Policy Governance Framework Procedure

Policy code: CG1978
Policy owner: Manager, Governance and Secretariat
Approval authority: Director, Strategy and Office of the Vice-Chancellor
Approval date: 03 April 2024
Next review date: 02 November 2025

Purpose

To set out the procedure for developing, making, reviewing and rescinding documents which (together with University legislation) establish the University’s policy governance framework. 

Scope

This procedure applies to the development, making, review and rescission of university policies, procedures, manuals and work instructions.  It does not apply to the making of university legislation, and it does not limit the powers, duties and functions of the University Council

Legislative context

  • Federation University Australia Act 2010 (Vic) 
  • Federation University Australia Statute 2021 
  • Federation University Australia AcademicRegulations 2022 
  • Federation University Australia (Operations) Regulations 2022 
  • Federation University Australia (Students) Regulations 2022 

Definitions

Term Definition
Approval Authority A person or body with responsibility for approving a governance document. 
Document Owner The person with responsibility as the proponent for establishment, maintenance, review or rescission of a governance document. 
Governance document A document which, together with University legislation, forms part of the University’s governance framework.  This includes policies, procedures, codes, manuals and work instructions. 
Periodic review Review of a governance document in accordance with Part 2 of this Procedure.
Policy Library A collective noun for approved governance documents. Policy library is a repository of current and expired documents of the University.
Policy Proposer A person proposing the addition or change to a governance document.
University legislation The Federation University Australia Act 2010 (Vic), the Federation University Australia Statute 2021, the Federation University Australia Academic Regulations 2022, the Federation University Australia (Students) Regulations 2022 and the Federation University Australia (Operations) Regulations 2022.

Overview of the University's governance framework

University governance is arranged in a hierarchy, as follows—

  1. The Federation University Australia Act 2010 is an Act of the Victorian Parliament.  The University’s status, powers, functions and responsibilities are established by this Act.
  2. The Federation University Australia Statute 2021 was made by the Council, with the approval of the (Victorian) Minister.  The statute makes high-level provision for the University’s operation and provides a context for the University regulations.
  3. University regulations. Three sets of regulations have been made, consistent with the Act and Statute—
    • the Federation University AcademicRegulations 2022.  These establish Charters for the Academic Board and four Committees, as well as addressing specific academic issues.
    • the Federation University (Students) Regulations 2022.  These deal with student-related matters such as student admission, enrolment, payment of fees, academic credit, assessments, academic progress, graduation, student misconduct and student appeals.  The Students Regulations also establish the Student Senate, a Student Misconduct Committee and a Student Appeals Committee.
    • the Federation University (Operations) Regulations 2022.  These deal with a diverse range of matters, including commercialisation of research, intellectual property, elections and the conduct of meetings.

The University’s governance documents operate in support of University legislation.  These are—

  1. Codes of Conduct. The Vice-Chancellor may make Codes of Conduct appliable to students, staff, library users and other persons associated with the University.  Codes of Conduct are referenced in University legislation so that failure to comply with a Code of Conduct may constitute misconduct.
  2. University policies and procedures and guidelines.  These guide decision-makers and establish procedures to be followed in making and implementing decisions.  Policies are coordinated by the Director, Governance, Legal and RiskProcedures and Guidelines are coordinated by the relevant senior manager.
  3. Manuals.  These are operational documents that may contain critical information and direct the reader to related procedures and work instructions. Manuals may apply across specific functional areas of the University and are approved by the relevant senior manager.
  4. Work instructions. These describe specific tasks for a localised audience or team, often in support of a procedure or business process.  Work instructions are approved and managed within each organisational unit.

As with any other legal entity, the University must comply with the laws of the Victorian and Commonwealth Parliaments.  These impose responsibilities and accountabilities, either directly (such as freedom of information and data protection legislation) or indirectly (such as guidelines for Commonwealth and State registration authorities).

Responsibilities in relation to governance documents

Document approval

A governance document comes into effect when it is approved by the University (or on a later date specified in the document).  Approval can occur in one of two ways—

  • by a person or body authorised to do so by university legislation.  These are identified in the legislation, and include—
    • the Council:  The Council is the governing body of the University and has the general direction and superintendence of the University.  It has power to approve, amend or rescind statutes (subject to Ministerial approval), regulations, policies, procedures, manuals and work instructions.
    • the Vice-Chancellor: the Vice-Chancellor is the ChiefExecutive Officer of the University generally is responsible for the conduct of the University’s affairs in all matters.  The Vice-Chancellor has power to approve, amend or rescind regulations, policies, procedures, manuals and work instructions.
    • persons and bodies identified in University legislation: University legislation confers specific powers and functions on persons or bodies within the University.
  • by a person or body with delegated powers.  Power to approve governance documents can be conferred by delegation.  The Council and the Vice-Chancellor have delegation powers.  Instruments of delegation are identified on the University website.

