Policy Framework - Procedures - University of the Sunshine Coast, Queensland, Australia

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Policy Framework - Procedures

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Approval authority
Vice-Chancellor and President
Responsible Executive member
Vice-Chancellor and President
Designated officer
Director, Governance and Risk Management
First approved
28 August 2007
Last amended
29 April 2020
Review date
5 December 2024
Related documents
Delegations Framework - Governing Policy
Governance Framework - Governing Policy
Policy Framework - Governing Policy
Linked documents
Policy Framework - Governing Policy
Related legislation / standards
University of the Sunshine Coast Act 1998 (Qld)
Tertiary Education Quality and Standards Agency (TEQSA) Act 2011
Higher Education Standards Framework (Threshold Standards) 2015
Human Rights Act 2019 (Qld)

1. Purpose of procedures

This document is to be read in conjunction with the Policy Framework – Governing Policy. It sets out steps to operationalise the Policy Framework – Governing Policy, and outlines processes for the management of the policies and procedures throughout their lifecycle.

2. Scope and application

These procedures apply to all University policies and procedures developed under the Policy Framework – Governing Policy. These procedures can be further supported by guidelines and other local documents as identified in the Policy Framework – Governing Policy.

3. Policy development and lifecycle

The section outlines steps in a normal lifecycle of a policy.

Figure 1: Policy development and lifecycle

The development or review of University policy and procedures may result from:

  • recognition of a need (such as legislation, Council or committee resolution)
  • a change in strategy or circumstances
  • organisational change
  • the regular cycle of the policy development and lifecycle
  • issues in implementing or interpreting policies or gaps in policy coverage

Policy development needs to:

  • be applied broadly across the University
  • endure across time and administrations, and (where possible) change infrequently and set the course for the foreseeable future
  • support operational efficiency
  • be aimed at reducing or managing institutional risk
  • be relevant and transparent in its intent and meaning
  • be developed with consultation
  • assign authority for decisions required under the policy
  • comply with legislation and regulatory requirements
3.1 Steps in the policy development and lifecycle:

(a) Assess

  • Confirm requirements for a new policy/procedure or amendments to existing policy/procedure
  • Gather background information on the issue to determine whether a policy or procedure is required (Example: there been a change in legislation or government policy, a new strategic direction for the University, or gaps identified in existing University policy)
  • Review existing legislative or regulatory requirements
  • Check existing policy and procedures which may cover the issue and could be amended to address the change
  • Consult with Governance and Risk Management regarding:
  • the requirement for the new policy/procedure and ensure that the issues do not overlap with other documents under development
  • determine where the proposed policy/procedure fits within the Policy Framework
  • templates and toolkit available: refer to Policy Framework Guidelines
  • Establish key principles which apply to the policy issue
  • Identifying human rights that may be affected by the decision
  • Consider issues of implementation actions for the proposed policy/procedures

(b) Consult – High Level

  • Consultation with key stakeholders is recommended to assist with testing the policy/procedure options and to identify gaps that may have been overlooked. The consultation process should:
  • Identify target groups and individuals to be consulted
  • explore the option of a working group if appropriate
  • Provide a mechanism to gather and consider options and concerns, and provide feedback to demonstrate that stakeholders’ views are being considered
  • Consider operational practicalities
  • Commence drafting the communication/implementation plan by:
  • identifying tasks to be completed to implement the policy
  • assigning responsibility to individuals or groups
  • identifying resources needed to implement the policy
  • specifying communication requirements for the policy including actions required for staff to implement the policy

(c) Research

  • Explore the issues in detail
  • Clarify any terminology, check the University’s Glossary of Terms for Policies and Procedures
  • Benchmark against other similar organisations where appropriate
  • Consider the University’s obligations as set out in the Human Rights Act 2019 (Qld).

