Considerations for Defining Your Governing Documents

Clear definitions for the types of documents your policy program manages help the program administrator and policy owners determine whether and when to codify a matter in policy. It also can provide guidance for determining what policies to retire. Here are some key points to consider when crafting your definitions.

Are the stated provisions and/or limitations required?

When units or employees have the option to choose whether to follow the guidance or not, the matter likely doesn’t warrant a policy. Recommendations and best practices can be communicated outside of policies. For example, if your institution allows individual units to determine whether and how to implement flexible work schedules and remote work for their employees, a policy that covers all possible scenarios would be difficult to craft. Instead, HR can provide resources for managers, such as position evaluation checklists, employee agreements, and offer letter templates. Where remote worker status coincides with other legal or policy implications, such as out-of-state income taxes or travel reimbursement, those policies or procedures can address the issues.

Who gives final approval for a policy?

Your institution’s culture will likely weigh into this decision. Policy approval needs to happen at a level high enough to demonstrate the authority of your policy program. However, consider whether that level needs to go all the way to the top. If your governing board has to sign off on all policies, your program’s ability to enact new or revised policies quickly may be limited when the board only meets six times a year and has a lot of other matters to address. Many institutions send policies to the president or chancellor for final approval, which is a more accessible last stop than the board. Another option is to have your president/chancellor delegate approval authority to a group that meets regularly for that purpose. This delegation can be achieved by defining the group and its responsibilities in your policy on policies.

Does each policy need an owner?

This, too, may depend on your institution’s culture. A policy owner is typically an executive officer who is seen as the “sponsor” of the policy. When looking at policy programs that oversee systemwide or campuswide policies, there are options for determining the owner. Some institutions assign the president or chancellor as owner of every policy. Other institutions list various senior executives as owners. When that is the case, it’s helpful to identify the criteria used to determine which executive owns a policy. Also consider whether you need to assign a responsible office for each policy. Most of the real work administering a policy happens further down the ladder from the executive rung. A responsible office may not oversee every aspect of a policy, but assumes the role of coordinating compliance efforts.

What do your policies look like?

An essential tool in the policy administrator’s toolbox is a policy template. When all your policies are outlined in a similar fashion, users learn how to read them and find the information they need quickly. Templates ensure that important information isn’t left out. One question that often comes up is whether the policy template should include procedures. I won’t advocate one way or the other here, but if your template does not include procedures, consider whether you should define what an operating procedure is. Which leads me to the next question.

Are policies the only way to convey information?

Your institution likely has varying levels of policies, such as systemwide, campuswide, and unit level. Consider defining in your policy on policies what the difference is between each type and what happens when there is a conflict between policies on the same topic. Other types of documents you may want to define include operating procedures, standards, and guidelines. Ask the same questions about whether something is required or optional, who has final approval, and whether the document must adhere to a template. Also, be sure to explain how the various types of documents relate to one another.

An Untapped Potential

In the past few years, crisis, cultural shifts, and financial woes have led to a rise of complexity in maintaining our policy systems within our institutions. Meeting all the regulations can be challenging, as they are constantly changing. In addition, institutions are feeling the pressure from regulators, internal staff and faculty, and the community at large to maintain the regulations. Challenges faced yesterday are not the challenges we will face tomorrow or next year. Do you have the confidence that your policies could stand up to regulatory scrutiny? Does this mean that we need to become even more resilient and inventive – is there any untapped potential out there?

As policy leaders we have learned that we need systems and processes to get things done. But is that enough? Even the most skilled person today is challenged with the immense workload of continuous changes and updates required for policy management. Even the way we distribute, collect, account for and present changes has undergone enormous change. It is not just a check list and process – we need to manage risk, ensure data security and privacy while balancing access and inclusiveness and external influences – it all seems daunting, and to top it all off, failing to comply with the ever-evolving regulations can lead to costly fines and lawsuits.

We are looking virtually everywhere for indicators of change, racing with time to have key policies, procedures and training completed to be compliant. Today, no one is standing waiting for the next change to come down the hall, which makes it even more important that we work with synergy across the institution.

