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Section 1 - About this Document
Introduction
(1) The University of Newcastle (University) is committed to effective governance and control over its operations, in accordance with the University of Newcastle Act 1989 and the University of Newcastle By-Law, 2017. Effective and well-crafted policy documents are critical to achieving strong governance.
Purpose
(2) This Framework documents the requirements and responsibilities for the development, review, amendment, approval, publication, implementation and rescission of University policy documents.
Scope
(3) This Framework:
- applies to:
- all University policy document types that are identified in the Hierarchy of University Policy Documents and are listed in Table 1 of this document;
- policy documents, as defined by the Government Information Public Access Act, and that are required to be publicly available in accordance with this Act.
- does not apply to policy documents owned by University controlled entities.
Audience
(4) This document should be read and understood by:
- any University staff member who has responsibility or been tasked with drafting or reviewing policy documents;
- Policy Owners;
- delegates who are authorised to approve policy documents;
- Legal and Governance Services staff with policy administration responsibilities.
Definitions
(5) In the context of this document the following definitions apply:
- “administrative amendment” means amendments to correct or update information that does not alter its intent, scope, or operational effect. This includes updates to position titles, organisational units, role descriptions, clarification of wording that improves readability without changing meaning, updates to references, links or supporting documents, alignment with the Policy Style Guide and structural or presentation changes that improve usability. Administrative amendments do not change responsibilities, rights, obligations, or compliance requirements.
- “benchmarking” means the comparison of policy documents, practices, or performance against peer organisations. It supports informed decision-making, identification of gaps and opportunities; and continuous improvement.
- “broad consultation” means a type of consultation that involves engaging with a wide range of stakeholders, including those who may be affected, interested, or able to provide diverse perspectives on a policy subject. Broad consultation is undertaken to:
- gather comprehensive input;
- test principles, procedures, or positions;
- ensure transparency and inclusiveness; and
- inform risk control effectiveness.
- “committee approval pathway” means the policy approval pathway, where the relevant delegation of authority requires the document to be endorsed or approved by a Committee;
- “editorial amendment” means amendments to correct minor errors that do not change the meaning, intent, or interpretation of the policy document. This includes typographical errors, grammatical corrections, formatting inconsistencies, punctuation and broken or incorrect hyperlinks;
- “enquiry contact person” means the role responsible for responding to enquiries regarding the policy document once it is approved and published;
- “major amendment” means substantive changes that alter the policy document intent, scope, or context and that have operational impact or that change responsibilities or compliance obligations;
- “minor amendment” means low-impact changes that do not alter the intent, context, or scope of the policy but may affect how it is applied in practice. This includes clarifying or refining requirements; correcting inconsistencies that affect interpretation; making updates that do not materially change responsibilities or compliance obligations;
- “policy amendment” means discrete updates outside of a scheduled review to maintain accuracy or address specific issues. The type of amendment being made (i.e. editorial, administrative, minor or major) will determine the approval pathway);
- “Policy Author” means the role responsible for preparing draft versions of a policy document. The Policy Reviewer may also be the Policy Author;
- “policy document review date” or “review date” means the date specific to a relevant Policy document and recorded within the Policy Library status and details page which indicates when a policy review must be initiated. The Policy document remains in effect in the event the policy document review date has passed and until such time as a policy document expiry date is applied;
- “policy document expiry date” means the date applied to a policy document that has been approved to be rescinded from the Policy Library. The policy expiry date reflects the date that the policy is no longer effective.
- “policy lifecycle” means the sequence of policy document stages that ensures the policy document is created and maintained in accordance with this Policy Framework;
- “Policy Owner” means the nominated executive who is responsible for the policy document and its implementation and maintenance;
- “Policy Review” means a structured re-assessment of a policy document’s effectiveness, risks, and fitness for purpose;
- “Policy Reviewer” means a subject matter expert nominated by the policy owner who is responsible for initiating and completing a policy review;
- “targeted consultation” means a type of consultation that involves selectively engaging identified stakeholders who are directly impacted by, responsible for implementing, or possess subject matter expertise that is relevant to a policy document. Targeted consultation aims to obtain focused, informed, and practical input to determine the effectiveness of a policy document; establish if a document is fit for purpose; and identify any minor amendments required.
