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Policy - Procedure Development Procedure

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Section 1 - Purpose / Objectives

(1) This Developing Procedures document describes the general processes used to develop, authorise, record and implement procedures which support and operationalise policy, Regulation and other requirements.

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Section 2 - Scope / Application

(2) Nil

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Section 3 - Definitions

(3) Nil

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Section 4 - Policy Statement

(4) See Policy Development Policy.

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Section 5 - Procedures

Part A - Roles and Responsibilities

Role Responsibilities
The Procedure Owner Drafts the procedure

Consults on the draft

Submits the procedure, with Consultation Report and Implementation Plan, to the authorising person to be made

Informs the Manager, Policy and Compliance Services of the procedure to allow for tracking (this step is not needed if the procedure is created alongside a new policy)
The Manager, Policy and Compliance Services Provides advice and assistance with drafting, review and identifying dependencies with other procedures

Tracks the procedure as part of the Policy Management System
The Policy Owner Determines the appropriate approval process for the procedure

Monitors the development of the procedure at a high level
The Authorising Person Approves and signs off the procedure

Part B - What are Procedures?

(5) Procedures define the detailed operational action (e.g. processes, templates, forms, etc.) required to support policies within the University. Each procedure must be linked to one or more relevant Act, statute, regulation or policy.

(6) While Procedures will differ in type, level of detail, and form, they should all:

  1. Be created within the Procedure Template
  2. Be linked to one or more authority objects (Act, Statute, regulation, agreement, code or policy)
  3. Explicitly define the process by which the procedures are made, approved, implemented, amended and disestablished
  4. Create relationships to other procedures with which they interact
  5. Be tested for useability and sufficiency before adoption
  6. Be registered with the Manager, Policy and Compliance Services to form part of the support structure to the relevant policy

Part C - Developing Content

Step 1: Are procedures needed?

(7) The need for procedures can be identified in several different ways, and may be driven by an operational need, a process gap, or an internal or external requirement. The following checklists will assist in determining when procedures are needed, and how to build content.

(8) Are procedures needed? YES if any of the following apply:

  1. Is there a new or substantially revised policy?
  2. Is there a regulatory requirement (external or internal) that obligates VU to satisfy certain procedural steps?
  3. Have you implemented a new or substantially revised business process?
  4. Do you have a business process or area of operation that is not well understood by staff?

(9) Procedures may NOT be needed if:

  1. The material you want to cover is purely explanatory rather than directive. In this case, a Guideline might be more appropriate.
  2. The detail you wish to provide is of a very low level of granularity (ie. fields within a database). A Guideline or How-To might better suit this purpose.

Step 2: What should be in the procedures?

(10) Once you have determined that a procedure or procedures is required, determining the content is the next step. Asking the following questions will help you to establish what the procedure will cover and how it will cover it.

Questions Process to answer
If the procedure is required to satisfy an internal or external obligation, what is the detail of the requirement? Outline all the relevant instruments, and be detailed in your citation, to avoid missing anything.
Does the requirement specify what areas are to be covered; does it prescribe VU's process in any way; and what reporting or audit obligations exist under the requirement? Note all the elements of the requirement — the order of events, the documentation required, the ways in which the obligation will be tracked.
Who are the key people who understand the work that the procedure will cover? How can they be engaged early? Working groups or review groups are a good way to make sure that the subject matter experts contribute to the making of the procedure.
Is there an as-is process in this area? Is it formalised in any documentation? How well is it working or not working? A brief analysis of the way things are currently done can help to pinpoint any process improvements you want the new procedure to support.
What is the logical sequence of steps that would be taken within the procedure to achieve the objective? What are the critical points that cannot be omitted? . This may be represented as a step by step guide to work and tasks
Does the procedure intersect with other procedures? If so, what are they? Are they in existence, or do they need to be created? Listing all related procedures will help to locate your procedure within its context.
Does the procedure involve workflow? If so, can it be represented visually in any way? Visual representations can help in understanding and application. The Manager, Policy and Compliance Services can advise on ways to visually represent procedural data.
Does the procedure involve any business rules, either currently stated or implied? It is important to capture business rules that define the parameters within which procedures operate.
What is the required retention period for any records that will be created or received in using the procedure? University Records staff can advise on the requirements for records retention that apply to the actions within your procedure. These should be built into the procedure itself.
Will the procedure rely on any forms, templates or other tools? Ensure that you have a full list of any tools that need to be gathered or created to support the procedure
Who will approve the procedures and how will this be done? See Authorisation Decision Tree below for advice on this area.
How often should the procedures be reviewed? Setting a review cycle at the start will help keep the procedures current.
How will the procedures be implemented? How will you judge that implementation has been successful? See Implementation Plan below for advice on this area.

Step 3: Consult on the procedures

(11) Consultation will differ in type and range depending on the nature of the procedures, who they affect, their dependencies on other procedures and policies, and their scope.

(12) Unlike for policies, there is no business rule requiring whole of University consultation for procedures. Nonetheless, this may be advisable for some procedures if they have a far-reaching impact.

(13) The minimum consultation requirements for procedures are:

  1. All procedures must invite consultation from any person directly involved in applying them.
  2. All procedures that exist to satisfy a regulatory or other requirement must be reviewed by subject matter experts, often including the Legal Services team.
  3. As appropriate, key procedures that relate to an area of oversight of an existing University committee should be referred to that committee for noting or review. (This involves a judgement about whether the procedural coverage is significant enough to warrant committee oversight).

(14) The Consultation Report template [link] can assist you to identify who you should consult with, how consultation can be done, and how you might report on the results of that consultation.

Step 4: Prepare your procedures for approval

(15) Once consultation is complete and procedures have been reviewed in line with feedback as required, procedures can be prepared for approval.

(16) The approval path for procedures will differ depending on the type and consequence of the procedures (see Authorisation Decision Tree). However, all procedures submitted for approval should have:

  1. A completed procedure, with all identified tools and templates presented as part of the package. Generally speaking it is not good practice to endorse a procedure that lacks all the elements needed for its success.
  2. A consultation report. If the procedures were developed and reviewed as a package with a new or revised policy, this may form part of one consolidated consultation report.
  3. An implementation plan that outlines how the procedures will be rolled out, monitored and assessed for success. If the procedures were developed and reviewed as a package with a new or revised policy, this may form part of one consolidated implementation plan.

Step 5: Implement your procedures and monitor their success

(17) Implementing procedures involves:

  1. Ensuring they are promoted, shared and available to all people who might need them. This may involve a communication strategy for procedures with very wide application, or may be a more limited and local communication for procedures that are specific to a work area.
  2. Identifying any support you will provide to the implementation of the procedures. This may include Guidelines, training or information sessions, online support, or one on one mentoring.
  3. Specifying a method by which you will consider the procedures to have been fully implemented. This could include a range of measures around changes in business processes or behaviours.
  4. The Implementation Plan template (pending) can assist you to create a simple view of your strategy to get your procedures being used successfully. (NB: If the procedures were developed and reviewed as a package with a new or revised policy, or if several related procedures are approved together, this may form part of one consolidated implementation plan.)
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Section 6 - Guidelines

(18) Consultation Guidelines

(19) Authorisation Decision Tree

(20) Implementation Plan template (pending)