We must support and arm ourselves with the tools, processes and technology that facilitate clear communication. We need to define the review and reflection process of our policies, cultivate open discussion and dialogue all while engaging with other departments and units about the need for change, seek an understanding of the barriers for everyone and then provide the necessary follow up to make the needed changes for lasting growth and compliance.

In September, I wrote “Don’t wait for a crisis to create an efficient policy management system.” That ‘safety net’ is one great way to engage a team to ensure compliance, a tool that builds structure – whether you are a small scale operation or a larger scaled institution, a system and a plan is critical. A plan gives both leaders and others a path forward and provides the principles needed to navigate change. In December 2022, Michele Gross (University of Minnesota) wrote “The First Element: Meeting at the Intersection of Policy and Compliance” - outlining the first of seven elements of a compliance program and the importance of the system to frame our compliance at our institutions. For those who may not be aware, the seven elements of a legally effective compliance program are:

1. Policies & Procedures
2. Chief Compliance Officer/Compliance Committee
3. Education & Training
4. Reporting
5. Monitoring & Auditing
6. Enforcement
7. Responding To Issues

GRC 20/20 Research, LLC wrote “A Tsunami of Change Overwhelms Compliance,” which states that some institutions have broken processes and insufficient resources to manage compliance. I know that there is not one size fits all -- there can’t be. This is why we must continue to evolve – we should rearrange our priorities when we have too much of anything as Sara Gigeroff (University of New Brunswick) wrote in her blog What’s In Your Closet? (Feb 2023). More importantly she states that communicating, setting boundaries, purging, and revaluating are all key elements in managing our policy framework…and our closets!

There's no time like the present to simplify. Legacy systems are expensive and difficult to use. Manual processing is far too time-consuming and in a hybrid environment its not effective. I say m ake retention simple for users and administrators, so they don’t have to interact with files in a separate, siloed repository or go through cumbersome, manual processes. We must invest in this process for it to be effective. Who can remember five-sheet carbon paper? Now that was cumbersome! We have evolved since carbon paper, but some institutions are still stuck in the dark ages when it comes to making a compliance program a priority.

Who is your untapped potential – identify them and get them on board. This process, more than ever, needs support and buy-in from our leadership and other stakeholders across the institution to be successful (more hands make less work). Beware of analysis paralysis – encourage administrators to work with broad strokes. Show them how proactively setting the boundaries for document lifecycle management, rules for sharing and record management classifications can make work simpler, more consistent and save money. If it was possible to make policies ‘fun’ I would say do that too!

Other areas that untap that potential are field experts like our colleagues at ACUPA . They are an excellent way to leverage all our tools – garner support and encourage others to join in the conversations and become members.

It only takes one incident, one mistake, one error to mark an institution’s reputation and erode trust. In my opinion, our untapped potential may simply be harnessing the power of workplace collaboration and an ability to accelerate the processes to protect our most valuable information.

Implementing a "Policy on Policies"

If you've been in the policy administration business for any length of time, you've likely heard about, considered, and/or implemented a "policy on policies" at your institution. For those of you who don't already publish such a policy, I thought I'd discuss why I believe that it's a valuable tool to have in place.

Policy development is an important function, but getting administrative buy-in and notice of the importance of consistent policy development and tracking is sometimes difficult. Having a "policy on policies" provides an agreed-upon process for developing, reviewing, and approving policies, and ensures better compliance with the rules, regulations, and agreements that govern the business of higher education.

Here are some things to consider when creating or updating a policy on policies at your institution:

• Applicability
• Equity Review
• Required Policy Review and Approval Steps
• Templates or Framework

I'm also providing brief descriptions below of how we've chosen to handle these considerations here at Washington State University (WSU).

Applicability

Do you want a policy on policies that applies to all or only some policies?

At WSU, as with many public research universities, we have many types of institution-wide policy publications in place -- administrative policy manuals, academic policies and procedures, personnel manuals, research-related manuals, and our Washington Administrative Code (WAC) regulations.

When we first published an executive policy on policies, our administration decided to apply it to all policies except academic and single-unit or single-campus policies and procedures. The policy at that time outlined a draft/review/approval process that all policy publication departments were required to follow. Our policy on policies was revised recently to apply only to policies intended for publication in the four administrative policy manuals and the WAC regulations, which are managed by my office.