Top of PageSection 2 - Policy Governance
Policy Governance Principles
(6) University policy documents must:
- demonstrate compliance with relevant associated legislation and legal obligations, without duplicating them;
- be developed and maintained through an understanding of associated risks and opportunities that is achieved through appropriate and timely exploration and consultation;
- offer high quality information that is useable, accessible, easily understood and complied with;
- meet the needs of relevant stakeholders and be implemented within a given timeframe;
- interconnect with associated policy documents, where relevant;
- align with the objects in the University of Newcastle Act, and the University's values and strategies;
- promote efficiency, consistency, and quality;
- be approved by a relevant and authorised delegate;
- once approved, be published in the University Policy library; and
- once published, be subject to a policy lifecycle that maintains the policy document.
(7) Each policy document must be assigned to a Policy Owner, who is responsible for ensuring:
- implementation of the requirements of the document through an effective implementation plan; and
- ongoing review and maintenance of the policy document in a timely manner.
(8) New policy documents must only be developed where the University is committed to, and able to fully implement the document and its requirements, including the allocation of resources to operationalise the document, review and maintain it.
(9) Policy documents must be kept up to date and current throughout the policy effectiveness period. This can be achieved through amendments or a policy review.
Types of Policy Documents
(10) University policy documents include and are limited to:
Table 1 – Types of Policy Documents
| Type |
Purpose |
| Rule |
A Council approved document, made in accordance with Section 29 of the University of Newcastle Act, that has the same force and effect as a by-law. Other than legislation, this is the highest level of policy document and has the highest level of authority. |
| Policy |
A document that conveys the University's intent (based on principles) on a particular subject or matter and establishes how the University deals with associated risks and opportunities. A policy may have lower-level associated documents, such as Procedures, Guidelines or Frameworks. A policy may be embedded in a Manual or Framework provided it is clearly marked as a Policy. |
| Framework |
A document that addresses how a wide-reaching activity is undertaken at an enterprise or organisational level. |
| Procedure |
A document that establishes a logical sequence of actions to achieve a desired output, or series of outputs. Procedures that are specific to a single business unit to provide instruction on how to undertake administrative tasks are not required to be held in the Policy Library and are therefore not considered a policy document in the context of this Framework. |
| Manual |
Provides a group of policies and/or related procedures. A manual must clearly identify policy content as separate to procedure content. |
| Guideline |
Provides supporting information that a reader may choose to comply with. The content is aimed at helping the reader make a decision or guide their action. |
| Schedule |
Provides information to support a policy, procedure, or Manual. |
| Code |
Establishes expectations of behaviour. |
(11) Please also see Examples of when a policy document might be required.
Hierarchy of Documents
(12) The hierarchy of University policy documents can be viewed here.
(13) Where multiple types of policy documents address the same subject matter, the policy documents must be established and preserved within a clear and coherent hierarchy to ensure clarity of authority, support effective implementation, and promote consistent interpretation and application.
(14) At a minimum:
- policies must articulate overarching principles, intent, and mandatory requirements;
- supporting procedures and guidelines must be explicitly aligned to, and consistent with, the relevant higher-order policy;
- each document must clearly state:
- its role and position within the hierarchy; and
- its relationship to any related documents addressing the same subject;
- content must be structured to avoid duplication, contradiction, or ambiguity across documents; and
- in the event of inconsistency, the higher-order document prevails, unless otherwise explicitly authorised.
Policy Library
(15) The Policy Library is the Council approved platform for publication of approved policy documents.
(16) Documents, other than those listed in Table 1, are not permitted to be published as policy documents in the Policy Library.
(17) Policy documents that are published outside of the Policy Library are not considered authorised University policies and therefore may not provide any recourse should non-compliance occur. Publishing content that meets the definition of a policy document on platforms that are outside of the Policy Library (e.g. SharePoint or knowledge-based article) is considered a breach of this Framework and such action may be subject to disciplinary action as it places the University at risk of non-compliance with the Government Information Public Access Act.
(18) To determine if a document constitutes a “policy document”, Legal and Governance Services will defer to the definition of “policy document” within the Government Information Public Access Act.
Top of PageSection 3 - Policy Lifecycle: Development to Implementation
(19) This section outlines the key stages of the policy lifecycle, including the development, approval, publication and implementation and review of policy documents.
Preparation: New Policy Documents
(20) The preparation stage forms part of the ongoing policy lifecycle and contributes to currency and effectiveness.
