01.A.01 – Creating and Maintaining System Policies

Section: General Administration

Area: Administrative Guide

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This policy establishes processes and guidelines for developing, reviewing, approving, revising, and retiring University of Houston System (UHS or System) policies, known as System Administrative Memoranda (SAMs).


UHS aspires to maintain a policy framework that best serves its mission; implements legal requirements and Board of Regents policies; and that represents and supports ethical conduct and compliance in all of its activities. This policy is intended to enhance operational efficiencies, best practices, shared governance, compliance, effective decision-making, and transparency with respect to the manner in which System-wide policies are developed and maintained.


3.1 Board: The Board of Regents of the University of Houston System.

3.2 Director of Policy Management: The University of Houston Assistant Compliance Officer serving as the policy development facilitator whose responsibilities include: a) chairing the Policy Advisory Committee (PAC), b) working with Subject Matter Experts (SMEs) to review and edit draft policies, c) addressing questions from the UHS community regarding policy development, and 4) otherwise managing the processing, dissemination, coordination of input from stakeholders, archiving, and review of SAMs.

3.3 Full Review Process: The process set forth in Section 5 for the review and processing of new SAMs and Substantive Changes to current SAMs (other than those designated as Legal Review, Interim Issuances, Housekeeping Changes and Minor Changes).

3.4 Housekeeping Change: A revision to a SAM that is clerical in nature and does not directly change meaning or intent of the policy. Housekeeping Changes include references to supporting law or other policies, corrected formatting or typos, corrected titles, change of authority for the policy, updated contact or URL information, or very minor text changes for clarity.

3.5 Policy Advisory Council (PAC): A standing committee of System representatives involved in the policy development process. The PAC is comprised of the Director of Policy Management (who shall serve as its chair), a representative of the University Faculties Executive Council, a representative of the University System Staff Executive Council, and representatives from each of the following areas, as appointed by the Chancellor: Administration & Finance; Academic Affairs; Student Affairs; the Office of General Counsel; and UHS Compliance. The PAC shall meet monthly from August – May, and as otherwise necessary.

3.6 Policy Office: An office within the UH Office of Compliance and Ethics, which handles the policy development process for the System.

3.7 Responsible Party(ies): The supervisor primarily responsible for the subject matter of the policy. Depending on the subject matter, a SAM may have more than one Responsible Party.

3.8 Subject Matter Expert (SME): The individual(s) designated by the Responsible Party(ies) as the curator of the SAM and the first point of contact to answer policy questions. The SME is the employee(s) with working knowledge of the SAM and/or direct (or "hands on") responsibility for the implementation of the policy.

3.9 Substantive Change: A revision to a SAM that materially alters its meaning or intent.


4.1 SAMs are intended to be governing principles that implement legal authority, Board policies and/or that establish uniform rules and procedures on matters of overall System concern not addressed in Board policy. This Policy does not apply to policies and procedures that, by their purpose and scope, apply only to a specific university, college or administrative unit within UHS.

4.2 The Chancellor delegates to the System-Wide Compliance Officer, the responsibility and authority for the development, processing, communication, archiving, and retirement of SAMs through the establishment of a Policy Office within the UH Office of Compliance and Ethics.

4.3 Board policies take precedence over SAMs. To the extent that a SAM conflicts with Board policy, it shall be retired or revised to comply with Board policy. Further, a policy adopted by a UHS university is void to the extent it conflicts with a SAM, and the university policy at issue will be retired or revised to bring it into compliance with the SAM. See Board of Regents Policy 01.01.4 – System Administrative Memoranda.

4.4 In the event of a conflict between a SAM and any law or regulation promulgated by a higher authority (e.g., federal or state law, regulation of an administrative body with oversight), the higher authority will govern, and the SAM at issue will be retired or revised to bring it into compliance with the law or regulation at issue.

4.5 In construing policies, compliance with Board policy and higher legal authority is presumed to be intended.


5.1 New Policies.

a) Should a Responsible Party determine a need to propose a new SAM, the Responsible Party or their delegate shall consult with the PAC to determine if a SAM is the appropriate policy mechanism, consistent with sub-paragraph b) below.

b) Policy Characteristics. Policies should be governing principles that have broad application or effect across the System, and:

(1) seek to ensure compliance with applicable Board policy, law or regulation,

(2) establish fundamental operational, administrative or budgetary principles,

(3) support UHS' mission and goals, and/or

(4) promote consistency, efficiency, and effectiveness or reduce institutional risk.

c) If appropriate, the Responsible Party shall assume the responsibility of preparing a draft document and shall designate one or more SMEs. The Responsible Party or SME(s) should consult with at least one representative of each UHS university in the drafting process.

5.2 Formatting. The standard template should be used for all SAMs. The policy should be drafted in such a way as to be understandable, concise and easy to navigate.

5.3 Revising Policies: Existing SAMs may be revised at the regular review period as specified in the policy, or may be revised upon a determination by the Responsible Party of the need to update the information in the SAM. The Responsible Party or their delegate shall assume the responsibility of preparing draft revisions as a redlined version of the existing SAM.

5.4 PAC Review and Assistance. As an integral part of the policy development process, both new SAMs and revisions to existing SAMs (other than those involving Legal Changes, Housekeeping Changes, and Interim Issuances) will be reviewed by the PAC. The PAC will assess the policy to evaluate whether the draft is sufficiently developed to the point that it is ready to be disseminated to the UHS community for feedback.

The PAC will assist SMEs in identifying issues to address before a SAM is disseminated to the UHS community for feedback, recognizing groups that will be affected and the need to incorporate the input of various constituencies, and identifying intersections or conflicts with other policies.

