relevant stakeholders listed above, EPAC deems the content of the University Policy creates extraordinary Institutional Risk for the University.

Chancellor's Cabinet

The Chancellor’s Cabinet provides a higher level of review and consultation following a request by EPAC.

Membership

The Chancellor's Cabinet membership is listed on the Office of the Chancellor's website.

Responsibilities

When tasked by EPAC, the Chancellor's Cabinet may coordinate with the:

• Unit Head,
• University Policy Officer,
• PRC Chair,
• University General Counsel,
• IIRM VC,
• University Communications,
• Respective designees, and/or
• Other relevant stakeholders.

After this consultation, the Chancellor's Cabinet may take one of three actions:

• Approve the University Policy with no changes and send the Policy back to the Unit Head for implementation;
• Revise the University Policy, approve the revised version, and send the Policy back to the Unit Head for implementation; or
• Reject the University Policy.

Consequences for Lack of Compliance with Publication, Review, and Formatting Requirements

University Policy Documents that do not adhere to the publication, review, and formatting requirements described in this Policy Framework may be retired at the discretion of the Office of Ethics and Policy in coordination with the Executive Policy Approval Committee (EPAC).

Exceptions

Style Guide Exemptions

The Office of Ethics and Policy will only grant an exemption to the mandatory use of the University Style Guide if an external legal or regulatory body requires a Policy Document to be formatted in a way that does not conform with the University templates. Contact the Office of Ethics and Policy if you believe you require an exemption.

Academic Policies

Policies, Standards, and Procedures that meet any of the following three criteria are excluded from this Policy Framework and are instead governed by University faculty via The Faculty Code of University Government:

• Related to the educational activities of the University;
• Related to the awarding of academic degrees by the University; and/or
• Are published in the University Catalog.

This Policy Framework does not change the processes for developing, approving, publishing, updating, or retiring the Policies, Standards, and Procedures established under The Faculty Code of University Government.

Expedited Policies

Criteria

The University Policy Process is not intended to prevent the University from meeting its business obligations. While having a transparent and standardized Policy Management process is important, sometimes the University faces new legal requirements (such as those imposed by an external regulatory body) or significant Institutional Risk that requires the University to implement University Policies outside the normal processes described elsewhere in this Policy Framework.

In such circumstances, the IIRM VC may approve a University Policy from any campus Unit. In such a circumstance, the approved University Policy is effective immediately.

PRC Review of Expedited Policies

The IIRM VC, or their designee, and a representative from the University Unit responsible for administering the University Policy, must present the Policy and the context around its creation and approval at the next PRC meeting following Policy implementation. Subsequent reviews and revisions to the University Policy must be conducted in a manner consistent with this Policy Framework and the Procedure for Policy Management.

Restricted Tier 2 and Tier 3 Policies

In rare instances, a University or Unit Policy Document may contain Sensitive Information, as defined in the University’s Information Classification Standard, and should not be published on a publicly accessible website. Please contact the Office of Ethics and Policy for additional guidance regarding University or Unit Policy Documents containing Tier 2 or Tier 3 information.

Definitions

EPAC: The Executive Policy Approval Committee. Functions as an authorizing step when Policies are referred to the committee.

Institutional Risk: Risk is the possibility of an issue, event or incident occurring and impacting the ability of the university to achieve its mission, strategic goals, and objectives.³ There are five major types of Institutional Risk: financial, legal, life/safety, operational, and reputational.

Issuing Officer: Individuals authorized to issue Policy Documents.

Material Substantive Revisions ("Major Edits"): Changes which alter the purpose or effect of a document.

Non-Substantive Revisions ("Minor Edits"): Changes which do not alter the purpose or effect of a document. This includes technical corrections.

Policy: A Policy is a written statement that mandates, specifies, or prohibits behavior in order to express basic values of the University, enhance the University's mission, ensure coordinated compliance with applicable laws and regulations, promote operational efficiency, and/or reduce Institutional Risk. A Policy includes criteria as mandated by the Office of Ethics and Policy document templates and must have a single Issuing Officer.

Policy Documents: Includes University and Unit Policies, Standards, and Procedures.

Policy Officer: The Director of the Office of Ethics and Policy. The Policy Officer oversees Policy organization, coordination, review, approval, and publication.

Policy Liaison: Representatives appointed by heads of Units designated by the Policy Officer to perform Policy administration functions both internally for the Unit and collaboratively with the Office of Ethics and Policy.

PRC: The Policy Review Committee. This committee functions as a review step to ensure consistency, quality, and appropriateness of scope for submitted Policy Documents.

Procedures: The process(es) required to accomplish an action necessitating specific instructions. Procedures are not intended to be detailed "help guide" documents, but instead higher-level process documents that can then point to specific and detailed instructions maintained by the appropriate Unit. Procedures often pertain to implementing Policy. Procedures may also provide guidance for behavior on issues that are not dictated by Policy. Procedures are created at the Unit level and changes do not go through the same review or approval process as Policies, but Procedures that impact multiple Units may need additional review or feedback before being implemented.

Sensitive Policies: Those University or Unit Policy Documents that contain Tier 2 or Tier 3 information (Sensitive Information) as defined in the University's Information Classification Standard.

Standards: The minimum acceptable limits or rules that may be used to achieve Policy implementation. While Procedures provide specific instructions for units (e.g, how to use specific applications to encrypt data in the HR department), Standards set overarching minimum requirements that must be met by all (e.g., minimum encryption strength for use with sensitive information throughout the University). Standards may be written as standalone documents or may be included in the body of a related Policy, at the discretion of the issuing Unit. Standards are created at the Unit level and changes are not required to go through the same review or approval process as Policies, but Standards that impact multiple Units may need additional review or feedback before being implemented.

Unit: Any administrative organization that is part of the University of North Carolina at Chapel Hill

Unit Head: Chancellor, Provost and the Provost’s direct reports, Vice Chancellors, Deans, the Director of Athletics, or the Director of Internal Audit.

Unit Policy: Has application only within the issuing Unit (e.g., applies only to Unit employees, staff, students, and others working for or studying at the Unit). A Unit Policy can create additional specifications, requirements, or restrictions but cannot contradict a University Policy Document.

University Policy: Applies to two or more Units. A University Policy informs someone outside the issuing Unit of rights and responsibilities or regulates the actions of the Unit as it interacts with other Units on campus.

Related Requirements

University Policies, Standards, and Procedures

• Procedure for Policy Management
• Information Classification Standard
• Digital Accessibility Policy
• Records Management Policy
• The Faculty Code of University Government

Contact Information

Policy Contact

Office of Ethics and Policy
123 W. Franklin Street, Chapel Hill, NC 27599
Phone: 919-445-8364
Email: policy@unc.edu
Website

Important Dates

Revised versions approved by:

Jen DeNeal, PhD April 18, 2022
Associate Director, Office of Ethics and Policy

Jen DeNeal January 13, 2021
Associate Director, Office of Ethics and Policy

Kim Strom-Gottfried, PhD June 28, 2019
Director, Office of Ethics Education and Policy Management

Initial approval by:

Kim Strom-Gottfried, PhD January 07, 2017
Director, Office of Ethics Education and Policy Management

References

1. Dehart-Davis, L. (2017). Creating effective rules in public sector organizations. Georgetown University Press. Specifically, see the "When to Write a Rule" section on page 107.
2. Ibid, p. 108.
3. University of Massachusetts. (2021). FY 2020 Enterprise Risk Management Report.