CoM Policy and Procedure Guidelines

This document is intended to provide guidelines on the development of policies and procedures in the College of Medicine. This document will be housed on the College of Medicine Dean’s Office SharePoint site and will be updated as needed. If you have any questions or comments, please contact greg.power@usask.ca. 

Table of Contents

• Definitions
• Policy Guidelines
• Procedure Guidelines
• Onboarding
• Storage
• Review Process
• Policy Template
• Procedures Template
• Tracking and Review Template

Policy: A high level statement uniformly applied to make decisions, incorporating reasoning and values and normally mandatory

Guidelines: Provide direction to actions or behaviours, intended to improve order, may require flexibility to respond to circumstance.

Process: A general description of how the activity or task is performed.

Procedure: A detailed description of the steps to carry out an activity or task.

Policy Hierarchy

Policies that have local (college) applicability may exist at the college, department or unit level. Such policies are subject to university-wide policies. Policies for an individual college may diverge from overall university policy when there are certain aspects of the policy that are integrally related to the program and its students.

In the same manner, policies for an individual department, division, school, may diverge from overall College of Medicine policies should specific items be required in the policy.

 

Policy Authority

At the University of Saskatchewan, University Council has authority for the creation and approval of policy. University Council has delegated authority to each college’s faculty council. The College of Medicine Faculty Council has authority for the creation and approval of policies in the college. Department / division/school councils can make changes to policies as required, although substantive changes to policies may require Faculty Council approval, while other changes may simply require a FYI to Council from the department/division/school council. Administrative policies may not require approval from Faculty Council.

The Policies and Procedures framework is developed by the Dean’s Office of the College of Medicine, and is intended to be a guideline to departments. College departments are responsible for the creation and review of their own policies. Policies that might encompass multiple departments are encouraged to be developed in a collaborative manner. Ownership of a policy could be an individual in a department (position) or a committee.

Within department/division/schools, the policy approval process may be complex. There may be different approval processes for administrative and academic policies. It is encouraged that the approval process be mapped out to clarify each step in the process.

 

When do I need a policy?

Policies are intended to[1]:

• State the College’s position on issues which have college-wide application;
• Reflect and uphold the College’s governing principles;
• Identify and prescribe compliance with applicable laws, regulations, and other policies;
• Promote operational efficiencies;
• Enhance the College’s mission and/or reduce risk;
• Provide decision makers with limits, alternatives and guidance;
• Change infrequently.

 

Policy development, approval and administration process[2]

1. Identification of Need: Any member of the College of Medicine community may suggest that a new policy, or revision to an existing policy, is required.
2. Drafting and Consultation: The designated sponsor, who may be, for example, a dean, department head, director, or other senior administrator, will take responsibility for drafting the policy, including a communications plan and an implementation plan. The sponsor will also be responsible for carrying out appropriate consultation and for seeking legal advice if required. It is recommended that an Equity, Diversity and Inclusion lens is considered during the drafting and consultation phase. Policies may inadvertently create barriers for groups or individuals.
3. Initial Approval: The draft policy will be reviewed and a decision made whether to recommend the policy to the appropriate committee for approval.
4. Final Approval: The appropriate governance body will make a decision whether to approve the policy.
5. Implementation of the New Policy: Once approved, introduction and implementation of the policy will be the responsibility of the sponsor. The policy should be communicated to all relevant units, employees, and faculty, and arrangements should be made by the sponsor for appropriate training, interpretation, and compliance monitoring.
6. Maintenance of the Policy Portfolio: The sponsor’s department/division/school will take responsibility for curatorial aspects of the administration of policies, including keeping a directory of all approved policies and making these available on the College web site or internal SharePoint.
7. Policy Portfolio Review: The department/division/school will undertake periodic reviews of existing policies, identifying anachronisms, gaps and overlaps, and monitor the effectiveness of the ongoing administration of its policies.

 

Policy Naming and Numbering

Policies should be named in a clear manner, reflecting the content of the policy.

Personal names (i.e., responsibilities) should not be used in a policy. Refer to the position title or general office name.

 

Policy storage

A master tracking sheet is suggested to keep track of all policies and review dates (see: Tracking and Review Template).

Responsibility for upkeep of this tracking list, and annual review would lie with an administrative support person within each department. Storage of the list (and copies of the policies) could be on SharePoint, or on Jade.

[1] University of Saskatchewan Development, Approval and Administration of University Policies

[2] Ibid.

When do I need to develop a procedure?

Procedures are developed when a policy requires clear guidance on how to implement. Not all policies require procedures.