Document Owners

A Document Owner (identified by office) should be allocated for each governance document below the level of University legislation.  The Document Owner is to act as the proponent for establishment, maintenance, review or rescission the governance document.  The responsibilities of the Document Owner are to—

  • develop and maintain an understanding of the governance document and its place in the governance framework;
  • provide advice on governance documents for which they are responsible;
  • draft, or oversee the drafting of, the governance document and associated documents;
  • consult with stakeholders;
  • obtain advice as required from subject matter experts;
  • ensure that new or amended governance documents for which they are responsible are promulgated in accordance with this procedure;
  • maintain currency of policy library documents in relation to the governance document.

Policy and Quality Assurance Services

Policy and Quality Assurance Services is responsible for facilitating the development, review, amendment and rescission of governance documents, including—

  • facilitating policy review processes which are consistent across the University;
  • monitoring the status of governance documents to ensure that they are developed, implemented and reviewed in a timely manner, and that—
    • policy gaps, overlaps and inconsistencies are identified and rectified in collaboration with the Document Owners; and
    • governance documents which are not required are rescinded with approval from Approval Authority;
  • facilitating processes to ensure that the Universitypolicy library is current, relevant and useful;
  • providing advice to Document Owners in relation to governance documents;
  • facilitating rescission of superseded or obsolete documents.

Part 1 - Establishing a governance document

If it appears to a University stakeholder that a new governance document is needed, the following activities should occur.

Activity 1: Identify the need for the new document

The first step is to review existing governance documents to ascertain whether there is a gap in governance framework.  There may be an existing gap, or a new gap due to—

  • a change in legislation or government policy;
  • a new strategic direction for the University;
  • a change in business process;
  • the need for transparency of process.

A member of the University community may propose that a governance document be made to fill the gap.  The proposer should seek advice from a member of Policy and Quality Assurance Services as to whether there is an existing governance document that can be revised to address the identified issues.  They should also consult with relevant Document Owners to confirm the need for action.

Activity 2: Obtain approval to proceed

If a need is confirmed, the proposer should obtain agreement to proceed from the person or body which would be the Approval Authority.  A new University policy should not be created without approval from the Vice-Chancellor’s Senior Team.

Activity 3: Commence the development process

The proposer should submit a request through ServiceNow, providing a completed Governance Document Request Form, signed by the proposed Document Owner and Approval Authority.  If the request is approved by the Manager, Policy and Quality Assurance Services—

  • Policy Administration should then file the application on the Universityrecords management system and provide to the proposed document owner a summary of the next steps;
  • the proposer should then create a draft of the document on the template provided by the Policy office with a notation that a governance document has been prepared in draft form.  The proposer then becomes the Document Owner of that document, unless otherwise delegated.

Activity 4: Consultation and approval

Following preparation of the draft document, Policy and Quality Assurance Services should—

  • copy the latest document stored in the records management system into the University’s approved policy management system and update the status to “Sent for Approval;”
  • email a PDF version of the document to the Document Owner for approval and request that they seek approval to publish from the Approval Authority.

Consultation with relevant university stakeholders must occur. The Document Owner may request the release of the document for university stakeholder consultation.  If so, Policy and Quality Assurance Services should—

  • update the document’s status in the Policy Administration System to “For Uni-Wide Comment;”
  • in consultation with the Document Owner, prepare and release a FedNews item to announce the release, providing a timeline and details as to how staff and studentscan provide comments.  The document should be available for comment for ten working days unless approval is obtained from the Approval Authority for a shorter period;
  • on receipt of comments—
    • email acknowledgment of receipt;
    • collate the comments on behalf of the Document Owner and request the Document Owner to review the comments and revise the documents as appropriate.

If comments are received, the Document Owner must—

  • acknowledge comments received and advise if/how their comments will be given effect;
  • forward any revisions to Policy and Quality Assurance Services for input into the policy administration system.

Following consultation (if any) the Document Owner should request approval of the document by the Approval Authority.

Activity 5: Publish the new document

If the document is approved, the Document Owner should forward it to Policy and Quality Assurance Services.  Policy and Quality Assurance Services should—

  • file the approved document in the records management system;
  • record in the document the scheduled review date;
  • publish the document through the policy management system and if appropriate (see below) on the University website;
  • in consultation with the Document Owner, prepare a FedNews item to announce the publication.

Policies and procedures should be published on the University website.  Other documents may be published on the University website if this is considered appropriate by the Approval Authority.  If a document is commercially sensitive consideration should be given to restricted publication, with access available only with staff login.

Note:    The University is an “agency” for the purposes of the Freedom of Information Act 1982 (Vic).  Documents held by it are subject to disclosure requirements as set out in that Act.

Activity 6: Communication and implementation

The Document Owner must—

  • ensure that affected Universitystaff and students are made aware of new document;
  • monitor implementation and ensure that staff are provided with appropriate information and training.

Part 2 - Administration of governance documents

The University’s governance documents are living, not static, instruments.  Over time they should be monitored closely and, as necessary, refined and revised.  New documents can be created if necessary and existing documents should be revised or revoked if no longer fit for purpose.