(21) The Policy and Delegations Officer must be contacted when considering the development of a new policy document and before drafting the document.
(22) The Policy and Delegations Officer:
- may seek approval from the General Counsel and Chief Governance Officer to proceed with the development of a new policy document;
- may confirm endorsement from the relevant Responsible Executive before proceeding, if not provided; and
- must be provided with the following information:
- the proposed Policy Owner (Responsible Executive);
- the Policy Author, who must be a subject matter expert; and
- the document Enquiry Contact Person.
Preparation: Policy Document Review
(23) The Policy and Delegations Officer will:
- provide a calendar or list of all policy reviews falling due in the forthcoming calendar year, in December. This will be provided to the Executive Leadership Team and is designed to assist with work planning;
- provide notification to the Policy Owner and/or their nominee, and the Enquiry Contact Person to advise of a forthcoming review, 3 months before the scheduled review date;
- consult with the Policy Owner or their nominee before the review date, to determine the type of review that may be completed (see Table 4), and seek confirmation from the Policy Owner of this review type;
- work with the Policy Owner or their nominee to identify appropriate stakeholders for the purposes of consultation for the policy review, where required.
Policy Review Commencement
(24) Policy reviews are a critical stage of the policy lifecycle and ensure policy documents remain current, effective, and aligned with the University's requirements. Policy Owners are responsible for devising work plans that will ensure policy reviews are completed in a timely manner, aiming to complete each review by or before the policy review date.
(25) The review of a policy document must commence on or before the scheduled policy document review date. Where this does not occur, the Policy Owner or their nominee must provide justification of delay to the Policy and Delegations Officer for reporting to the General Counsel and Chief Governance Officer.
(26) Commencement of a policy review is indicated by agreement on the policy risk level, the review type (see Section 4), and establishment of the stakeholder reference group, which should be determined in consultation with the Policy Owner, or their nominated Policy Reviewer and the Policy and Delegations Officer.
(27) Approval and publication of a revised version of the policy document indicates completion of the policy document review.
Policy Document Review Direction and Resourcing
(28) The Policy Owner is responsible for:
- ensuring sufficient resources are in place to complete all requirements of a policy review including nominating a Policy Reviewer. The Policy Reviewer must have sufficient knowledge of the policy subject and context to carry out the review;
- establishing the objectives of the review, particularly for major reviews;
- monitoring policy review completion to ensure it is completed on time and when due.
Associated Document Review
(29) An associated document review is required for
- new policy documents;
- all policy document reviews;
- major amendments to policy documents; and
- proposals to rescind policy documents.
(30) The associated document review should occur prior to consultation and drafting and involves the Policy Owner or their nominee identifying any relevant or associated legislation and University Policy documents to determine if:
- associated documents are current and up to date;
- any change has occurred (e.g. legislative, regulatory change);
- the associated documents are not in conflict with the policy document.
(31) Where the policy document may deal with or address highly contentious or litigious issues, the Legal and Governance Services must be consulted to determine best practice policy inclusions based on legal precedent.
(32) For Post Implementation Reviews, the associated document review will be undertaken by the Policy and Delegations Officer.
Policy Risk and Opportunity Assessment
(33) A Policy Risk and Opportunity Assessment is required for:
- new policy documents; and
- major reviews of existing policy documents.
(34) The assessment is aimed at identifying the critical issues that the policy document may deal with, and to allow a better understanding of the subject to inform its content. This assessment must be informed by relevant key stakeholders. (Please also see Risk Management Framework).
(35) Completion of the assessment is the responsibility of the nominated Policy Reviewer in consultation with relevant key stakeholders. (Please also see Policy Consultation Guideline).
(36) The assessment must:
- consider the full range of risk categories articulated in the Risk Management Framework that relate to the subject that the policy document will deal with; and
- consider the risks to successful and ongoing implementation of the policy document.
(37) Legal and Governance Services should be consulted where the subject matter relates to legislation, where a Rule is being developed or reviewed, or where any legal risk is identified.
(38) The Policy Risk and Opportunity Assessment tool may be used.
Consultation
(39) Please see the Policy Consultation Guideline for further information on consultation.
(40) The Policy and Delegations Officer will work with the Policy Owner or their nominee to establish a stakeholder reference group for the purposes of consultation.