Equity Review

Do you want to include an equity review requirement in your policy on policies?

Our administration, including academic leadership, recently approved an equity review process, which includes an equity lens tool. My office agreed to publish the equity lens tool from our new Policy Development website, and to include discussion of the required process in the policy on policies.

Equity lens review includes review and approval both during the policy discussion phase and during the formal drafting and review phase of policy development.

And in the interest of increasing transparency and WSU community input, our Policy Development website includes descriptions of administrative policies under development and copies of drafts of the policies under review. (Copies of administrative policy drafts are available to WSU members only.) Copies of proposed WAC amendments continue to be published through the Washington State Register (WSR), and our Proposed WACs website links to the WSR proposals and public hearing information.

Required Policy Review and Approval Steps

Do you want to include specific actions for policy developers to complete when requesting new or revised policies, or removing policies? Do you want to have separate processes for major revisions and minor revisions?

In order to ensure that steps such as conducting the equity review, involving my office (for preparation and process oversight), and obtaining approvals from necessary administrators are completed, we decided to include step-by-step process instructions in our updated policy on policies. Our administration agreed to allow an abbreviated approval process for minor revisions.

Our policy on policies also includes periodic review requirements. For the most part it was decided to make the applicable administrative departments responsible for periodic review, as my office has a very limited staff (just two of us).

Template or Framework

Do you want your policy developers to use a template, or will you provide a policy framework to them for reference?

As I wrote in a previous blog a year or so back, we had for many years not required templates for policy development, but instead provided framework recommendations upon request. However, our compliance administration decided to implement a template for our executive policies and a template for our business and safety policies and procedures. (Links to these policy templates are available from our Policy Development website In the interest of moving forward with the updated policy on policies requirements as soon as possible, we have not applied the templates to our existing policies, but plan to restructure our policies as revisions occur. (Again, this is mainly due to staffing limitations and workload.)

In conclusion, if you haven't already implemented a "policy on policies," I highly recommend doing so. Having one in place greatly assists both policy developers and members of the policy administration office, by providing readily-accessible guidance and structure.

Note to ACUPA Members

Be sure to look at the ACUPA Templates and Other Tools webpage for samples to use to guide policy development, revision, review, and removal. These templates, guides, and tools have been developed from samples provided by policy administrators at multiple institutions and can be invaluable resources.

How Knowing What Others are Doing Can Help You

Why does this policy have these requirements? Why does that policy exclude those? Why do we even have a policy on this? These are questions that often garner the response, “That’s just how we’ve always done it.” If that is the best answer you can find, it’s time to benchmark. This post offers a few suggestions for organizing your search.

What to Look For

First, decide what aspects of a given policy you want to review. Just reading through policies from other colleges and universities without an idea of what to look for will be a waste of your time. Consider what it is you want to change about an existing policy or what questions about a new policy you want to answer. This may include things like:

• Policy owners. Some policies have an obvious owner, like HR, IT, or Dean of Students Office. Others might be a little gray if they have wide application and straddle more than one area, like records retention or volunteers on campus. This is a data point that you can easily look for.
• Administrative structure. This includes things like whether to have a committee review something or just one person, the level at which a decision can be made, and what needs to be approved in advance.
• Scope. Which employees are covered by the policy? Does it also apply to students? Is there a dollar limit or threshold? Should the topic be broken down into more than one policy or should two policies be combined? These are just a few examples of the kinds of things that you might be questioning about your policy scope.
• Forms. Maybe you have a great policy already but need to create or update a form. Benchmarking can be used for that too by identifying which fields to include, whether to require a signature, etc.

Where to Look

Which institutions you include in your benchmarking will depend somewhat on who will be reviewing the results and how drastic the proposed changes may be.

