Adams School of Dentistry: Procedure for Policy Management

Summary

To provide specific steps to create, review, revise, publish, and decommission official Adams School of Dentistry Policies, Standards, or Procedures. This Procedure applies to all Policies, Standards, and Procedures developed to support the internal operations of the Adams School of Dentistry, including the Dental Faculty Practice.

Body

Title

Adams School of Dentistry: Procedure for Policy Management

I. Introduction

A. Purpose

To provide specific steps to create, review, revise, publish, and decommission official Adams School of Dentistry Policies, Standards, or Procedures.

B. Scope

This Procedure applies to all Policies, Standards, and Procedures developed to support the internal operations of the Adams School of Dentistry, including the Dental Faculty Practice.

II. Definitions

Expressly delegated subject matter oversight: Explicit delegation of authority by the Dean's Office to a standing committee or work group as reflected by some written instrument (e.g., committee charge).

Material change: A substantial change in the document that may alter its interpretation or effect.

Notice: Calling affected individuals' attention to a Policy, Standard, or Procedure that has come into effect (active notice may be informal, such as via email). Constructive notice alone – i.e., only posting to PolicyStat – is not recommended.

Outlining sanctions: Refers to any Policy, Standard, or Procedure which sets forth violation levels and describes specific disciplinary actions that may be imposed depending on the type of infraction. This does not refer to a Policy, Standard, or Procedure that describes – in general terms – that sanctions may be imposed for noncompliance.

Refer to the Adams School of Dentistry Policy on Policies for other definitions.

III. Procedure

A. Management of Policies

Approval of New Policies

Policies may originate in several ways such as the result of a collaborative effort between a standing committee or work group, or the product of a single officer. Policies must adhere to the Adams School of Dentistry Policy Template, which is based on the University-recommended format, and all other requirements specified in the School's Policy on Policies.

When contemplating or drafting new policies, the Issuing Officer and/or originator(s) should consult with the Adams School of Dentistry Policy Officer for informal review. The Policy Officer will:

  1. Examine whether the draft policy is redundant or in conflict with existing authorities, such as University or School policies.
  2. Verify that the draft policy complies with the School's Policy on Policies.
  3. Assist the Issuing Officer in identifying other relevant stakeholders who should have first-level review (e.g., standing committee).
  4. Provide substantive feedback on the draft policy if requested by the Issuing Officer.

Once this process is completed, the Policy Officer will refer the proposed policy to an appropriate administrative body for final approval. The Issuing Officer is the point-of-contact for any substantive questions the reviewing body may have about the proposed policy. The Policy Officer may create a Flow Chart based on existing committee structure to define a standard approval routing process based on the policy type (e.g., clinical, academic, financial, research, etc.). If a Flow Chart is created, it will be attached as an addendum to this Procedure. Final approvals must be documented via the University policy website.

Once a new policy has been formally adopted, the Issuing Officer must notify affected individuals.

Revising Existing Policies

All policies must be reviewed at specified intervals. If no revision is required, the Issuing Officer may unilaterally renew the policy. If non-material changes are required, the Issuing Officer may unilaterally renew the policy. For clarification on whether or not proposed changes are material, the Issuing Officer should consult with the Policy Officer.

If material changes are required, the draft revisions must be formally approved by (1) a relevant standing committee or work group that has been expressly delegated subject matter oversight by the Dean's Office; or (2) in the absence of such a body, the Vertical Leadership Team (VLT). The Dean's Office will maintain a list of standing committees or work groups that are authorized to approve the modification of existing policies. Once material changes to an existing policy have been formally approved, the Issuing Officer must notify affected individuals.

All revision dates – whether material or non-material – must be reflected in the document history. If an existing policy has been materially revised, the Issuing Officer must notify affected individuals and ensure the policy is accessible on the University policy website.

Decommissioning Policies

There are a number of reasons why an existing policy should be decommissioned. School policies may be preempted by a change in law or by University policy. New personnel in positions of leadership may have different perspectives on a particular policy than previous administrators. Redundancy with a University policy or similarly-themed School policy is also a basis for decommissioning.

The decommissioning of any policy must be approved by the Dean's Office in consultation with the Issuing Officer, Policy Officer, and any other relevant stakeholders. The Issuing Officer must notify affected individuals.

B. Management of Standards and Procedures

Approval of New Standards and Procedures

Except as otherwise provided in this Procedure, Issuing Officers may unilaterally issue new Standards or Procedures to support existing School or University policies. The Issuing Officer must notify affected individuals of any new Standard or Procedure.

Revision of Existing Standards and Procedures

Except as otherwise provided in this Procedure, Issuing Officers may unilaterally revise existing Standards or Procedures to support existing School or University policies. The Issuing Officer must notify affected individuals of material changes to any existing Standard or Procedure.

Decommissioning Standards and Procedures

Except as otherwise provided in this Procedure, Issuing Officers may unilaterally decommission existing Standards or Procedures. The Issuing Officer must notify affected individuals when a Standard or Procedure has been decommissioned.

C. Exceptions

  • An Issuing Officer may not unilaterally issue a new Standard or Procedure outlining sanctions for employee non-compliance or other misconduct.
  • Any Standard or Procedure that prescribes sanctions for employees must be approved by HR and either:
    • (1) relevant standing committee or work group that has been expressly delegated subject matter oversight by the Dean's Office;
    • or (2) in the absence of such a body, the VLT.
  • Any material changes to an existing Standard or Procedure must also be approved pursuant to this process.
  • Sanctions standards are typically not necessary, as discipline for non-compliance should be handled pursuant to the best judgment of the supervisor in consultation with HR.

IV. Related Requirements

A. External Regulations

B. School of Dentistry Policies, Standards, or Procedures

V. Contact Information

Contact Information
Topic Officer Contact Information
General questions about this Procedure

Policy Officer

Associate Dean for Strategy & Compliance

VACANT
General questions about this Procedure

INTERIM Policy Officer

Director of Clinical Compliance

ASOD_ClinicalCompliance@unc.edu

Details

Details

Article ID: 131305
Created
Thu 4/8/21 9:06 PM
Modified
Wed 2/7/24 9:08 AM
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 2:38 PM
Last Revised
Date on which the most recent changes to this document were approved.
05/09/2023 2:38 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.
03/02/2022 10:51 AM
Origination
Date on which the original version of this document was first made official.
10/05/2018 12:00 AM

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