Policy and Procedure Development Framework Procedure
| Effective Date: | May 20, 2022 |
| Downloadable Version: |
 Policy and Procedure Development Framework Procedure
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| This document is available in alternate format on request. |
Purpose:
To outline the procedures for new and existing policy and procedure (where applicable) planning, development, review, approval, implementation and revisions.
Unless otherwise indicated, capitalized terms will be given the definition(s) set out in the Policy.
Procedures:
The following steps are generally involved in policy and procedure (where applicable) development, approval, implementation and review. These steps may not occur in a linear order. Templates for Policies and Procedures are included as Appendices A and B. The process as further illustrated in Appendix C – Development, Approval and Implementation Process.
1. Planning
a) Identification of Need
A policy may be developed when there is a need for clarity and consistency on an issue and/or a need to control, direct or inform all or some members of the College community on such matters as health and/or safety, human resource issues, a legal liability, a licensing or regulatory requirement, issues where there may be serious consequences, accountability and/or where there is institutional risk. Policies have College-wide application and are mandatory to those identified in the scope.
The need for a college-wide procedure(s) related to the policy will also be determined by the Policy Holder. Not all policies require a procedure(s). However, procedures will be developed where there is a need to provide specific operational instructions on steps to take when a situation occurs. Some policies may require more than one procedure to address different situations.
In addition, existing policies and related procedure(s) (where applicable) will be reviewed periodically, at least every five years, and updated as required.
The Administrator responsible for the policy and related procedure(s) (where applicable) will outline the rationale for the new policy and procedure(s) or for the update to the policy and procedure(s) (where applicable) to the Policy Holder and receive approval to proceed.
The Administrator will consult with the applicable Executive Team member, the Legal, Risk and Privacy (LRP) team and the Associate Vice President, Academic (where applicable) before beginning the development process.
b) Develop a Plan
The Administrator will develop a plan with phases and timelines that typically include the following: analysis, research, drafting, consultation, review, revision, editing, finalization and implementation.
Key stakeholders for consultation will be identified by the Policy Holder and Administrator. They may determine that a Policy Development Team comprised of those directly impacted by the policy and procedure (where applicable) would be beneficial to the development process.
c) Research
The Administrator, in conjunction with the Policy Development team, if applicable, will conduct research on issues, legislation and best practices related to the policy and procedure (where applicable) and may prepare interview questions for the consultation phase. Subject matter experts and others who have information may be consulted at this stage.
2. Development
a) Draft
All policies and procedures (where applicable) will be documented on the Policy and Procedure Template following the instructions in Appendix A and B. Policy statements should be clear, concise, and specific. They should be written in simple language and include what the policy is and what is expected of the users. Sections within the policy body should be numbered and subsection headings introduced.
b) Consult
The initial draft policy and procedure(s), if applicable, will be presented by the Administrator to the appropriate stakeholders in the College for consultation and/or information sharing purposes. This may include all or some of the parties listed on checklist outlined in Appendix C.
c) Revise
The Administrator will review feedback with the Policy Holder and revise the policy and procedure(s) (where applicable) as required.
d) Develop implementation & communications strategy
The Administrator, in consultation with the Communications Department and the Organizational Excellence department when required, will develop a strategy to roll out the new policy which may include presentations to key stakeholders, training, emails, Communique postings and Academic and Administrative Leaders’ Forum (AALF) announcements.
3. Review, Recommendations and Approval
a) Classification and Format Review
The Administrator will provide the draft policy and procedure (where applicable) to the Legal, Risk and Privacy (LRP) team for classification and numbering:
- Academic AC
AC 100 Learning
AC 200 Research - Human Resources
HR 100 - Student Success and Engagement
SSE 100 - General Administration
GA 100 - Financial Services
GA 200 - Facilities and Property
GA 300 - Information Management
GA 400 - Public Safety and Security
GA 500 - Communications, Marketing
GA 600 - General Operations
Procedures will have the same classification as the policy with a P1 added to the end. If more than one procedure is associated with the policy, the same number will be used with P2, P3, and P4 etc. added to the end.
The Administrative Assistant will review the documents to ensure that the format is correct and will return a copy with any revisions and with the number to the Administrator.
b) Review
The Administrator will complete the Policy and Procedure Checklist and Approval Cover Sheet (Appendix D) and forward this with the new or revised policy and procedure (where applicable) for review to the Legal, Risk and Privacy office.
The Administrator will present the policy and procedure (where applicable) to stakeholders and committees and modify as required.
c) Approval - Executive Team
The President will schedule the policy and procedure (where applicable), for review and approval by the Executive Team and will invite the Policy Holder and the Chief Legal, Risk and Privacy Officer to present the policy and procedure(s) (where applicable) to the Executive Team. The Executive Team will provide feedback on any modifications to the Policy Holder.
d) Approval Board of Governors (where applicable)
The President may request Board of Governors’ approval on policies such as those that pertain to governance, those that apply to members of the Board of Governors, those specified by the Ministry of Training, Colleges and Universities and/or those related to legislation. By exception and at the discretion of the President, other approved policies may be sent to the Board of Governors for information.
4. Implementation
a) Final Copy
Once final approval is obtained from the Executive Team and the Board of Governors, (where applicable), the approved document(s) will be returned to Legal, Risk and Privacy. The Legal, Risk and Privacy team will produce a final copy of the policy and procedure (where applicable) with an effective date and will forward the final hard copy to the Policy Holder for signing. Final copies of policy and procedures (where applicable) will be retained by Legal, Risk and Privacy with the Policy and Procedure Checklist and Approval Cover Sheet (Appendix D) notating date approved by the Executive Team and Board of Governors, if applicable.
b) Implementation
The Policy Holder and Administrator will be accountable for ensuring a communications and implementation plan is undertaken with assistance from Humber’s Communications and Change Management teams where required to ensure students, faculty, support staff and administrators impacted by the policy understand the content. Generally, implementation plans should follow the template set out in Appendix E. Some complex policies with broad implications may require customized plans.
c) Posting
Once the implementation plan is completed and employees are informed of the policy and procedure (where applicable) the Policy Holder or Administrator will request that Legal, Risk and Privacy post the documents(s). All approved policies and related procedure(s) (where applicable) will be posted on the Humber website on the Policy and Procedure page, including a PDF version of the signed copy of the approved document(s).
5. Review
a) Monitor
The Administrator will monitor the implementation of the policy and related procedure (where applicable) for compliance and to ensure that it is understood. Further training, clarification or communications may be required if any issues are identified in the monitoring.
b) Policy Review
The Policy Holder and Administrator will initiate a review of the policy and procedure (where applicable) based on the specified timeframe established in the development process and noted on the policy or earlier, if there is a change in legislation or requirements. Policies and procedures must be reviewed at least once every five (5) years.
c) Update
The same procedure will be followed as outlined in Steps 2-4 to update the policy and procedure.
References:
Nancy J. Campbell, Writing Effective Policies and Procedures, AMACON American Management Association, 1998
Acknowledgements:
St. Lawrence College Policy Development and Review