Policy on Policies

Effective: 2/20/2026

To whom this policy applies

This policy applies to all departments, offices, and units within the medical school that develop or maintain institutional policies. It governs institutional, departmental, academic and administrative policies.

Definitions

1. Policy: A written rule or standard that guides decisions and actions to ensure consistency and compliance within an organization.
2. Standard Operating Procedure ("SOP"): A set of step-by-step instructions on how the organization will implement policies and manage operations. This includes who is responsible for each task and what steps need to be taken.
3. Policy Oversight Committee (POC): This committee serves an administrative review function to ensure that drafted policies align with existing policies without creating redundancies; edits policy content for clarity or consistency of language with other policies. The POC is responsible for ensuring the proper flow of policies through the process, however, does not maintain authority to approve policies.
   1. Committee Composition
      • Assistant Dean, Institutional Assessment and Accreditation
      • Senior Associate Dean, Institutional and Faculty Affairs
      • Director, Operations and Strategic Initiatives
      • UNR Med General Counsel
      • Administrative Support
      • Policy Sponsor
4. Policy Making Bodies (Pfv1B): Groups in the UNR Med bylaws that have the authority to create and approve policies. They are responsible for drafting, revising, approving, and disseminating policies. (e.g., Executive Committee, Graduate Medical Education Committee (GMEC)).
5. Policy Sponsor: An individual who initiates the policy process and serves as the point of contact with the POC. A policy sponsor who is not from a PMB, must consult with the appropriate PMB prior to submission. The policy sponsor is expected to serve as subject matter expert throughout the process.

Purpose/Background

To establish a standardized framework for the development, approval, implementation, review, revision, and retirement of institutional policies within the medical school. This ensures consistency, compliance, transparency, and alignment with the school's mission and regulatory requirements.

Policy

All institutional policies must:

• Be written using the standard policy template.
• Include clear titles, effective dates, approval authorities, and version histories.
• Be reviewed at least every three years or as required by regulatory changes.
• Be approved by the designated leadership or committee.
• Be stored in a centralized repository accessible to stakeholders.

1. Policy Development Process
   1. Initiation: Identify the need for a new policy or revision.
   2. Drafting: Use active voice, clear language, and avoid ambiguity. Include purpose, scope, definitions, and procedures. Use the policy template
   3. Review: Collaborate with stakeholders and legal/compliance offices.
   4. Approval: Submit to the Policy Review Committee for review (policy will ultimately be routed as per the SOP on policies). Following the Policy Review Committee's review and recommendation, the policy will be sent to the relevant committees for approval (i.e. faculty council, executive council) and then routed to the Dean for signature. Policies potentially leading to student dismissal must also be reviewed by the provost and signed by the president.
   5. Publication: Post in the official policy repository and notify affected groups.
   6. Training: Provide education and guidance on policy implementation.
   7. Communication: Communicate policy changes to impacted groups or units.
2. Expedited (Emergency) Policy Development and Approval Process
   In limited circumstances where urgent action is required, an expedited policy development and approval process may be used to ensure timely institutional response while preserving appropriate governance and oversight
   1. Purpose and Standard

      The expedited process is intended to allow critical policies to be developed, reviewed, and approved within a compressed timeframe when use of the standard approval cycle would create significant institutional, legal, operational, or compliance risk.

      The goal of the expedited process is a total approval turnaround time of less than thirty (30) days from initiation to final signature

   2. Criteria for Emergency Use
      An emergency approval may be initiated when all of the following apply:
      
      1. Time Sensitivity - Delay would result in operational disruption, safety risk, legal or regulatory noncompliance, or significant institutional harm.
      2. Operational or Compliance Necessity - Immediate action is required to maintain core functions or meet external obligations
   3. Eligibility Limitations

      The expedited approval process may not be used for any policy that requires review or approval by the Provost and/or President, including but not limited to policies that could result in student dismissal.

      Such policies must follow the standard approval process regardless of urgency.

   4. Expedited Review and Approval Workflow
      When the expedited process is invoked:
      
      1. Policy Review Committee Review

         If a Policy Review Committee meeting is not already scheduled within seven (7) calendar days, an emergency meeting of the Committee shall be called to review the draft policy.

      2. Executive Committee/Policy Making Body Approval

         If a Medical Executive Committee or other Policy Making Body meeting is not already scheduled within fourteen (14) calendar days, the policy may be submitted for electronic (email) vote of the appropriate approving body. If faculty review or feedback is required under existing governance processes, this may extend the expedited approval timeline.

      3. Final Signatures

         Once approved by the appropriate Policy Making Body, the policy shall proceed immediately to required institutional signatories.

   5. Limitations
      Use of the expedited process:
      
      1. Does not bypass required legal review, and
      2. Does not eliminate required approval by the appropriate Policy Making Bodies.
3. Roles and Responsibilities
   1. Policy Sponsor/Policy Making Body: Drafts and maintains the policy.
   2. Policy Review Committee: Reviews for regulatory alignment, legal concerns, and consistency.
   3. Approving Committee(s): Approves policies and ensures institutional alignment.
   4. Office Assigned to Manage Policy Documents: Maintains review schedules and records.
4. Review and Revision
   1. Policies must be reviewed regularly (every 3 years minimum).
   2. Revisions must be documented in the version history.
   3. Policy sponsor must forward policies recommended for retirement to the Policy Review Committee for recommendation.
   4. Approving committee must vote to retire policies.
   5. Retired policies must be archived with date of retirement.
5. Contact Information
   For questions or support regarding policy development, contact the Office of Continuous Institutional Assessment.
   

Review

Approved by Medical Executive Committee 2/18/2026