How to Develop Policies and Procedures

1. Introduction and Purpose

Policies and procedures promote consistency, efficiency, and transparency of College processes and practices. They also align business operations across the institution, reflect the College’s values, and serve as a resource for decision-making, acceptable behaviours, and ethics.

This procedure sets out the necessary steps for:

• developing a new operational policy or procedure (section 4)
• reviewing an existing policy or procedure (sections 5 and 6)
• rescinding an existing policy or procedure (section 7)

2. Application

This procedure applies to those in the Loyalist College community who play a role in policy development, approval, maintenance, review, amendment, and/or repeal.

3. Definitions

College operational policies: Documents that guide the efficient and effective business operations of the College. These policies are formally approved by the College Executive Team (CET).

College operational procedures: Documents that are linked to related operational policies and provide a sequence of instructions to be followed. Procedures may also identify roles and assign responsibilities for specific actions. Each procedure will be classified in the same format as College Operational Policies and approved by CET.

Policy owner: An employee who typically reports to a CET member and is responsible for developing, implementing, monitoring, and communicating a College operational policy and related procedures. A policy or procedure can have more than one policy owner.

Policy sponsor: The senior administrative officer accountable for overseeing a policy and its related procedures, and for monitoring and enforcing compliance. A senior administrative officer is usually a member of the College Executive Team (CET) and holds the title of president, senior vice-president, vice-president, or executive director. A policy or procedure can have more than one policy sponsor.

4. Developing a New Operational Policy or Procedure

• Step 1. The need for a new College policy or procedure may be identified by an employee and/or initiated directly by a senior administrator on CET. In either case, the first step is to consult with the Manager, Policy and Governance to help confirm who the policy sponsor should be based on the issues, scope, application, and implementation. In the process of this consultation, a policy owner should also be identified.
• Step 2. Once the policy sponsor has been identified, the sponsor and/or policy owner meets with the Manager, Policy and Governance to:
  • Identify the policy issues that need to be addressed (e.g., employee/student confusion about appropriate behaviours; clear and consistent guidance to address a specific situation; legal protection or legislative compliance; etc.).
  • Validate the need for a new policy/procedure and confirm that the issue is not already covered in an existing policy/procedure.
  • Determine whether the policy/procedure requires a co-sponsor or co-owner.
  • Identify the key stakeholders and who should be involved in the policy development related consultation process and participate in the associated ad hoc policy committee.
  • Identify other resources and/or legislative or binding directives that may be relevant to the development of the new policy/procedure.
  • Review the policy development process and applicable timelines.
  • Discuss roles, responsibilities, first review date, implementation, and communication strategy.
• Step 3. The policy owner convenes an ad hoc policy committee that includes representation from all areas of the College effected by the new operational policy and/procedure. It must consist of at least four stakeholders including the policy owner and Manager, Policy and Governance. The committee should be involved throughout the policy development process, providing guidance, input, and recommendations on the issue and on its implementation and communication plan.
• Step 4. The policy owner uses the Loyalist College operational policy/procedure template to draft the policy and/or procedure, ensuring that it adheres to the established structure and style guide. The final draft should be approved by the ad hoc policy committee.
• Step 5. The policy owner sends the final draft to the Manager, Policy and Governance for review and assignment of a prefix and number.
• Step 6. The policy owner briefs the policy sponsor, who submits the policy/procedure for review and approval by CET. The submission package should include:
  • A briefing note (see Appendix C: Policy/Procedure Briefing Note Template) that identifies the issue that the policy/procedure seeks to address; the composition of the ad hoc policy committee; the other stakeholders who were consulted; and any examples that were reviewed in the process.
  • The final draft of the policy and/or procedure and its related documents.
• Step 7. If CET approves the policy/procedure, the policy sponsor sends the final version to the policy owner and the Manager, Policy and Governance as an official record.
  • If CET does not approve the policy/procedure, the policy sponsor conveys the changes to the policy owner who works with the Manager, Policy and Governance to incorporate any revisions. Once the revisions have been made, the policy sponsor presents the updated draft to CET for approval.
• Step 8. Once approved, the Manager, Policy and Governance is responsible for publishing the policy/procedure working with the policy owner to ensure that the policy/procedure is communicated to the College community and that an implementation plan is in place as required.

5. Reviewing an Existing Operational Policy or Procedure (without changes or with minor changes)

Each policy/procedure indicates a date by which it must be reviewed. On a quarterly basis (i.e., every three months beginning in January), the Manager, Policy and Governance provides policy sponsors with a list of policies and procedures that need to be reviewed. Prior to the next review date, the policy owner is responsible for undertaking a full review of the policy/procedure, updating dates, terminology, titles etc., as required and ensuring that the content remains applicable.

