Institutional Policies

The Integrity Framework

The Office of Institutional Integrity and Awareness (OIIA) follows an integrity-based approach to compliance. The Integrity Framework consists of six key components, three of which are specifically related to the understanding of policies and procedures.

A sequence of six circles, each featuring icons that represent the six functions of OIIA’s Integrity Framework. Beginning with the first circle: Determining & Defining Integrity (magnify glass icon), Guiding Towards Integrity (finger pointing up icon), Monitoring Integrity (eye icon), Enforcing Integrity (scales of justice icon), Improvement of the Integrity Framework (a gear icon with an arrow pointing up in the middle of it), and Structuring Integrity (icon of an organization chart).

Policies and procedures are essential instruments in fostering a culture of integrity at UNT Health. They establish a strong foundation by offering clear structure, expectations, and guidance on behavior and decision-making. These guidelines reflect the institution’s core values, ethical standards, and overall environment.
.
A circle icon with a lower-case “i” in the middle to symbolize information.
  • A Policy serves as a guideline that establishes expectations and direction within the institution.
  • A Procedure is a detailed, step-by-step guide on how to perform a specific task or action to achieve a particular outcome.

.

Accessing Policies & Procedures

UNT Health’s policies align with the institution’s mission, values, and strategic objectives, as well as federal and state laws, Regents Rules (overseen by the Office of General Counsel), and Systems Regulations (administered by UNT Systems).

A simple icon showing the scales of justice, encircled by a laurel wreath in the center.     UNT System Regents Rules An icon showing a document with a courthouse emblem at the top. Below this, there are three lines accompanied by check boxes aligned to the left side. A badge featuring a check mark is prominently displayed over the document. UNT System Regulations

 

PolicyTech serves as the official repository for all policies and procedures at UNT Health. Within PolicyTech, users can search for documents by title, keywords, department area, employee title, or through a custom search.

Imagine depicted as a square button with "Public PolicyTech Access Graphic" in the middle. Imagine depicted as a square button with "PolicyTech FAQs" in the middle. Imagine depicted as a square button with "Report an Issue with PolicyTech" in the middle.

Click to access PolicyTech.

Click the image to view FAQs for PolicyTech.

Click the image to report an issue with PolicyTech.

.

Latest Updates

.

Announcement: Due to the transition in our web management platform, this section will not be updated until January 2026. For updates on policies and procedures, please refer to the DailyNews and 3 ops Newsletter (subscribe below).
The following section provides a quick overview of updates regarding institution-wide policies and procedures. Please be sure to review the complete policy or procedure to ensure compliance.
.
15.106 Donated Body Program
November 13, 2025
Modification.  Revised to improve efficiency in the documentation process.		 6.110 Educational Governance and Program Effectiveness
October 2, 2025
Modification. Revised to align with the updates provided by the Texas Higher Education Coordinating Board.		   7.107 Hazing
September 18, 2025
New. A policy has been established to guarantee a safe, haze-free environment for every member of the community.
View Policy View Policy   View Policy

 

.

3 ops Newsletter 

A search box displays “Policies at UNT Health,” while directly beneath it, there’s a news post featuring a photo of a doctor with their hands clasped, accompanied by the headline “Physician Pays $250K!” These elements are positioned on top of a cell phone.
No more need to frequently check the website or sift through PolicyTech for updates! Beginning in January 2026, OIIA will provide quarterly updates featuring trending news in healthcare compliance, policy developments, and OIG investigations delivered straight to your inbox. Now, you can keep up with the latest happenings with just a simple email.
.

If you have any questions, don’t hesitate to reach out to Martika Jacobs (Martika.Jacobs@unthealth.edu)!

.

Submission Process

Policies and procedures evolve over time. There may come a moment when an institution needs to introduce new ones to comply with regulations, adapt to trends, or achieve strategic objectives. Any employee at UNT Health can initiate the process to propose a new policy/procedure or update an existing one. The duration of this process varies based on the specific action being undertaken.

You can download a visual representation of the different processes at the end of this section. The PDF features comprehensive flowcharts paired with straightforward infographics that outline the steps for implementing new or revised policies and procedures at UNT Health.

Any employee can propose a new policy. The individual who is responsible for drafting it is known as the Subject Matter Expert (SME). The SME must follow their department’s approval process, obtaining consent from the Policy Owner (the cabinet member) and Department Head before sending the draft to OIIA. Approval is verified by completing the Policy Approval Form attached to the Official Policy Template.
.
After securing necessary approvals, the SME submits the policy via the Policy/Procedure Intake Form. Final approvals from the Policy Committee, Office of General Counsel, and President are required before implementation.
.
For a better grasp of this process, review the accompanying infographic or download the comprehensive Policy Approval Process Flowchart for additional insights.
.
New Policy Submission Process 9.5.25Click the image to expand and download.

