Procedure for Policy Management

Title

University of North Carolina at Chapel Hill Procedure for Policy Management

Introduction

Purpose

To provide the process for University Units to create, review, revise, publish, and retire official University Policies, Standards, and/or Procedures ("Policy Documents") for which the Units are responsible, as well as guidance for the management of Unit Policies.

Scope

This Procedure applies to all Units of the University of North Carolina at Chapel Hill ("University").

Procedures

Appointing or Replacing a Policy Review Committee Liaison

If notified by the Office of Ethics and Policy that a University Unit requires a Policy Liaison to serve on the University's Policy Review Committee (PRC), the Unit must select an individual from the Unit and provide contact information for that individual to the Office of Ethics and Policy.

When a Policy Liaison transitions to another role within the University or leaves the University entirely, the Unit must select a replacement Policy Liaison as soon as possible and notify the Office of Ethics and Policy of the change in writing.

New Documents or Material Substantive Revisions

University Policy

Unless a University Policy is published under the "Expedited Policies" exception in the Policy Framework, new or current University Policies with proposed Material Substantive Revisions must use the following process as illustrated in Image 3 and as described below.

1. The Policy Liaison for the authoring Unit:
   • Coordinates with subject-matter experts in the Unit to develop or revise a Policy using the current University Policy template;
     • Microsoft Word versions of the templates are available from the Office of Ethics and Policy's "Training and Resources" webpage.
   • Circulates the draft Policy for coordination and review by subject-matter experts in other Units (including the Office of Ethics and Policy) as necessary;
   • Ensures Office of University Counsel review; and
   • Ensures Issuing Officer review.
2. When the Policy draft is ready for external review, the Unit provides the updated Policy and a completed Executive Summary to the Office of Ethics and Policy.
   • The Executive Summary form is available from the Office of Ethics and Policy's "Training and Resources" webpage.
3. The Office of Ethics and Policy:
   • Reviews the Executive Summary and Policy draft and asks the Unit any follow-up questions as necessary;
   • Emails the Executive Summary to the PRC members before the next meeting; and
   • Invites the PRC group to provide feedback on the Policy in the electronic University Policy Repository.
4. The PRC Liaisons:
   • Review the Executive Summary before the PRC meeting; and
   • Provide guidance and feedback (no response will be counted as tacit concurrence).
     • Feedback should consider any overlapping existing Policies, operational challenges presented, related risks, factual errors, conflict with law or regulation, ambiguity, gaps, and environmental conditions.
   • The PRC is not an approval committee, however Units are encouraged to consider PRC feedback prior to giving final approval for policy publication.
5. After PRC review, the Unit:
   • Determines how and/or whether to incorporate PRC feedback;
   • Considers revisiting early steps in this process to re-engage stakeholders and make further edits to the Policy (if needed); and
   • Performs a final review of the finalized Policy checking for errors.
     • If the Unit finds any errors, the Policy Liaison, Issuing Officer, or their designee should contact the Office of Ethics and Policy for guidance.
6. The Office of Ethics and Policy will:
   • Perform a final reading of the Policy;
   • Task the Executive Policy Approval Committee (EPAC) as necessary per the "Additional Review by EPAC" section below.
   • Publish the finalized Policy in the electronic University Policy Repository; and
   • Assist the issuing Unit as needed to coordinate campus communications appropriately.

Note: Policy Liaisons may also bring new University Standards or Procedures or existing University Standards or Procedures with Major Edits to PRC if the Policy Liaison believes additional review and coordination is necessary.

Additional Review by EPAC

Depending on the Unit’s response to PRC feedback or the risk associated with the policy documents, the University Policy Officer may elevate the policy documents to a higher level of review by the EPAC or Chancellor’s Cabinet (Image 4) which are approval committees.

1. If the University Policy Officer tasks the EPAC based on the criteria described in the University's Policy Framework, the PRC Chair will:
   • Prepare an agenda for EPAC members to review;
   • Distribute the agenda, relevant Policy, and any additional resources (PRC meeting minutes, comment history from the electronic University Policy Repository, etc.); and
   • Invite relevant stakeholders to attend the EPAC meeting.
2. If EPAC determines the Policy in question should be elevated to Chancellor's Cabinet, the PRC Chair will work with administrative staff in the Chancellor's Office to place the Policy on the agenda for the next Cabinet meeting.

