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DHHS POLICIES AND PROCEDURES

_______________________________________________________________________________________________________________

Section I:

Policy Coordination

Title:

Policy Development and Publication

Current Effective Date:

2/24/09

Revision History:

Formerly titled “Departmental Policies and Procedures” Revised 3/1/04; 5/1/05

Original Effective Date:

2/16/04

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Purpose

To ensure that all appropriate stakeholders are involved in the development, review and approval of proposed departmental policies, and to establish a process to facilitate the review and approval of proposed policies.

Policy

The development and revision of departmental policies must be a collaborative process that affords all impacted divisions/offices the opportunity to review and provide input on the proposed policy. The DHHS Policy Coordinator shall coordinate the review and approval process for new or revised departmental policies per the steps described in the “Implementation” section of this policy.

Roles and Responsibilities

  1. DHHS Policy Coordinator
    It is the responsibility of the DHHS Policy Coordinator to:
    1. Maintain a contact list of all divisional Policy Coordinators.
    2. Provide technical assistance to divisions/offices on policy development as needed.
    3. Coordinate the review and approval of proposed departmental policies.
    4. Publish approved departmental policies on the Department of Health and Human Services (DHHS) website.
  2. Division/Office/Facility/School Director
    1. Designate a Policy Coordinator and provide the person’s contact information to the DHHS Policy Coordinator.
  3. Division/Office Policy Coordinator
    Each division/office shall name a Policy Coordinator, whose responsibilities will include:
    1. Serve as the point of contact on all policy-related matters for the division/office.
    2. Ensure that the division/office is in compliance with this policy.
    3. Coordinate internal division/office review of proposed policies
    4. Facilitate the dissemination of new policies within the division/office.

Implementation

  1. Policy Types
    The development and approval process for a proposed policy will depend on the scope and scale of the policy. A policy may impact only one division/office or program, or it may impact several or all divisions/offices. A policy that affects the administrative procedures of another division/office, service delivery programs, or clients should be understood as impacting that other division/office. In addition, certain situations may call for a single new or revised policy, and others may call for multiple policies or an entire policy manual to be developed. The development processes for the different types of policy are described below:
    1. Division Specific Policy
      If the proposed policy would impact only the originating division/office, that division/office may proceed with developing the policy internally in the format the division/office chooses. The Policy Coordinator for the division shall coordinate the development, review and publication process of division specific policy.

      There are no further requirements for Division or Program-Specific-Policy.

    2. Departmental Policy
      If a new or revised policy is proposed as the result of an issue which impacts two or more divisions, the proposed policy shall be considered “departmental policy.” The Policy Coordinator from the division/office that identified the need for the policy shall notify the DHHS Policy Coordinator. If the issue in question can be effectively addressed in a single new or revised policy, generally the originating division/office will draft the new or revised policy.

      If the issue in question requires several new policies or a policy manual, a work group may be assembled with representatives from various divisions/offices to draft the policies. Once the work group has finished drafting the proposed policies, they are subject to the same review and approval process as a policy drafted by a single division.

      All departmental policies are subject to the requirements described under sections 2 – 5 below.
  2. Departmental Policy Format
    All new departmental policies must be drafted in the prescribed format. If the proposed policy would be a chapter within a larger policy manual (a policy manual is a set of interrelated policies with a chapter for each individual policy), click here for the template. If the proposed policy would stand alone, click here for the template. The template is required to ensure that exact formatting is retained when the document is converted to HTML and PDF formats.

  3. Initial Review
    Once a final draft of a proposed departmental policy has been prepared by the originating division/office (or by a workgroup), the draft policy shall be submitted to the DHHS Policy Coordinator, who will disseminate the policy to all Policy Coordinators for an initial review. The standard timeframe for comments shall be two weeks for a single policy and three weeks for a batch of policies, though under certain circumstances more or less time may be provided. The DHHS Policy Coordinator will compile the comments and embed them within the draft policy so that they will be appropriately documented and clearly visible to the originating division/office or work group and then forward them to the originating division/office or workgroup members for revision.

    If there are no requests for changes from Policy Coordinators, other than grammatical corrections, the DHHS Policy Coordinator will consider the policy final and proceed to publication.

  4. Subsequent Revision and Approval
    Once the originating division/office or workgroup has received and responded to the initial feedback, the modified draft of the policy shall be resubmitted to the DHHS Policy Coordinator.

    The DHHS Policy Coordinator shall re-circulate the revised draft policy showing comments and changes made. Policy Coordinators shall review changes and indicate whether they approve or do not approve of publishing the policy in its existing version. If all Policy Coordinators indicate that they approve of publishing the policy in its existing version, the DHHS Policy Coordinator will consider the policy final and proceed to publication. If one or more Policy Coordinators indicate they do not approve of publishing the policy, the DHHS Policy Coordinator shall facilitate discussions between the disputing parties in an effort to resolve the concerns in a way that is amenable to all parties. If the parties are not able to reach an agreement on the language of a proposed policy, then a decision about the final language of the policy will be made by executive DHHS management. Once such a decision has been made, the DHHS Policy Coordinator will consider the policy final and proceed to publication.

  5. Publication
    Once the DHHS Policy Coordinator has determined that a departmental policy is ready for publication per the review/approval process described above, the DHHS Policy Coordinator will work with the Policy Coordinator from the originating division to ensure the document follows proper formatting guidelines and that all links are functional. The DHHS Policy Coordinator shall be responsible for publishing all new and revised policies and notifying all Policy Coordinators when new or revised policies have been published. Policy Coordinators will be responsible for alerting their divisions/offices of the new policy.

All departmental policies will be published on-line at the DHHS On-Line Publications website.

All departmental policies will be published in one of the following sections of the Department of Health and Human Services Policy and Procedure Manual:

Exceptions

Medicaid Clinical Policy: Although Medicaid clinical policy impacts the clients of multiple divisions, the Division of Medical Assistance (DMA) clinical policy review process is exempt from the departmental policy review and approval process described herein. Medicaid clinical policies are subject to review by the NC Physician’s Advisory Group and then a 45-day public comment period. [SL 2003- 284, Section10.19(bb)] Once completed they are published on the DMA web site.



For questions or clarification on any of the information contained in this policy, please contact the DHHS Policy Coordinator.



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