Policy on Policies

1. Policy

Issued: May 2, 2011
Last Revised: February 28, 2022
Last Reviewed: February 28, 2022

2. Policy Purpose

The University of Southern California (“USC” or the “University”) is committed to ensuring that all University Policies and related resources are managed in a manner that is compliant and consistent with legal and regulatory requirements and the University’s culture and values. This policy defines a University Policy, explains the relationship to related resources, and describes the key expectations, requirements, and methodology throughout the policy lifecycle, including development, maintenance, retirement, and archiving.

This document outlines USC’s policy and standards regarding the development, approval, implementation, and maintenance of University Policies and related Standards, Procedures, and Guidelines (defined in Section 4). This policy seeks 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 values, and take 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 are in a consistent and accessible format and written as clearly as possible
  5. Policies are maintained in a user-friendly, organized, central repository to increase awareness and mitigate risk
  6. Policies and related resources are kept up-to-date and compliant with relevant requirements

3. Scope and Application

This policy applies to the development, approval, implementation, and maintenance of University Policies and related Standards, Procedures, and Guidelines (defined in Section 4). All faculty, staff, students, and contractors involved in the development, approval, implementation, or maintenance 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.  Department, school, or unit policies must be reviewed against University Policies to ensure there are no provisions that conflict with a University Policy. The parties accountable for drafting department, school or unit policies are responsible for identifying and addressing such conflicts and should 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.

Consistent with longstanding practice and guidance, all school-specific documents related to academic policies, or changes to them, must be submitted in advance for review and approval by the Provost.  The Provost may authorize exceptions to such school specific documents, interpret them, or amend, rescind or replace them. If a school does not adhere to USC academic policy, the Provost will decide what remedy, if any, is appropriate.  

The review and revision process for Faculty Handbook is governed and described in the applicable resolution of the Board of Trustees and falls outside of the provisions of this Policy.

4. Definitions

TermDefinition
Policy Jurisdiction OwnerHas the final authority to approve policies aligned with their subject matter area. The individual(s) assigned to this role holds a Senior Vice President or Provost level role. If a University-wide policy is applicable to faculty, the policy must be approved by the Provost in addition to be approved by a Policy Jurisdiction Owner.
Policy DrafterResponsible for the drafting of a policy and manages the various stages of its development and subsequent modifications and revisions. The individual(s) assigned to this role may differ depending on the policy area or category.
Policy OwnerMonitors the implementation and life cycle of the policy from the time it is enacted. Generally, the policy falls under this roles’ responsibility, and questions, exceptions, violations, and complaints will be filtered to the Policy Owner. 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-wide policies to validate that the proposed policy changes are aligned with the University’s policy governance framework and related processes. When appropriate, the PRCT may also review University-wide procedures and be called in as advisors on policy changes during emergencies.
Responsible OfficeOffice 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.
SME Advisory PoolA cross-functional group of subject matter experts engaged on an ad hoc basis who advise on policy reviews and provide guidance on governance process changes, policy impacts, and policy effectiveness.
Department, School, or Unit PolicyFormal policy that applies only to the operation of an individual department, school, or unit within the University; includes Keck Medicine of USC.

University-wide 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 Code of Ethics, and outline expected behaviors of USC personnel.
University Policy not applicable to Keck Medicine of USCA 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.
GuidelinesServe as recommendations to advise on best practices.
ProcedureProcedural 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. Procedures involve specific required actions, generally presented in a high-level step-by-step description, and the conditions under which those actions must be taken. 
StandardsSet of mandatory rules in support of the Policy and are intended to be prescriptive.

5. Policy Details

5.1  Policy Creation or Revision

5.1.1.  Need Identification

Once the need for a new or revised policy is identified, the designated Policy Owner should complete the Policy Notification & Assessment Form (linked in section 7) and submit the request to the Office of Culture, Ethics and Compliance (“OCEC”) for review.

Administrative revisions that are technical and not substantive (e.g., new contact details, new position titles, date of last review, links to related policy materials, policy taxonomy changes, 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).

5.1.2.  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 Affairs (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.

5.1.3.  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 should adhere to this template. Information regarding tone, tenor, voice, level of detail, and language can be found in the Policy Style Guide (linked in section 7).  

5.2  Policy Review and Approval

5.2.1  Policy Review

Policies will be 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 will be reviewed by 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

5.2.2. Policy Document Concurrence

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

5.3  Policy Management

5.3.1  Policy Hierarchy, Categorization, and Taxonomy

The University utilizes a Policy Document Hierarchy pyramid (linked in section 7) 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. The OCEC is responsible for creating the USC Policy taxonomy. A full index of University Policies can be found on the USC policy website.