(41) New policy documents, major reviews and major amendments must be informed by broad consultation.
(42) The consultation undertaken for a policy document review is dependent on the type of review (see Table 4). The consultation must be directed at confirming that the purpose of the review type is met.
(43) In the event the proposed changes do not meet the review type and purpose, the review type will be changed by the Policy and Delegations Officer and the consultation requirements for the revised review type must be undertaken.
(44) Where broad consultation is undertaken, this must be undertaken via the Policy Library bulletin board, but may be supported by other mechanisms such as focus groups, zoom sessions, surveys, benchmarking, feedback tools, and individual or team submissions).
(45) Benchmarking may be used to inform policy development, reviews or amendments. Where a policy document is proposed to be adopted, in whole or in substantial part, from another institution, consultation with that institution must occur to inform the effectiveness and suitability of the document prior to adoption.
(46) When using other organisation’s policies to inform a policy document, copyright law must be adhered to. Please see the University's Copyright Compliance Policy.
(47) A Policy Owner may opt to use the Policy Library bulletin board for policy document feedback as a consultation mechanism for any policy document regardless of the review type or proposed amendment types. In these circumstances, the Policy Owner or their nominee should consult with the Policy and Delegations Officer to facilitate this.
Consultation with Controlled Entities
(48) Where a policy document applies to controlled entities, consultation with representatives from the controlled entities must be undertaken.
(49) The General Counsel and Chief Governance Officer is responsible for determining if a University policy should apply to controlled entities. Such determinations are made by the General Counsel and Chief Governance Officer on behalf of the Vice-Chancellor after considering the views of the entity board.
Drafting
(50) Policy authors are responsible for maintaining effective version control of all draft policy documents.
(51) The Policy Style Guide provides supporting information to assist Policy Authors and Policy Reviewers when drafting, and should be adhered to as far as reasonably possible.
(52) Policy document templates are available to use and can be found here.
(53) Policy Authors and Policy Reviewers must continue to consult with key stakeholders during the drafting phase to arrive at a final draft document that is fit for purpose.
(54) The Policy Owner must endorse a final draft before it can proceed to the Policy and Delegations Officer for Quality Review.
Quality Review
Preliminary Quality Review
(55) The Preliminary Quality Review is conducted by the Policy and Delegations Officer, and must be completed for:
- new policy documents;
- high and medium risk policy documents subject to major review;
- medium risk policies subject to minor review; and
- major and minor amendments to medium or high risk policies.
(56) Policy documents submitted for approval without a Quality Review where it is required may be rejected from committee meeting agendas by Secretariat.
Final Quality Review
(57) A Final Quality Review may be conducted after the feedback period (see clause 61-69), and is required for:
- new policy documents;
- high and medium risk policies that have undergone a major review or major amendment;
- medium risk policies that have undergone a minor review where significant changes emerge from the feedback provided.
(58) Table 2 outlines the purpose of Quality Reviews.
Table 2 – Quality Review Purpose
| Policy Type |
Preliminary Quality Review Purpose |
Final Quality Review Purpose |
| New policy – all risk levels |
Determine if the policy document meets the requirements of this Framework, including the Policy Style Guide.
Determine if the policy document is appropriate to be released for feedback. |
Determine if the policy document is appropriate to be submitted for approval. |
| Policy Reviews and Amendments |
Confirm the type of review is appropriate.
Ensure the amendments and draft document meet the requirements of this Framework, including the Policy Style Guide.
Confirm the approval pathway.
Confirm the next review cycle. |
(59) The Preliminary Quality Review may result in recommendations:
- to improve the document in consideration of the Policy Governance Principles and this Framework, including the Policy Style Guide;
- for further consultation; or
- for legal review.
(60) Recommendations made by the Policy and Delegations Officer that speak to the foundations of the document that remain unresolved following quality review but prior to approval will be reported to the relevant delegate to inform their decision.
Policy Document Feedback Period
(61) A policy document feedback period must be established for:
- new policy documents;
- all policy documents that have undergone a major review; and
- high or medium risk policies that have undergone a major amendment.
(62) The feedback period involves the revised policy document being placed on the bulletin board for a period of no less than 2 weeks. This period may be extended by the Policy and Delegations Officer without notice in the event no views have been recorded during this 2 week period.
