Policy on Policies

Policy #: 
ADM 201.001
Executive Owner: 
Chief Compliance Officer

The policy is effective throughout the University.


This policy describes and establishes process and standards for developing, reviewing, approving, updating, and amending AdventHealth University (AHU) policies as defined below.  By adopting this policy, the University seeks to enhance ethics and integrity, operational efficiencies, best practices, effective decision making and compliance with laws and regulations across the University.

The policy also helps ensure that University policies/standard operating procedures are easily accessible and understandable, widely disseminated, consistent and standardized to the extent possible, and approved in an appropriate way.  AHU aspires to maintain a policy framework that best serves its mission and represents and supports excellence, ethics and compliance in all its activities.  This policy is not intended to confer legal rights on anyone. This policy does not establish required procedures that must be followed for a policy to be legally binding.



A University Policy is a policy with broad application throughout the University, which enhances the University’s mission, promotes operational efficiencies, reduces institutional risk, helps ensure compliance with applicable laws and regulations, promotes ethical standards and integrity, and is approved in accordance with the procedure described in this policy.

Development of a New University Policy

When a new University Policy is needed, the appropriate Executive Owner oversees the drafting and development process and may designate and authorize others to assist. In developing or amending a University Policy, the Executive Owner will confer with others in the University who may be significantly affected by the Policy or who have relevant expertise in the subject matter.  Executive Owners may consult with the Office of the President at any stage in the development process and in interpreting policies that have been adopted.  The University Policy will be submitted for approval (see approval below).

Policy/Standard Operating Procedure Format

To ensure consistency, a standard policy/standard operating procedure templates have been created.  Use of the standard templates facilitates the adoption of clear, concise policies and procedures throughout the University.  All policies/standard operating procedures should conform to the University Templates and all sections must be included.  If a section is not applicable enter “N/A” under the section heading.  Policy numbers will be assigned by the Policies and Procedures Committee.


The approval process stated here applies to adoption of new University Policies and significant amendments to existing University Policies.  Any Executive Owner, as identified above, is able to develop a University Policy, however all University Policies must be approved by the President’s Council prior to implementation.  The Board of Trustees has given authority to AHU administration to approve and implement the policies  The Board of Trustees will ensure that the institutional policies and procedures are current and properly implemented.

Policy Dissemination Communication and Availability

University policies are posted on my.ahu.edu under Policies and Procedures by the Chief Compliance Officer.  Any electronic republication of, or reference to, a University Policy must be by hyperlink to the official AHU policy web site.  An email to campus will notify employees of new and currently revised policies.

Review Period/Policy Amendments

Every University Policy shall be reviewed at least once every two (2) years, or more frequently at the discretion of the Executive Owner.  Executive Owners should review and update policies to ensure compliance with best practices, laws and regulations and seek approval of any material changes. The Chief Compliance Officer will send an email to the Executive Owner when the review is needed.  The Executive Owner will make any changes needed.  If substantial changes, the policy will go through the approval and dissemination process.  If no changes or non-substantial changes, the Executive Owner will let the Chief Compliance Officer know and the policy will be updated with the review date and post it to the web site.

Other Policies

Policies that do not meet the definition of University Policies and do not come within the scope of this Policy – for example, campus or unit level policies- may be promulgated by authorized individuals but must not be inconsistent with any applicable University Policy.


Academic Policies:  Academic Policies are policies which directly affect the educational and research mission of the university.

Administrative Policies:  Administrative Policies are non-academic policies governing the operations of the university.

Student Policies:  Student Policies are policies which directly affect student life at the university.

Executive Owner:  An Executive Owner includes the President, members of the President’s Council, and an employee specifically delegated by such individuals to develop a University Policy.

Procedure:  A procedure is a guideline or series of interrelated steps taken to help implement the policy.

Approved by: 
Edwin Hernandez
Effective Date: 
Monday, March 9, 2015
Review Date: 
Friday, August 23, 2019
Tuesday, March 21, 2023
Friday, April 7, 2023