New University Standards or Procedures, or Minor Edits to Any University Policy Document

Units that create new University Standards or Procedures, or have Minor Edits to existing University Policy Documents, should use the following process (unless the Policy Liaison wishes to bring the University Standard or Procedure to PRC as described above):

1. The Policy Liaison for the authoring Unit:
   • Coordinates with subject-matter experts in the Unit to develop a new University Standard or Procedure or make Minor Edits to an existing University Policy Document using the appropriate University Policy template;
   • Circulates the draft Policy Document for coordination and review by subject-matter experts in other Units (including the Office of Ethics and Policy) as necessary;
   • Ensures Office of University Counsel review as necessary; and
   • Ensures Issuing Officer review.
2. Unit Policy Liaison or other employee designated by the Unit logs into the electronic University Policy Repository.
3. The designated Unit employee creates the new University Standard or Procedure or makes Minor Edits to any existing University Policy Document.
4. The designated Unit employee emails the University Policy Analyst so the Office of Ethics and Policy knows the document is ready for review and publication.
5. The University Policy Analyst reviews the edits on each document for basic formatting and digital accessibility issues.
6. The Policy Analyst makes technical corrections to address those formatting and digital accessibility concerns.
   • The Policy Analyst emails the designated Unit employee as needed with any questions.
7. Assuming there are no questions, or after any questions have been resolved, the University Policy Analyst publishes the draft Policy Document in the electronic University Policy Repository.
8. The University Policy Analyst emails the designated Unit employee back to confirm the Policy Document has been published.

Unit Policy, Standards, and Procedures

Units may develop internal processes to create or revise Unit Policy Documents. Policy Liaisons may consult with the Office of Ethics and Policy, request courtesy review from other Liaisons, or request full review by the Office of Ethics and Policy of Unit document drafts to improve quality, consistency, efficiency, or coordination.

If a Unit has elected to publish its Unit Policy Documents in the electronic University Policy Repository, the Unit Policy Liaison or other employee designated by the Unit should follow the same process outlined in the "New University Standards or Procedures, or Minor Edits to Any University Policy Document" section above to ensure coordination with the Office of Ethics and Policy.

Request to Retire a Policy Document

University Policy

1. A representative of Unit must download and complete the "Memorandum of Request to Retire a University Policy" form.
   • The Memorandum is attached to this Procedure as a fillable PDF document.
   • The Policy's Issuing Officer must sign the completed memorandum using a wet-ink signature or a digital/electronic signature method that is acceptable to the University. In rare cases where the Issuing Officer is no longer with the University, a designee selected in consultation with the Office of Ethics and Policy.
2. The Unit must email the completed memorandum to the Office of Ethics and Policy.
3. The Office of Ethics and Policy must review the memorandum to ensure that any related legal and regulatory requirements are met by other means and to provide notice to address references in other Policy Documents, help documents, training materials, etc. to avoid confusion.
4. The Office of Ethics and Policy must send the retirement memorandum to PRC members before the next PRC meeting and add the retirement request to the agenda for the next PRC meeting.
5. The Policy's Issuing Officer, or the Issuing Officer's designee, must attend the next PRC meeting to discuss the relevant University Policy and memorandum.
6. Unless PRC liaisons raise substantive objections that require additional time for the Issuing Officer, in coordination with the Office of Ethics and Policy, to review, the Office of Ethics and Policy retires the relevant University Policy from the electronic University Policy Repository at the end of the time period described in the "PRC Chair" section of the University's Policy Framework.
   • If PRC raises objections that the Issuing Officer feels are substantive and in need of additional review, the University Issuing Officer will work with the Office of Ethics and Policy and the Unit's PRC Liaison to review the substantive objections and determine next steps.

University Procedure or Standard

1. The Issuing Officer must notify the Office of Ethics and Policy of the request to retire a University Standard or Procedure in writing, including the reason for retiring the document.
2. The Office of Ethics and Policy must review the notification and remove the relevant document from publication in the centralized electronic repository.
   • The Office of Ethics and Policy may consult further with the Issuing Officer or the Issuing Officer's designee if the Office of Ethics and Policy has substantive questions or concerns about retiring the University Standard or Procedure.
3. The issuing Unit and the Office of Ethics and Policy will coordinate to provide placeholders with appropriate information to reduce confusion for a duration deemed appropriate and ensure that all relevant records retention requirements are met.

Procedural Notes

The Office of Ethics and Policy should:

• Manage review and approval for efficiency, and may employ a "first-come, first-served" process or appropriate prioritization method ,
• Coordinate with Policy Liaisons to ensure that the publication of drafts can occur in a timely and orderly way,
• Frame reviews to assume that a lack of response indications agreement.

Drafts are expected to be well-constructed and reviewed by subject-matter experts before entering an official review process. In many cases, no change will be needed and no feedback will result.

Definitions

Please refer to the University Policy on Policies for definitions.

Related Requirements

University Policies, Standards, and Procedures

• University Policy on Policies
• Records Management Policy

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