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Compliance - Policy Development Procedure

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Section 1 - Summary

(1) This Procedure describes the operational processes required to develop, review, implement and maintain University Policy, Procedure and Regulations. 

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Section 2 - HESF/ASQA/ESOS Alignment

(2) The development and implementation of Policies and Procedures is important to ensure the University maintains quality in its learning and teaching activities; maintains its licence to operate and meets its ongoing regulatory obligations, in particular:
Higher Education Standards Framework (Threshold Standards) 2021 (Cth), Standards for Registered Training Organisations (RTOs) 2015 (Cth) and the National Code of Practice for Providers of Education and Training to Overseas Students 2018 (Cth).

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Section 3 - Scope

(3)  This Procedure applies to all staff who work with, and develop, Policy, Procedure and Regulation. 

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Section 4 - Definitions

(4) Act: The VU Act details the overarching functions and powers of the University. One function and power is the ability of the Council to make statutes for the good governance of the University or the management of its affairs.

(5) Compliance Change: Change that is a result of a change to legislation, code, etc. that does not consequentially change the intent of the document. It may involve a consequential change to a single provision as a result of legislative amendment or amendments to a related policy. 

(6) Minor Change: A change that includes cosmetic changes to ensure that the Policy or Procedure is current, up to date, succinct and clear. A minor change will not alter the intent, effect or application of the Policy or Procedure. 

(7) Major Change: A change that impacts the intent, effect or application of the Policy or Procedure.

(8) Policy: Policies are binding on all staff and students and are statements of principle that establish VU’s position on an issue in accordance with all relevant legislation, regulation and codes. They state the general approach that the University will take when making administrative decisions that affect staff or student rights and obligations.  Policies are required to facilitate the effective, efficient and equitable administration of the University. 

(9) Procedure: 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.

(10) Regulation:  Regulations provide the procedural detail to give effect to the functions and powers of the University.  University regulations are communicated and made available to the University community and must be complied with.

(11) Statute: The Governance, Academic and Student Affairs Statute 2013 provides further detail of the functions and powers of the University.  The University statute is communicated and made available to the University community and must be complied with.

(12) Supporting Documents: Any documents that support the interpretation or implementation of the Policy or Procedure.

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Section 5 - Policy/Regulation

(13) Compliance Policy.

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Section 6 - Procedures

Part A - Roles and Responsibilities

Role Responsibilities
Accountable Officer
Accountable for content, compliance and adherence. The Accountable Officer is a senior member of staff, preferably a member of the Senior Executive Group.
Approves new, and changes to existing, Procedures.
Manages Policy and Procedure development and maintenance.  
Sponsors Policy and Procedure reviews, providing strategic knowledge and corporate accountability.
Approves the waiving of consultation on Policy if regulation, legislation, Codes or strategic objectives require.
Approves Policy and Procedure to be released for consultation.
Approve governance Policy and Procedure, and Regulations, after considering any advice from the Academic Board or other Council Committee and the Vice-Chancellor and President.
Council Secretary
Advise Legal Services; the proponent and Risk & Compliance of the outcome of Council deliberations in relation to Governance Policy and Procedure and Regulations.
Provide Legal Services; proponent; and Risk & Compliance with a copy of the minutes and approved version for sealing.
Vice-Chancellor Approves academic and operational policy, after considering any advice from the relevant authority.
Legal Services
Reviews draft Policy, ensuring proposed Policy and Procedure achieves the objectives of Risk & Compliance and Subject Matter Expert, is consistent with any law which has necessitated development of the Policy, and that University risk is reduced.
Draft new and/or revised Regulations, if required.
In conjunction with relevant Subject Matter Expert, coordinate consultation of new or revised Regulations.
Arrange for sealing of approved Regulations and provide sealed version to Risk & Compliance for publication.
Processes requests for the removal or revocation of a Regulation.
Responsible Officer
Responsible for the operational implementation of the approved Policy and Procedure, under direction of the Accountable Officer.
Responsible for the development, review and maintenance of their respective Policy and Procedure.
Reviews Policy and Procedure in consultation with Accountable Officer every 3 years, or earlier if required.
Informs Accountable Officer of regulatory or compliance changes that may affect the Policy or Procedure, or if hyperlinks or forms need to be updated.
Informs the Director, Risk and Compliance of required changes or updates.
Consults on draft Policy or Procedure.
Ensures an Implementation Plan is developed; submitted with approval; and implemented post publication.
Risk & Compliance
Co-ordinates the Policy and Procedure development process.
Oversees the Policy and Procedure review cycle, advising and supporting Responsible & Accountable Officers when reviews are due.
Manages overall policy scope and quality; and determines if a policy change is minor, major or compliance-related.
Provides policy drafting support to Responsible & Accountable Officers as appropriate, considering strategic priorities and resourcing.
Advises on appropriate consultation and approval processes for Policy and Procedure.
Coordinates global consultation on developed Policy and Procedure.
Where appropriate, forwards the draft Policy and Procedure to Legal Services for review.
Communicates approved Policy and Procedure to the University community via the Global email list.
Processes requests for the removal or revocation of a Policy or Procedure.
Director, Risk and Compliance
Approves extensions to Policy or Procedure review dates.
Approves the waiving of consultation on Policy if regulation, legislation, Codes or strategic objectives require.

