Adams School of Dentistry: Policy on Policies


Adams School of Dentistry: Policy on Policies

I. Introduction

A. Purpose

To create a structure for consistency and clarity in Policies as well as their supporting Procedures and Standards within the UNC Adams School of Dentistry ("ASOD" or the "School").

B. Scope

This Policy applies to all Policies developed to support the internal operations of the ASOD, including the Dental Faculty Practice.

II. Definitions

  1. Policy: A written statement that mandates, specifies, or prohibits behavior in order to express basic values of the School, enhance the School's mission, ensure coordinated compliance with applicable laws and regulations, promote operational efficiency, and/or reduce institutional risk (where used in this document, the term "Policy" refers to a Unit Policy only, unless otherwise specified).
  2. Standard: The minimum acceptable limits or rules that may be used to achieve Policy implementation. While Procedures provide specific "step-by-step" instructions (e.g., how to use specific applications to encrypt sensitive data), Standards set overarching minimum requirements that must be met (e.g., minimum encryption strength for use with sensitive data throughout the School).
  3. Procedure: The specific operational steps required to accomplish an action that necessitates specific instructions. Procedures often pertain to implementing a Policy. Procedures may also provide guidance for behavior on issues that are not dictated by Policy.
  4. Manual: A compilation document containing – and often hybridizing – Policies, Standards, Procedures, and/or additional reference materials across a broad subject area.
  5. Unit Policy: Has application only within the School.
  6. University Policy: Has application throughout the University or regulates the actions of the School as it interacts with other units on campus.
  7. Vertical Leadership Team: Because the working title of this group is subject to change, this term refers to the highest administrative decision-making body meeting regularly at the ASOD.
  8. High-Risk Policies: Policies where noncompliance by the School may result in significant financial or reputational harm
  9. Issuing Officer: Employee specified in each Policy, Standard, or Procedure that is responsible for managing the content of the document. The Issuing Officer should be an employee with sufficient authority and visibility at the School to promote compliance. The Issuing Officer may delegate the actual drafting and revision, publication and education, and/or enforcement to a subordinate employee. However, the Issuing Officer is ultimately accountable for managing the Policy, Standard, or Procedure.
  10. Policy Officer: Employee designated by the Dean's Office to coordinate the organization, approval, publication, periodic review, and decommissioning of Policies, Standards, and Procedures. This term does not refer to the University's Policy Officer, who performs an analogous function at the University-level.
  11. Policy Liaison: Representative from the School that is responsible for collaborating with the University Policy Office and serving on the University's Policy Review Committee (PRC). This may or may not be the same individual who is designated as the Policy Officer.

III. Policy

A. Policy Statement

Policies and their supporting Standards and Procedures must be developed, reviewed, and approved in a manner that ensures their consistency with the School's Mission, with applicable law and guidance from regulatory authority, and with applicable University Policies, Standards, and Procedures. Review and approval processes must be appropriate to the scope and impact of each Policy, Procedure, and Standard.

1. Oversight

Oversight of all Policies at the School rests with the Dean. In order to efficiently and effectively oversee Policies, Procedures, and Standards according to their scope of applicability, potential impact, and risk to the School, oversight may be delegated by the Dean to the Vertical Leadership Team ("VLT"), standing Committees, or other ad hoc working groups.

2. Policy Officer

The Dean's Office shall designate a Policy Officer for the School to coordinate with Issuing Officers and facilitate the organization, approval, publication, periodic review, and decommissioning of Policies, Standards, and Procedures. The Policy Officer is authorized to implement Standards and Procedures to support of this Policy.

3. Ownership

Clear ownership of all Policies is required – the owner must hold a specific position within the School. Each Policy, Standard, and Procedure must specify an "Issuing Officer." The Issuing Officer shall facilitate the drafting, periodic review, and substantive modification of Policies, Standards, and Procedures in consultation with other School or University personnel as appropriate.

4. Approval

All new Policies must be approved by an appropriate administrative body. The process for approving new Policies, as well as modifying existing Policies, is governed by the ASOD Procedure for Policy Management. In the event that a proposed Policy is developed as a collaborative effort without a clear Issuing Officer, the Dean's Office must assign an appropriate Issuing Officer in consultation with the Policy Officer and relevant stakeholders before approval.

5. Publication

All Policies shall be published by the School in a central location accessible by all faculty, staff, residents, students, and any other individuals who may be affected by the Policies. Procedures and Standards with broad applicability should be published in the same location. Issuing Officers are strongly encouraged to provide active notice whenever new Policies are adopted or existing Policies have been materially revised (e.g., communication by in-person training, e-mail, or other appropriate methods).

6. Compliance

Compliance with all Policies, Standards, and Procedures is the responsibility of each individual member of the ASOD community. The Issuing Officer of each Policy is responsible for providing adequate notice of the Policy, as well as training and periodic reminders where appropriate. High-risk Policies should have an accompanying Standard describing sanctions for non-compliance. Where non-compliance is suspected or detected, the Issuing Officer should conduct or direct an investigation in coordination with supervisors and/or other School offices (e.g., Human Resources, Clinical Operations, Academic Affairs, OCIS, etc.) and recommend sanctions as appropriate.

7. Periodic Review

Substantive review of all Policies, Standards, and Procedures must occur at regular intervals appropriate to the type and nature of the document, and sufficient to comply with governing law and regulation.

8. Decommissioning

Policies, Standards, and Procedures shall be decommissioned according to the process defined in the ASOD Procedure for Policy Management.

B. Exceptions

  1. University Policies. University Policies, Standards, and Procedures are those that have applications beyond the ASOD's internal operations and affect other units within the University.
  2. Faculty Senate decisions. Nothing in this document shall be construed to abridge the jurisdiction of the Faculty in its deliberation of matters relating to the ASOD Constitution and Bylaws.
  3. Grandfathered Unit Policies. Nothing in this document shall be construed to abridge the authority of Policies governing School operations prior to this Policy's effective date. However, any Policy in effect prior to this Policy's effective date is subject to the revision process outlined in the ASOD Procedure for Policy Management. All grandfathered Policies should be converted to the standard format upon the first substantive review occurring after this Policy's effective date.
  4. Departmental Procedures. Procedures that do not have any material application outside a specific department are not subject to this Policy. The issuing department may, at its discretion, publish these procedures.

IV. Related Requirements

A. External or University Regulations

B. Unit Policies, Standards, and Procedures

V. Contact Information

Topic, Officer, Contact Information Table
Topic Officer Contact Information
General questions about this Policy

Director of Risk & Regulatory Affairs

Policy Officer (VACANT)


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Article ID: 131294
Thu 4/8/21 9:05 PM
Tue 5/30/23 2:16 PM
Responsible Unit
School, Department, or other organizational unit issuing this document.
Adams School of Dentistry
Issuing Officer
Name of the document Issuing Officer. This is the individual whose organizational authority covers the policy scope and who is primarily responsible for the policy.
Issuing Officer Title
Title of the person who is primarily responsible for issuing this policy.
Director of Clinical Compliance
Next Review
Date on which the next document review is due.
05/09/2025 12:00 AM
Last Review
Date on which the most recent document review was completed.
05/09/2023 2:08 PM
Last Revised
Date on which the most recent changes to this document were approved.
05/09/2023 2:08 PM
Effective Date
If the date on which this document became/becomes enforceable differs from the Origination or Last Revision, this attribute reflects the date on which it is/was enforcable.
10/30/2020 1:12 PM
Date on which the original version of this document was first made official.
10/05/2018 12:00 AM