Policy on Policies

1. Policy

Issued: May 2, 2011
Last Revised: July 1, 2024
Last Reviewed: August 8, 2024

2. Policy Purpose

The University of Southern California (“USC” or the “University”) is committed to ensuring that all University Policies are managed in a manner that is compliant and consistent with legal and regulatory requirements and aligns with the University’s unifying values.

This document outlines USC’s policy and standards regarding the development, approval, implementation, maintenance, and retirement of University Policies and related Standards, Procedures, and Guidelines (defined in Section 4). The purpose of this policy  is to create a standardized policy governance framework based on the following guiding principles:

1. Policies align with and strengthen the University’s mission, vision, and unifying values, as well as take in account of higher education leading practices.
2. The policy governance model creates clear ownership and accountability in the policy development and implementation process.
3. The policy governance model enables an efficient and collaborative policy management process and recognizes the importance of engaging stakeholders in the development and review process.
4. Policies, procedures, and related resources  adhere to USC’s policy and related document templates,  are accessible and are written clearly.
5. Policies are maintained in a user-friendly, central repository that is accessible to increase awareness and visibility to mitigate risk.
6. Policies and related resources are kept up-to-date and compliant with applicable requirements.

3. Scope and Application

This policy applies to the development,  revision, approval, implementation, maintenance, and retirement of University Policies and related Standards, Procedures, and Guidelines (defined in Section 4). All faculty, staff and contractors involved in the development, review, approval, implementation, maintenance or retirement of University Policies and related resources are expected to comply with this policy.

Any policy that applies to one or multiple departments, schools, or units is required to adhere to the principles of this policy.

Policies that apply to a single department, school, or unit must be  reviewed against University Policies to ensure there are no provisions that conflict with a University policy. The parties accountable for developing department, school or unit policies are responsible for identifying and addressing such conflicts and must contact the Office of Culture, Ethics and Compliance (“OCEC”) for assistance if there is a potential conflict in policy provisions. If a department, school, or unit policy conflicts with a University policy, Standard or Procedure, the University Policy governs.

Amendments to the Faculty Handbook are governed by Trustee resolution and the process set out in Faculty Handbook 2-B (5) and fall outside the provisions of this Policy

4. Definitions

Term	Definition
Policy Jurisdiction Owner	Has the final authority to approve policies under their purview. The individual(s) assigned to this role holds a Senior Vice President or Provost level role. If a University policy is applicable to faculty, the policy must also be approved by the Provost in addition to the Policy Jurisdiction Owner.
Policy Drafter	Responsible for the drafting of a policy and manages the various stages of its development and subsequent modifications and revisions.
Policy Owner	Monitors the implementation and life cycle of the policy from the time it is enacted. Generally, the Policy Owner reports, directly or indirectly, to the Policy Jurisdiction owner and is responsible for handling  any questions, exceptions, violations, and complaints related to a policy under their ownership . Works closely with the Policy Drafter and the Policy Review Core Team. The individual(s) assigned to this role may differ depending on the policy area or category.
Policy Review Core Team (“PRCT”)	The PRCT reviews all University policies in accordance to the University’s policy review schedule to validate that policy changes are aligned with the University’s policy governance framework and related processes. When appropriate, the PRCT may also review University procedures and serve as advisors on policy changes during emergencies.
Responsible Office	Office responsible for operationalizing, monitoring, and enforcing the policy (may or may not be the same office as the Policy Owner’s office).
Subject Matter Expert (“SME”)	An individual or an office that has specialized expertise in a particular area and is expected to be consulted during the policy development and/or update process.
Department, School, or Unit Policy	Formal policy that applies only to the operation of an individual department, school, or unit within the University; includes Keck Medicine of USC.
University Policy	Applies to all departments, schools and units of University of Southern California including Keck Medicine of USC.   A University-wide Policy is a statement of USC’s intent and commitment to operate in a way that meets legal and regulatory requirements, that yields beneficial impact for the university, its partners, customer, and community relationships. Policies tie to USC’s Values, its Integrity and Accountability Code, and outline expected behaviors of USC personnel.
University Policy not applicable to Keck Medicine of USC	A USC policy that does not create and/or address policy requirements pertinent to Keck Medicine of USC and thus not applicable to Keck Medicine of USC. Such USC policy continues to apply to all USC departments, schools, and units other than Keck Medicine of USC.
Frequently Asked Questions (“FAQs”)	FAQs are an organized collection of valuable information about a policy.
Guidelines	Serve as recommendations to advise on best practices.
Procedure	Procedural documents identify the tasks and processes that must be followed to ensure quality, consistency, and compliance with policies. A procedure details the “how” of the policy and specific required actions, generally presented in a high-level step-by-step description, and the conditions under which those actions must be taken.
Standards	Set of mandatory rules in support of the Policy and are intended to be prescriptive.

