IS - 2526 Policy and Procedure Document Development	Administration Release Date: 6/26/02 Revision 1: 3/29/04 Revision 2: 12/1/05 Revision 3: 5/28/08
Policy

Administrative Directive

Introduction

The Policies and Procedures Office (PPO) offers a centralized quality-based process for designing, developing, implementing, and maintaining College-wide standard operating practices.  The Source, the policies and procedures online and hard-copy manual, is designed for use by all employees and students at Central New Mexico Community College (CNM) and offers a system that encourages involvement in the identification and development of new or revised policy, administrative directive, and procedure through the use of Task Force Teams.

The Policies and Procedures Office supports CNM's mission, vision, and the supporting concepts presented in the Strategic Plan and incorporates these principles in the document development process.  In partnership with the document requestor and the Task Force Team, PPO uses a collaborative process and contemporary technology to provide standardized documentation for the College.

1. Services Provided

The Policies and Procedures Office offers development activities, informational services, writing services, and training regarding policy and administrative directive documentation and implementation.

The Policies and Procedures Office maintains The Source website and other websites (e.g., the Employee Handbook,  the Governing Board Policy Handbook, and the Collective Bargaining Agreements website), assists in developing forms, offers consultation regarding process improvement, and designs, develops, and facilitates training sessions.

Some of the services provided are:

1.1  Process analysis:

An in-depth examination of the components, activities, procedural steps, products, and services of a designated department, area, or subject.  This review of systems and processes includes a comprehensive look at the areas affected by the department's services and/or activities.

1.2  Process improvement:

Following process analysis, a comprehensive re-structuring of processes to enhance quality, productivity, customer service, and cost effectiveness.

1.3  Research:

Compiling the information necessary to thoroughly document a process or group of processes, including investigating existing state and federal codes and regulations to ensure compliance.

1.4  Document design:

Determining the format and layout that best suits the information to be delivered, with consideration given to the prospective audience and method of delivery.

1.5  Document draft:

Partnering with the document requestor in leading the Task Force Team through the document development process to create a document that is cohesive, comprehensive, and logical.

1.6  Document review:

Appraising the document with consideration given to content, compliance issues, and dependencies. The review focuses on the accuracy and consistency of information when it appears in several formats (e.g., the Employee Handbook and The Source).  The review also ensures that all key processes are included in the document, even those outside the area.

1.7  Compliance evaluation:

Researching existing state and federal codes and regulations to ensure conformity.  The evaluation also includes a review of other College documentation to ensure compliance with CNM policy and administrative directives.

1.8  Task Force Team meeting facilitation:

Partnering with Task Force Team members to compile and organize subject material; achieving consensus on the document's language, content, and intent; adhering to the document's review and approval schedule; and assisting with the analysis and sequencing of content information.

1.9  Implementation and training:

Providing the processes necessary to put an administrative directive document into practice and instructing affected areas and employees in the procedural steps.  This includes notifying the Public Information Office (PIO) and Computer Information Technology (CIT) to make broadcast announcements to the CNM community, publishing the document online, and assisting supervisors in training their staff.

1.10  Source maintenance:

Ensuring that the hard-copy Source binders are available at key locations on campus and are updated regularly with the most current document information; also includes auditing the online system via ongoing document review.   

1.10.1 Hard-copy Source binders are located at:

• President's Office

• Vice Presidents' Offices

• Main Library

• Montoya Library

• Westside Administrative Office

• South Valley Administrative Office

• Workforce Training Center Administrative Office

• Policies and Procedures Office

2. Requesting a New Document or a Document Revision

New Document

Documentation of processes is initiated for a number of reasons, some of which are:

• process improvement in support of quality principles
• standardization of processes
• College-wide need for information and/or processes
• compliance with federal and/or state regulations
• Governing Board mandate
• the result of a departmental audit
• managers/department heads desiring to document the practices of their areas

2.1 To initiate the documentation process, the document requestor must submit a Policy, Administrative Directive and Procedure Request to the Policies and Procedures Office. 

2.1.1 Suggestions for completing the request appear on the back of the form.

2.1.2 Forms can be picked up in the Policies and Procedures Office, printed from the PPO Administrative Directive in the The Source, or requested from PPO by e-mail.

2.2 Signature approval is required on the Policy, Administrative Directive and Procedure Request form, including the signatures of the document requestor, the requestor's immediate supervisor, and the appropriate vice president.  The vice president's signature is obtained by the Policies and Procedures Office.

2.3 If the requestor believes that the subject matter in an administrative directive and procedure has significant enough impact on CNM's internal and/or external community, the request can be made to PPO that the document becomes Governing Board Policy.  PPO discusses the request with the requestor to determine if the document meets the basic criteria to be submitted to the appropriate vice president for evaluation as CNM Board Policy.  If the vice president agrees with the request, the document is taken to the president for review.  The president determines if a document can be taken before the CNM Board for approval as Board Policy.

