Creating & Maintaining Policies & Procedures

I. Scope

This policy applies to William & Mary as a whole university, including the Virginia Institute of Marine Science (the university).  It applies to all members of the university community, including faculty, staff and students. 

II. Purpose & Policy Statement

William & Mary is committed to supporting and promoting a culture of integrity and accountability in which all university employees and students act in an ethical, honest, and lawful manner. William & Mary communicates expectations for such conduct to members of the university community through written policies and procedures. University members are required to follow and uphold all applicable policies and procedures and to comply with this policy when creating and maintaining policies and procedures.

Responsibility for developing, implementing, and training to a specific policy falls to the designated Responsible Office. The Office of Compliance & Equity (OCE) is responsible for ensuring that a Responsible Office follows proper policy development and approval processes in compliance with this policy.  The Responsible Office is accountable for the policy’s accuracy, timeliness, and education and awareness to appropriate audiences.

III. Definitions

• An Administrative Policy addresses operational expectations applicable to the whole university and/or compliance with applicable laws, regulations, policies and procedures.  Creation of or substantial revisions to an administrative policy are subject to approval by the President’s Executive Leadership Team (ELT).
• A BOV Policy is an Administrative Policy that addresses matters of university governance or requires BOV approval to be effective. The authority to determine when a Policy warrants Board of Visitors’ level of approval rests with the ELT in consultation with the President and University Counsel.
• Enforcement is the consequences for the failure of an individual, department, unit, division or school to comply with the requirements of a policy or consequences for engaging in prohibited conduct of a Policy.  Consequences may include, but are not limited to, corrective actions, educational requirements, financial implications and/or disciplinary action.
• The Executive Leadership Team is the senior leadership of the university administration; the designated group that works with the President to set strategic direction and communicate it to stakeholders.
• Guidelines provide additional detail and direction on Administrative or BOV Policy and suggest a recommended or preferred course of action or behavior; guidelines are generally relevant to implementing university policy and do not supplant the requirements of established Policy. Guidelines are distinct from policies and procedures which mandate actions by university members. Guidelines should not be used in lieu of a policy when certain behaviors and actions are required of university members.
• An Interim Policy is a provisional Administrative or BOV Policy that fulfills an emergent need, which requires implementation pending the prescribed approval process. An Interim Policy is limited in term to one year or less and is subject to approval by the ELT.
• Local Policy meets the unique needs of, and generally applies to or affects, one unit, division, department or school.
• Minor Revisions are those changes that do not alter the scope or application of an existing Policy. Examples of Minor Revisions include, but are not limited to, title changes for individuals or departments, spelling corrections, updated hyperlinks, or addition of new relevant documents.
• A Policy articulates requirements and expectations for behavior, actions and activities of the university community. A Policy may require or prohibit an action, support compliance with applicable laws and regulations and/or mitigate risk.
• The Policy Library is the official repository of all interim and final Administrative or BOV Policies currently in effect. Local Policies reside in the applicable unit, division, department, or school.
• The OCE’s Policy Program oversees the development, review and approval processes for policies and procedures. This Program provides guidance to the Responsible Office, President, ELT or respective designees and maintains a current and comprehensive Policy Library website to provide access to all Whole University Policies.
• The Policy Statement describes the purpose, key requirements and expectations of the Policy.
• Procedures include mandatory actions and processes necessary to comply with a Policy, support compliance with applicable laws and regulations, and mitigate risk. Policies may or may not include procedures. For purposes of this Policy, all references to Policies include procedures unless otherwise noted.
• Related Documents are documents critical to the development of relevant Policies and Procedures and may include federal regulations, state regulations, state policies and other William & Mary Policies, Procedures and Guidelines.
• The Responsible Office is the administrative office responsible, through the action of an individual policy owner within the office, for developing and implementing the Policy, including ensuring accuracy of the subject matter, training appropriate audiences, enforcing and monitoring compliance with the policy, and timely review.
• Subject Matter Experts are individuals who have significant knowledge and skills in a particular area or topic through extended study and practice.
• Substantive Revisions are those that alter the scope or application of an existing Policy and, therefore require approval through the prescribed Policy process.
• For purposes of this policy, Timely Review means a required review and revision at least as often as every three (3) years (triennial review) and more frequent revisions as required by legal, regulatory and other developments.
• Whole University Policy refers to Administrative Policies and BOV Policies that apply to William & Mary as a whole university, including the Virginia Institute of Marine Science

