Policy process

Step 1: Identify the need for governance document development, amendment, revision or rescission

The need for the development of a new governance document, or the amendment, revision or rescission of an existing one can be identified by any member of the University community.

The main reasons for a development of a new governance document, such as a procedure, are:

  • Change in legislation or government policy;
  • A new strategic direction for the University has been established;
  • A gap in the existing University documentation being identified.

The main reasons for amending or rescinding an existing governance document are:

  • Scheduled review
  • Managing risk
  • Outcomes of internal and external audits/reviews
  • Significant changes to practice
  • No longer relevant or required.

Once the appropriate Document Owner has been identified, they need to confirm/approve that a governance document needs to be developed. Check for the possible enhancement of an existing document which may cover the issue before developing a new one. It is important to establish principles which apply to the document subject and consider issues of implementation for the potential governance document.

A Policy is a formal statement of principle consistent with relevant legislation, and University Statutes and Regulations, that regulates, directs and controls University-wide operations and is formally reviewed every five years. Federation University has seven overarching policies. A Policy can only be created with the approval of the Vice-Chancellor.

A Procedure outlines a series of Actions, Activities and Steps required (and by whom) to implement a process or requirement across the University and is formally reviewed every three years. All procedures relate to a Policy Domain and are consistent with the Policy to which they refer.

An Operations Manual is a working document, designed to guide regular work practices. It is generally an internal document and is reviewed annually for currency.

A Work Instruction is a working document that refers to specific, granular level detail and is dependant on the requirements of the job. Work Instructions are reviewed annually for currency, or as required.

Step 2: Completing and Submitting a Governance Document Review Form

The Document Owner must submit a signed Governance Document Request Form (GDRF) to the Manager, Policy and Quality Assurance Services by ServiceNow. The Manager, Policy and Quality Assurance Services will meet with the Owner to review the requirements in the form, the documents intent and need.

The Manager, Policy and Quality Assurance Services will take into consideration:

  • That the proposed governance document does not overlap with other documents under development.
  • The University's need for the governance document.
  • Where the document sits within the existing Policy Domains.

Once approval has been given:

For a new document – Policy Services establishes the new document in the University's approved policy management system (PAMS) with the status 'Under Review - With Editor' and provides a blank template document to the Document Owner to use in developing the new governance document (e.g., procedure, operations manual). A new Policy can only be created with the approval of the Vice-Chancellor.

Where the approval is for the amending of an existing document, the Document Owner is advised and PAMS is updated with the status 'Under Review - With Editor'.  A Word format version of the existing document can be provided to assist as well as updated templates to ensure consistency.

For a document approved for Rescinding, PAMS is updated to status 'To Be Rescinded' and a job is logged with CeRDI to rescind from the Policy Library.

Step 3: Document development or revision

All governance documents are drafted or revised in consultation with relevant stakeholders, using the templates provided to ensure that the structure and style of documents are consistent.

The Policy Office can assist in reviewing the draft governance document by providing advice on the quality of drafting and compliance to the definitions of the Policy framework hierarchy, including offering suggested revisions and reorganisation of content as appropriate.

When forms are required to be attached to a procedure, Document Owners or delegates should forward these to the Policy Systems Administrator for inclusion in PAMS. If forms are required to be included on individual web pages e.g. Academic Board, the forms should be stored in PAMS and linked to this version to ensure all versions are current. The Policy Office can provide the URL to link forms or other governance documents.

Template documents:

Step 4: Consultation

The Document Owner should consult with all relevant stakeholders in regard to the governance document to assist with testing the document's options and to identify gaps that may have been overlooked.

Internal stakeholders may include:

  • Departments
  • Institutes
  • Schools
  • Academics
  • Researchers
  • General staff
  • University committees and any other area of the University community that may be directly affected by the governance document.

Refer to the original Governance Document Request Form to confirm who has been identified as key stakeholders and to ensure all relevant areas have been consulted.

In some cases, external stakeholders may also need to be consulted.

Once the Document Owner has consulted with the relevant stakeholders and the first draft of the new/revised governance document has been created it must be forwarded this to the Policy Systems Administrator for uploading to PAMS. A Document Owner may choose to release the document for university-wide comment. The Policy Systems Administrator will change the status in PAMS to 'For University-wide Comment' and make an announcement via the FedNews web page for this stage of the consultation process.

The university-wide comment phase is recommended for between 5 - 10 working days. All feedback received will be collated and provided to the Document Owner for consideration by the relevant stakeholders and working parties and this should be captured as evidence that the stage has been completed. The Feedback Form has been developed to assist in this stage of the process. If necessary, revise the governance document based on the comments received.

Step 5: Approval

All governance documents must be approved by the appropriate Approval Authority as stipulated in the Policy Governance Framework Procedure. The Document Owner forwards the final draft including valid feedback, of the governance document to the appropriate Approval Authority for final approval. The Document Owner or EO of Approval Authority, if a committee, forwards the resolution/memo to the Policy Systems Administrator, as evidence prior to publishing in the Policy Library

The Policy Systems Administrator will advise the Document Owner when the document has been published.

All new and revised governance documents automatically appear on the 'Newly Published Documents' section of the Policy Central Website.

Step 6: Communication and implementation

The Document Owner must:

  • ensure that affected University staff and students are made aware of new document;
  • monitor implementation and ensure that staff are provided with appropriate information and training.

Step 7: Periodic review

Governance documents should be reviewed as follows—

  • University codes and policies should be reviewed every five years;
  • University procedures should be reviewed every three years;
  • Manuals and work instructions should be reviewed annually for currency of information and as required for other issues.