 

Procedure development and approval process

Procedures should be developed during the policy development stage, by the same group developing the policy. Consider the “implementers” in the procedure development stage, or you run the risk of developing procedures that do not work or are not feasible.

Procedures should be kept separate from their related policies (i.e., not in the same document). Policies should not be updated other than their regular review schedule, while procedures may be updated and changed regularly. A separate procedure document for the policy will not be subject to the approval process and will be easier to change as current practice changes.

 

Procedure naming and numbering

Procedures should be named to coincide with the related policy. Procedures can also be included on the website, if appropriate. Otherwise, procedures should be kept in an accessible location (SharePoint or Jade).

Units should develop a plan to inform new faculty/employees of the policies, including:

• Where policies are stored in the unit
• The policy creation and review process
• Important policies and procedures related to their position

• Policies essential to public use are placed on the website. The PDF or word documents of these policies should be stored in SharePoint or in Jade. Administrative procedures related to the policies do not need to be placed on the website, but should be stored alongside the policies in the same location (SharePoint or Jade).
• Policies not essential to the public (i.e., administrative policies only for staff use) should be stored in SharePoint or on Jade and accessible to all team and department members.

All policies (and related procedures) should undergo a review process. Each unit should develop their own review process. The policy template includes an area to indicate when the policy should be reviewed (or when it was last reviewed).

Policies should be reviewed at an interval that works for the unit. For example, on a rotating 5-year term, all of the Operations policies are reviewed, and are good for 5 years, then in the next year, all of the Finance policies are reviewed, and are good for 5 years. This eases the burden on reviewing all of the policies at once. Should substantive changes (i.e., compliance measures for accreditation) be required within the 5 year interval, the policy should be reviewed then. During the review, it is important to consider:

• Is the policy still necessary and accurate?
• Are changes required to clarify the policy or improve its effectiveness?
• Has the policy been reviewed with an EDI lens and by diverse stakeholders recently (see EDI Lens below)?
• Do any policy changes require consultation with the stakeholders?
• Do any tools or worksheets (or procedures) related to the policy require updating?
• Is this policy still in compliance and up to date with accreditation requirements?
• How will we communicate changes to this policy (if needed)?

Procedures can be informally updated as needed; they are a working document and should reflect current practice and not left to become outdated. As practice changes, the procedure should change.

Equity, Diversity and Inclusion (EDI) Lens

Policy development may create barriers for groups or individuals. Developing and reviewing policies with an equity, diversity and inclusion lens will ensure that potential impacts on all peoples are considered. When developing a new policy or reviewing a current one, ensure that you consider impacts from a broad concept of diversity (i.e., gender diversity, racialized peoples, Indigenous peoples, people with disabilities, 2SLGBTQ+, parents, caregivers, newcomers, etc.). Best practice is to develop and/or review policy in partnership with diverse individuals and groups.

For more information or support, connect with the College of Medicine’s Senior EDI Specialist, Erin Prosser-Loose.

New policies

Considerations

• Is this policy going to disproportionately affect individuals or communities (positively or negatively)?
  • Are there assumptions included in the creation of this policy that might not take into account others’ experiences?
• Does this policy perpetuate or help to dismantle historical, legal, or other barriers set in the past?
• Does this policy take into account:
  • systemic barriers, which are the result of the dominant social group, who are often those with decision making power, determining what is acceptable and appropriate
    • For example, consider power differentials, such as complaints made by a student or employee about an instructor or supervisor. a third party decision maker or advisor role to be involved in the process
  • fairness and flexibility in which decisions are made based on specific facts and circumstances, and not necessarily on the rigidity of having everyone follow the same process. The focus is on fair outcomes which does not always equate to treating them the same.
  • The Saskatchewan Human Rights Code, which prohibits discrimination against people based on the following protected grounds: 
    • (a) religion; (b) creed; (c) marital status; (d) family status; (e) sex; (f) sexual orientation; (g) disability; (h) age; (i) colour; (j) ancestry; (k) nationality; (l) place of origin; (m) race or perceived race; (n) receipt of public assistance; (o) gender identity
  • Is the language in this policy inclusive and clear enough for everyone to understand?
    • Use gender neutral language (ie. they/them rather than he/she), avoid stereotypes and biases, use person first language (ie. person with a disability rather than a disabled person) and acknowledge differences.

 

Recommended actions

• Broad consultation with a variety of different perspectives, including those who have different points of view about a Policy, (e.g. those who use service animals and those who have concerns about animals on campus)
• Ensure processes address power differentials, inequities and barriers to access
• Consider including EDI principles and values in the Policy. For example, in a section about principles or values that are the foundation of the Policy.
• Review academic research articles, relevant to the subject matter, from an equity, diversity and inclusion perspective 

Policies in need of review

Considerations and recommended actions (in addition to the “new policies” section above):

• Does the policy review group include enough diversity? Are there more perspectives to include?