IV. Policy

A. Administrative Policy

Creation of or substantive revisions to an Administrative Policy applicable to William & Mary as a whole university require:

1. Approval for development of a new Administrative Policy by the Executive Leadership Team (ELT)
2. A review by the University Counsel
3. An optional period of 10 business days to allow for notice and comment from the university community
4. Final approval from the ELT prior to becoming effective
5. Certain Administrative Policies require additional approval from the Board of Visitors (BOV).

B. Local Policies

Policies applying to individual units or departments within the university do not require approval from the President’s ELT or BOV. Local Policies must not conflict with Administrative or BOV Policies. If a Local Policy conflict exists, the conflicting elements of the Local Policy have no effect.

C. Interim Policy

In certain circumstances, an Administrative Policy requiring expedited implementation may take effect with interim approval according to this policy (See §V.D).

D. Policy Library

The OCE maintains in the Policy Library official versions of all Whole University Policies in effect and is responsible for retention and destruction of policy documents in accordance with the Library of Virginia’s Records Retention and Disposition Schedule.

V. Procedures

A. Creating New Administrative & BOV Policies

• Initiation Phase: Responsible Office assesses the need for an Administrative Policy through consultation with the ELT member with oversight of the Responsible Office.  Assessment shall include:
    A. A summary of the Policy purpose
    B. The goal of the Policy (e.g. requirement or prohibition of conduct, risk mitigation, compliance with state or federal regulation, state policies, protection of health or safety, fiscal responsibility)
    C. The justification for creating an Administrative Policy
• Concept Approval: The ELT member with oversight of the Responsible Office will secure approval from the entire ELT for initial drafting of the proposed Policy to proceed.
• Drafting Phase: The Responsible Office is responsible for completing the following steps prior to seeking final approval:
  • Designate an individual representative within the Responsible Office who will communicate with the OCE and draft the policy in consultation with stakeholders and relevant subject matter experts.
  • Consider appropriate substantive requirements, potential impact on university stakeholders, and other university Policies either in final or draft form.
  • Contact the Office of University Counsel, as needed, for legal advice regarding the need, scope, and substantive requirements of the new Policy.
• Review Phase: The Responsible Office submits a draft policy utilizing the William & Mary Policy Template and an Executive Summary of Proposed Policy to the OCE. The Executive Summary of Proposed Policy includes: the reason for the Policy’s creation; general points covered in the Policy; information noting the stakeholder offices or personnel that have provided input to the Policy draft; other universities’ policies or resources considered in drafting; and a general assessment of the Policy’s impact.
  • The OCE reviews the draft Policy to ensure proper formatting, compliance with applicable regulations, compatibility with other Administrative and BOV Policies and consistency and clarity throughout the policy. The OCE will also identify any additional stakeholders and recommend collaboration with other university units (e.g. Human Resources, Finance, Faculty and/or Staff Assembly) as appropriate.
  • The OCE submits the draft Policy and Executive Summary to the Office of University Counsel for legal review and further revisions or recommendations to the draft according to relevant legal advice. The Responsible Office through the ELT member with oversight over the Responsible Office submits the revised draft and Executive Summary to the entire ELT for review, questions, suggestions and comments. The Responsible Office, in cooperation with the OCE, responds to questions and comments and presents a further revised draft for final approval.

• Final Approval Phase: ELT may approve the draft policy or return the draft policy to the Review Phase for more editing and collaboration with stakeholders.  Approval or request for more editing shall be communicated by the ELT member who has oversight over the Responsible Office to the individual representative from the Responsible Office.
  • ELT shall determine whether an approved draft should be published for feedback from the entire university community prior to implementation. If publication is desired, the OCE shall publish the policy on its webpage and request feedback from the university community through the W&M Digest and Student Happenings for a period of at least 10 business days. For Policies that are published, Responsible Office and OCE shall review the feedback from the community and make amendments as appropriate. Submission of a final Policy document with amendments highlighted shall be submitted to the ELT for final approval. Final approval shall be communicated to the Responsible Office by the ELT member who has oversight over the Responsible Office.
• Implementation Phase: After obtaining final approval from the ELT, the Responsible Office shall:
  Submit the final approved Policy to the OCE for inclusion in the Policy Library. Notify the whole university community via W&M Digest and/or Student Happenings of the new policy’s effective date. Communicate, educate and train appropriate audiences on policy content and compliance.

