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Handbook of Operating Procedures

Policy and Procedure Development and Maintenance

Policy Number: 128


University policies and procedures


All policies and procedures adopted by The University of Texas Health Science Center at Houston

Date Reviewed:
December 2016
Responsible Office:
Office of Legal Affairs
Responsible Executive:
Vice President and Chief Legal Officer


The University of Texas Health Science Center at Houston (“university”) has a uniform and systematic procedure for creating and maintaining policies and procedures within the Handbook of Operating Procedures (HOOP). This process includes an opportunity for faculty, staff and student governance bodies to provide advisory input regarding proposed changes to policies that may impact the respective groups. The HOOP contains the official policies and procedures for the governance of the university. This policy must be followed to create or change policies or procedures. Policies and procedures developed or changed in violation of this policy will not be published in the HOOP.

University policies and procedures (including school, unit, department and office policies and procedures) shall not conflict with the Regents’ Rules and Regulations. Any university policy or procedure that is in conflict with any rule or regulation in the Regents’ Rules and Regulations is null and void and has no effect.

All exhibits attached or linked to a HOOP policy or a procedure are extensions of that policy or procedure.


Educational Policy: Policy that pertains to the areas of faculty responsibility as set forth in Regents’ Rule 40101.

Governance of the University: Policies and procedures, except medical procedures or protocols, affecting the way university officials direct, administer or control the university. This includes policies and procedures:

  • Directing compliance with applicable state and federal laws and regulations, Regents’ Rules and Regulations, and UT System policies and policies with System-wide application;
  • Addressing or affecting the responsibility and/or authority of the various offices and bodies that make up the university; and
  • Addressing the relationship between administration, faculty, students, and staff and university values and/or goals.

HOOP Review Committee: The Committee appointed by the President to review and make recommendations regarding policies and procedures to the Executive Council. The HOOP Review Committee membership includes the President or designee; the Executive Vice Presidents or respective designees; the Senior Vice-President, Finance & Business Services or designee; the Chief Human Resources Officer or designee; the Assistant Vice President of Auditing & Advisory Services or designee; the Executive Vice Dean for Clinical Affairs or designee; the Chairs of the Interfaculty Council, the Student InterCouncil, and the University Classified Staff Council or respective designees; an Associate Dean for Management (or equivalent title) who will  be selected by the group of deans holding that title; and a member of management from The University of Texas Harris County Psychiatric Center. The committee is chaired by the Policy Coordinator.

Policy Coordinator: The Chief Legal Officer is appointed by the President to ensure compliance with this policy. The Chief Legal Officer may delegate this responsibility.

Responsible Executive: University executive responsible for the programmatic, functional or administrative areas affected by a policy or procedure.

Significant change: A change in the scope or application of a policy or procedure that has a significant impact on daily operations, responsibilities, procedures or expectations for one or more key university communities.

Stakeholder Review Plan: A plan for obtaining advisory input from faculty, staff and student governance bodies that may be affected by changes in policies and procedures.


A. Designation of Responsible Executive, Educational Policy and Next Scheduled Review: For each HOOP policy, the Policy Coordinator will designate a responsible executive, determine if the policy is educational, and determine a periodic review schedule.

B. Creating and Maintaining HOOP Policies and Procedures:

  1. A university office proposing a new HOOP policy or procedure will draft the policy in correct HOOP format as shown in Exhibit A.  The university office will also provide a rationale for the new policy as well as a list of departments or groups that should have input.  The Proposal and Stakeholder Review Plan as shown in Exhibit B may be used. Offices proposing amendments to the HOOP also will prepare a draft clearly delineating the changes from the current version. All documents will be routed through the appropriate Responsible Executive. The Policy Coordinator will provide assistance upon request.
  2. The Responsible Executive will submit the proposal to the Policy Coordinator for distribution to the HOOP Review Committee for review and approval. The HOOP Review Committee will confirm the Proposal and Stakeholder Review Plan and develop a review timeline that takes into consideration the best interests of the university regarding timely implementation of the proposed HOOP policy including, but not limited to, legal or otherwise mandated deadlines for policy implementation. The HOOP Review Committee is authorized to deny a proposal for a new policy or a proposal for amendment to an existing policy.
  3. The Policy Coordinator will distribute the proposed HOOP policy in accordance with the confirmed Stakeholder Review Plan and timelines.
  4. Advisory input from stakeholders returned timely to the Policy Coordinator will be provided to the Responsible Executive for consideration.
  5. The Responsible Executive will resubmit the proposed HOOP policy with any incorporated changes to the HOOP Review Committee through the Policy Coordinator.
  6. Once the HOOP Review Committee has approved the proposed HOOP policy, it will be submitted to the Executive Council for review and approval.
  7. Upon approval by the Executive Council, the President and the Chief Legal Officer, the Policy Coordinator will post the approved policy to the HOOP. At the election of the President, the policy may be submitted to the UT System Vice Chancellor and General Counsel for review and approval.  In certain circumstances, the Board of Regents or UT System may require that a particular policy be submitted to the Executive Vice Chancellor for Health Affairs and/or the Vice Chancellor and General Counsel.
  8. Recommendations and comments from university attorneys are legal advice provided to university administration and are to be treated as privileged and confidential attorney-client communications.
  9. For Educational Policies, the following additional step is required: The Proposal and Stakeholder Review Plan must include review by the Interfaculty Council.  The review timeline for the Interfaculty Council must be no more than 60 calendar days.
  10. HOOP Policies with No Significant Changes: Proposed changes to HOOP policies that are not significant will be approved by the Policy Coordinator. The Policy Coordinator shall determine whether the change is significant.
  11. Maintenance: The Responsible Executive must review and recommend revisions to HOOP policies as necessary in accordance with a five-year review cycle using the applicable process in Section III.B.

C. Creation and Maintenance of School, Unit, Department, and Office Policies and Procedures: Policies and procedures adopted by individual schools, units, departments and offices of the university shall not conflict with the policies published in the HOOP. These policies and procedures must be reviewed and approved by the appropriate authorities within the school, unit, department or office and must be made readily accessible to those who are affected by them. These policies and procedures must be reviewed and revised regularly by the appropriate authorities.


    • Office of Legal Affairs
    • 713-500-3268