5.5 Communication. Unless circumstances necessitate an expedited process (see paragraph 6 below), drafts assessed by the PAC as ready for dissemination will be communicated to the UHS community via the SAM listserv, posted electronically on the UHS policy website, and communicated in such other manner as the PAC may recommend to reach the broadest UHS audience in light of the scope and content of the draft.

5.6 UHS Community Review. The comment period for new SAMs and for Substantive Changes to existing SAMs will be for a period of thirty (30) calendar days from the date of dissemination, during which time members of the UHS community, which includes faculty, staff, students and executives, have the opportunity to submit written feedback that will be delivered to, and considered by, the SME.

5.7 Updated Draft. Once the comment period has closed, all written feedback received will be forwarded by the Policy Office to the applicable SME who will take all comments received from the UHS community under advisement and implement such changes evaluated and considered by the SME as necessary or appropriate. The SME will prepare an updated draft to provide to the Policy Office for electronic posting and for submission to the Office of General Counsel.

5.8 Legal Review. All new SAMs and changes to existing SAMs (with the exception of Housekeeping Changes) must be reviewed and approved for legal sufficiency and clarity by the Office of General Counsel prior to adoption, and shall be updated as necessary. Once the SAM has undergone legal review, the final version of the SAM will be transmitted by the Office of General Counsel to the Policy Office for final processing.

5.9 Policy Adoption. A SAM is approved and considered official UHS policy after approval by the Office of General Counsel, the Responsible Party(ies), the appropriate Vice-Chancellor, and the Chancellor.

5.10 Distribution and Publication. The Policy Office will coordinate the distribution of new policies and policy revisions by communication through the SAM listserv and shall be published electronically on the UHS website, or as otherwise required by law. In addition, the Responsible Party or their designees, will determine if other effective methods for policy dissemination should be undertaken and if training should be conducted.

5.11 Retirement of a Policy. A SAM is to be retired when it is no longer needed or is more effectively combined with or superseded by another SAM. A SAM is considered retired upon documented approval by the Responsible Party, the Office of General Counsel, the appropriate Vice-Chancellor, and the Chancellor. Upon retirement, the Policy Office will remove the SAM from the UHS website and archive it.

5.12 Archiving. When a SAM is revised or retired, the Policy Office will maintain the prior or retired version(s) in its electronic archives.


6.1 Legal Changes. Certain information within an official SAM may become obsolete or require revision due to changes in legislation or other higher authority. Additionally, legal authority may require that the Board of Regents or Chancellor implement or approve certain policies to comply with federal or state law. When such information is not open for interpretation or debate, the document will not be subject to the Full Review Process. Instead, the PAC shall be notified as a courtesy, and the document will be revised in consultation with the Vice Chancellor for Legal Affairs/General Counsel and submitted directly to the Responsible Party(ies), the appropriate Vice Chancellor and the Chancellor for approval. The revised policy shall then be distributed as indicated in paragraph 5.10 above.

6.2 Minor Changes. If a SME desires to modify an existing SAM in order to reflect a minor improvement or update to a process or procedure, or to better align the SAM with other SAMs or Board rules, such changes will be processed by the Policy Office on an expedited basis, but only to the extent such proposed changes are reviewed by the PAC and are determined that they do not affect the purpose and meaning of the SAM, that no amount of feedback will negate the need for the change. Revisions processed by the PAC on this basis shall be submitted to the Responsible Party(ies), the Office of General Counsel, the appropriate Vice-Chancellor, and the Chancellor for approval. The revised policy shall then be distributed as indicated in paragraph 5.10 above.

6.3 Housekeeping Changes. The Director of Policy Management, in consultation with the SAM's SME, has the authority to make non-substantive, housekeeping changes to a SAM without the necessity of going through the Full Review Process. The PAC shall be notified as a courtesy of any housekeeping revisions, and the document will be submitted directly to the Responsible Party(ies), the Office of General Counsel, the appropriate Vice-Chancellor, and the Chancellor for approval.

6.4 Interim Issuances. When a new SAM or revisions to an existing SAM are needed in a timeframe that does not allow for the Full Review Process due to a regulatory, accreditation, or other pressing need, it can be proposed as an interim policy, which shall be implemented on an interim basis with notice to the PAC. Revisions on this basis shall be submitted to the Responsible Party(ies), the Office of General Counsel, the appropriate Vice-Chancellor, and the Chancellor for approval. The policy shall then be distributed as indicated in paragraph 5.10 above. The interim policy must undergo the Full Review Process as soon as practicable.


7.1 Periodic Review. The Responsible Party, by and through the SME, is responsible for maintaining and updating SAMs in his or her area to ensure that they reflect current policy and practices and that they are in conformance with applicable laws and regulations. To ensure policies remain current, all SAMs should undergo a periodic review at least once every five years, or more often if required by law or circumstances. If such a periodic review does not result in changes, the SME and Responsible Party will confirm to the Policy Office that the SAM has undergone review and is current, and the SAM documentation will be updated to reflect the most recent review date.

7.2 Enforcement and Monitoring. University presidents are responsible for promoting and enforcing the compliance of all SAMs at their institutions.

7.3 Compliance. Faculty, staff and students are responsible for knowing, understanding and complying with SAMs that relate to their position, employment or enrollment at a UHS university. Responsible Parties are responsible for following the policy development and implementation process established by this policy, communicating their policies effectively, reviewing and updating their policies regularly, and monitoring their policies for compliance and effectiveness.


Texas Education Code § 111.35 – Bylaws; Rules; Regulations

University of Houston System Board of Regents Policy 01.01.4 – System Administrative Memoranda.


Issued: 05/01/1988
Last Reviewed/Revised: 11/18/2019
Responsible Office(s): UHS Office of Compliance and Ethics