(d) Draft

  • Use templates and toolkit available: refer to the Policy Framework Guidelines
  • Adhere to the principles set out in the Policy Framework
  • Adhere to the University Style Guide for Print and Web
  • Be clear about actions required, ensure actions are practical and able to be implemented
  • Use version control – retain a tracked change version
  • Prepare the draft communication plan and liaise with staff in units who will be responsible for communication/implementation tasks to establish timeframe and mechanism for completing the task
  • Prepare the draft statement of compatibility in accordance with the requirements of the Human Rights Act 2019 (Qld)
  • Consult with Governance and Risk Management for feedback on draft

e) Consult – Broad Level

  • Make draft policy/procedures available for comment by stakeholders affected by the document – preferably all staff (where appropriate) on MyUSC
  • Make draft policy/procedures available for comment by committees and advisory groups if appropriate
  • Obtain legal advice if appropriate
  • Collate feedback information to inform the final draft where appropriate
  • Make appropriate amendments to the drafts, revise communication/implementation plan where required

Note that it is mandatory that all impacted stakeholders are consulted in relation to amendments to existing policies/procedures or the introduction of new policies/procedures.

f) Pre-approval

  • Submit completed documentation to Governance and Risk Management for review and endorsement, prior to seeking approval.
  • For Operational Policies and Governing Policies, submit to the University Executive for discussion and endorsement – note that consultation must have taken place prior to this occurring.
  • Academic Policies will be considered by Academic Board and its standing committees.
  • When undertaking the pre-approval process, the following documents need to be submitted:
  • Relevant Cover Sheet or Memo for signature
  • Policy Cover Sheet, including a communication/implementation plan and statement of compatibility with human rights
  • Draft policy/procedures
  • Summary of consultation and feedback where appropriate

g) Approve

  • Submit to the appropriate approval authority with the accompanying paperwork and cover sheet.
  • Once approved, Governance and Risk Management will record documents in the University’s Policy Repository, which then updates nightly to the University’s Policy and Procedures webpage.

h) Implement

  • Advise relevant stakeholders of the approved policy/procedure and the impact including any publications and information available – this is to be undertaken by the Designated Officer.
  • Communicate and implement the policy as per communication/implementation plan – this is to be undertaken by the Designated / Responsible Executive Member.
  • Annually attest to compliance with the policy as per the annual compliance attestation process set out in the Compliance Management Framework and procedures.

i) Review

  • Follow up regarding implementation of the policy/procedure by stakeholders
  • Undertake a comprehensive review process at least every five years, or more frequently as required.
  • If a new policy/procedure or amendments are required, commence step (a) Assess

4. Templates and toolkit

The templates and toolkit available have been developed to reflect the policy development and lifecycle. These are made available in the Policy section of MyUSC.

5. Policy management

5.1 Governance and Risk Management is responsible for the implementation of the Policy Framework through facilitation of processes identified in the policy development and lifecycle.

5.2 Central to the policy management system is the University’s Policy Repository. The Repository is managed by Governance and Risk Management to ensure the integrity of the University’s policy information management. The Repository is considered the authoritative source for the University’s policies and procedures. The Repository provides the ability for the University to monitor and report on the progression of policy throughout its lifecycle.

5.3 Governance and Risk Management may make the following type of minor editorial and consequential amendments to policies and procedures without requiring formal approval:

Type of minor editorial change Examples
Document Title Student Grievances and Appeals – Governing Policy > Student Complaints and Appeals – Governing Policy  
New Documents replacing rescinded Documents Doctoral Degrees – Academic Policy > Higher Degrees by Research – Academic Policy
Position Title Program Leader > Program Coordinator  
Organisational Student Life and Learning > Student Services and Engagement  
Legislation title Workplace Health and Safety Act 1995 (Qld) > Work Health and Safety Act 2011 (Qld)  
Government Department name Department of Education, Employment and Workplace Relations (DEEWR) > Department of Education and Training  

5.4 No editorial changes shall be made without approval if they alter the scope, purpose or intent of the document. Organisational restructures or position title changes that would result in changes to authorisations require formal approval.

