CON Policy Development and Update Procedure

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Appendices

UNIVERSITY OF NEBRASKA MEDICAL CENTER COLLEGE OF NURSING
Policy Development and Update Procedure	Subsection: TBD
Section - Information	Originating Date: July 2015
Responsible Reviewing Agency: Policy Task Force	Revised: September 2017

Purpose:

To assure that the UNMC CON policies and appendices are properly developed, approved, and published on the CON wiki.

Scope:

This procedure applies to the control of all policies and appendices.

Responsibilities:

1. Committee Chairs
   1. reviews policies and appendices in their areas of responsibility for accuracy and cycle status
   2. verify that policies and appendices conform to UNMC policies and procedures
2. Faculty Coordinating Council (FCC)
   1. reviews policies and appendices in its area of responsibility
   2. determine routing of policies and appendices if multiple responsible agencies identified
   3. resolves any conflict between the reviewers and preparers of new or updated policies and appendices
   4. assign committee(s) as responsible agency to new policies or appendices
   5. reviews policies and appendices for review cycle status
3. Program Directors
   1. reviews policies and procedures in their area of responsibility
4. Policy Task Force
   1. provide orientation of policy development and updated procedure
   2. brief FCC on first meeting of the academic year to develop plan for policy review for responsible agencies
   3. identify administrative, grammatical, and spelling errors not requiring a vote to approve
   4. ensures correct formatting conventions are followed
   5. suggest improvements to policy development and update procedure
   6. update flow diagram, policy change request form, and procedure
5. Webmaster
   1. archives superseded or obsolete documents
   2. code and deploy approved changes to policies and appendices on wiki
   3. update responsible committee cross matrix to show revisions and updated review cycle dates
   4. make administrative, grammatical, and spelling error corrections identified by the policy task force
   5. provide existing policy template, PCR form or application, new policy template to responsible agency
   6. ensures correct formatting conventions are followed
6. Executive Council
   1. reviews policies and appendices in its area of responsibility
   2. is the final reviewing and approving authority for policies and appendices for which it is the responsible agency
7. General Faculty Organization (GFO)
   1. is the final reviewing and approving authority for faculty and student policies and appendices requiring a vote
   2. GFO minutes shall reflect that policy changes have been presented, voted on, and status of vote
8. Committees
   1. reviews and determines need for new procedures or modification of procedures
   2. initiates changes by completing a Policy Change Request (PCR) form or initiating a revision in a web application, and
   3. ensures correct formatting conventions are followed.
   4. review policy revisions as presented at GFO meetings or in GFO provided materials
   5. vote on policy initiation or revisions

Procedure:

1. Policy Change Request
   1. Policy Change Request (PCR) form is used to initiate the development or change of policy and appendix documents. The PCR form is provided by the webmaster upon request. The PCR contains at least the following information:
      • policy number
      • policy name
      • responsible committees
      • initiated by
      • initiated date
      • document involved
      • summary of reason for recommended change with supporting documentation
      • action to be taken and date
      • PCR number, which will be assigned later in the process
   2. The PCR is submitted to responsible committees for action and evaluation. The committees notify the requester of the decision to create, revise, remove or take no action after completion of the process.
2. Developing, Reviewing and Approving
   1. Policy Development
      1. For policy creation or revision, the responsible agency reviews the PCR and prepares a draft of the new or changed policy. These changes will be summarized in the updated PCR form.
      2. For policies with more than one responsible agency, the chairs of all responsible agencies must communicate with each other any new or changed information, as well as the process for all agencies to review draft before submission to final approving agency (e.g., Executive Council or GFO).
      3. Policy Task Force may facilitate the communication process for all responsible agencies involved.
   2. Policy Review
      1. The responsible agency or agencies review the draft policy, make any revisions needed and members vote on the policy. If approval is not met, agencies can repeat review process until policy receives majority approval or policy is rejected.
      2. For policies with more than one responsible agency, all involved agencies must approve policy before it can be moved forward to final approving committee.
      3. Policy Task Force may facilitate communication process for all responsible agencies involved.
   3. Policy Approval
      1. PCR form is finalized and submitted to final approving agency (e.g., Executive Council or GFO).
      2. Per CON Policy 1.3, responsible agency chair presents policy to final approving agency for information, discussion and vote.
      3. If policy is not approved, it may go back to responsible agency for review and revision to be submitted at a later time. If approved, the policy is updated on the Wiki, archived, disseminated to others and implemented as submitted in PCR.
   4. Amendments or changes to documents by hand are not able to be processed. Minor changes identified are noted and made during the next review and revision.
3. Monitoring
   1. Location and status of policy documents under review or revision
   2. Policy or procedure on the CON wiki, index pages of administration, faculty, student and appendices, and responsible agency crossmatrix shall be reviewed for accuracy
   3. MS Word versions of current policies
   4. archive copies of policies
4. Document Numbering
   1. Numbering format will be numeric for policies and alphabetic for appendices. Policies have a number representing the category of the policy (i.e. faculty, student, or administrative) followed by a period and then followed by a sequence number. Appendices can be followed by a number indicating a subset of a related, master appendix (e.g. A1).
   2. Versions are indicated by revision or review date
   3. New policies are generally assigned the next higher sequential number in the category of the policy
5. Document Formatting
   1. All policies, procedures and appendices shall consist of a header and a body as a minimum. The header uses the following format:
      

      UNIVERSITY OF NEBRASKA MEDICAL CENTER COLLEGE OF NURSING
      Full Policy Name	Subsection: Policy number or Appendix letter
      Section - Section name	Originating Date: Month Year
      Responsible Reviewing Agency: Committee name(s)	Revision or Review date(s)
      Referenced Documents

   2. Policies and appendices may have additional forms, diagrams or other attachments linked
6. Notification
   1. webmaster shall be notified by authorized approving agency of policy approval
   2. notification shall consist of an e-mail requesting an update of the policy, information concerning the authorizing vote, and an MS Word version of the approved policy with changes identified within.
   3. approval date will be the revision or review version of the policy when finalized by final approving agency
7. Document Retention and Archival
   1. MS Word versions of all policies and appendices will be retained on the CON network server.
   2. MS Word versions of previous versions of policies and appendices will be retained in an archive area of the CON network server.
   3. Previous versions of policies and procedures will be retained on the wiki and linked from the revision or review version date in the header on the active version of each policy or procedure.
8. Definitions
   1. Controlled copy - A controlled copy is a formal copy of the latest, correct version of a document; an identified issue of a document to an individual or committee. The controlled copy is officially tracked, updated and destroyed to assure that it is current.
   2. Uncontrolled copy - An informal copy of a document for which no attempt is made to update it after distribution.
   3. Minor changes or revisions - Those changes that do not affect the content or the quality of the action being prescribed in the document, such as typographical or grammatical changes, template formatting or small changes within the document.
   4. Major changes or revisions - Those changes that affect the content of quality or the action being prescribed in the document, such as updated technology resulting in change of procedure or multiple changes within the document.
   5. Review - Policies must be at least reviewed every five years regardless of the need for revisions.
   6. Revise - Policies requiring any major change.
   7. Responsible agency - The entity responsible for conducting regular evaluations of the policy
   8. Wiki - website containing all policies, procedures, appendices, organizational structures of the College of Nursing
9. Supporting Documents
   1. College of Nursing and Parent Institution Policies
   2. Formulation, Evaluation, and Revision Dissemination of Policies
10. Attachments
    1. Policy Change Request
    2. Policy Flowchart