1. Purpose of procedures

1.1 These procedures sets out the steps to operationalise the Policy Framework – Governing Policy, and outlines processes for the management of policy documents throughout their lifecycle.

2. Scope and application

2.1 These procedures apply to all staff and members of University decision-making and advisory bodies.

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

3. Definitions

Please refer to the University’s Glossary of Terms for Policies and Procedures. Terms and definitions identified below are specific to this policy and are critical to its effectiveness:

Amendments:

• Consequential amendment is made to bring a policy document into conformity with a University committee resolution or legal requirement or approved title change.
• Editorial amendment includes updating redundant terminology and a typographical change such as amending spelling, grammar, links or formatting that does not change the substance of a policy document.
• Minor amendment includes changes to enhance clarity or initial intent and does not change the substance of a policy document.
• Major amendment includes amended the substance of a policy document such as strategic direction or updating processes and amendments to delegations.

Approval authority is the committee or position with authority (or delegated authority) to approve a policy document within this Policy Framework.

Designated Officer is the most senior officer responsible for operationalising the policy document. The Designated Officer has delegated responsibilities to develop and implement the policy document on behalf of the Responsible Executive Member. Specific responsibilities are listed in full in the Policy Framework – Procedures.

Guidelines supports a procedure by providing further detailed statements on how to undertake the procedural element.

Local document sets out operational processes that facilitates policy documents or University activities.

Policy a statement of principles or position that is intended to direct decision-making and operations.

Policy documents includes any document that is part of the Policy Framework and includes policies, procedures, and guidelines.

Policy exception is a rare formal approval process to allow deviation from the policy document.

Procedures outline the operational steps required to implement policy.

Responsible Executive Member is the member of the University Executive with whom the policy matter most clearly resides. The Responsible Executive Member has overarching responsibility and accountability for the policy and related procedures and is accountable for the implementation and compliance of the policy. Specific responsibilities are listed in full in the Policy Framework – Procedures.

4. Development and amendments of policy documents

4.1 Prior to developing a new policy document or making amendments contact Governance and Risk Management for guidance on the process.

4.2 The development or review of University policy documents may result from:

(a) recognition of a need (such as legislation, Council or committee resolution);

(b) a change in strategy or circumstances;

(c) organisational change;

(d) the regular cycle of the policy development and lifecycle; or

(e) issues in implementing or interpreting policies or gaps in policy coverage.

4.3 There are three overarching steps in developing and amending policy documents:

• Step 1: Create
• Step 2: Approve
• Step 3: Implement

Figure one: Steps involved when developing and amending policy documents

4.4 Step one: Create

4.4.1 Contact Governance and Risk Management. If a new policy document is sought, an assessment on the suitability will be undertaken (see below). If amending a current policy document, Governance and Risk Management will provide the relevant word template and will provide guidance on the process as required.

4.4.2 New policy documents assessment

4.4.2.1 To meet the policy principle of simplifying and rationalising policy documents the following will need be addressed before a new policy document will be supported by the Director, Governance and Risk Management:

(a) is the policy document required? Is there another way to achieve the same outcome? or

(b) is there another policy document that contain similar or related information and if so, can that policy document be amended with the new content?

4.4.3 Assess

4.4.3.1 Prior to drafting, and throughout the create process, it is important to consider the issues and requirements. Key actions include:

(a) identifying the issue and consider the options for the appropriate solution;

(b) reviewing existing legislative or regulatory requirements;

(c) reviewing related and linked policy documents to ensure a cohesive approach;

(d) establishing the policy key principles;

(e) identifying human rights that may be affected or limited by the policy document; and

(f) identifying key stakeholders, consider whether a working party is required and identify issues for implementation.

4.4.4 Research

4.4.4.1 During the create process the following key research activities may be required:

(a) exploration of the issues in detail with relevant areas;

(b) clarify terminology and review the University’s Glossary of Terms for Policies and Procedures and ensure consistency;

(c) benchmarking against other similar organisations; and

(d) consider the University’s obligations as set out in the Human Rights Act 2019 (Qld).

4.4.5 Draft

4.4.5.1 Using the templates provided by Governance and Risk Management draft the policy document or the amendments (using tracked changes), ensuring:

(a) the policy document adheres to the principles set out in the Policy Framework – Governing Policy;

(b) use plain English and keep the language clear and concise as possible;

(c) use appropriate headings and sub-headings; and

(d) when proposing amendments, use tracked change.

4.4.5.2 Policy documents also need to:

(a) be applied broadly across the University;

(b) endure across time and administrations, and (where possible) change infrequently and set the course for the foreseeable future;

(c) support operational efficiency;

(d) be aimed at reducing or managing institutional risk;

(e) be relevant and transparent in its intent and meaning; and

(f) assign authority for decisions required under the policy document.

4.4.5.3 Consult with Governance and Risk Management for feedback on the draft to ensure consistency with the policy templates.

4.4.6 Consult

4.4.6.1 Depending on the changes the consultation process may take place before and/or after drafting or continuously throughout the create process.