(63) Policy documents must not be posted on the Policy Library bulletin board, or any other feedback mechanism, without:
- endorsement from the Policy Owner;
- being subject to a Preliminary Quality Review where required by this Framework; and
- communications being prepared by the Policy Reviewer or Policy Owner to invite feedback.
(64) Policy Reviewers are responsible for identifying all impacted stakeholders and undertaking timely and effective communication to invite them to provide feedback on the document.
(65) Post feedback, the Policy Reviewer is responsible for reviewing all feedback received and drafting any required amendments to the document.
(66) Feedback received must be given objective consideration as it may indicate further edits to the draft document are required.
(67) The Policy Owner or the Policy Reviewer may exercise discretion in responding to feedback.
(68) Once all final edits to the document have been made to address relevant and appropriate feedback, the final draft document must be:
- endorsed by the Policy Owner; and
- submitted to the Policy and Delegations Officer.
(69) Depending on the outcomes of the Preliminary Quality Review and changes made post feedback, the document may be subject to a Final Quality Review by the Policy and Delegations Officer.
Approval
(70) New versions of documents, including initial versions must be approved in accordance with the University's delegations of authority prior to their publication and implementation. (Please see Delegations Register).
(71) The Policy and Delegations Officer can provide support and assistance in identifying the appropriate approval pathway.
(72) Subject to the approval pathway, approval (except for administrative and editorial amendments) must be sought using one of the following cover sheets:
- Delegate – Policy Cover Sheet, for delegate approval pathways; or
- Committee – Policy Cover Sheet, for committee approval pathways.
(73) The completed cover sheet must be provided to policy@newcastle.edu.au in the first instance, who will facilitate submission to the delegate for approval.
Major Reviews and New Policy Documents
(74) To seek approval for a new policy document or major review of an existing policy document, the following must be undertaken by the Policy Owner, or the Policy Reviewer:
- where the document has been drafted outside of the policy library workspace, the final draft version being submitted for approval must be provided to the Policy and Delegations Officer for transfer into the workspace to ensure version control;
- completion of the Policy Document Checklist and provision to the Policy and Delegations Officer;
- a drafted Committee – Policy Cover Sheet must be provided to the Policy and Delegations Officer for review. The Policy and Delegations Officer is responsible for adding any outstanding recommendations that need to be considered by the approving delegate to the cover paper and for ensuring resolutions are appropriate.
(75) The Committee – Policy Cover Sheet must include, at a minimum:
- a draft resolution seeking specific approval from the authorised delegate of the policy document (using the policy document title) and approval of the next review date;
- details of the need for the policy document where it is a new policy document;
- a summary of the amendments being made, where it is a minor or major review, or major amendment;
- details of consultation that has occurred (See Policy Consultation Appendix template);
- the Implementation Plan (if required) (as an appendix); and
- the final draft Policy, and the completed Policy Document Checklist as appendices.
(76) Draft resolutions provided on the cover paper for submission for approval must also be considerate of any related matter that may require approval to give effect to the policy. For example, where approval of a new policy document will result in the rescission or amendment of another policy, approval should be sought for the rescission or amendment at the same time.
(77) Where the publication of a new or revised policy will create a conflict with any delegation of authority, the request for approval for any change in delegation must be submitted with the paper to approve the policy.
Policy Rescission
(78) Approval to rescind a policy document must be provided by an authorised delegate and is subject to a committee approval pathway.
(79) Where the rescission of a policy document will require associated changes in other policy documents or delegation schedules, the proposed amendments to these documents must be outlined in the Committee – Policy Cover Sheet requesting approval of rescission and the associated proposed changes.
(80) The drafted Committee – Policy Cover Sheet seeking approval to rescind a policy document must be provided to the Policy and Delegations Officer for review.
(81) The policy document will not be rescinded from the Policy Library until such time as:
- approval has been confirmed; and
- amendments to associated policy documents have been approved, where required;
- references to the rescinded policy document in the Delegations Schedules have been amended and approved.
Review Cycle and Next Review Date
(82) The review cycle for a policy document commences from the date of publication of the most recent approved version.
(83) The next policy review date must be determined in consultation with the Policy and Delegations Officer. The Policy Owner or their nominee may seek to align the review date with associated documents (such as overarching documents, contracts, or agreements) or with operational work plans. In all circumstances, review cycles must align with the requirements for the relevant review type and policy risk level.
