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SOP-QMS-05 — Leadership & Quality Policy

Establishes leadership responsibilities, the Quality Policy, and how roles and authorities are assigned (ISO 9001 §5).

Owner: SVP OperationsApprover: B. HuseltonVersion: 3.0Updated: 10/23/1969

1. Purpose

Ensure top management demonstrates leadership and commitment to the QMS, maintains the Quality Policy, and assigns clear roles and authorities.

2. Scope

All UBC executives, function heads, and QMS process owners.

3. Definitions

  • Top management — The SVP Operations and the Quality Director, jointly accountable for the QMS.
  • Quality Policy — UBC's public statement of intent regarding quality, patient safety, and continual improvement.

4. Roles & Responsibilities (RACI)

ActivityRACICadence
Approve Quality PolicySVP OperationsSVP OperationsQuality DirectorAll staffAnnual
Communicate policy to workforceQuality DirectorSVP OperationsHR, CommsAll staffAnnual + onboarding
Assign process ownersSVP OperationsSVP OperationsQuality DirectorFunction leadsAnnual
Chair Management ReviewSVP OperationsSVP OperationsQuality CouncilBoardQuarterly

5. Procedure

  1. Review the Quality Policy annually against strategic direction and interested party expectations.
  2. Publish the current Quality Policy on the intranet, in onboarding materials, and in the QMS portal.
  3. Assign or reconfirm process owners for every QMS process, recorded in the RACI Master.
  4. Verify each process owner has authority commensurate with accountability.
  5. Chair the quarterly Management Review per ISO 9001 §9.3.
  6. Cascade quality objectives from the Policy into function-level scorecards.

6. Inputs & Outputs

Inputs

  • Strategic plan
  • Interested Parties Register
  • Prior Management Review outputs

Outputs

  • Approved Quality Policy
  • RACI Master
  • Management Review minutes

7. Controls & Metrics

MetricTarget
Workforce awareness of Policy≥ 95% (annual survey)
Process owner coverage100%

8. Exceptions & Escalation

  • Policy amendments outside the annual cycle require SVP + Quality Director sign-off and Board notification.

9. Records & Retention

RecordRetention
Signed Quality Policy10 years
Management Review minutes7 years
RACI Master7 years

10. Related Documents

  • QMS Manual
  • SOP-QMS-09 Performance Evaluation
  • Management Review Procedure

11. References

  • ISO 9001:2015 §5
  • CMMI-DEV v2.0 OPF

12. Revision History

See the Versions tab for the full change history maintained by the Auto-Doc Engine.

Document code: SOP-QMS-05 · Aligned to ISO 9001:2015 §5.1–5.3. Controlled document — reproduction outside the UBC QMS requires the Quality Manager's approval.

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Frameworks
ISO 9001
CMMI-DEV