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 decommission official University Policies, Standards, and/or Procedures, for which the Units are responsible, as well as guidance for the management of Unit Policies.

Scope of Applicability

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

Procedures

Appointing or Replacing a Policy Review Committee Liaison

If notified by the Office of Ethics and Policey 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 should select a replacement Policy Liaison as soon as possible and notify the Office of Ethics and Policy of the change.

New Documents or Material Substantive Revisions

University Policy

Unless an approved exception exists, new University Policies or current University Policies with proposed Material Substantive Revisions should use to the following process:

  1. The Policy Liaison for the authoring Unit:
    1. Coordinates with subject-matter experts in the Unit to develop or revise a Policy using the current University Policy template;
    2. Circulates the draft Policy for coordination and review by subject-matter experts in other Units (including the Office of Ethics and Policy) as necessary;
    3. Ensures Office of University Counsel review; ;and
    4. 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.
  3. The Office of Ethics and Policy:
    1. Reviews the Executive Summary and Policy draft and asks the Unit any follow-up questions as necessary;
    2. Emails the Executive Summary to the PRC members prior to the next meeting; ;and
    3. Invites the PRC group to provide feedback on the Policy in the electronic University Policy Repository per the University Standard on Policies.
  4. The PRC liaisons:
    1. Review the Executive Summary prior to the PRC meeting; and
    2. Provide guidance and feedback (no response will be counted as tacit concurrence).
      1. Feedback should reflect consideration of any overlapping existing Policies, operational challenges presented, related risks, factual errors, conflict with law or regulation, ambiguity, gaps, and environmental conditions.
  5. After PRC review, the Unit:
    1. Determines how or whether to incorporate PRC feedback;
    2. Considers revisiting early steps in this process to re-engage stakeholders and make further edits to the Policy (if needed); and
    3. Performs a final review of the finalized Policy checking for errors.
      1. 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:
    1. Perform a final reading of the Policy;
    2. Publish the finalized Policy in the electronic University Policy Repository; and
    3. Assist the issuing Unit as needed to coordinate campus communications appropriately.
Additional Review by EPAC
  1. If, after PRC review, the University Policy Officer or the Issuing Officer responsible for creating and administering the University Policy in question determines that the Policy should be elevated to the Executive Policy Approval Committee (EPAC), the University Policy Officer will:
    1. Prepare an agenda for EPAC members to review;
    2. Work with administrative staff in the Chancellor's Office to distribute the agenda, relevant Policy, and any additional resources (PRC meeting minutes, comment history from the electronic University Policy Repository, etc.); and
    3. Invite relevant stakeholders to attend the EPAC meeting.
  2. If EPAC determines the Policy in question should be elevated to Chancellor's Cabinet, the University Policy Officer will work with administrative staff in the Chancellor's Office to place the Policy on the agenda for the next Cabinet meeting.

University Standards and Procedures

In keeping with the University Policy Framework and University Standard on Policies, Issuing Officers and their designees may create University Standards and Procedures hosted in the electronic University Policy Repository which apply University-wide and within the context of the Issuing Officer's authority.

Policy Liaisons must coordinate with the Office of Ethics and Policy to determine, based on potential cost, operational change, or risk from compliance, whether a proposed University Policy, Procedure, or Standard warrants review by the PRC. If so, the Procedure outlined above for University Policy should be followed, although the Office of Ethics and Policy may opt to abbreviate or otherwise expedite review as needed. If only nominal risk/change/cost is anticipated, the Policy Liaison should follow internal Unit Procedures for communication of changes to Procedures or Standards and coordinate with the Office of Ethics and Policy to have the Standards and Procedures hosted in the electronic University Policy Repository.

Unit Policy, Standards, and Procedures

Units may develop their own internal processes to create or revise Unit Policies, Standards, and Procedures. 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 in order to improve quality, consistency, efficiency, or coordination.

Decommissioning

University Policy

  1. A representative of Unit must download and complete the Memorandum of Request to Decommission a University Policy template.
    1. The completed memorandum must be printed on the Unit's letterhead and signed by the Policy's Issuing Officer, or, 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 reviews 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 Policies, Procedures, Standards, help documents, training materials, etc. to avoid confusion.
  4. The Office of Ethics and Policy sends the decommissioning memorandum to PRC members prior to the next meeting and adds the decommissioning request to the upcoming PRC meeting.
  5. The Policy's Issuing University Officer, or their designee, should 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 decommissions the relevant University Policy from the electronic University Policy Repository.
    1. If PRC raises objections that they University 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 decommission a University Procedure of Standard in writing, including the reason for decommissioning.
  2. The Offce of Ethics and Policy will review the notification and remove the relevant document from publication in the centralized electronic repository.
  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 records retention requirements are met.

Procedural Notes

The Office of Ethics and Policy should manage review and approval for efficiency, coordinating with Policy Liaisons to ensure that publication of drafts can occur in a timely and orderly way. The Office may employ a "first-come, first-served" process or any appropriate prioritization to stagger reviews in order to avoid burdening reviewers. Reviews should be framed to assume that no response is an indication of concurrence, as the expectation is that drafts will 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 Framework for definitions.

Related Requirements

University Policies, Standards, and Procedures

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

Revisions approved by:

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

Revisions approved by:

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

Approved by:

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

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Details

Article ID: 132081
Created
Thu 4/8/21 9:23 PM
Modified
Thu 7/29/21 4:59 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.
01/25/2021 12:56 PM
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.
Administrative Director
Last Review
Date on which the most recent document review was completed.
01/25/2021 12:56 PM
Last Revised
Date on which the most recent changes to this document were approved.
01/25/2021 12:56 PM
Origination
Date on which the original version of this document was first made official.
01/06/2017 11:00 PM
Responsible Unit
School, Department, or other organizational unit issuing this document.
Ethics and Policy Office