Faculty and Clinical Affairs

Policy 24: Policy on Policies

Policy Number: 100

Date Approved/Revised: 6/13/2019; 11/6/2020

Executive Responsibility: BSOM Executive Committee

Related Information: https://policy.wright.edu/policy/0001-policy-policies

100.1 Purpose

In accordance with LCME Element 4.6, “the dean and a committee of the faculty 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 the BSOM; (b) directs actions of faculty, staff, students and others who engage with the 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.

100.2 Location of BSOM Policies

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

100.3 Compliance with BSOM Policies

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

100.4 Policy Administration

The Director of Medical Education & Accreditation is responsible for adding, modifying, and deleting policies to the BSOM Policies website as approved by the committee(s) with Executive Responsibility, and as otherwise permitted by this policy (see “100.7 Policy Maintenance,” below); maintaining records of Reviews and Revision Approvals; coordinating a review of all policies, at a minimum, every five years by the Continuous Quality Improvement (CQI) Steering Committee; and promulgating policy changes to the BSOM community.

100.5 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 Director of Medical Education & Accreditation so as to best fit within the organizational scheme of the BSOM Policies

Date Created/Revised

the most recent date of approval by the Responsible committee/department/unit



one or two individuals (e.g., Dean of Medicine) and/or entities (e.g., Executive Committee or Faculty Curriculum Committee) with academic or supervisory authority related to a BSOM Policy.

As appropriate, policies will have additional headers such as:



the individual or department/office/unit most closely associated with implementation of a BSOM Policy

Applies To

restrictions of applicability where such restrictions are not clearly evident in the policy statement


Links to government regulations and state or federal laws directing or controlling a policy


100.6 Approval of New and Revised Boonshoft School of Medicine Policies

Written proposals for new policies, amendments, or rescindments should be submitted to the person(s) and/or committee(s) with Executive Responsibility, who will oversee and facilitate the process of reviewing, further modifying as necessary, and seeking approval for the new or revised policy.

While there is no prescribed sequence by which a proposed policy change undergoes consideration, the process of approving a new BSOM policy or modifying an existing BSOM policy routinely includes the following committees with Executive Responsibility:

Type of Policy

Executive Responsibility

Operational Responsibility

1. Medical Student


Faculty Curriculum Committee (FCC)


Office of Medical Education (OME);


2. Medical Student Services

Dean’s Council

Office of Student Affairs & Admissions (OSAA)

3. Medical Student Admissions

Admissions Committee


4. Medical Student Promotion

Student Promotions Committee (SPC);

Executive Committee


5. Marketing, Social Media, Communications

Executive Committee

Office of Advancement and Communications


6. Faculty

Faculty Promotion and Advancement Committee;

Bylaws Committee;

Executive Committee

Office of Faculty Affairs (OFA)


7. Graduate Medical Education (GME)

Graduate Medical Education Committee (GMEC)


GME Programs

8. Research

Research Committee

Executive Committee

Office of Research Affairs


9. Continuing Medical Education (CME)





100.7 Policy Maintenance

Changes that the Director of Medical Education & Accreditation may make to BSOM Policy are restricted to:

  1. additions, modifications, and rescindments approved by the Dean of Medicine in compliance with this Policy on Policies. The date the Dean of Medicine signs approval of these formal changes is entered as the “Date Created/Revised.” Changes listed in items 2-5, below, do not affect the “Date Created/Revised.”
  2. correction of obvious errors (e.g., spelling, punctuation, and grammar).
  3. necessary changes to links within a policy, names or titles, contact information, or other specifics that do not alter the statement of policy. (Requires the written approval of all persons named as having Executive Responsibility for the policy)
  4. names of persons or entities with Executive Responsibility. (Requires the approval of the Dean of Medicine)
  5. names of individuals or offices with Operational Responsibility. (Requires the approval of the Dean of Medicine or the individuals and entities with Executive Responsibility for that policy)

100.8 Policy Review

While policies may be revised as needed, all BSOM Policies will be reviewed every five years at minimum. The Director of Medical Education & Accreditation is responsible for overseeing the review process, and those persons and entities with Executive Responsibility are responsible for conducting the reviews.

Each policy will be reviewed, at minimum, in the fifth year following its “Date Created/Revised,” by the Continuous Quality Improvement (CQI) Steering Committee. Following the review, the CQI Steering 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 created/revised” will be updated to the date of the review. If revisions are recommended, then the Executive Responsibility as listed in affected policy

100.9 Notification of Policy Revisions (*TBD*)


Last edited on 12/14/2020.