Virginia Commonwealth University is committed to supporting and promoting an ethical culture of compliance and accountability in which all university employees and students act in an ethical, honest, and lawful manner. VCU communicates expectations for such conduct to members of the university community through its Code of Conduct and written policies and procedures. University members are required to follow and uphold the Code of Conduct and all applicable policies and procedures and to comply with this policy when creating and maintaining policies and procedures.
Responsibility for developing, implementing, and training to a specific policy falls to the designated Responsible Office. The Integrity and Compliance Office (ICO) is responsible for ensuring that a Responsible Office follows proper policy development and approval processes in compliance with this policy. The Responsible Office is accountable for the policy’s accuracy, timeliness, and education and awareness to appropriate audiences.
Universitywide policies (Administrative policies as defined herein) require a review by the University Council and final approval from the President’s Cabinet. Certain universitywide policies (Board of Visitors policies as defined herein) require additional approval from the Board of Visitors (BOV). In certain circumstances, universitywide policies requiring expedited implementation may take effect with interim approval according to this policy (Interim policies as defined herein).
Policies applying to individual units within the university (Local policies as defined herein) do not require review by University Council or approval from the President’s Cabinet or BOV. Local policies must not conflict with Administrative or BOV policy. If a local policy conflict exists, the conflicting element(s) of the Local policy have no effect.
The ICO maintains in the Policy Library official versions of all universitywide policies in effect and is responsible for retention and destruction of policy documents in accordance with the Library of Virginia’s Records Retention and Disposition Schedule.
Noncompliance with this policy may result in disciplinary action up to and including termination. VCU supports an environment free from retaliation. Retaliation against any employee who brings forth a good faith concern, asks a clarifying question, or participates in an investigation is prohibited.
All university members responsible for creating and maintaining policies and procedures should know this policy and familiarize themselves with its contents and provisions.
Administrative policy addresses universitywide operational expectations and/or compliance with applicable laws, regulations, policies and procedures and are subject to approval by the President’s Cabinet.
BOV policy addresses matters of university governance and /or requires the BOV to take an action item (such as a vote to approve). The authority to determine when a policy warrants Board of Visitors’ level of approval rests with the President’s Cabinet in consultation with the president and University Counsel.
Guidelines provide additional detail and direction on university policy and suggest a recommended or preferred course of action or behavior; they are generally relevant to implementing university policy and do not supplant the requirements of established policy. Guidelines are distinct from policies and procedures which mandate actions by university members. Guidelines should not be used in lieu of policy when certain behaviors and actions are required of university members.
An interim policy is a provisional Administrative or BOV policy that fulfills an emergent need, which requires implementation pending the prescribed approval process. An interim policy is limited in term to one year or less and is subject to approval by the President’s Cabinet.
Local policy meets the unique needs of, and generally applies to or affects, one unit, division, department or school. Local policies are accessible within the unit, division, department or school.
Minor revisions are those changes that do not alter the scope or application of an existing policy. Examples of minor revisions include, but are not limited to, title changes for individuals or departments and spelling corrections.
A policy articulates requirements and expectations for behavior, actions and activities of the university community. A policy may require or prohibit an action, support compliance with applicable laws and regulations and/or mitigate risk.
The Policy Library is the official repository of all interim and final universitywide policies currently in effect.
The ICO’s Policy Program oversees the development, review and approval processes for policies and procedures. This Program provides guidance to the Responsible Office, president, members of the
President’s Cabinet or respective designees and maintains a current and comprehensive Policy Library website to provide access to all universitywide policies.
The policy statement describes the purpose, key requirements and expectations of the policy and may include reference to consequences of noncompliance, including disciplinary actions, when appropriate.
The President’s Cabinet or Cabinet consists of the vice presidents and others reporting directly to the president.
Procedures include mandatory actions and processes necessary to comply with a policy, support compliance with applicable laws and regulations, and mitigate risk. Policies may or may not include procedures. For purposes of this policy, all references to policies include procedures unless otherwise noted.
Related documents are documents critical to the development of relevant policies and procedures and may include federal regulations, state regulations, state policies and other VCU policies, procedures and guidelines.
The Responsible Office is the administrative office responsible, through the action of an individual policy owner within the office, for developing and implementing the policy, including ensuring accuracy of the subject matter, training appropriate audiences, enforcing and monitoring compliance with the policy, and timely review.
Subject matter experts are individuals who have significant knowledge and skills in a particular area or topic through extended study and practice.
