When a nursing operations leader at Emory Healthcare, part of Emory University in Atlanta, launched a policy management initiative, she thought the project would involve consolidating an estimated 500 disparate policies. “Without a unifying way to keep consistency and keep reasonableness among the policies and consolidate them, you end up with chaos and inefficiency,” says Bill Dracos, chief business practice improvement (BPI) officer at the university, whose team was brought in to assist.
As it turns out, the estimate was way off. The number of policies was more like 15,000.
So over the course of three years, BPI administrators helped the health care system identify, categorize and eventually consolidate their policies.
That desire to bring order to the myriad policies at the health care system—and later the university—is gaining traction nationwide. Today, a growing number of colleges and universities are instituting policy management efforts to manage risk, enhance communication and transparency, maintain consistency, uphold accountability, and ensure that clear, well-organized policies are readily available to guide decision-making. An active U.S.-based organization is even dedicated to the discipline: the Association of College and University Policy Administrators (ACUPA). It includes members from 190 institutions in five countries.
Policy management process tends to involve a set of critical components. Following are six related steps for administrators on a policy cleanup mission.
1. Define your scope
Making it easier to manage, align and produce policies is a significant undertaking, so project scope and expectations must be clearly defined at the outset. What does the institution hope to achieve? Who should lead the effort? How many policies are actually involved?
pol-i-cy pÁ¤-lÓ-sÄ“ n., pl. -cies 1. An essential component of a successful policy management effort is to define what rises to the level of a policy. This varies from institution to institution, but from the outset, consider what everyone needs to follow based on law or administrative regulation. A true policy tends to have broad implications across campus. Internal standards, procedures, instructional documents and job aids used by individual departments or across campus don’t generally meet the policy criteria.
Dracos recommends determining whether the effort will address only central, campuswide policies or also consider those specific to individual departments and units.
Now is also the right time to create a standard definition of a policy and how it differs from a procedure, form or job aid. Many institutions have developed a policy on policies—a framework to ensure that every policy clearly indicates what it does, the process for review and adoption, who can change it, and who must follow it. (See an example, the 2017 policy framework for Northeastern University in Boston.)
2. Engage the right people
Policy process tends to be siloed, as institutions are by nature. To address this, some colleges establish a policy management office, department or team to serve as the backbone of the effort. Most often, this isn’t a body responsible for writing or approving policies, but rather one that includes liaisons from various departments who can provide expertise, give feedback, encourage action and spread the word across campus about the effort.
While some team members at Emory University were self-selected, others were assigned by department heads, says Sara Dicker, senior associate for BPI. “People were excited and grateful to have a process that would get us to a cleaner place,” she says. “They recognized it would be a lot of work, but everyone was willing to do that work to get a better result.”
Policy management: A team effort
Examples of how various higher ed institutions tackle policy management
James Madison University (Va.): A policy management program got underway in 2001 with a nine-member policy committee; all staff have other job duties.
University of California, Davis: One FTE, who has had the role for about four years, focuses on policy management. Eleven unit policy coordinators track policies and distribute them for review.
Rice (Texas): A formal policy management effort began in 2016. The chief compliance officer has policy management duties in his job description. Each policy has ¨an “owner.”
Emory University (Ga.): The business practice improvement team started working with Emory Healthcare in 2015 and with the university in spring 2018. The health care system dedicates three to four FTEs to policy; the university has two with policy as part of their job duties
The University of North Carolina at Chapel Hill: The policy management effort kicked off in 2016. One team member works full time on policies, and two others work on issues related to both policy and integrity or ethics. The policy review committee has 36 seats; 32 are currently filled.
Members of the James Madison University policy committee have reported that the work is interesting, meaningful and important, says Rick Larson, assistant vice president for HR, training and performance at the Virginia institution.
Jennifer DeNeal, associate director of The University of North Carolina at Chapel Hill’s Office of Ethics Education and Policy Management, says that UNC has continued to struggle with a balance between the right people and the necessary people. There, and at many other schools, deans, vice chancellors or designees are required to sign off on policy changes. However, they may not be policy subject-matter experts and tend to be busy, so documents can sit for a long time awaiting approval—an issue that is still being worked through.
3. Set a clear time frame
As with other committees, policy management teams have members whose core roles tend to include pressing deadlines. Campus officials should discuss with campus stakeholders the necessity of the policy management effort to help ensure managers and department heads understand how they can benefit from a more organized system and why they should allow their staffers time to complete policy management tasks. Setting a deadline for measurable progress can help.
At the University of California, Davis, leaders recently implemented a technology-based policy management system to complement an existing policy management effort. Policy Coordinator Maria Eynon says success depends on top leadership; vice chancellors at UC Davis are “taking ownership and seeing the importance of policy and advocating for it.”
4. Be patient and flexible
The fact is, says DeNeal of UNC Chapel Hill, “some departments are going to be slower to embrace change than others, especially in a university with a culture of decentralization.”
Her team received feedback from several departments wanting a table of contents or an organizational structure that would align with existing policy numbers used by the UNC system office. Other departments wanted to retain their own policy numbering and system.
“We’ve had to think about other ways we might be able to build an overarching organizational structure that meets everyone’s needs and existing internal structures,” says DeNeal.
In other words, what works for one department won’t necessarily work for another. So avoid restrictive policies on policy, says Dracos, of Emory.
5. Enhance policy access
Bringing all policies into a central location and making them easy to access is a way to ensure transparency. Colleges are centralizing where policies are housed online to make them easier to find, follow and identify for updates.
At Rice in Houston, for example, various policy versions and formats were scrapped in favor of a fully searchable website where all policies are accessed in the same way.
Policy management-specific tech systems, or broader document management or enterprise content management systems, can help bring order to the chaos. They not only make the policies more readily available, but they also streamline how a policy moves from creation and review to approval, giving visibility to each step and allowing policies to be carefully monitored.
UC Davis leaders determined that the best system for maintaining policies would involve user focus groups.
Policy users, approvers and developers helped review demos of vendor systems and provided feedback to ensure that the structure made sense and was accessible for the audience.
Emory’s Dicker cautions that technology solutions should not come into play before policies are reviewed and updated. After all, as the saying goes,“if you put garbage in, you get garbage out,” she says.
6. Set maintenance expectations
The never-ending, critical final phase for a policy management effort is this: maintenance. “If the policy is out of date or wrong, you can’t hold anybody to it; you can’t have accountability,” says Ken Liddle, chief compliance officer at Rice. The rule of thumb is to review policies every two to five years. Some policy management systems are built with default reminders about policy review.
Creating templates can help with a manual review process (as well as with the creation of new policies moving forward).
ACUPA’s policy development process document contains 14 best practices, including four covering the maintenance stage (UBmag.me/acupa). It advises developing a plan for maintenance and review; encouraging users to provide feedback (to help catch outdated information); archiving changes and including an “effective date” on new releases; and measuring outcomes by monitoring or testing.
All administrators and staff across campus must understand that even after an initial push is done, policy management is ongoing. It’s not simply an exercise in compliance, but rather a key component of the structure and culture of the institution.
Heather Kerrigan is a Washington D.C.-based writer.