Any employee has the opportunity to suggest changes to an existing policy. The person responsible for drafting these modifications is referred to as the Subject Matter Expert (SME). The SME must adhere to their department’s approval process, securing consent from both the Policy Owner (the cabinet member) and the Department Head before submitting the draft to OIIA.
.
Once approved, the SME submits changes via the Policy/Procedure Review Form using the updated Official Policy Template. If the modifications meet requirements, OIIA will present the revised policy to the President for approval before implementing the changes on PolicyTech..
.
Note: If a policy undergoes substantial modifications, it must first be reviewed by the Policy Committee and OGC before being submitted to the President for approval.
.
Policy Modification Approval Process V2 (10.27.25)
Click the image to expand and download. 

Any employee is welcome to propose a new procedure. The person responsible for drafting this procedure is referred to as the Subject Matter Expert (SME). The SME is required to adhere to their department’s approval process, which includes obtaining consent from both the Administrative Authority and the Department Head before forwarding their draft to OIIA.
.
To confirm approval, the SME must complete the Procedure Approval Form, which is attached to the Official Procedure Template and the Official Procedure Manual. It is important to note that all procedures must align with a current policy. SMEs should indicate the associated policy on the Procedure Approval Form.
.
After completing the Procedure Approval Form, the SME will submit the new procedure along with the necessary documents via the Policy/Procedure Intake Form. Final approval from both the Policy Committee and OIIA is required before the procedure can be put into effect.
New Procedure Submission Process
Click the image to expand and download. 

Any employee has the opportunity to suggest changes to an existing procedure. The person responsible for drafting these modifications is referred to as the Subject Matter Expert (SME). The SME must adhere to their department’s approval process, securing consent from both the Administrative Authority (listed on the procedure document) and the Department Head before submitting the draft to OIIA.
Once approved, the SME submits changes via the Policy/Procedure Intake Form using the updated Official Procedure Template or Official Procedure Manual. If the modifications meet requirements, they will be implemented.
Procedure Modification Submission Process
Click the image to expand and download. 
.

Graphite Information Icon

 

The Policy Committee

The UNT Health Policy Committee is a standing committee responsible for reviewing policies, ensuring compliance with approved formats, securing necessary approvals, and facilitating education on new or modified policies. Members are chosen for their experience and expertise, serving as a voice for their departments.

Committee Members

Visualize two rows of rectangles. In the top row, there are five rectangles containing the names Tracy Broomes (Operations & Business Management), April Daniel (Office of Institutional Integrity & Awareness), Tania Ghani (Research Compliance), Tiffany Grant (Human Resources), and Michael Hollis (Information Technology). In the bottom row, there are four rectangles with the names Dr. Emily Mire (Student Affairs), Desiree Ramirez (Office of Institutional Integrity & Awareness), A.J. Randolph (Health Administration), and Dr. Amber Smallwood (Provost Office).

.

Resources

Icon of a paper with a pencil over it in the writing position.Writing Guide   A visual icon showcasing a sheet of paper containing four squares of varying sizes, intended to symbolize a template.Standard Template   A visual icon showcasing a sheet of paper containing four squares of varying sizes, intended to symbolize a template.Standard Template   A visual icon showcasing a sheet of paper containing four squares of varying sizes, intended to symbolize a template.Standard Template
Policy on Policies
  Official Policy Template
  Official Procedure Template
  Official Procedure Manual

Utilize this policy to guarantee that all compliance requirements are fulfilled.

View Policy.

 The necessary format that all policies must adhere to.

Download Policy Template.

 The template format is designed for users submitting a single procedure.

Download Procedure Template.

 The template to use when users have a collection of related procedures to submit.

Download Manual Template.

.

Submission Form

To request modifications of a current policy or submit a new policy, please complete the UNT Health Policy/Procedure Review Intake Form. If you need assistance completing the form or have questions, please contact Martika Jacobs.

Please have the following supporting documents available and ready to submit before you access the Review Intake Form:

  • Redlined Policy Document (a version of the document showing all tracked changes)
  • Final Draft (finalized version with all corrections applied)
  • Approval Confirmation Memo (documentation confirming the approval of the new or updated policy/procedure)

.

*OIIA oversees the process of defining, developing, implementing, and maintaining up-to-date university-wide policies and procedures. However, it is important to note that OIIA does not write policies or procedures for individual departments, programs, or organizations.