Substantive revisions are those that alter the scope or application of an existing policy and, therefore require approval through the prescribed policy process.
For purposes of this policy, timely review means a required review and revision at least as often as every three (3) years (triennial review) and more frequent revisions as required by legal, regulatory and other developments.
The University Council or Council is the representative body of faculty, classified staff, postdoctoral scholars, students and administrators who reviews Administrative and BOV policies prior to seeking final approval from the President’s Cabinet and BOV, as appropriate.
For purposes of this policy, universitywide policy means those policies that apply to individuals throughout the entire university community.
The Integrity and Compliance Office (ICO) within Audit and Compliance Services interprets this policy and serves as the oversight authority for implementing the requirements of this policy. The ICO is responsible for obtaining approval for any revisions as required by this policy through the appropriate governance structures. Please direct policy questions to the ICO, specifically to the program manager, policy and state compliance, or send questions to policy@vcu.edu.
NOTE: Interim Policy Status
This status is to be used sparingly and in the most urgent of situations so as to provide great deference to this process in support of shared governance. In cases of urgent need, such as when required by accreditation, legal, regulatory, or remedial actions a Responsible Office may acquire interim approval from the President’s Cabinet to implement an Administrative or BOV policy, whether the situation calls for a new policy or substantive revisions to existing policy. To acquire interim approval, the Responsible Office must have the interim draft reviewed by the ICO and University Counsel, then acquire President’s Cabinet approval.
3. Approval Phase: A Responsible Office must complete the following procedures to acquire approval for a new policy.
4. Implementation Phase: After obtaining formal approvals, the Responsible Office must take the following steps to implement an approved new policy.
5. Compliance Monitoring and Enforcement: The Responsible Office is charged with monitoring for compliance with policy requirements; identifying and reporting or addressing compliance issues; and evaluating the policy’s effectiveness at achieving desired results and necessity for changes on an ongoing basis.
6. Timely Review: The Responsible Office must review a policy at least as often as every three years and follow the procedures below, as appropriate. The ICO will provide advance notice that the triennial review date is forthcoming.
If a Responsible Office identifies a need for a policy applicable only to an individual unit or units within the university, the Responsible Office or policy owner benefits from consultation with the ICO to ensure the appropriate classification of a Local policy and consider any related university policies.
NOTE: If an Administrative or BOV policy conflicts with a Local policy, the conflicting element(s) of the Local policy will have no effect. The ICO recommends that a Responsible Office follow the relevant procedures above to create, implement, and maintain a Local policy, including acquiring approval from the President’s Cabinet member or designee with appropriate oversight.
Executive Summary of Proposed Policy
Executive Summary for Policy Retirement
This policy supersedes the following archived policies:
| Approval/Revision Date | Title |
|---|---|
| May 17, 2002 | Policy on Creating and Establishing University Policy |
| May 20, 2011 | Creating and Maintaining Policies and Procedures |
| November 10, 2011 | Creating and Maintaining Policies and Procedures |
| September 6, 2016 | Creating and Maintaining Policies and Procedures-Interim |
| December 9, 2016 | Creating and Maintaining Policies and Procedures |
o Gap assessments;
o Archival of policies beginning January 1, 2012;
o Email notifications approximately 6 months before timely review deadline; and
o Drafting support, tips and resources.
4. Does a policy have to go through the approval process again if revisions are needed?
It depends on the level of revisions. Minor revisions, such as placing the policy in the template, changing contact information or office name changes, or updating a URL do not require approval. Substantive revisions, such as adding, changing, or removing a procedural step, require review, public comment and approval.
5. If University Counsel has reviewed the draft policy prior to my submitting it to the ICO for review, must I submit it to University Counsel again after ICO’s review?
It depends. If you make any substantive changes to the draft after ICO’s review, you must submit the draft to University Counsel again pursuant to the review and governance process outlined in this policy.
6. What if I have revisions to make prior to triennial review?
It is the policy owner’s responsibility to make timely revisions on an ongoing basis. As business needs, laws or regulations develop, VCU policies should reflect these changes as soon as practicable. Triennial review and appropriate revision is a minimum requirement, but revisions can be made at any time and, in certain cases, more frequent revisions are required.
7. What if there are no changes to the policy, do I still respond to the triennial review email notification?
Yes, simply respond that the Responsible Office has reviewed the policy and indicate the revision date so that the ICO can maintain accurate university records.
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