Minor amendments

A Document Owner may initiate a minor amendment to a governance document without the need to conduct a comprehensive review.  Examples of minor amendments are—

  • a change to a title, or a reallocation of a function, following a change in University terminology or responsibilities;
  • correction of spelling, grammar, or a hyperlink;
  • aligning content with legislative or regulatory requirements where—
    • the University’s business processes are specified in those requirements; or
    • changes to the University’s business processes are urgently required.  It is expected that (in this case) consultation with key stakeholders would still occur before the modification takes effect;
  • changes to align with business process changes already approved by the Vice-Chancellor’s Senior Team, a member of the VCST, the Academic Board or a standing committee of the Council or of the Academic Board.

A minor amendment must be approved for publishing by the Document Owner.

Periodic review of governance documents

Governance documents should be reviewed as follows—

  • University codes and policies should be reviewed every five years;
  • University procedures should be reviewed every three years;
  • Manuals and work instructions should be reviewed annually for currency of information and as required for other issues.

Policy and Quality Assurance Services will contact the Document Owner three months prior to the periodic review date and will offer assistance with the review process.  Policy and Quality Assurance Services will not change the document’s status unless the Document Owner advises that it is being actively reviewed or once it is three (3) months past the scheduled review date.

Early review

A Document Owner may request an early review by submitting a Governance Document Request Form through ServiceNow, selecting Early Review.  The request should be approved by the Approval Authority.

On receiving a request, Policy and Quality Assurance Services should—

  • check that the request form has been properly completed and approved;
  • forward the request form to the Manager, Policy and Quality Assurance Services for approval and signature;
  • if approved, file the form in the record management system;
  • change the status of the document to Under Review in the policy management system and reporting documents;
  • forward the current version of the document to the Document Owner for revision and advise the next steps in the process.

Responsibilities of the Document Owner - document review

Where periodic review or early review is to occur, the Document Owner should—

  • identify the extent stakeholder's consultation to occur.  This will vary according to the circumstances—
    • if it is proposed to only verify currency and accuracy of the described business processes, minimal consultation will be required;
    • if documents require significant revision (for example to meet legislative or regulatory requirements or the University’s strategic direction), there may be a need to conduct broader stakeholder consultation;
  • identify whether the Approval Authority has decided if the document should be distributed for university-wide comment;
  • if required, seek advice from Policy and Quality Assurance Services in relation to current legislative and regulatory requirements and the use of approved templates.

When revising the document, the Document Owner should—

  • check that the document accords with the current template.  If it does not, the contents should be transferred to the current template.  This can be done before it is released to stakeholders or after revision following stakeholder consultation.  The Document Owner should seek advice on this from Policy and Quality Assurance Services if required;
  • track the changes and return a Word version to Policy and Quality Assurance Services in the template format if stakeholder consultation results in minimal revisions;
  • inform Policy and Quality Assurance Services that the document has major changes and return a finalised Word version if stakeholder consultation indicates more than minimal revisions.

Note:    Document Owners should ensure appropriate structuring, writing and editing of the document to enhance readability and user-friendliness.

Rescinding a governance document

Responsibilities for rescinding a governance document are set out in the following table.

Activity Responsibility Steps
Rescinding a policy document

Document Owner

Approval Authority

Manager, Policy and Quality Assurance Services

Where a document has been identified for rescission, a Governance Document Review Form with a supporting rationale should be provided.  This should be submitted through ServiceNow with the Approval Authority’s agreement in writing.

The Manager, Policy and Quality Assurance Services may then rescind the document and advise Policy and Quality Assurance Services to update its records.

Note: If a new document is to replace the rescinded one, ensure that this is approved before the old one is rescinded.

Part 3 - Design of governance documents

A governance document should include the following components.

Heading Content
Purpose A description of content of the document in the context of the University’s governance framework.
Policy statement A description of the policy content of the document.  The statement may include headings to direct readers to supporting documents.
Supporting documents Documents which support the University community in implementing the policy, such as procedures, manuals, work instructions and forms.  These should be identified.
Legislative context Relevant Commonwealth and State legislation should be identified.  Where relevant, regulations, guidelines, codes and similar documents made under that legislation should also be identified.
Modification history The date of original publication, the currency of the version and the date scheduled for periodic review of the document. The history of the modifications will be stored in the Policy Management system.
Records management The mandated minimum retention period (as required by applicable legislation and regulatory bodies).

Part 4 - Administration

Supporting documents

Forms

Promulgation

This procedure will be placed on the University website and will be available for download.

Information about governance documents will be communicated through the University by internal communication including FedNews, VC Comms, staff emails, staff inductions and documentation distribution.

Records Management

DOCUMENT TITLE LOCATION RESPONSIBLE OFFICER MINIMUM RETENTION PERIOD
Governance Document Review Form The University’s approved records management system Policy Systems Administrator Electronic record will be retained in the University’s records management system