Policy 001: Policy on BSOM Policies

Policy Number: 001

Date Approved: 08/06/2024

Executive Responsibility: Executive Committee

Related Information: Wright State University Policy on Policies; LCME Element 4.6

001.1 Purpose

In accordance with LCME Element 4.6, “the dean and a committee of relevant medical school administrators and faculty representatives determine the governance and policymaking processes within their purview.” A Boonshoft School of Medicine (BSOM) Policy is an officially approved written statement that (a) sets standards or procedures for academic and administrative functions of BSOM; (b) directs actions of faculty, staff, students and others who engage with BSOM; and (c) applies School-wide, across departments and units. All BSOM policies will be associated with a number series to reference the classification of a given policy.

001.2 Location of BSOM Policies

The current official version of all BSOM Policies, both administrative and academic, is maintained on the BSOM Policies website. To ensure consistency, all other web appearances of BSOM Policies should be links to the BSOM Policies website.

001.3 Compliance with BSOM Policies

BSOM faculty, staff, and students, as well as other persons who visit or have contact with BSOM are expected to comply with federal and state laws, applicable regulations, and BSOM and Wright State University Policies.

001.4 Policy Administration

The Chair of the Continuous Quality Improvement (CQI) Committee, or their designee, is responsible for adding, modifying, and deleting policies to the BSOM Policies website as approved by the individual or entity with Executive Responsibility, and as otherwise permitted by this policy (see “001.7 Policy Maintenance,” below); maintaining records of reviews and revision approvals; coordinating a review of all policies, at a minimum, every three years by the CQI Committee; and promulgating policy changes to the BSOM community.

001.5 Policy Format

All policies will be entered into the BSOM Policy website in a consistent format, with the following headers:

Policy Name
Policy Number	Assigned by the Chair of the CQI Committee, or their designee, to best fit within the organizational scheme of the BSOM Policies.
Date Approved	The most recent date of approval by the responsible committee/department/unit.
Executive Responsibility	The individual (e.g., Dean of Medicine) or entity (e.g., Executive Committee, Faculty Curriculum Committee, Faculty Assembly) with approval authority related to a BSOM Policy.

Policy Name

Policy Number

Assigned by the Chair of the CQI Committee, or their designee, to best fit within the organizational scheme of the BSOM Policies.

Date Approved

The most recent date of approval by the responsible committee/department/unit.

Executive

Responsibility

The individual (e.g., Dean of Medicine) or entity (e.g., Executive Committee, Faculty Curriculum Committee, Faculty Assembly) with approval authority related to a BSOM Policy.

As appropriate, policies will have additional headers such as:

Applies To	Restrictions of applicability where such restrictions are not clear in the policy statement.
References	Links to government regulations and state or federal laws directing or controlling a policy, links to Wright State University policies/procedures, links to LCME standards/elements.

001.6 Approval of New and Revised BSOM Policies

Written proposals for new policies, amendments, or rescindments should be submitted to the person or entity with Executive Responsibility via the Chair of the CQI Committee, or their designee, who will oversee and facilitate the process of reviewing, further modifying as necessary, approving, and updating the new or revised policy.

001.7 Policy Maintenance

Changes that the Chair of the CQI Committee, or their designee, may make to BSOM Policies are restricted to:

Additions, modifications, and rescindments approved by the person or entity with Executive Responsibility in said policy in compliance with this Policy on Policies. The approval date of these formal changes is entered as the “Date Approved.” Changes listed in items 2-4, below, do not affect the “Date Approved.”
Correction of obvious errors (e.g., spelling, punctuation, and grammar).
Necessary changes to links within a policy, names/titles, contact information, policy numbers, or other specifics that do not alter the statement of policy. (Requires written approval of person or entity having Executive Responsibility for the policy.)
Name of person or entity with Executive Responsibility. (Requires written approval of the Dean of Medicine.)

001.8 Policy Review

While policies may be revised as needed, all BSOM Policies will be reviewed, at minimum, in the third year following its “Date Approved,” by the CQI Committee. Following the review, the CQI Committee will determine if the existing policy is (a) accurate and current, or (b) in need of revision. If no revisions are needed, the “Date Approved” will be updated to the date of the review. If revisions are recommended, then the person or entity with Executive Responsibility is responsible for conducting the revision. The Chair of the CQI Committee, or their designee, is responsible for overseeing the review process.

001.9 Notification of Policy Revisions

Upon policy approval by the person or entity with Executive Responsibility, the Chair of the CQI Committee, or their designee, will make the changes to the BSOM Policy website and promulgate policy changes to the BSOM community via email and/or other official channels of communication.

001.10 Authority of BSOM Procedures

Each person or entity with Executive Responsibility for a policy shall have the authority to develop, amend, and rescind procedures pursuant to that policy to execute said policy.