5.5 In the circumstance where structural changes to the University result in a position change referenced in a particular policy or procedure, the Vice-Chancellor and President may nominate an alternate member of the University community to operationally undertake the role or authority associated with the particular policy or procedure action, until such time as a formal amendment is made.

5.6 Whilst Governance and Risk Management is responsible for publishing approved policy and procedures information, the Responsible Executive Member is ultimately responsible for the communication and implementation of the policy and/or procedures.

6. Compliance

The University’s approach to compliance is outlined in the Compliance Management Framework – Governing Policy and associated Compliance Management Framework – Procedures. Several policies and procedures set out specific steps to be taken in the event of a breach or suspected breach, while others fall under the broader scope of compliance breach processes.

7. Roles and responsibilities

The following outlines roles and responsibilities of officers under this procedure:

Roles Responsibilities
Responsible Executive Member
  • Has overarching responsibilities for the policies and procedures within their portfolio
  • Ensures that all policies and procedures for which they are responsible are developed, approved and implemented within the requirements of the University’s Policy Framework
  • Ensures that appropriate consultation has taken place before seeking formal approval
  • Ensures that reviews of policy and procedures in their area are conducted as required by the Policy Framework to ensure that policies and procedures are accurate, widely understood and achieving their intended purpose. This includes ensuring that policy reviews are completed within the agreed policy review cycle timeframes.
  • Determines the effective date of the policy taking into account formal approval and the activities outlined in the Communication/Implementation Plan
  • Determines the need for an implementation review and any interim reviews as required.
  • Attests that when the policy or procedures were developed or reviewed, that the University has given proper consideration to its decisions in terms of compatibility with human rights.
  • Submits the proposed policy to the appropriate Approval Authority, via Governance and Risk Management, for approval as identified in the Policy Framework
  • Approves all procedures associated to the policy, unless otherwise indicated
  • Ensures that all approved policies and procedures are submitted to Governance and Risk Management
  • Approves any exceptions to policies or procedures (note Governance and Risk Management endorsement is needed for any exceptions to policy and procedures prior to approval).
Designated Officer
  • Has responsibility for operationalising the policy and/or procedure
  • Develops and implements the policies and procedures on behalf of the Responsible Executive Member within the requirements of the University’s Policy Framework
  • Undertakes appropriate consultation before submitting the policy or procedures to the Responsible Executive Member for formal endorsement/approval
  • Conducts reviews of policy and/or procedures in their area, as required by the Policy Framework, to ensure that policies and procedures are accurate, widely understood and achieving their intended purpose
  • Ensures that when the policy or procedures are developed or reviewed, that the University gives proper consideration to its compatibility with human rights by:
  • identifying human rights that may be affected by the decision; and
  • considering their compatibility with human rights; and
  • if any rights are limited, how that limit is reasonable and justifiable.
  • On behalf of the Responsible Executive Member, ensures that the all approved policies and procedures are submitted to Governance and Risk Management
  • Undertakes an attestation in regards to policy compliance annually as part of the broader Annual Policy Attestation Process.
Approval Authority
  • Approval Authorities for policies and procedures are outlined in the Policy Framework – Governing Policy, Section 5
  • Has authority to approve policies and procedures in accordance with the requirements of the Policy Framework
  • Approves policy on condition that the policy:
  • is lawful and consistent with any internal or external compliance requirements
  • is consistent with other existing policies
  • has suitable arrangements in place for implementation
  • Approves an effective starting date for the policy as recommended by the Responsible Executive Member
Governance and Risk Management
  • Monitors the consistency between high level policies and their associated procedures
  • Provides advice and support in policy development
  • Provides a quality and compliance check against the Policy Framework and other University governing policies
  • Manages policies and procedures through the Policy Repository and policy webpages
  • Maintains the currency and availability of policy templates and tools
  • Makes minor editorial amendments, as set out in Section 5.3.
  • Ensures policy amendments are reported to Council and Academic Board for noting as relevant.