Retains editorial control of VU Policy and Procedure.
Manages the Policy Library Glossary.  

Part B - Review Cycle

(14) Risk & Compliance will advise Accountable and Responsible Officers when a Policy, Procedure or Regulation is due for review. 

(15) Extensions of review dates may be approved by the Director, Risk and Compliance upon request.  The Responsible Officer should ensure all hyperlinks, legislation, and regulatory requirements are reviewed and updated as part of this process.  

(16) Policy and Procedure review consultation and approval moves through the same process as Policy and Procedure development. Minor changes to Policy can be approved by the Accountable Officer.   

(17) VU Policy and Procedures are published using the standard Policy Template and Procedure Template.

(18) The Director, Risk and Compliance retains editorial control of VU Policy and Procedure. 

Part C - Consultation

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

(20) Accountable and Responsible Officers are responsible for consulting on Policy and Procedure with key stakeholders. Risk & Compliance is responsible for coordinating broad consultation via the Consultation Bulletin Board, and appropriate internal referrals (e.g. Legal Services), and forwarding the feedback to the Responsible Officers. 

(21) Relevant Accountable Officers and Legal Services coordinate consultation of new or revised Regulations.

(22) The minimum consultation requirements are:

  1. All Policy, Procedure and Regulation must invite consultation from any person directly involved in applying them, particularly those with delegated powers.
  2. Publish and communicate draft Policy or Regulation on the Consultation Bulletin Board for a minimum period of 10 business days.  Procedures supporting the Policy which have also been redrafted should be included.  Procedures developed or reviewed independent of Policy are not required to be placed on the Consultation Bulletin Board, however this is recommended where feedback from a broad range of stakeholders is required.
  3. All Policy and Procedure that exist to satisfy a regulatory or other requirement must be reviewed by subject matter experts, including Legal Services.
  4. All Policy and Regulation must be referred for consultation by the Accountable Officer as follows:
    1. Governance: to the Council or other relevant body;
    2. Academic: to the Academic Board, and appropriate sub-committees;
    3. Operational (non-academic) Policy: Vice-Chancellor’s Executive.
  5. 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).

(23) The Director, Risk and Compliance may approve the waiving of consultation on Policy if regulation, legislation, Codes or strategic objectives require.

(24) Accountable and Responsible Officers are responsible for reviewing the feedback received and incorporating feedback, where applicable, into the final draft.

Part D - Delegations

(25) Risk & Compliance will review draft Procedure and ensure any formal delegations attached to a position are documented within the associated Policy, and approved by the Vice-Chancellor. 

Part E - Approval

(26) Policy, Procedure and Regulation Approvals are detailed in Table 1 Policy, Procedure and Regulation Approval.

(27) A Policy and Procedure Implementation Plan Template must be included in Regulation, Policy and Procedure Approval submissions. One implementation Plan may be developed to cover a Policy and Procedure Suite.  The Implementation Plan will be developed by a University Staff member, and not by an external party.

(28) Policies, Procedures and Regulations take effect from the date they are published on the University Policy Library. 

(29) The removal or revocation of a Policy, Procedure or Regulation must be approved by the Committee or position that originally approved it.  The Director, Risk and Compliance will process such a request for Policy and Procedure; and the Head of Legal Services will process such a request for Regulation.   To make such a request, please email

(30) The Council Secretary will advise Legal Services; the proponent; and Risk & Compliance of Council’s decision regarding Regulations, and provide a copy of the minutes and approved version.  Legal Services will arrange for sealing of approved Regulations, and provide a sealed version to Risk & Compliance for publication. 

Part F - Communication

(31) Risk & Compliance will:

  1. Advise the Accountable and Responsible Officer of approved Policy and Procedure;
  2. Coordinate the publication of approved Policy and Procedure to the University Policy Library;
  3. Communicate newly published Policy and Procedure to the University community via global email announcement and Policy News Subscriber alert;
  4. Where required, consult with the Responsible Officer and the Manager, Student Communications & Operations regarding the most appropriate method of communication to students.

(32) The Responsible Officer will communicate to key stakeholders, in particular those with delegated powers under the Policy.

Part G - Implementation

(33) Implementation involves:

  1. Ensuring Regulations, Policy and Procedure are promoted, shared and available to all people who might need them. This may involve a communication strategy for Regulation, Policy and Procedure with very wide application, or may be more limited and local communication that are specific to a work area.
  2. Identifying any support to be provided to the implementation of the Regulation, Policy and Procedure. This may include Guidelines, training or information sessions, online support, or one on one mentoring.
  3. Completion of tasks within the Policy and Procedure Implementation Plan Template which is submitted at Regulation, Policy and Procedure Approval stage. 
  4. Ensuring continued monitoring of the effectiveness of the Regulation, Policy or Procedure, which may include checkpoints to monitor implementation success (e.g. changes in business processes or behaviours).  
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Section 7 - Guidelines

(34) Policy and Procedure Consultation Guidelines

(35) Procedure Content Development Guidelines