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: Appendix Y
Section - Information	Originating Date: July 2015
Responsible Reviewing Agency: Policy Task Force

Purpose:

To assure that the UNMC CON policies and procedures that apply to students and faculty are properly developed, approved, and published on the CON wiki.

Scope:

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

Responsibilities:

1. Responsible Committee Chair
   1. reviews policies and procedures in their area of responsibility for accuracy and review cycle status
   2. verify that policies and procedures conform to UNMC policies and procedures
2. Faculty Coordinating Council (FCC)
   1. reviews policies and procedures in their area of responsibility
   2. determine routing of policies and procedures if multiple responsible agencies identified
   3. resolves any conflict between the reviewers and preparers of new or updated policies and procedures
   4. assign committee(s) as responsible agency to new policies or procedures
   5. reviews policies and procedures for review cycle status
3. Academic Directors
   1. reviews policies and procedures in their area of responsibility
4. Policy Task Force
   1. provide orientation of policy development and update procedure
   2. brief FCC on first meeting of the academic year to develop plan for policy review for responsible committees
   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 archives superseded or obsolete documents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 procedures 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 procedures in their area of responsibility
   2. is the final reviewing and approving authority for policies and procedures for which it is the responsible agency
7. General Faculty Organization (GFO)
   1. is the final reviewing and approving authority for policies and procedures requiring a vote
   2. GFO minutes shall reflect that policy changes have been presented, voted on, and approved
8. Faculty
   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 prior to meetings
   5. vote on policy revisions
9. Staff
   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.

Procedure:

1. Policy Change Request
   1. Policy Change Request (PCR) form is used to initiate the development or change of policy and procedural documents. The PCR form is provided by the webmaster upon request or can be downloaded below in attachments section. The PCR contains at least the following information:
      • PCR number
      • date of request
      • requester's name
      • contact information
      • document involved
      • Comments and instructions with supporting documentation
      • action to be taken, date and by whom
   2. The PCR is submitted to responsible agency or agencies for action and evaluation. The agency or agencies notifies the requester by e-mail of the decision to create, revise, remove or take no action after completion of the process.
2. Developing, Reviewing and Approving
   1. Policy Initiation
   2. Policy Review and Revision
   3. Policy Approval
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 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)

   2. Policies, procedures 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 used on the wiki
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 change that do not affect the content of the quality of the action befing 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 which affect the content of quality of 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. A minor change or a reading of a policy by the responsible agency that finds no changes are required constitute a review release.
   6. Revise - Policies requiring any major change.
   7. Responsible agency -
   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 Flow Diagram