5. Policy Details

Policy Creation or Revision

Need Identification

 When the need for a new or revised policy is confirmed, the designated Policy Owner must complete the Policy Notification & Assessment Form (linked in section 7).

The Policy Owner must also consult the USC Policy Decision Flowchart (linked in section 9) to determine which type of policy or related document is needed to fulfil the policy need.

Creating or Revising a Policy

A policy must be created or revised using the University policy template (linked in section 7). Throughout the policy creation or revision, the Policy Drafter and/or Policy Owner must consult with the appropriate SMEs to gather guidance and understand impacts across departments and the USC community. SMEs should be selected by the Policy Drafter, Policy Owner, Responsible Office, and in consultation with OCEC, as needed. In addition to consulting SMEs, the following offices must also be consulted prior to submitting a policy for approval:

• Academic Senate (if policy impacts faculty)
• Human Resources
• Office for Equity, Equal Opportunity, and Title IX
• Office of Culture, Ethics and Compliance
• Office of General Counsel
• Office of the Provost (if the policy impacts faculty)
• Student Life  (if the policy impacts students)

The Policy Owner must also inform their Jurisdiction Owner of the new policy or policy revision prior to submitting the policy for approval.

Minor, non-substantive administrative revisions (e.g., new contact details, new position titles, date of last review, links to related policy materials,  etc.) do not require a Policy Notification & Assessment form and do not require the formal policy review and approval process. Revisions of this nature should be requested through the Administrative Change Request form (linked in section 7).

Policy Format

Policy format and required information to be included in policies can be found in the USC policy template (linked in section 7). All policies must  adhere to this template, absent unique circumstances such as a specific format prescribed by law. Information regarding tone, tenor, voice, level of detail, and language can be found in the Policy Style Guide (linked in section 7).  

Policy Review and Approval

Policy Review

Policies are submitted for review in USC’s policy management system by completing the Policy Submittal Form (linked in section 7) and will follow the approval workflow set within the system according to policy area.

Policies are reviewed by OCEC and the Policy Review Core Team for the following:

• Adherence to applicable law or regulations, USC’s values and culture including a clear statement of accountability measures
• Consistency, integration, and impact on other policies
• Diversity, equity, and inclusion
• Format, accessibility, style, and language
• Impact on students, faculty, and staff, as well as external stakeholders (e.g., youth, contractors)
• Impact on University operations and culture

Policy Approval

Each Policy Review Core Team member who reviews the policy must document their approval in USC’s policy management system.

Policy Management

Policy Hierarchy, Categorization, and Taxonomy

The University utilizes a Policy Document Hierarchy pyramid (linked in section 9) to demonstrate the relationship of university policies to the following related documents: Standards, Procedures, and Guidelines.

All new University policies will be assigned a policy identifier as part of the overall university taxonomy, to ensure clear understanding of the policy hierarchy and to easily identify related resources. A full index of University Policies can be found on the USC policy website.

Policy Distribution, Communications, and Training

All University policies will be retained in the policy management system and active University policies will be made available on the University policy website and applicable intranet sites.

The Policy Owner and/or the Responsible Office is responsible for understanding change impacts and determining communication and training needs required for the policy. If a new or revised policy requires communications or training, such communications and trainings will be developed by the Policy Owner and/or Responsible Office in consultation with appropriate stakeholders and, if necessary, prior to the policy taking effect.  The Office of the Provost must be consulted on policy distribution, communication, and training for University policies applicable to faculty.

Periodic Policy Review

At minimum, the University intends to review policies on a biennial basis.  University policy reviews will be prompted by OCEC.

Off-cycle updates or reviews may be prompted by, but not limited to, a change in regulation, an investigation, an audit, a change in campus leadership, an emergency situation or a change to University operations.

If an update is needed, Policy Owners must develop and submit a request for policy creation or revision as outlined under “Creating or Revising a Policy.” If a policy is found to be duplicative or unnecessary after a review, the Policy Owner must submit a request to retire the policy by submitting the USC Policy Archive Request Form.

