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Policy Governance Procedure

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Section 1 - Context

(1) This procedure details how to:

  1. propose and categorise new policy documents
  2. develop policies, procedures and resources
  3. communicate and implement approved policy documents
  4. conduct reviews
  5. amend policy documents.
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Section 2 - Authority

(2) Authority for this document is established by the Policy Governance Framework.

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Section 3 - Scope

(3) All staff proposing and maintaining policy documents must follow this procedure.

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Section 4 - Procedure

Policy Categories

(4) The category of a policy document is determined with reference to the definitions in the Policy Governance Framework.

(5) If the appropriate category is unclear, the University Policy Manager will recommend the category to the approval authority. In doing so, the University Policy Manager must consider:

  1. subject matter
  2. content
  3. the intended consequence of the policy document.

(6) A decision on policy category by the approval authority will be final.

The University Policy Manager

(7) The Chief Audit and Risk Officer is the University Policy Manager.

(8) The University Policy Manager manages the Policy Register and attends to administrative and advisory matters (including policy assurance) to direct implementation of the Framework.

(9) The University Policy Manager may establish Terms of Reference for an internal working group to consider policy governance matters, good practice and develop awareness initiatives for RMIT Group policies. The working group shall provide advice and general guidance to champion policy practice.

Stage 1 – Identify and Propose

(10) Policy proposals constitute the first stage in the process for new policies and procedures and must be submitted in the form specified in the Policy Governance Manual.

(11) Policy proposals are reviewed by the University Policy Manager against the principles of the Framework to ensure consistency and unnecessary duplication, prior to seeking endorsement to develop.

(12) A policy proposal will proceed once in-principle endorsement is obtained, see Policy Governance Procedure Schedule 1 - Policy Proposal and Approval.

(13) A policy proposal is not required where:

  1. the proposal is necessary to address a material compliance obligation and time is of the essence
  2. the policy document is expressly referred to in an approved policy
  3. an amendment is proposed to give effect to an outcome of formal review (Stage 4)
  4. The University Policy Manager must advise the intended policy owner of the review outcome.

Stage 2 – Develop and Consult

(14) Policy development commences once a policy proposal (Stage 1) has received in-principle endorsement, as required.

(15) The policy owner can direct the policy author to conduct an impact assessment to inform the development of policy documents.

(16) Policies and procedures are developed using the prescribed templates under the Policy Governance Manual.

(17) The policy owner, with the assistance of the University Policy Manager, must ensure and be able to evidence that key stakeholders (including relevant committees) are adequately consulted during the development of policy documents.

(18) For policies, endorsement must be obtained from each of the following prior to submission to the approval authority:

  1. policy owner
  2. University Policy Manager
  3. Chair of the Academic Board or relevant standing committee for Academic policies.

Stage 3 – Approve and Implement

Policy Approval

(19) Draft policies and any associated procedures must be submitted together where reasonable to the approval authority in the form specified in the Policy Governance Manual.

(20) The policy owner may nominate an effective date when seeking approval from the approval authority.

(21) The approval authority for policy documents is set out in Schedule 1.

(22) The approval authority must inform the University Policy Manager of all approved policies and procedures.

(23) Where ambiguity arises, the University Policy Manager may determine whether a policy document is in effect or requires approval.

Procedures and Resources

(24) Procedures developed for approved policies must follow the same process described for policy proposal and development (Stages 1 and 2).

(25) The policy owner may delegate ownership of a procedure to a policy author by:

  1. express delegation in the relevant policy; or
  2. nomination in the form prescribed by the University Policy Manager as part of the initial approval of the procedure.

(26) The policy owner will determine the process for proposing, developing and approving policy resources, including assigning a policy author as the owner of resources.

(27) The University Policy Manager provides guidance material as part of the Policy Governance Manual.

(28) Resources must be registered with the University Policy Manager if they are mandatory and are to be published with headlining policies and procedures.