(84) Completion of a major review replaces all other review requirements and resets the review cycle from the date of publication of the approved policy document.
(85) New policy documents will be assigned a 12-month review date to enable a Post Implementation Review to be conducted by the Policy and Delegations Officer. The subsequent review cycle will be confirmed in consultation with the Policy Owner or their nominee upon completion of the Post Implementation Review.
(86) If approval for the policy and any related matter cannot be achieved at the same time (i.e. needs to be approved by different delegates), the relevant policy will not be published until such time as the related matter is approved.
Implementation Plan
(87) An Implementation Plan must be documented for:
- new policy documents; or
- policy documents that have undergone major review or major amendment.
(88) The Implementation Plan should identify what actions are required, and by whom, to successfully implement and comply with the policy. This may include, but is not limited to:
- communications;
- training;
- changing, updating, or implementing resources and/or systems, including testing where appropriate;
- changing practices and review of these to ensure compliance.
(89) Implementation Plans should be proportionate to the scale, risk and operational impact of the new policy, or the policy amendment, but must clearly address the objective of achieving compliance with the document’s requirements.
Publication
(90) The Policy and Delegations Officer is responsible for publishing approved policy documents upon receipt of confirmation of all relevant and associated approvals from the authorised delegate and in accordance with any conditions associated with the approval. Confirmation of approval must be sourced from the Secretariat where the committee approval pathway has been applied.
(91) Publication of draft policy documents without confirmation of approval may be delayed until such evidence can be sourced or provided.
(92) The University Secretary may authorise publication of a policy document without confirmation where:
- the approval pathway is via a Committee; and
- the provision of the confirmation may be delayed but immediate publication is operationally necessary.
(93) The effective date of the policy document will be the date of publication, or a later date. Backdating of policy documents is prohibited.
(94) The policy review date will be established as per the approval.
Implementation
(95) Implementation is a critical stage of the policy lifecycle, ensuring that approved policy documents are operationalised and embedded within the University. Implementation must aim to ensure compliance with the policy document requirements.
(96) Once published, the Policy and Delegations Officer:
- will notify the Policy Author, Policy Owner, Enquiry Contact Person, and Responsible Executive of the publication;
- notify the key stakeholders that the document is now in effect and must be complied with; and
- schedule a 12-month Post Implementation Review if the policy document is new (see Table 4).
(97) The Policy Owner is responsible for ensuring that the revised or new policy document is effectively operationalised.
Top of PageSection 4 - Policy Lifecycle: Maintaining Published Policy Documents
(98) This section outlines the ongoing maintenance stage of the policy lifecycle, ensuring policy documents remain current, accurate and effective following publication.
(99) The Policy Owner is responsible for ensuring the content of a published policy document remains current and up to date to ensure its continued integrity and validity. This includes, but is not limited to:
- seeking amendments where:
- regulatory changes occur;
- operational changes or improvements are introduced;
- roles and responsibilities change; or
- new risks emerge; and
- ensuring policy reviews are completed on time and when due.
(100) Whilst undertaking projects to improve systems and processes Policy Owners must ensure that concurrent efforts are undertaken to maintain the currency of related policy documents.
Issues Register
(101) The Issues Register supports the ongoing maintenance stage of the policy lifecycle.
(102) Policy Owners are responsible for maintaining a Policy Issues Register for each policy document that they are assigned to, to record any issues identified with the policy. The Policy Issues Register must be reviewed to inform any future policy review or amendments.
Policy Reviews
Policy Risk Level
(103) Review types are based on the level of risk a policy presents to the University. A formal risk assessment is not required.
(104) The policy risk level must be determined in consideration of the current environment that the policy operates in at the time of commencing the policy review. In determining the current environment, consideration should be given to:
- legislative and regulatory change;
- organisational change;
- implementaton issues;
- compliance incidents;
- audit findings;
- stakeholder feedback; and
- emerging risks.
(105) The Policy Risk Level Matrix determines the risk level of the policy document, having regard to the:
- compliance, rights and governance criticality of the document; and
- consequences arising if the document is inaccurate, ineffective or out of date.
(106) The policy risk level is determined using the Policy Risk Matrix by the Policy Owner, or their nominee, in consultation with the Policy and Delegations Officer. The Policy Risk Matrix assesses review frequency requirements only and does not represent the University's enterprise risk rating for the subject matter governed by the policy document. The corresponding review type is determined by the policy risk level. A Policy Owner may elect to apply a more rigorous review type, but cannot apply a less rigorous review type. Any disagreement regarding the policy risk level will be determined by the Senior Compliance Manager.
