PURPOSE / SCOPE:
The Policy Process and Structure outlines the development and approval requirements for the creation, implementation, and life cycle management of ICOM policies. The Policy Process and Structure is intended to create consistency and predictability throughout the organization by ensuring policies are established, applied, monitored, reviewed, and retained consistently and appropriately across the organization.
DEFINITIONS:
- Policy Administrator – The individual selected by the President/CEO to assist in the administration and maintenance of ICOM policies.
- Policy Owner – The individual, department, or committee with overall responsibility for the ongoing review of the assigned policy.
- Policy Review Team – A team selected by the President/CEO tasked with ensuring policy proposals are properly and expeditiously reviewed, approved, and implemented in accordance with the Policy Process and Structure set forth herein.
POLICY:
1. Policy Review Team (PRT). Policy Review Team participants are assigned by the President/CEO. The
team meets monthly or as needed to ensure policy proposals are properly and expeditiously reviewed,
tracked, and implemented. The team has three primary functions: (a) to serve as an advisory body to
the President/CEO, Dean/CAO, Chief Legal/Compliance Officer, and other organizational stakeholders;
(b) to ensure that policies and procedures are thoroughly vetted, approved, disseminated,
communicated to ICOM stakeholders, and periodically reviewed in accordance with applicable laws,
rules or regulation, and organizational requirements; and (c) to oversee the development and effective
dissemination of other materials that support compliance with policy and good operating practices.
The PRT generally considers the following when reviewing policies to ensure a thorough and thoughtful
review:
▪ Need for policy
▪ ICOM's mission, values, and objectives
▪ Effectiveness (understanding and clarity of policy)
▪ Application (can the policy be followed?)
▪ Conflict with existing policies or procedures
▪ Legal requirements and best practices
▪ Sanctions for non-compliance, if applicable
▪ Review timelines
2. Policy Format. Each policy will contain the following sections, as applicable and/or necessary, in the
order identified below. See the ICOM Policy Template.
▪ Policy Title
▪ Policy Category and Code - see list below
▪ Policy Effective Date – the date the policy goes into effect
▪ Last Date Updated- the date the policy was updated
▪ Purpose / Scope – a brief description of the policy intent and scope
▪ Definitions – provides definitions of unique terms or acronyms contained in the policy
▪ Policy – provides policy details and guidance to ICOM stakeholders
▪ Policy Owner – identifies who has official responsibility for the policy
▪ Cross Reference and Supporting Documents – lists supporting information, such as forms or
other ICOM policies, with hyperlinks when available.
▪ Content Revisions
▪ Signatures
3. Policy Code, Category, and Category Description. ICOM policies are classified within the categories
identified below.
Codes | Category | Category Description |
Administrative Policies: non-academic policies governing the operations of ICOM | ||
0-99 | Mission & Governance |
framework to implement and comply with the requirements of the Board |
100-199 |
General Administration |
general administrative or operational nature |
200-299 | Finance |
accounting, budgeting, procurement, travel, and other financial functions |
300-399 | Employment, Benefits, and Workplace |
employment, benefits, and workplace topics that impact all employee groups |
400-499 | Facilities | use and care of facilities, equipment, and property |
500-599 | Information Technology | Information Technology (IT) technical, information systems, and security requirements for faculty, staff, and students |
600-699 | Safety and Security |
security and safety of faculty, staff, students, and guests |
Academic Policies: policies which directly affect the academic and research mission of ICOM | ||
700-799 | Faculty Administration | apply primarily to ICOM faculty |
800-899 | Curriculum | apply primarily to the ICOM curriculum |
900-999 | Research | address research and scholarly activities |
1000-1099 |
Graduate Medical Education |
address GME programs |
1100-1199 | Learning Environment | applicable to academic operational activities |
Student Policies: policies which directly affect student life | ||
1200-1299 | Students | applicable to status as a student |
1300-1399 | Clinical | applicable to clinical affairs activities |
4. Policy Creation, Modification, Review, and Approval Process.
a. Any ICOM stakeholder may initiate or request the development of a new or modified policy. The
stakeholder will communicate the request along with pertinent information to the appropriate
Policy Owner.
b. The Policy Owner, whether operational or academic, will work with relevant stakeholders who
may be affected by the policy as well as those who may render expertise and/or support in its
creation or modification. The properly formatted draft policy will be submitted to the Policy
Review Team (PRT). Any new policy should clearly explain its purpose and need for existence
and include a proposed effective date; modified policies should show the current policy with
strikeouts to indicate deletions and underlining and/or bolding to indicate additions. A policy
that has outlived its usefulness or been superseded by another policy should be identified for
removal.
c. The PRT will determine whether the draft policy has been vetted appropriately and is in line with
existing policies and/or procedures. The PRT may remand any draft policy back to the Policy
Owner for additional review and/or revision.
d. Following completion of its review, the PRT will forward such policy with any
recommendation(s) or comment(s) to the President/CEO or the Dean/CAO for review and
approval. The Administrative Council (Admin Council; non-academic) or Academic Leadership
Council (ALC; academic), respectfully.
- If both councils require a review of the policy, the policy administrator will usher the policy
through each council’s review and approval process. - If needed, the President/CEO or Dean/CAO may remand any such policy back to the Policy
Owner for additional review and revision, then repeat the process for approval.
e. Once approved by the council(s), the policy will be directed to the President’s Executive
Assistant or designee to ensure the format of the policy is correct and signatures are affixed properly. With input from the Policy Administrator, the President/CEO or Dean/CAO will
establish an effective date deemed to be in the best interests of the College.
f. A fully vetted and approved policy will be forwarded to the Policy Administrator, who will ensure
the policy is posted on the ICOM website (unless otherwise directed), published in the ICOM
Newsletter, and copied and retained in a proper and secure location.
g. Policy Structure and Process Flowchart.
5. Interim Policies. The President/CEO or Dean/CAO may establish an Interim Policy where there is a need for a policy in a time frame too short for the completion of the formal process described above. In such a situation, the Interim Policy will remain in force as long as necessary until a formally approved policy becomes effective, which shall generally be no more than Sixty (60) days.
6. Policy Review Schedule. Between November 1 and December 1, Policy Administrators will review all
policies to ensure they are applicable and correct based on the policy tracking review chart or when
required due to situational changes. The document will be circulated internally by the Policy
Administrator to the appropriate individual(s) for review and edits, including policies deemed to be
retired/deleted. Policy changes follow the format outlined in #4 above. It is expected that the policy
creation or edits will remain in the review process for no longer than Thirty (30) days. All policies under review will have a “Last Date Updated” publication date whether they require updating or not. Those dates will be located on the ICOM Policy tracking chart. All policies modified or reissued will be signed by the President/CEO by January 15. Those modified or reissued policies will be reviewed by the ICOM Board Budget, Audit & Compliance Committee in February and approved by the ICOM Board in March.
7. Policy Retention Location. To ensure ready access to ICOM policies, a web page with the most current, approved versions of policies will be maintained. Except as otherwise required, the web page will constitute the official electronic depository of organization-wide policies. In some situations, policies may be protected, creating limited access where there is confidential information.
POLICY OWNER:
President and CEO
CROSS-REFERENCE AND SUPPORTING DOCUMENTS:
COCA Standard
SUPPORTING DOCUMENTS LOCATION:
ICOM Policy Template
APPROVAL:
Effective: 9/30/23
Last Reviewed: 10/16/23
Review Requirement: