Policy Approval and Distribution Policy 

Policy Number: EC.00.01.170131

Applies to: Washington State University’s Elson S. Floyd College of Medicine Policies, procedures, guidelines, and statements related to academic and administrative policies that are implemented college wide. 

Date: 8/1/2023 

1.0 Policy Statement 

Washington State University’s Elson S. Floyd College of Medicine (COM) policies and procedures follow a uniform process and are to be appropriately developed, approved, published, distributed, and tracked in designated and authorized publications and web locations. This policy outlines the consistent policy making process including: drafting, review, approval, and distribution processes for the College of Medicine academic and administrative policies. 

• 1.1 COM personnel are to obtain appropriate approvals prior to publication of the COM policies and procedures. 
• 1.2 COM policies are to be consistent with provisions of the Washington Administrative Code and the Revised Code of Washington, WSU Executive Policy #5 Policy Approval and Distribution, and the COM Bylaws for faculty participation in the leadership of the college. 
• 1.3 COM policies, procedures, and guidelines and statements are published and distributed in accessible designated and approved publications and approved web locations. 
• 1.4 Guidelines and statements that do not apply college-wide and supplement COM policies, procedures, and guidelines and statements may be published and distributed by departmental or campus websites, with appropriate approval. 
• 1.5 Final approval body for all College of Medicine MD Program policies and other policies and guidelines that apply college-wide is the College of Medicine Executive Cabinet. 
• 1.6 Policies written by individual Departments within the college and applying only to the department that has authored or revised the policy statement or guidelines must be submitted to the College of Medicine Policy Review Committee, and the Executive Cabinet for review prior to finalization through the Office of Compliance. (The Office of Compliance determines if any policy is exempted from the approval process described in this college-wide College of Medicine Policy Approval and Distribution Policy). 

2.0 Definitions 

Policy: A policy is a plan or general course of action having a broad implication throughout the COM and intended to influence and determine decisions, actions, and other matters. A policy seeks to maintain compliance with the applicable accreditation standards of the Liaison Committee on Medical Education, and applicable laws and regulations. Policies promote operational efficiencies and the College of Medicine’s mission, and/or reduces risk to the institution. 

Procedure: A procedure is an established method of implementing a College of Medicine policy. 

Guidelines: Provides additional instructions for implementing an administrative process or criteria by which decisions or processes are determined. 

Statement: An official account of facts, views, opinions, or plans. 

Administrative office/Unit lead or Designee: This individual is responsible to develop and administer the policy/procedure. 

3.0 Responsibilities

Office of the Dean 

4.0 Procedures 

Document Preparation

All policy documents are prepared by their respective administrative office, unit lead, designee, or respective standing committee of the faculty council. The policy draft is prepared in accordance with the requirements that include consulting with related stakeholders who review and comment on content, process and consistent with the College of Medicine Policy Approval and Distribution Policy. 

Required Format for Policy and Guidelines

The required format for policy and procedure statements and guidelines include the elements as found in the Policy Template found at (to insert new link when policy ready to be published). 

Procedures, Records, and Forms

The College of Medicine Office of Compliance manages a central policies website and coordinates approval and the publication of all items included on the website. 

Determination of Need and Analysis/Drafting 

The administrative office responsible for implementing and administering the policy/procedure analyzes the issues and conceptualizes the substance of the policy/procedure. Policy drafting may originate within a functional office administered by an individual with an administrative title of Associate or Assistant Dean or Director, or by a Standing Committee. 

Draft Preparation 

The administrative office or Standing Committee, where the policy draft originated, routes the first draft to the constituencies immediately involved or affected by the proposed policy. See Document Preparation above. 

Preliminary Review/Approval 

Responsible Designee

All constituents’ input, together with the draft policy, is routed to the responsible designee within the administrative office of implementation. The Designee may take one of the following actions regarding the proposed policy: 

• Return the draft back to the administrative office or Standing Committee noting that the policy is not to be considered further. 
• Return the draft back to the administrative office or Standing Committee for further analysis, for consideration of other options, or redrafting. 
• Forward the draft policy to the Director of Compliance for further action (e.g. submission to a Standing Committee, Policy Committee, Dean, or College Executive Cabinet, as appropriate). 

Policies

Policies, policy statements, and policy changes that affect the entire college are routed for approval per the approval workflow below. Guidelines, and statements written by departments for their own governance should be in compliance with WSU and COM policies, guidelines, and statements are exempt from the approval process described in this college-wide College of Medicine Policy Approval and Distribution Policy. 

Procedures

Policies that affect the entire college are routed for approval per the approval workflow below and must be reviewed by the Policy Committee, and approved by the Executive Cabinet, and Dean. 

Comments

The Office of Compliance notifies faculty that they have 10 days to comment on the policy, guidelines, or statements. 

Reviewers’ Considerations

Reviewers are to consider a draft’s consistency with college priorities and directions, impact on operations, ease of administration, provisions of the Washington Administrative Code and the Revised Code of Washington, WSU Executive Policy #5 Policy Approval and Distribution, and the College of Medicine Bylaws for faculty participation in the leadership of the college. 

Dean Review

A policy draft and comments are forwarded to the Dean. The Dean may approve, approve with revisions, or return to the Policy Committee for further review. 

Legal Review

The Office of Compliance may route the draft for preliminary review and/or approval by the Attorney General’s Office and others suggested by them for a more thorough review. 

Executive Cabinet Review

The Dean brings the policy draft and comments to the Executive cabinet. The Executive Cabinet may approve, approve with revisions, or return to the Policy Committee for further review. 

Notification of Decisions

The Director of Compliance informs reviewing and implementing organizations of the College Executive Cabinet’s decisions regarding the proposal. 

Final Approval/Implementation 

After final approval, the policy, guidelines, or statement is implemented and distributed in accordance with distribution requirements described below. 

Distribution 

After the proposed policy, guidelines, or statement is approved, the Director of Compliance ensures that the document is published in the appropriate approved college publication and/or website. 

Publication 

Approved publications and website for posting of College of Medicine policies and procedures are listed below. (Department websites should link to official college policy websites as appropriate.) WSU Academic Catalog College of Medicine MD Student Handbook College of Medicine Academic Policies College of Medicine Operations Policies 

Review of Existing Policies and Procedures 

The administrative office/unit lead or designee or the Standing Committee where the policy/procedure originated is responsible for ensuring that a policy/procedure document reflects current practices and are up to date. Policies are to be reviewed comprehensively at least once every three years and should be updated as necessary consistent with the procedures provided above. The College of Medicine Office of Compliance shall track and notify appropriate parties of the need for policy/procedure review. Use the procedures indicated above when reviewing or revising policies, guidelines, and statements. Maintain the original policy number and list the review date(s) in section 7.0. 

Retention of Policies and Procedures 

The Compliance Office in coordination with the issuing administrative office/unit lead or designee or Standing Committee is responsible for retaining policies and procedures for at least six years after they are superseded. 

5.0 Related Polices and Bylaws 

Washington State University Executive Policy Manual, Executive Policy #5 
EP05 – Policy on Policies | Office of Policies, Records, and Forms | Washington State University
Revision Approved November 2, 2022 
Faculty Bylaws of the Elson S. Floyd College of Medicine, reviewed and updated annually on Month, date, 2023
COM Policy Template
Equity Lens Tool

6.0 Key Search Words 

Policy, guidelines, procedures, approval 

7.0 Revision History

Original Approval Policy number 1/13/2017 EC.00.01.170131
Review/Revision 1/13/2017, 12/13/2019, 8/1/2023 

Policies, Procedures, Guideline Overview

Policy 

A policy is a plan or general course of action intended to influence and determine decisions, actions, and other matters. A policy seeks to maintain compliance with the applicable accreditation standards of the Liaison Committee on Medical Education, and with applicable laws and regulations. Policies promote operational efficiencies and the COM’s mission, and/or reduces risk to the institution. 

• College-wide Policies are owned by Standing Committees or administrative offices. 
• College-wide policy statements go through the COM Executive Cabinet’s.

Administrative Office/Unit Lead 

• Identify needed policies for LCME requirements. 
• Advise standing committees and administrative offices, but do not write. 
• Collaborate on policy drafts for review by cognizant standing committee or administrative office. 
• College-wide Policies are owned by Standing Committees or administrative offices. 

Procedures 

• Procedures are established methods of implementing a COM Policy. 
• Procedures are drafted within a functional area, administered by an individual with an administrative title of Associate or Assistant Dean or Director, or by a standing committee. 
• Must be in alignment/incorporated with its respective policy. 

Standing Committees 

• Work with functional administrative office leads 
• Finalize all policies before submitting to review process. 
• Responsible for maintenance and edits of policies that originated with that standing committee. 

Guideline 

• Guidelines provide a recommended method, framework, or criteria for implementing an administrative process by which all decisions of processes are determined. 
• Statements are official accounts of facts, views, opinions, or plans. 
• Department Chairs, Administrative Offices, and Standing Committees can recommend or write Guidelines or Statement. 
• Drafts are reviewed and approved by appropriate Vice Dean or Department Chair, or Standing Committee. 
• Only policies, guidelines or statements that apply college-wide go to the College Executive Cabinet for Review. 

Functional Leads 

• Collaborate with faculty and staff in functional administrative office area to draft procedures and/or guidelines and statements. 
• Obtain approval from cognizant administrator for procedures and/or guidelines/statements. 
• Collaborate with the Executive Cabinet’s Policy Committee prior to finalization of guidelines and statements that apply college wide. 

Workflow

College Executive Cabinet Policy Review and Approval Process for College-Wide Policies/Guidelines/Statements 

1. Office of Compliance 
   • Ensure policies and procedures are up to date. 
   • Comprehensively review policies and procedures at least once every three years. 
   • Monitor policies and procedures for accuracy, efficiency/effectiveness. 
   • Send reminders to the responsible Administrative Office or Unit responsible to develop and administer the policy. 
   • Schedule and submit requests for policy review to Policy Committee. 
2. Policy Committee 
   • Review policies that need further discussion and revision. 
   • Administrative Office representative, Standing Committee chair and cognizant Standard leads attend. Relevant members of the College Executive Cabinet may attend. 
   • Policy may progress to the next step with revision(s) or returned to Administrative Office representative or Standing Committee. 
3. Dean 
   Review outcomes may be: 
   • Approved for the next step. 
   • Approve for the next step with revisions. 
   • Return back to Policy Committee for further review. 
4. Office of Compliance 
   • If Dean determines to move to Executive Cabinet notify faculty that they have 10 days to comment. 
   • Send out survey to seek all-faculty feedback. Post for a 10-day comment period. 
   • Compliance Office working with Standing Committee or administrative office to incorporate all edits. 
   • Send back to the Policy Committee for review or prepare for review with Dean. 
   • Dean recommends when it is appropriate to move to Executive Cabinet. 
5. WSU COM Executive Cabinet/Office of Compliance 
   Follow the Policy Approval and Distribution Policy. Review outcomes may be: 
   • Approve. 
   • Approve with revisions. 
   • Send to monthly Policy Committee meeting for further review. 
   • After final approval notify Office of Compliance. 
   • Office of Compliance will publish policy or guideline on appropriate official COM websites.