(107) The following types of review may be undertaken for approved policy documents:
Policy Document Review Types
(108) Not withstanding clause 109, the following types of review may be undertaken for approved policy documents:
| Review Type |
Purpose |
Consultation Requirements |
| Post Implementation Review |
A desktop review conducted by the Policy and Delegations Officer to verify a policy document has been operationalised. The review is not designed to assess a document’s effectiveness. |
The Policy and Delegations Officer, or their nominee, will consult with staff and/or controlled entities, where relevant, who have responsibilities within the policy document to verify it’s operationalisation. The Policy and Delegations Officer will consult with the Policy Owner / subject matter expert to determine any future review date. |
| Major Review |
Improve the policy document and it’s effectiveness. |
Policy and Risk Opportunity assessment.
Broad consultation.
Benchmarking – optional. |
| Minor Review |
Confirm the currency and accuracy of the content. Assess the effectiveness of the document and ensure no new risks have emerged since last review. Amendments should focus on addressing new moderate risks or operational impacts. |
Targeted consultation, unless metrics are appropriate, available and valid to inform the review. |
| No Change Review |
Confirm the policy document remains current and fit for purpose, with minimal impact or change required. Review should include a legislative scan and stakeholder confirmation of fitness for purpose. A No Change Review can be accompanied by editorial or administrative amendments.
A No Change Review is only appropriate where no significant legislative, operational, governance or stakeholder changes have occurred since the previous review. |
Targeted consultation to confirm currency and fitness for purpose.
Issues Register review (if available), operational data or Policy Owner knowledge may also validate confirmation of fitness for purpose. |
Policy Document Review Requirements per Policy Risk Level
(109) As a minimum:
- policy documents assessed as high risk must undergo a major review at least every 3 years;
- policy documents assessed as medium risk must:
- undergo a major review at least every 6 years; and
- undergo a minor review 3 years after the major review, unless a No Change Review is undertaken;
- policy documents assessed as low risk must undergo either a minor review or No Change Review at least every 7 years.
(110) The Policy and Delegations Officer may require a review to be escalated to a higher review type where the proposed amendments are assessed as having a greater risk, impact, complexity or organisational significance than originally anticipated.
(111) In the event a policy risk level changes during a policy document’s effectiveness period, the Policy Owner may initiate a review prior to the policy review becoming due.
(112) Policy risk level determines minimum review requirements, and does not determine the significance of any future amendments.
Policy Amendments
(113) Policy amendments form part of the ongoing policy lifecycle and ensure policy documents remain current between scheduled reviews.
(114) All proposed amendments to a policy document must be classified as either:
- a policy review; or
- an out-of-cycle amendment.
(115) Where amendments are proposed within 6 months prior to the policy document review date, the Policy and Delegations Officer must determine whether the changes should instead be undertaken as a policy review, having regard to the extent, impact, and risk of the changes.
Table 5 – Policy Amendment Types
| Type |
Consultation Requirements |
Approval Pathway |
| Editorial |
Nil. |
Not required.
Email policy@newcastle.edu.au. |
| Administrative |
Nil. |
Endorsement by Policy Owner.
Approval by authorised delegate, facilitated by Policy and Delegations Officer.
Email policy@newcastle.edu.au. |
| Minor |
Targeted Consultation |
Approval by authorised delegate, via email.
Approval to be forwarded to policy@newcastle.edu.au. |
| Major |
Broad Consultation |
Approval by authorised delegate, via relevant committee approval pathway. |
Policy Amendment Requirements
(116) All proposed amendments to policy documents are subject to review by the Policy and Delegations Officer prior to being submitted for approval.
(117) Where there is uncertainty regarding the classification of an amendment, the Policy and Delegations Officer will determine the appropriate amendment type in consultation with the Senior Compliance Manager.
Amendments and Review Cycle
(118) The review cycle is a key mechanism within the policy lifecycle.
(119) The completion of a major, minor or no change review resets the review cycle from the date of publication of the updated document.
(120) Where a policy document amendment meets the requirements of a defined review type, the amendment may be recognised as that review type, having regard to the policy’s risk level. In such circumstances, the review cycle will be reset in accordance with the requirements of that review type, from the date of publication of the updated document.