• Your conference peers. If your college has athletics, you can’t go wrong benchmarking the institutions within your conference. This often holds a lot of water when you need to share the results with executives and/or faculty. Most schools have their policies posted online, especially public institutions. Bookmark the policy libraries of your peers so you can quickly browse to them when you need to. If your conference includes schools that publish their policies behind a login, you may need to email each institution individually to ask if they will share their policy with you.
• ACUPA colleagues. Post your questions to the ACUPA forums. Many of our members are willing to share their documents, and posting to the forums prevents you from having to send individual emails. The results can supplement the findings from your conference peers or be used alone.

How to Document

I find spreadsheets to be the best way to organize my information. Use one axis to list all the institutions and the other for your findings. Try to word the headings in a way that allows for easy comparison within a column or row. For example, using a question that can be answered yes or no makes it easy to see whether there is a strong tendency one way or another. Not all information can be answered with a yes or no, so in those cases, consider converting terminology, office names, or titles into ones that your institution uses. This allows you to compare apples to apples rather than a hodgepodge of terms. I also like to include a link to each policy as one of the columns or rows for easy reference.

Whether it’s time to revise a long-standing policy or draft a new one, benchmarking what other institutions are doing can save you time in the long run.

Don’t Wait for a Crisis to Create an Efficient Policy Management System

Policy management, by definition, is the creation, organization, approval, and dissemination of policy and procedure documents...and so much more. With our university structure developing, changing, and delivering at a faster pace, it's no wonder that chaos can ensue when there is an abundance of changes and many individuals and departments involved. Once, not so long ago, we were all in the same relative space—now we find ourselves in a virtual world with multiple campuses amid constant change.

Policy management is the art of taming the chaos, organizing the mess, and streamlining the entire process. In the university we look to the boards, senate, and leadership to set the standards for the institutions to follow and our policies articulate those visions set in everyday concrete terms. 

A policy management strategy helps everyone set expectations, provides direction for institutions, and guides important decision making. Strong policy management also minimizes the potential risks and liabilities for all areas of the university or organization.

Did everyone read this policy? Where is the latest update? Who’s responsible for monitoring and enforcement? Why are there similar policies from different units? And why do these two contradict each other?

No matter how advanced your policy management is, an institution can always benefit by making it centralized and easy to access and distribute. It is more than just keeping everything in a three-ring binder. It’s the creation, approval, organization, and dissemination of all policy and procedure documents. It also refers to the modernization of your manuals and records. In today’s world records management is not a physical item in a file drawer, it’s a virtual system of living documents that adapt to the changing landscape and the ever-changing threats and risks to the institution. It must be an accessible and easy way of disseminating new or amended policies to the stakeholders, and in many cases the institution or responsible authorities need to track and collect data on who reads them, and track compliance with rules, regulations, and laws that affect our institutions.

Policy management (a unified system) in the 21st century is critical. It’s your plan for distributing information simultaneously and efficiently. More importantly, it ensures that policy communication and implementation are in sync and centralized in one location. Its important that there be a clear and visible records management system and team in place at every institution.

It only takes one incident, one mistake, one error to mark an institution’s reputation and erode trust. As my colleague Deborah Bartlett, Washington State University recently wrote in Protecting Essential Records -- Key to Surviving a Catastrophe, “It’s crucial to consider the importance of your records and how to protect them...”

Policies should not be a ‘set-and-forget’ list of rules. If 2020 has shown us anything, it’s that we need to adapt and change with the times, and our policies need to reflect those ideologies.
Think without a box, be creative (where budgets are tight), and importantly be centralized and organized. I enjoyed this quick video that the University of British Columbia's Records Management Office created when they introduced key concepts of UBC Policy 117. It’s a fun watch and gave me a sense of direction and confidence in the system: Records Management 101: Policy and Responsibility.

This doesn’t mean you need a policy for every incident or change in the business or social climate. Rather, you should set up a regular review process that includes a centralized team to ensure the policies are accurate, relevant, and effective.

Everyone learns and understands differently, which for me emphasizes the need to ensure that the system and documents are accessible, understandable, and that training is provided. The right policy management system lets you be proactive in preventing problems, as well as giving you concrete processes to resolve the situation quickly and professionally. Frustration is only amplified when individuals can’t find the policy, or the wrong policy is being used.

Don’t wait for a crisis to change policies. You need a framework that addresses our new reality, and the need for responsive change and innovation is now.