Policy on Policies

Policy #:
ADM 201.001
Executive Owner:
Chief Compliance Officer
Scope:

The policy is effective throughout the University.

Purpose:

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.

Policy:

Policy

AHU will have one (1) policy management site administrator to oversee and manage the policy management site with AHU website. Additionally, every policy must have one (1) document owner to manage document content, review, and approve the workflow.

Policies, standard operating procedure (SOPs), and supporting documents will be authored, reviewed, approved, and periodically updated by individuals possessing the proper experience, expertise, and authority. The documents gain official status only when managed through the AHU approved Policy Management System. All documents will require formal approval by assigned AHU approving bodies.

Retired documents or previous versions of documents living in the Policy Management System, should be archived in the Policy Management System.

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 Policy Owner/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. 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. Each document is required to include at a minimum the effective date, scope, purpose, and the specific provisions of the policy and/or SOP guidelines.

Approval

The approval process stated here applies to adoption of new University Policies and significant amendments to existing University Policies.  Any Policy Owner/Executive Owner, as identified above, is able to develop a University Policy, however all University Policies must be approved by the AHU Cabinet prior to publishing and implementing.  

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 AHU all will notify employees of new and currently revised policies every quarter

Review Period/Policy Amendments

AHU policies, SOPs and any supporting documents must be reviewed and revised or affirmed based on regulations and standards set forth by governmental bodies, accrediting agencies, and internal institutional policies every two (2) years, if there are any changes, the policy must be updated to reflect the changes to be current. The Policy Owner/Executive Owner  must verify that the documents are accessible, relevant, accurate and current when submitting a policy. 

For substantial changes, the policy will go through the approval and dissemination process. If no changes or non-substantial changes, the Policy Owner/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.

For AHU Policies

It is the responsibility of the document owner/SME to verify any regulatory requirements regarding policy review.

  1. Identify Policy/SOP – New/ change is required/ needs revision.
  2. Create Draft for Policy/SOP
  3. For academic policies
    1. Present draft to the appropriate AHU committees for vetting and approval.
  4. For nonacademic policies
    1. Present draft in the policy and procedure committee for vetting and approval.
  5. Once approved in the appropriate committees, the final draft be placed in the AHU “workbench” for publishing and email will be sent to Chief Compliance Officer.
  6. The Chief Compliance Officer will publish the policy within 5 business days of approval from AHU committee.
  7. Once policies are published, education on the policies needs to be communicated on the departmental level and/or campus depending on the importance/risk.
  8. The Chief Compliance Officer will send out quarterly emails (March, June, September, December) with all the updated and new policies.

 

Definition(s):

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