(121) The determination of whether the requirements of a review type have been met through policy amendment must be confirmed by the Policy and Delegations Officer and the next review date approved by the authorised delegate.
Policy Amendment Pathway
(122) All requests for policy amendments must be sent to policy@newcastle.edu.au, including details of any consultation required and undertaken.
(123) Requests made by staff other than the Policy Owner will be directed to the Policy Owner, or their nominee, for endorsement.
(124) Where the proposed amendments do not align with the amendment type proposed (and subsequent consultation and approval pathways), the Policy and Delegations Officer may advise the Policy Owner of alternate consultation or approval requirements.
(125) Published minor amendments:
- to operational policy documents will be reported to the Executive Leadership Team by the Policy and Delegations Officer;
- to academic policy documents will be reported to Academic Senate by the President Academic Senate.
(126) Details of amendments will be recorded in the policy document status and details page in the policy library.
(127) Editorial amendments will not produce an updated version of the document in the policy library. All other types of amendments must produce a new version of the document.
Quality Scans
(128) Quality scans support the maintenance stage of the policy lifecycle.
(129) The Policy and Delegations Officer may undertake periodic quality scans of published policy documents to identify minor issues, including formatting inconsistencies, broken links, outdated references, grammar or readability concerns, or administrative inaccuracies.
(130) Where issues identified through a quality scan meet the definition of an editorial or administrative amendment, the Policy and Delegations Officer may initiate amendments in accordance with this Framework and must seek endorsement from the Policy Owner or their nominee prior to seeking approval by an authorised delegate if required.
(131) Quality scans are not a substitute for policy review and do not assess the effectiveness or fitness for purpose of a policy document.
Published Policy Document Feedback
(132) Feedback on published policy documents can be submitted at any time by accessing the relevant policy document in the Policy Library and then selecting the “feedback” option.
(133) Feedback submitted will be emailed to the Policy and Delegations Officer, who will forward the feedback the Policy Owner and/or Enquiry Contact Person for consideration.
Top of PageSection 5 - Exception Handling
Deferral of Policy Review
(134) A Policy Owner may seek approval from the General Counsel and Chief Governance Officer to defer a review, under exceptional circumstances. A policy review deferral may only occur once within a 5 year period and the review date may only be deferred for 12 months. Exceptional circumstances include:
- evidence confirms that legislative change is likely to occur within the next 12-month period;
- a major organisational restructure is about to, or is occurring and it is anticipated that this will impact on the policy document;
- resourcing for the review is subject to critical operational pressures (such as emergency response, critical incidents) and resources must be legitimately redirected to these high priority tasks.
(135) Once a policy review deferral has been approved the Policy and Delegations Officer will amend the policy document review date, in accordance with the approval.
Policy Review Type Consensus
(136) In the event the Policy Owner and Policy and Delegations Officer fail to reach consensus on the type of policy review that must be conducted, the General Counsel and Chief Governance Officer will determine the review type.
Overdue Policy Reviews
(137) A policy review will be become overdue if it is not completed on or before the policy document review date. The policy document review is complete when the revised document is approved and published in the Policy Library.
(138) Overdue policy reviews may be reported to Executive Leadership Team or Council Committees at their request.
Waiving of Consultation Requirements
(139) Waiving of consultation requirements may be approved by:
- the General Counsel and Chief Governance Officer or Vice-Chancellor for operational or Council owned policy documents; or
- the President Academic Senate for academic and research policy documents.
(140) Any such approval must be provided to the Policy and Delegations Officer.
Top of PageSection 6 - Associated Information
(141) Examples of when a policy document may be required
(142) Policy Risk and Opportunity Assessment Tool
(143) Policy Consultation Guide
(144) Policy Consultation Appendix Template
(145) Policy Document Checklist
(146) Policy Risk Level Matrix
(147) Policy Document Quality Review
(148) Policy Template
(149) Procedure Template
(150) Policy Style Guide
(151) Issues Register Template
(152) Policy Document Lifecycle Requirements
(153) Implementation Plan Template
(154) Flow Chart – New Policy Document
(155) Flow Chart – Policy Reviews
(156) Policy Document – Committee Cover Sheet
(157) Policy Document – Delegate Approval Cover Sheet