Policy on Policies

Academic, Rural and Regional Affairs policy – A policy with application within the UW School of Medicine MD program.

Authorized Individuals and Governing Bodies – The appropriate units, departments, committees, or individuals whose jurisdiction covers the subject matter of the policy.

Exceptions – Refines the understanding of the circumstances wherein the policy is not applicable.

Guidelines – Additional context the reader may need to comply with the policy and/or carry out the procedure.  Although not required, guidelines may be formally approved and adopted in accordance with policy.

Policy – A high-level management statement or decision approved and adopted by governance. A policy

• is a governing principle that mandates or constrains actions,
• has broad application across the UW School of Medicine MD program,
• changes infrequently and sets a course for the foreseeable future,
• ensures compliance with laws, regulations, and accreditation requirements; and
• may reduce institutional risks.

Procedures – Directions for how to implement the policy. Procedures

• identify and link to the applicable policy by identification number,
• are written in a format that is easy to follow, using numbers or bullets to delineate steps,
• will be reviewed and updated as necessary; and
• although not required, procedures may be formally approved and adopted in accordance with policy.

Protocol – A checklist of specific technical action steps that must be completed in a precise order. Protocols are linked to the applicable policy by identification number (for example, Blood/Body Fluid Exposure Protocol)

Requirement – A condition stipulated as necessary to comply with laws, policies, procedures and guidelines prescribed by governing bodies (e.g. federal or state agencies, UW, UW School of Medicine, standing committees, etc.). (For example, pre-medical course requirements).  Although not required, requirements may be formally approved and adopted in accordance with policy.

Superseded Policy – Denotes a policy that is no longer in effect and has been replaced or supplanted by a new policy

University policy – A policy with broad application across the University of Washington.

UW Medicine policy – A policy with application across the eight entities of UW Medicine, including UW School of Medicine, UW Medical Center, Harborview Medical Center, Northwest Hospital & Medical Center, Valley Medical Center, UW Neighborhood Clinics, UW Physicians, and Airlift Northwest.

UW School of Medicine – A policy with application across UW School of Medicine, including undergraduate and graduate medical education.

WWAMI partner university policy – A policy with specific application at one of the five regional WWAMI campuses (Gonzaga University, University of Wyoming, University of Alaska, Montana State University or University of Idaho). These policies typically apply to students only on the WWAMI partner university campus during the Foundations Phase of the curriculum.

Requirements, Procedures and Guidelines
For developing new policies, ARRA leadership and governing bodies (including but not limited to ARRA committees) will develop procedures and guidelines aligned with this Policy on Policies and utilize the Policy Template:

1. Confirm the authority of the individual(s) or governing bodies responsible for the subject matter of the policy, procedures and guidelines.
2. Develop the policy, procedures, guidelines and other necessary documentation in consultation with this Policy on Policies and utilizing the format of the Policy Template. For additional assistance, reference the FAQ page (URL).
3. Notify and consult with other authorized individual(s) or governing bodies with whom there is potential policy subject matter overlap, as appropriate.
4. Consult with the policy and procedure management and oversight body or designee to complete the policy template (i.e. identification number, LCME standard, keywords, etc.).
5. Approve the policy through the authorized governing bodies, followed by the Vice Dean of Academic, Rural and Regional Affairs, and if appropriate, the Dean of the School of Medicine.
6. After the authorized individuals or governing bodies has approved and adopted the policy, submit the final policy to the policy and procedure management and oversight body or designee.

Exceptions
ARRA policies are not intended to contradict or supersede any Washington Administrative Code, University of Washington policy, UW Medicine or UW School of Medicine policy.

Additionally, ARRA policies are not intended to supersede or contradict WWAMI partner universities’ autonomous policies as applicable to students on the WWAMI partner university campus during the Foundations Phase of the curriculum.

Policy Record Keeping
The Medical Education Program Policies webpage contains all current policies and procedures. To maintain an organized system and ensure consistency, individual departments, units, WWAMI partner universities, clerkships, etc. will not maintain separate copies or versions of policies. Instead, these entities will direct users to the Medical Education Program Policies webpage. In the event that different versions of a policy appear in more than one location (i.e. clerkship blog, WWAMI campus website, etc.), the policy contained in the Medical Education Program Policies webpage will be considered the official version.  All retired and superseded policies will be archived in accordance with records retention policies.

Related Policies
Identification of and linking to related policies will be completed in consultation with the policy and procedure management and oversight body or designee.

Legal Review
Legal review by the University of Washington Division of the Attorney General’s Office should be considered if any of the following criteria are met:

1. Could the policy lead to significant consequences subject to legal claims (e.g. dismissal from the program)?
2. Does the policy create obligations between the school and the student?
3. Is the policy related to an area that is governed by a legal framework (e.g. state or federal law or regulations, such as disability accommodation, technical standards, student conduct)?
4. Is there overlap with UW policy/process (e.g. student code)?
5. Is it a developing area where potential risks are unclear?

The name of the attorney performing the legal review and the date of completion will be recorded.

Maintenance and Review
Policies will be reviewed every four years or less by the authorized individual(s) and governing bodies and maintained centrally by the policy and procedure management and oversight body or designee.