Retirement and Archiving

Policies may be retired for several reasons, including but not limited to:

• Changes in federal, state, regulatory or local legislation
• Changes to University operations
• Identification of an existing policy that is duplicative

If a Policy Owner believes a policy should be retired, the Policy Owner must submit the USC Policy Archive Request Form, which will be reviewed and approved by OCEC and the Policy Review Core Team. The Policy Jurisdiction Owner must also approve of the retirement.

Policies that are no longer in effect will be archived and removed from the University policy website including any University websites that references or links to the policy. The Policy Owner is responsible for the removal of the policy from all other applicable sites. Archival of policies will be maintained in accordance with the University policy on Record Management.

The Policy Owner is responsible for working with the Responsible Office to communicate the retirement of the policy to all applicable stakeholders. If the retired policy has been replaced by a new policy, the communication of the retired policy should be included in the new policy announcement.  

Procedures, Standards, and Guidelines

Creation or Revision

Procedures, Standards, and Guidelines related to a University policy should be developed using the University Templates (linked in section 7) and in consultation with appropriate SME’s. Once final, the Procedure, Standard, and Guideline documents should be linked within the externally facing policy document under the procedures or related information sections (sections 6 and 9 of the policy, respectively).

Review and Approval

Procedures that require engagement from the USC community in a significant manner may be subject to the same approval process as University policies.. The Policy Owner must work with OCEC and the Policy Review Core Team on a case-by-case basis to determine the Procedure may have a significant impact to the USC community.

Distribution, Communications and Training

The Policy Owner is responsible for determining communication and training needs required for the Procedures, Standards, and related Guidelines. If a new or revised Procedure, Standard or Guidelines requires communications or training, such communications and trainings will be developed by the Policy Owner in consultation with appropriate stakeholders.  

Periodic Review

Procedures, Standards, and Guidelines should be reviewed each time a policy is reviewed or updated, and whenever there is an operational change at the University which impacts how the Policy is implemented or monitored.

Exceptions

In the event of an urgent situation, legally mandated requirement, agency audit, or any other circumstance that requires a University policy be approved on an expedited basis, The Policy Owner or Responsible Office should consult the stakeholder engagement requirements listed in section 5.1.2 to determine what is reasonable based on the situation and contact the Office of Culture, Ethics and Compliance at usc.policy@usc.edu to jointly determine how to proceed.

6. Procedure

Procedure on Policies

7. Forms

• Administrative Change Request Form
• Policy Notification and Assessment Form

• Policy Writing Style Guide

• Policy Submittal Form

• Policy, Procedure, Standard, Guideline Templates

• Policy Archive Request Form

8. Responsibilities

The below units or roles are responsible for aspects of the policy.

POSITION or OFFICE	RESPONSIBILITIES
Office of Culture, Ethics and Compliance (“OCEC”)	Chair the Policy Review Core Team and Policy Governance Committee, and facilitate policy approvals, revisions, and retirement requests. Support and provide guidance to Policy Owners in the policy submission or revision process and operationalize USC’ Policy framework.
Policy Review Core Team (“PRCT”)	Review and approve new policy requests and/or revisions. Provide guidance and advise on policy changes during emergencies  Note: See the Policy Review Committee Charter that describes the governance and jurisdiction.
Policy Owner	Oversee policy drafting, revisions, monitoring, attestations, and retirement. Determines communication and training needs required for new and revised policy. Responsible for handling  any questions, exceptions and violations related to a policy under their ownership.  Coordinate reviews with  SME’s and required stakeholders who have expertise to policy-related content.
Policy Jurisdiction Owner	Provide final sign-off of policy once approved through the policy management workflow system. Approve retirement and archiving of a policy.
Responsible Office	Track required policy attestations and develops policy communication and training. Support Policy Owner in updating policy and related content on applicable websites and communicating to impacted stakeholders.

9. Related Information

• Policy on Policies FAQ’s
• Policy Submission Process Infographic
• Records Management Policy
• Policy Writing Style Guide
• Policy Document Flowchart
• Policy Document Hierarchy

10. Contacts

Please direct any questions regarding this policy to:

OFFICE	PHONE	EMAIL
Office of Culture, Ethics and Compliance.	213-740-8258	usc.policy@usc.edu