Developing Policies and Procedures

1. Introduction and Purpose 

In addition to the provincial legislation, government directives, and policies that it adheres to, Loyalist College is governed by internal policies and procedures that set out its overall direction in terms of oversight, practices, and how it will execute its business operations. Policies and procedures promote consistency, efficiency, and transparency of College processes and practices. They also align business operations across the institution.  

This policy provides a framework and format for developing and revising all internal policies and procedures at Loyalist College.  

2. Application 

This policy applies to those in the Loyalist College community who play a role in policy development, approval, maintenance, review, amendment, and repeal. While this policy may be instructive for the purpose of developing departmental processes, those processes are typically developed and implemented at the departmental level (i.e., they are specific to an area or function of the College and are not College-wide in scope and application).  

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. Policy Statement 

College operational policies and procedures must:  

• comply with all current applicable laws and regulations, and be consistent with all Ministry of Colleges and Universities (MCU) binding policy directives;  
• align with the College’s mission, vision, and values; 
• be developed using the appropriate approved templates (Appendices A & B) and classified and numbered according to the predetermined scheme; 
• be written in plain language and with a tone of respect, positivity, inclusivity, diversity, and equity; 
• be developed in consultation with the relevant departments, key stakeholders, and audiences; 
• be presented by the policy sponsor to CET for approval; 
• be approved by CET before it’s considered operational and/or enforceable; 
• be reviewed every three years, unless otherwise specified;  
• be communicated to the Loyalist College community; and 
• be made widely available to promote transparency and accountability. 

5. Roles and Responsibilities 

• Policy Sponsor:
  • Identifies operational concerns or matters that need to be addressed within their portfolio and initiates the process for new policy/procedure development when necessary. 
  • Ensures that the policies/procedures in their portfolio have appropriate oversight and a designated policy owner. 
  • Presents new policies/procedures, existing policy revisions, and/or recommendations to rescind them to CET for approval.  
• Policy Owner: 
  • For new policies/procedures: 
    • Develops new policies/procedures as identified by the policy sponsor and in accordance with associated procedures and templates. 
    • Convenes an ad hoc policy committee with representatives from various College departments and employee groups and ensures that key stakeholders are consulted throughout the development process. 
    • Presents proposed policy/procedure drafts to an ad hoc policy committee and seeks input, guidance, and recommendations on any associated revisions.  
    • Creates an effective communication and implementation strategy for newly developed policies/procedures once they are approved.  
  • For existing policies/procedures: 
    • Ensures that policies/procedures are reviewed by the associated review date and that any resulting changes/amendments are documented and advanced through the formal review process.  
    • Provides guidance to the Loyalist College community on issues addressed in the policy and takes steps to ensure that the community understands the document(s). 
    • Makes changes to policies/procedures at the request of the policy sponsor or CET, and/or as a result of changes to relevant legislation, collective agreements, governmental policy directives, etc. ensuring that any changes are documented and formally approved.  
• Ad Hoc Policy Committee: 
  • Consists of at least four people: the policy owner, the Manager of Policy and Governance, and two subject matter experts. 
  • Works closely with the policy owner and provides guidance, input, and recommendations on proposed/revised policies. 
  • Ensures that appropriate consultation and feedback is incorporated into the policy development process. 
  • Provides recommendations to the policy owner on strategies for communicating and raising awareness of new policies/procedures and/or significant revisions to existing policies.   
• College Executive Team (CET): 
  • Reviews and approves all new policies/procedures, revisions, and proposals to rescind existing policies/procedures.  
  • Acts as the final approval body for proposed or amended policies. 
• Manager, Policy and Governance: 
  • Establishes a policy management framework that includes development, implementation, and maintenance. 
  • Ensures policies are written in plain language and are inclusive.  
  • Serves as a member of ad hoc policy committees.  
  • Acts as a resource for policy input, compliance, and interpretation purposes as necessary. 
  • Maintains awareness of federal and provincial legislation and ensures adherence to legislated requirements, identifying internal policies/procedures and/or departments that may need to respond to legislation. 
  • Ensures that new policies/procedures are classified appropriately and assigns the prefix and number.  
  • Keeps track of existing, revised, and newly created policies/procedures, maintaining the College’s official inventory.  
  • Tracks and maintains College policies from development to approval and posting.  
  • Supports the policy sponsor and policy owner with presentations to CET.  
  • Supports the research, writing, and editing phases of new policies/procedures. 
  • Ensures that all policies/procedures posted on the College’s website are compliant with the Accessibility for Ontarians with Disabilities Act (AODA). 
  • Supports the communication of approved new/revised policies to the Loyalist College community. 
  • Maintains the College’s policy/procedure webpage, database, and archive and coordinates the posting and deletion of policies. 
  • Provides policy sponsors with a list of their policies each quarter for review. 
• Loyalist College Community Members: 
  • Responsible for ensuring ongoing familiarity and compliance with all relevant Loyalist College policies and procedures. 
  • Encouraged to communicate policy concerns or needs to the appropriate policy owner or sponsor.  

6. Policy and Procedure Classification 

College Operational Policies and Procedures are organized into categories that reflect the major areas of accountability of the College and are as follows: 

• Academic and Student Affairs 
  • ACAD — Academic Operating Policies  
  • STU — Student Services 
• Corporate and Infrastructure 
  • CORP – General Corporate (e.g., Risk, Privacy, Insurance)  
  • FIN — Finance 
  • IT — Information Technology 
  • PHY — Facilities 
• General Administration 
  • ADMIN — Administrative 
  • COMM — Communications 
  • EXT — External Affairs 
• People and Equity 
  • EDI — Equity, Diversity and Inclusion 
  • HR — Human Resources  
  • IIR — Indigenous Initiatives and Reconciliation 
  • OHS — Occupational Health and Safety 

7. Related Documents 

• ADMIN 100 How to Develop 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