2.3.1 This request requires the president's signature in addition to the other signatures required on the Policy, Administrative Directive and Procedure Request form in 2.2. 

Revised Document

Revisions to existing processes and support documentation are necessary to support the ongoing quality efforts of the College.  Some instances where revisions are required include:

• process improvement evaluations
• changes in federal and/or state regulations
• change in the daily practices at the College
• new forms created to support existing processes
•  periodic PO document review 

2.4 To request a document revision, the requestor must submit a Policy, Administrative Directive and Procedure Request to the Policies and Procedures Office. 

2.4.1 Suggestions for completing the request appear on the back of the form.

2.4.2 Forms can be picked up in the Policies and Procedures Office, printed from the PPO Administrative Directive in the The Source, or requested from PPO by e-mail.

2.5 Signature approval is required on the Policy, Administrative Directive and Procedure Request form, including the document requestor, the requestor's immediate supervisor.

2.6 The Policies and Procedures Office determines if the vice president's signature is needed based on whether the revision is major or minor.

3. Document Responsibility

PPO encourages as much participation as possible by the document requestor in order to promote cooperative and collaborative processes, including researching internal and external sources of information and facilitating Task Force Team meetings.

3.1 In general, the actual writing of the draft document is the responsibility of PPO unless extenuating circumstances exist (e.g., a team has convened and written a rough draft prior to contacting PPO).  This expedites the documentation process because PPO has a working knowledge of the strategic directions, cross-functional compliances, and the ongoing process improvement projects of the College.

3.2 Because PPO has specific hard-copy and Web formatting standards, PPO re-formats pre-written drafts so they are consistent with other Source documentation.

3.3 Pre-written drafts are also reviewed for content to ensure that the document is cohesive, comprehensive, and logical.

3.4 PPO provides support materials such as the Sample Document Layout and Document Creation and Submission Guidelines to assist those who under extenuating circumstances write the draft independently. 

3.5 For the purpose of this administrative directive, the assumption is that PPO writes the initial draft.

4. Document Analysis

When the need for documentation has been determined, the Policies and Procedures Office partners with the document requestor in analyzing the document in the context of the larger systems of the area, department, and College.  Document analysis is a quality-based in-depth examination of the components, activities, key processes, products, and services of the department, area, or subject.  This analysis helps to formulate an approach to document development which is directly linked to quality initiatives involving ongoing process improvement. 

4.1 The first step in document analysis is identifying the systems, processes, and sub-processes of an organization.  Defining the boundaries of the system helps in breaking out the processes and sub-processes of the unit, which can then be organized into one or more subjects for document development.

4.2 Existing policy documentation is also reviewed to avoid redundancy.  Existing documentation includes departmental training material, supervisory handbooks, informational brochures, and departmental handbooks, as well as College-wide documentation in The Source, the Employee Handbook, the Governing Board Policy Handbook, and the Student Handbook.

4.3 Document analysis considers the justification for the document and its use:

• Is it the result of a process improvement effort?

• Is it a training tool?

• Is it for informational purposes only?

• Is it in place to comply with audit findings or codes and regulations?

4.4 Document analysis also involves the following:

• Ideas for content:  How much information is enough?

• Areas of impact:  How much of the College will be affected?

• Audience and end user:  Who will be reading and using the document?

• Logic check:  Is this the best way to organize the material?

• Priorities:  Department's, PPO's, and College's

• Timelines:  What schedules and deadlines have to be met?

• Levels of review:  Who needs to be aware of the document and review its contents for ways it will affect various areas and departments?

4.5 The analysis process results in the type and number of documents to be created by the Task Force Team. 

4.6 If the requestor believes that the subject matter in an administrative directive and procedure has significant enough impact on CNM's internal and/or external community, the request can be made to PPO that the document becomes Governing Board Policy.  PPO discusses the request with the requestor to determine if the document meets the basic criteria to be submitted to the appropriate vice president for evaluation as CNM Board Policy.  If the vice president agrees with the request, the document is taken to the president for review.  The president determines if a document can be taken before the CNM Board for approval as Board Policy.

4.6.1 This request requires the president's signature in addition to the other signatures required on the Policy, Administrative Directive and Procedure Request form in 2.2. 

5. Task Force Teams

Task Force Teams are formed to participate in the development of each document to ensure that the administrative directive addresses the needs of all areas of the College that are affected by the directive.  This team approach reinforces cooperative processes and fosters collaboration among CNM's departments and emphasizes the partnering of PPO with the appropriate departments. 

5.1 Task Force Team members are chosen by the Policies and Procedures Office in conjunction with the document requestor and suggestions/recommendations of the appropriate vice president.