Communication and Implementation of Policy Documents

(29) All policies, procedures and resources that are to be submitted to the University Policy Manager must be emailed to

(30) A communication and implementation plan must be developed prior to the policy document being registered and coming into effect. It should include: education and awareness program, transition arrangements or roll-out schedule, systems or process requirements, and identify affected stakeholders including controlled entities and partner locations.

(31) For Group policies, the policy owner must seek the approval of the communications plan by the Executive Director, University Communications or their nominated delegate.

(32) The University Policy Manager will support group-wide communication of approved policy documents.

(33) The University Policy Manager can at any time request information to determine the implementation status of policy documents.

Stage 4 – Review and Revise

Reviewing Policy Documents

(34) The University Policy Manager must inform the policy owner of the requirement for review of policy documents within a reasonable time prior to the review date or effective end date, whichever comes first. 

(35) In addition to the requirement for review of policy documents under the Policy Governance Framework, the policy owner may commence review of any policy document at any time. In this case, the policy owner must inform the University Policy Manager of their intention to review.

(36) The policy owner must review policy documents at least every three years from the date of first approval or last major review where they have not been reviewed through other mechanisms such as internal or external audits, and compliance assurance activities.

(37) Reviews must consider:

  1. any concerns which have arisen during operation
  2. the level of compliance
  3. whether the intended effect has been achieved
  4. any changes to legislative or regulatory requirements
  5. the impact of any consequential amendments to related policy documents

(38) Policy documents continue to be in force while review is underway except for where the policy includes a sunset clause that might be adopted from time-to-time.

(39) The policy owner determines whether reviewed policy documents are to be amended, replaced or rescinded.

(40) Where a policy document under review has not been transitioned to this Framework, it must be replaced as an outcome of the review.

(41) The approval authority must be notified of review outcomes.

(42) New policies and procedures proposed as an outcome of review must follow the same process as described for policy proposal and development (Stages 1 and 2).

(43) The University Policy Manager must be notified on completion of the review for monitoring and reporting, and to ensure currency of the Policy Register.

Amending Policy Documents

(44) The policy owner determines the timing, nature and scale of required amendments to their policies and procedures.

(45) Amendments that are not deemed to be minor must proceed through the same process as described for policy development (Stage 2).

(46) For minor amendments:

  1. The policy owner may implement minor amendments at their discretion and must notify the University Policy Manager of the change and the reason for the change so that this can be noted in the Policy Register.
  2. The University Policy Manager has authority to review amendments to ensure they are minor and do not change the intent of the policy document.
  3. Reasonable notice must be given to the University Policy Manager to register the minor amendments prior to them taking effect.
  4. The policy owner must notify the relevant approval authority of any minor amendments implemented in any calendar year.

(47) The University Policy Manager can initiate minor amendments and notify the policy owner, where required, to ensure currency and clarity of the Policy Register.

Rescinding Policy Documents

(48) The policy owner must identify policy documents to be rescinded as required, and must advise the:

  1. University Policy Manager
  2. approval authority.

(49) The approval authority rescinds policies and procedures on the advice from the policy owner at its discretion.

(50) For the avoidance of doubt, rescission of a policy automatically rescinds all underpinning policy documents in the hierarchy.

(51) Rescinded policy documents may be accompanied by a sunset date to support transition where the effective date of new policy documents is to be delayed for any reason.

(52) The University Policy Manager must update the Policy Register and communicate changes accordingly.

The Policy Register

(53) The University Policy Manager maintains the Policy Register in accordance with information management policies.

(54) Policy documents are only registered on approval by the approval authority. The University Policy Manager will register the policy document within 28 days of approval.

(55) Approved or amended policy documents do not take effect prior to registration by the University Policy Manager.

(56) If the policy owner has not nominated an effective date at the time of submission to the approval authority, it will be taken to be the date it is registered by the University Policy Manager. 

(57) Registration must occur prior to the publication of policy documents.

Policy Document Templates

(58) Policy documents, including any schedules, must conform to any templates which are published by the University Policy Manager and form part of the Policy Governance Manual.

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Section 5 - Schedules

(59) Policy Governance Procedure Schedule 1 - Policy Proposal and Approval