Document change history

Effective date	Significant changes
September, 2020	Added EDI review questions
May, 2018	Document creation and approvals

 

[Title of Policy]

Category:	Leave this blank; a category will be assigned
Number:	Leave this blank; a number will be assigned
Responsibility:	Indicate the senior administrative position responsible for the policy(the sponsor)
Approval:	Who approves this policy?
Date:	Date initially approved: Date(s)  reformatted or revised

Purpose:

State the overarching purpose of the policy.

Principles:

Identify one or more guiding principles on which this policy is founded.

Definitions:

Identify one or more guiding principles on which this policy is founded.

Scope of this Policy:

Scope may include the groups (students, faculty, staff) to which the policy pertains, or other statements with respect to time periods, geographic locations (e.g. all campus buildings), funds (e.g. operating funds, research funds), etc.

This section should also reference other pertinent policies, legislation, regulations, collective agreements, etc. and explain their relationship to the policy.

Policy:

The statement of policy should be brief and direct.

Responsibilities

Indicate what responsibilities are assigned, and to whom, under the policy.  If there are different categories or levels of responsibility, this section can be used to delineate these.

Non-compliance:

If necessary, a statement can be made about the consequences of non-compliance with this policy. For example, students may be subject to discipline under the academic or non-academic discipline regulations; employees may be subject to discipline under procedures defined in collective agreements. 

Procedures:

For any given policy, sets of procedures may exist in different units to reflect local application, but all procedures must be compliant with the policy itself and should reference it.  This section should indicate where such procedures may be found, and who is responsible for maintaining them.  The procedures themselves should not be included in the policy. (Note that not all policies will necessarily require associated procedures).

Contact: 

Provide a name, title and unit, including e-mail address and telephone number.

SOP Number	Insert Number
SOP Title	Insert Title
	NAME	TITLE	SIGNATURE	DATE
Author
Reviewer
Authoriser

 

	Effective Date:
	Review Date:

 

Consultation
NAME	TITLE	SIGNATURE	DATE

 

purpose

A brief description of the purpose of the SOP, it should describe why the SOP is required (e.g. compliance with GCP and other internal procedures and guidelines).

Any regulations or procedures referred to in “Purpose” section should be identified. The source should be given in the reference section rather than direct quotes.

introduction

A general introduction, with a statement of rationale.

Scope

A statement that outlines the areas and context covered by the SOP. 

If there are any areas in which this SOP specifically does NOT apply, these should also be mentioned.

Definitions

When appropriate, a list of definitions should be included for terms used in the SOP. Acronyms and abbreviations should be explained at the point of use within the SOP and not listed in this section.

responsibilities

A summary of the roles listed in the procedure and the responsibilities of each role holder for the procedures detailed in the SOP.

The details of the responsibilities should be a brief list of the key tasks performed. This section should not be a complete summary of the SOP.

SPECIFIC PROCEDURE

This section is the main text of the SOP. It details the procedure for the task to be performed.

There should be sufficient detail, clearly expressed, to enable a trained person to perform the procedure without supervision.

There should also be sufficient detail to enable a trained person to use the document to train others to perform the task.

The use of flow diagrams may be useful, especially in complex procedures.

forms/Templates to be used

Where Forms/Templates are referenced in the text, the numbers and titles are listed under this section. 

internal and external references

This section is used to list all controlled internal references (e.g. SOPs) and external references referred to within the text of the SOP only.

Internal References

Insert relevant references as required, sufficient for the user to find the source document.

External References

Insert relevant references as required, sufficient for the user to find the source document. Web references should be included were possible.

Change History

Where the SOP is the initial version:

SOP No: Record the SOP and version number

Effective Date: Record effective date of the SOP or “see page 1”

Significant Changes: State, “Initial version” or “new SOP”

Previous SOP no.: State “NA”.

Where replacing a previous SOP:

SOP No: Record the SOP and new version number

Effective Date: Record effective date of the SOP or “see page 1”

Significant Changes: Record the main changes from previous SOP

Previous SOP no.: Record SOP and previous version number

 

SOP no.	Effective Date	Significant Changes	Previous SOP no.

Tracking and Review Template

 

Policy / Guidelines (short version name as written on our policy page)	Committee / Entity (responsible)	Person responsible for diarizing the review	Posted on website	*Adopted (date originally adopted if applicable)	Review period (# of years)	Last review / amended (date)	Next review (date)