• Step 1. The policy owner sends an email to the Manager, Policy and Governance and the policy sponsor confirming that the policy/procedure has been reviewed and that there are either no changes or only minor changes. Minor changes include:
  • employee title changes
  • formatting changes (aligning to the approved style guide and template)
  • grammar/spelling corrections.
• Step 2. The policy owner updates the policy/procedure to incorporate minor changes (if applicable), updates the next review date and then forwards the document(s) to the Manager, Policy and Governance.
• Step 3. The Manager, Policy and Governance publishes the updated policy/procedure.

6. Reviewing an Existing Operational Policy or Procedure (with changes)

Each policy/procedure indicates a date by which it must be reviewed. On a quarterly basis, the Manager, Policy and Governance provides the policy sponsor with a list of policies and procedures that need to be updated. Prior to the date, the policy owner is responsible for undertaking a full review of the policy/procedure, updating as required, and ensuring that the content remains applicable.

• Step 1. The policy sponsor and/or policy owner meets with the Manager, Policy and Governance to:
  • identify what content needs to be updated (e.g., clarity and consistency, changes in policy direction or practice, legislative compliance, etc.);
  • identify the key stakeholders and who should be involved in the policy revision and consultation process and who should participate in the associated ad hoc policy committee;
  • identify other resources, and/or legislative or binding directives that may be relevant to revising the policy/procedure;
  • discuss any relevant deadlines (e.g., legislation annual reviews, beginning of fall semester); and
  • discuss the review cycle (1–, 2–, or 3–year-review cycle) and communication strategy.
• Step 2. The policy owner convenes an ad hoc policy committee that includes representation from all areas of the College affected by the new operational policy and/procedure. It must consist of at least four stakeholders including the policy owner and Manager, Policy and Governance The committee should be involved throughout the policy development process, providing guidance, input, and recommendations on the issue and on the implementation and communication plan.
• Step 3. The policy owner updates the policy and/or procedure ensuring that it adheres to the established structure and style guide and follows the current template. The final draft should be approved by the ad hoc policy committee, if applicable.
• Step 4. The policy owner sends the final draft policy/procedure to the Manager, Policy and Governance for review.
• Step 5. The policy owner briefs the policy sponsor, who submits the policy/procedure for review and approval by CET. The submission package should include:
  • a briefing note (see Appendix C Policy/Procedure Briefing Note Template) that identifies the changes to the policy/procedure, the composition of the ad hoc policy committee, identification of other stakeholders who were consulted, and any examples that were reviewed in the process
  • the final draft of the updated policy and/or procedure.
• Step 7. If CET approves the policy/procedure as presented, the policy sponsor sends the final version to the policy owner and to the Manager, Policy and Governance as an official record.
  • If CET does not approve the policy/procedure, the policy sponsor communicates required changes to the policy owner who works with the Manager, Policy and Governance to incorporate any revisions. Then, once the revisions have been made, the policy sponsor presents the updated draft to CET for approval. This step will be repeated until the policy/procedure is approved by CET.
• Step 8. Once the policy/procedure is approved, the Manager, Policy and Governance is responsible for publishing it, and updating the date on which it was last approved by CET and the next review date. The Manager, Policy and Governance works with the policy owner to communicate the policy/procedure to the College community and to execute an implementation plan, if required.

7. Rescinding an Existing Operational Policy or Procedure

As part of the cyclical review of policies/procedures, the sponsor and/or owner may determine that a policy/procedure is no longer relevant or required.

• Step 1. The Manager, Policy and Governance meets with the owner and sponsor to discuss the application of the policy/procedure and confirms that it is no longer required.
• Step 2. The Manager, Policy and Governance then drafts a briefing note (see Appendix C), indicating the rationale to rescind the policy or procedure.
• Step 3. Once the change is approved by CET, the Manager, Policy and Governance sends an email to the College community indicating that the policy/procedure has been rescinded and removed from its shared or public location and is no longer enforceable.

8. Related Documents

• ADMIN 100 Developing Policies and Procedures
• ADMIN 100 Appendix A College Operational Policy Template
• ADMIN 100 Appendix B College Operational Procedure Template
• ADMIN 100 Appendix C Policy/Procedure Briefing Note Template
• ADMIN 100 Appendix D Policy Communication Email Template