B. Maintaining Existing Administrative & BOV Policies 

1. Compliance Monitoring and Enforcement: The Responsible Office is charged with monitoring for compliance with Policy requirements; identifying and reporting or addressing compliance issues; and evaluating the Policy’s effectiveness at achieving desired results and any necessity for changes on an ongoing basis.
2. Timely Review: The Responsible Office must review a Policy at least as often as every three years and follow the procedures below, as appropriate. The OCE will provide advance notice that the triennial review date is forthcoming.
      A. No revisions necessary: The Responsible Office notifies the OCE that the triennial review is complete and no revisions are necessary. The next revision date will be set for three years from the date of completion.
      B. Minor revisions: The Responsible Office makes all minor revisions, as defined by this policy, and submits the revised Policy to the OCE for verification and posting to the Policy Library.
   If only minor revisions are made during the triennial review, then the revision date will be updated; however, if the minor revisions occur off-cycle then the revision date will remain consistent with the triennial review schedule.
      C. Substantive revisions: If substantive revisions are necessary, a full review of the draft Policy is required. The Responsible Office is required to follow the Review and Final Approval Phase procedures noted in §V.A.4 and §V.A.5 of this policy.   The Executive Summary shall consist of the rationale for the substantive changes.
3. Retiring a policy: When a Responsible Office, in consultation with the applicable ELT member, determines that a Policy is obsolete, the Policy’s retirement may be considered as provided below.

• Retirement of an Administrative Policy requires approval by the ELT.
• Retirement of a BOV Policy requires approval by the ELT and BOV. The BOV reserves the right to delegate this to the ELT.
• The OCE will remove the retired policy from the Policy Library and take responsibility for document retention.
• The Responsible Office shall communicate the retirement of the Policy to the whole university community through the W&M Digest and Student Happenings. 

C. Local Policies

If a Responsible Office identifies a need for a Policy applicable only to an individual unit or units within the university, the Responsible Office or Policy owner should consult with the OCE to ensure the appropriate classification as a Local Policy and consider any related university Policies.
Local Policies that conflict with an Administrative Policy shall have no effect.  Responsible Offices are encouraged to follow the relevant procedures above to draft, implement, and maintain a Local Policy, including acquiring approval from the ELT member or designee with appropriate oversight.

D. Interim Policy Status 

This status is to be used sparingly and in the most urgent of situations so as to provide great deference to this process in support of shared governance. In cases of urgent need, such as when required by accreditation, legal, regulatory, or remedial actions a Responsible Office may acquire interim approval from the ELT to implement an Administrative or BOV Policy, whether the situation calls for a new Policy or Substantive Revisions to existing policy. To acquire interim approval, the Responsible Office must have the interim draft reviewed by the OCE and University Counsel, then acquire ELT’s final approval.
 
Within one (1) year of the approval as an Interim Policy, the Responsible Office must complete all required policy making procedures outlined herein to make the Interim Policy final. If a Responsible Office fails to acquire such approval within one (1) year, the policy may be removed from the university policy library and be deemed ineffective or the substantive changes may be removed and the previously approved version of the policy will become active again. The ELT reserves the right to extend this term.

VI. Enforcement; Complaints, Grievances or Appeals

This policy is enforced by the ELT and the OCE.  Noncompliance with this policy shall be referred to the ELT member over the Responsible Office and may result in disciplinary action up to and including termination.   William & Mary supports an environment free from retaliation.  Retaliation against any employee who brings forth a good faith concern, asks a clarifying question or participates in an investigation is prohibited. 

VII. Authority & Amendment, Implementation

This policy is approved by President. The ELT is charged with implementation of this policy.

VIII. Related Documents

William & Mary Policy Template (docx)