5.2 Task Force Team members are selected to represent all areas impacted by the document.

 5.3 Task Force Team members' roles are to:

• Provide input/feedback regarding compliance, practice, and process;

• Provide knowledge/awareness of codes and regulations affecting team member's area in relation to the document being developed;

• Consider all possible dependencies and areas affected by the process; 

• Be a consultant/liaison between the department represented and the document development team; and

• Provide consensus approval of the final document.

5.4 Task Force Team members' responsibilities are to:

• Build the team meetings into the work schedule;

• Be aware of schedules and deadlines, including meeting schedules, document review deadlines, and signature approval deadlines; and

• Provide information specific to team member's area regarding compliance issues and key processes, including existing documentation regarding the processes in team member's area that impact the document being developed.

5.5 The Policies and Procedures Office role with the Task Force Team is to:

• Assist with team member identification and selection;

• Facilitate or co-facilitate team meetings;

• Provide meeting training for the document requestor;

• Partner with the document requestor in the document development process;

• Develop the initial draft document; 

• Provide ongoing logic-check and analysis of progressive documentation; and

• Provide training and implementation of the document being developed.

5.6 The Policies and Procedures Office provides forms and sample memos to assist first-time document requestors with Task Force Team contacts and meetings.  These include:

• Sample Team Contact Memo

• Task Force Team Member Roles and Responsibilities

• Guidelines for First Team Meeting

6. Types of Documentation

Policies

Policies are guiding principles and goals established and approved by CNM's Governing Board that are designed to influence and determine decisions and actions.

6.1 Only the Governing Board creates CNM policy.  These policies are presented to employees, students, and the community in the Governing Board Policy Handbook, the Employee Handbook, and the Student Handbook. 

Administrative Directives

Administrative directives are guiding principles and goals established by Task Force Teams and approved by CNM's president that are designed to influence and determine decisions and actions.

6.2 Administrative directives further define and explain approved Governing Board policies.  They also document the College's philosophy on College-wide practices that are not directly addressed in the Governing Board Policy Handbook, the Employee Handbook, or the Student Handbook; therefore the term administrative directive is used instead of policy.

6.3 Throughout the online format of The Source there is a direct link to either the Governing Board Policy Handbook, the Employee Handbook, or the Student Handbook where an administrative directive stems from Governing Board Policy.

6.3.1 Links are provided to external sites for further information regarding federal and/or state regulations, codes, acts, or any other external material associated with the document.

6.3.2 Links are also provided to internal references such as other Source documents and departmental websites.

6.4 The Policies and Procedures Office ensures consistency of information among the various formats in which CNM policy and administrative directives are presented. 

Procedures

Procedures are the defined action steps required to comply with policies and administrative directives.

6.5 Procedures provide the process steps and paperwork needed to comply with policies and administrative directives.  It is possible to have a policy or administrative directive document without a procedure, but a procedure cannot exist without a policy or administrative directive. 

7. Document Development

Policy and Administrative Directive Development

Policy and administrative directive development is the result of a comprehensive document analysis.  The Policies and Procedures Office (PPO) uses the PDSA cycle (Plan, Do, Study, Act) while partnering with the document requestor in developing a document.

7.1 PPO reviews the document analysis with the document requestor. 

7.1.1 In cases where the initial draft is prepared by the requestor, PPO provides a Document Start-up Packet which includes forms and guidelines to help standardize the documentation process.  These include:

• Policy, Administrative Directive and Procedure Request

• Document Creation and Submission Guidelines

• Completed Document Checklist

7.2 PPO works closely with the document requestor while preparing the initial draft document prior to the first Task Force Team meeting.

7.3 PPO works with the document requestor to establish a release date for the document.  Some considerations are:

• If the document is compliance-driven, when must compliance take place?

• Externally-driven deadline (i.e., Governing Board mandate)

• Existing departmental priorities and daily tasks

• Other documents in development in PPO

7.4 In partnership with PPO, the document requestor establishes expectations with the Task Force Team regarding document review (e-mail comments and responses, etc.), priorities, and timelines consistent with the release date of document.

7.5 The document requestor and the Task Force Team provide additional information as needed to the initial document to ensure that it meets the needs of the College and addresses the necessary concerns and issues. 

7.6 When the team and the document requestor agree that the information in the document is complete, the procedure segment of the document is developed for processes that require action steps.

7.6.1 At times policy statements/administrative directives do not require procedural steps.

Procedure Development

Procedure development is a matter of establishing the sequential steps necessary to carry out the intention of the associated policy statement or administrative directive.  Many of the considerations associated with policy and administrative directive development are also important in procedure development.

7.7 Procedures are written in sequential order.  The person responsible for each step is emphasized to enable a quick review of specific responsibility.

7.8 Procedures provide links to the forms and samples needed to carry out the procedure.

7.9 Procedures are flow-charted to provide a visual representation of the process steps.

7.10 When the team and the document requestor agree that the document is complete, the document goes to PPO for review.  This review initiates the review and approval cycle. 