4.4.6.2 It is mandatory that all impacted internal and external stakeholders are consulted, prior to seeking approval, in relation to amendments to existing policy documents or the introduction of new policy documents.

4.4.6.3 Governance and Risk Management can provide guidance on who should be consulted.

4.4.6.4 Consultation may involve:

(a) committee discussion paper prior to drafting to gain endorsement in principle for the proposal;

(b) a working party with all key stakeholders present;

(c) a mechanism for feedback to be captured and to demonstrate that stakeholders’ views are being considered;

(d) consideration of the operationalisation impacts;

(e) all staff consultation through MyUSC;

(f) targeted staff consultation;

(g) obtaining legal advice;

(h) obtaining external stakeholders’ feedback (i.e. Student Guild) as appropriate; and

(i) inclusion of feedback or if unresolved through further consultation, the issue to be considered by the relevant decision-makers or committee.

4.5 Step 2: Approve

4.5.1 Provide the final draft to Governance and Risk Management for review. Governance and Risk Management will:

(a) ensure that the terminology and formatting are aligned with the policy templates;

(b) ensure consistency between the related and linked policy documents;

(c) provides a quality and compliance check against the Policy Framework and other University governing policies; and

(d) determines the appropriate approval pathway based on the amendments or new policy document contents in line with the approval authority set out in the Policy Framework – Governing Policy.

4.5.2 Generally, the following committees will be required to endorse the changes prior to formal approval unless otherwise determined:

(a) Governing Policies to be considered by USC Executive and any other relevant committee(s) depending on the content and change;

(b) Operational Policies to be considered by USC Executive and any other relevant committee(s) depending on the content and change;

(c) Academic Policies to be considered by the relevant Standing Committee(s) of Academic Board and any other relevant committee(s) depending on the content and change;

(d) new and rescinded procedures and guidelines require endorsement from the same committees as their linked policy document; and

(e) procedures and guidelines amendments may require endorsement from the same committees as their linked policy document depending on the proposal.

4.5.3 The following documents are required for the endorsement process:

(a) Committee Coversheet (Governance and Risk Management will assist with the drafting);

(b) draft policy documents with tracked changes if proposing amendments;

(c) summary of consultation and feedback, where appropriate; and

(d) if a Governing Policy, a high-level summary of changes.

4.5.4 Committees may request changes that are to be implemented prior to approval progression. The requests may or may not be able to be met; the requests and outcome should be noted on the subsequent coversheets.

4.6 Step 3: Implement

4.6.1 Following approval, Governance and Risk Management will update the Policy Repository as per the effective date and the version will update on the Policy Library overnight. The changes will be noted on the Policy Review Schedule.

4.6.2 The Designated Officer is responsible for ensuring their Organisational Unit communicates the changes to the relevant stakeholders and for operationalising the policy document.

5. Policy document lifecycle and review

5.1 Policy documents must be reviewed at least every five years. Governance and Risk Management will advise the Designated Officer when their policy documents are due for review.

5.2 The considerations under sections 4.3.3 and 4.3.4 guide the review process.

5.3 Following a review, it may be determined that:

(a) no changes are required;

(b) minor changes are required;

(c) major changes are required; or

(d) rescission is required.

5.4 If minor, major amendments or rescission is required, section 4 of these procedures is to be followed.

5.5 If no changes are required, Governance and Risk Management will advise the relevant approval authority for the policy document and update the review date accordingly.

6. Templates and toolkit

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

7. Policy document management

7.1 Governance and Risk Management is responsible for the implementation of the Policy Framework through facilitation of processes as identified in these procedures.

7.2 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 policy documents. The Repository provides the ability for the University to monitor and report on the progression of policy throughout its lifecycle.

7.3 Governance and Risk Management may make the following type of minor editorial and consequential amendments to policy documents without requiring formal approval:

7.4 Editorial amendments do not include changes that 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.

7.5 In the circumstance where structural changes to the University result in a position change referenced in a particular policy document, 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.

7.6 Whilst Governance and Risk Management is responsible for publishing approved policy documents information, the Responsible Executive Member is ultimately responsible for the communication and implementation of the policy documents.

8. Compliance

8.1 The University’s approach to compliance is outlined in the Compliance Management Framework – Governing Policy and associated Compliance Management Framework – Procedures. Several policy documents 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.

8.2 The Designated Officer is required to annually attest to compliance with the policy document as per the annual compliance attestation process set out in the Compliance Management Framework and procedures.

8.3 On very rare occasions there may be a need for a policy exception that allows deviation from a policy document to enable a more appropriate result. The approval process for a policy exception must be followed prior to the deviation of the policy document.

8.4 Policy exceptions for policies and procedures must be endorsed by the Director, Governance and Risk Management prior to approval being sought from the Responsible Executive Member, who is the final decision-maker. The approval will be recorded by Governance and Risk Management.

8.5 Policy exceptions for guidelines and local documents must be approved by the Designated Officer. The approval will be recorded by the relevant unit.

9. Roles and responsibilities

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

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