5.3.2  Policy Distribution, Communications, and Training

The University intends that all USC policies will be retained in the policy management system and active USC Policies will be made available on the University Policies web page and applicable intranet sites.

The Policy Owner 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 in consultation with appropriate stakeholders and prior to the policy taking effect.  The Office of the Provost must be consulted on policy distribution, communication, and training for university wide policies applicable to faculty.

Minor revisions that are technical and not substantive (e.g., new contact details, new position titles) do not require communications and training.

5.3.3  Attestations and Tracking

Certain University Policies may require that parties to which a policy applies, acknowledges that they have read, understood, and agree to comply with a policy. Attestation of policies is managed by the Responsible Office and attestation records are maintained in accordance with the University Policy on Record Management. Any impact metrics that are required to be tracked by nature of the policy are the responsibility of the Policy Owner and Responsible Office.

5.4  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, investigation, audit, change in campus leadership, emergency situation or a change to University operations.

If an update is needed, Policy Owners should develop and submit a request for policy creation or revision, as outlined in section 5.1.2.  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.

5.5  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 policies that overlaps or is duplicative

 If a policy must 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.

The OCEC will initiate retirement of the policy from the policy management system. The Responsible Office will assist in the removal of the policy from all applicable sites.

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. The Policy Owner must consult the Office of the Provost on proposed policy retirement for university wide policies applicable to faculty.

Policies that are no longer in effect will be removed from the University Policy webpage including all applicable sites and archived. Archival of policies will be initiated by OCEC and maintained in accordance with the University Policy on Record Management. Timing of retirement and archival will be coordinated between the Policy Owner and OCEC.

5.6  Procedures, Standards, and Guidelines

5.6.1 Creation or Revision

USC community facing Procedures, Standards, and Guidelines 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).

5.6.2 Review and Approval

USC community facing Procedures that require engagement from the USC community in a significant manner may be subject to the same approval process as University-wide policies described in section 5.1. The Policy Owner must work with OCEC and the Policy Review Core Team on a case by case basis to determine if the Procedures in question may have a significant impact to the USC community.

5.6.3 Distribution, Communications and Training

The Policy Owner is responsible for understanding change impacts and 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.  

5.6.4 Periodic Review

Procedures, Standards, and Guidelines should be reviewed against Policy requirements 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.

5.7 Exceptions

In the event of an emergency situation, legally mandated deadline, agency audit, or any other circumstance that requires a University policy be approved on an expedited basis, refer to the Procedure on Emergency Policy Creation, Review, and Approval (see section 6).

6. Procedure

6.1 Procedure on Emergency Policy Creation, Review, and Approval

If a policy requires emergency creation, review and approval due to legal, regulatory, statutory, or other requirements at the University, the Policy Owner or Responsible Office should consult the stakeholder engagement requirements listed in section 5.1.2 to determine what is considered reasonable based on the scenario, and contact the Office of Culture, Ethics and Compliance at usc.policy@usc.edu to jointly determine how to proceed.

6.2   Procedure on Policies

7. Forms

8. Responsibilities

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

POSITION or OFFICERESPONSIBILITIES
Office of Culture, Ethics and Compliance (“OCEC”)Chair the Policy Review Core Team and Policy Governance Committee, and facilitate policy approvals, revisions, and retirement requestsSupport the end-to-end USC Policy lifecycle process
Policy Review Core Team (“PRCT”)Review and approve new policy requests/revisionsProvide guidance and advise on policy changes during emergencies   Note: See the Policy Review Committee Charter that describes the governance and jurisdiction.
SMEs Advisory BoardAdvise on policy reviews and provide guidance on governance process changes, policy impacts and policy effectiveness on an ad hoc basis.
Policy OwnerOversee policy drafting, revisions, required tracking, attestations, and retirement.Determining communication and training needs required for new and revised policy.Coordinate reviews with SME Advisory Board members who have expertise to policy-related content. 
Policy Jurisdiction OwnerProvide final sign-off of policy once approved through the policy management workflow system.Approve retirement and archiving of policy.
Responsible OfficeTrack required policy attestations and develop policy communication and training. Support Policy Owner in updating policy and related content on applicable websites and communicating to impacted stakeholders.

9. Related Information

10. Contacts

Please direct any questions regarding this policy to:

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