7.11 The Completed Document Checklist and the supporting documentation used in the document's development is submitted to PPO.

8. Review and Approval Cycle

Document review and approval is a continuous process throughout the document's development and, like the document development process, the four-level review and approval process is also a collaborative effort.  When an existing document is revised, the extent of the revision determines its review and approval cycle. 

New Document

8.1 Until the document reaches its final form, it is subject to interim reviews by the Task Force Team and the Policies and Procedures Office.  These interim reviews ensure that the document contains the information necessary to convey the purpose and processes of the subject being documented.  When the document reaches its final form, the team members give their approval by signing the Administrative Directive Document Approval form.  These signatures indicate that the team has reached a consensus regarding the contents of the document.

8.2 The second level of review is conducted by outside legal counsel.  Legal review ensures that the document's content and language have been examined for potential risk to the College. 

8.2.1 Legal review may or may not result in changes to the language and/or content of the document.  If changes occur, the Task Force Team is notified but is not required to re-sign the Administrative Directive Document Approval form.

8.3 The third level of review and approval is conducted by the document requestor's supervisor and the appropriate vice president.  This review ensures that the final document reflects the supervisor's intent and that the processes are correctly and thoroughly set forth.  The supervisor/manager and appropriate vice president also sign the Administrative Directive Document Approval form.

8.4 Final review and approval is the responsibility of the president.  This review ensures that the document is consistent with the mission, goals, and strategic directions of CNM.  The president indicates approval of the document by signing the Source Document Approval form.

Revised Document

8.5 If the document requires major revision (e.g., changes that have an impact on the form, fit, or function of the document), the original Task Force Team is asked to participate in the revision.  In this case, new document review and approval steps are followed. 

8.6 If there are only minor changes that do not have an impact on the form, fit, or function of the document, the Task Force Team is not reconvened and the review and approval steps are not necessary. 

8.7 The President has signature approval on all major revisions to The Source.

9. Document Implementation

Once an administrative directive has been developed, reviewed and approved, it becomes a visible and living document through proper implementation.  Implementation ensures greater visibility and awareness of the documents, which in turn ensures that the CNM community has the information and tools necessary to be in compliance with College policies and administrative directives.

9.1 Implementation processes are handled by the Policies and Procedures Office in conjunction with the document requestor and the supervisor of the department(s) affected by the administrative directive.  They include one or more of the following actions:

• Publishing the administrative directive in its online format in The Source

• Notification of New Releases under the What's New on The Source's homepage

• Notification of New Releases on the CNM Passport Employee Tab under the Policies and Procedures Channel

• Notifying the CNM community through an announcement in The Express

• Including information sheets in paycheck envelopes

• Distributing hard copies of the document to the offices that house The Source hard-copy binders

• Announcing the document's existence to the CNM community via e-mail

• Distributing the necessary forms to the appropriate departments

• Training employees on new procedures associated with the document

9.2 When implementing any new procedure, department supervisors should consider the impact that training and "learning curves" might have on their respective areas and make appropriate scheduling adjustments so customer service and production are not affected.

9.3 Implementation, revision and removal of Governing Board Policies are under the purview of the President's Office.

10. Document Maintenance/Revision

The Policies and Procedures Office performs periodic reviews of documents in The Source.  These reviews ensure that the documents reflect current CNM practice and are still in compliance with related codes and/or regulations. 

10.1 The original document requestor is contacted and asked to review the existing document.  PPO provides a list of topics to consider to ensure the document is a reliable tool and source of correct information. 

10.2 If the document requires substantial revision, the original Task Force Team is asked to participate in the revision.  In this case, review and approval steps are followed.  If there are only minor changes that do not have an impact on the form, fit, or function of the document, the Task Force Team is not reconvened and the review and approval steps are not necessary. 

10.3 The President has signature approval on all major changes to The Source.

10.4 Documents can be revised at any time when compliance issues or current CNM practices associated with the document have changed. 

11. Document Files

For the purpose of internal and external audits, and to provide a history of each document's development, the Policies and Procedures Office keeps historic files on all documents using a departmental system of identification for maintenance purposes. 

11.1 Current revisions are kept as hard copies in department files.

11.2 Previous generations are stored as electronic files.

11.3 The document files can be viewed by any CNM employee with the knowledge and approval of PPO.

11.4 The document files must remain in the Policies and Procedures Office; however, copies can be provided upon request. 

12. Definitions

Forms:	Administrative Directive Document Approval Completed Document Checklist Policy, Administrative Directive and Procedure Request Source Document Approval
Support Materials:	Document Creation and Submission Guidelines Guidelines for First Team Meeting Sample Document Layout Sample Team Contact Memo Task Force Team Member Roles and Responsibilities
Reference Materials:	Not Applicable