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
4. Drafting: Use active voice, clear language, and avoid ambiguity. Include purpose, scope, definitions, and procedures. Use the policy template
5. Review: Collaborate with stakeholders and legal/compliance offices.
6. 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.
7. Publication: Post in the official policy repository and notify affected groups.
8. Training: Provide education and guidance on policy implementation.
9. Communication: Communicate policy changes to impacted groups or units.

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
   1. Policy sponsor must forward policies recommended for retirement to the Policy Review Committee for recommendation.
   2. Approving committee must vote to retire policies.
   3. Retired policies must be archived with date of retirement.

For questions or support regarding policy development, contact the Office of Continuous Institutional Assessment