Occupations and Terms of Reference › Chief medical officer (CMO)
Universal terms of reference · POS-005 · version 1.0 · status: draft · next review 2027-10-27
Chief medical officer (CMO)
To lead medical practice across the organisation, so that every patient receives safe, effective and evidence-based medical care, and to be the professional lead for doctors and clinical governance.
Each part of this page links to the related trainings, competencies and policies. The links are the same for every facility, so an organisation can see at a glance what a role requires and what it is trained in.
Job description
Job summary. You are the senior doctor for the organisation. You set and assure the standard of medical practice, lead the clinical governance system, make sure doctors are competent, licensed and supported, and take responsibility for medical decisions that affect safety.
Reports to: Chief executive officer.
Leads or supervises: Medical director, clinical governance lead, laboratory, radiology, emergency and pharmacy leads, and the practice manager for ambulatory services.
What you do on a typical day
- Review clinical incidents, mortality and morbidity reviews, and complaints involving medical care.
- Lead the medical governance meeting; agree clinical priorities and actions.
- Support doctors with difficult cases, and decide on escalations.
- Check medical staffing and cover for emergencies, nights and weekends.
- Review clinical guidelines and protocols, and approve changes.
- Represent medical practice to the board, the regulator and the public.
Working conditions and demands
- On call for serious clinical incidents.
- Accountable for the licences and competence of doctors.
- Balance between clinical duty, management and external representation.
What good looks like
- Clinical incidents lead to learning and visible change.
- Doctors are licensed, competent, supported and up to date.
- Guidelines are used and reviewed on time.
- Patients and families trust the medical decisions made in the organisation.
Place in the organogram
Reporting line, from the top: see the organogram on the Occupations page. The lines above and below this role are listed in section 3.
1. Golden rules
These rules apply in every setting.
- Every decision that affects patient safety is made on evidence and recorded.
- Patient safety and quality come before financial targets; no trade-off that puts patients at risk is accepted.
- Every staff member can raise a concern without fear of reprisal, and every concern is answered.
- Legal, licensing and accreditation duties are known, owned and reviewed.
- Finances, people and information are managed openly and within the law.
- Mandatory training and policies apply to the executive as much as to frontline staff.
2. Identification
| Item | Detail |
|---|---|
| Position code | POS-005 |
| ISCO-08 | 1342 (skill level 4) |
| ESCO | to map |
| Department | Governance |
| Facility types | Hospital, Ambulatory, Aesthetic |
3. Reporting line and working relationships
Reports to: POS-003. Supervises: POS-012, POS-014, POS-111, POS-038, POS-135, POS-129, POS-229.
| Works with | Nature of the relationship |
|---|---|
| Chief nursing officer | Joint leadership of clinical care and safety. |
| Chief quality and safety officer | Clinical audit, safety and accreditation. |
| Chief operating officer | Clinical capacity, theatres and beds. |
| Regulator and professional bodies | Licensing and professional standards. |
4. Key accountabilities
| Domain | Accountability | Evidence of delivery | Checked | Linked competencies | Linked trainings | Linked policies | Standards |
|---|---|---|---|---|---|---|---|
| Clinical standards | Sets and assures the standard of medical practice across the organisation. | Clinical standards approved; audit results reviewed | Quarterly | C-01 · C-02 | T-05 | POL-INC | 2 |
| Clinical governance | Runs the clinical governance system: audit, incident learning, guidelines and mortality review. | Governance meetings held; actions tracked to completion | Monthly | C-02 · C-03 | T-05 · T-07 | POL-INC | 2 |
| Medical workforce | Makes sure doctors are licensed, competent, supported and sufficient for safe cover. | Licence register current; cover plans; appraisal completed | Quarterly | C-04 · C-05 | T-08 | POL-EQUAL · POL-WHISTLE | 2 |
| Safety and speaking up | Makes sure medical staff can raise concerns, and that concerns about medical care are investigated fairly. | Concerns handled within the policy timeframe; no reprisal | Quarterly | C-03 | T-08 | POL-WHISTLE | 2 |
5. Decision rights
| The post holder decides | Consults or escalates |
|---|---|
| Clinical standards and guidelines for the organisation | Changes to clinical services with budget or strategic impact (CEO and board) |
| Medical staffing decisions within budget | Serious clinical incidents with legal or public consequences |
| Clinical escalations and case-level interventions | Licensing matters that need the regulator |
6. Qualifications and experience
| ID | Qualification | Mandatory | Validity |
|---|---|---|---|
| Q-01 | Medical degree and current licence to practise | Yes | per regulator |
| Q-02 | Specialist qualification in a clinical field | Yes | Lifetime |
| Q-03 | Clinical leadership or health management qualification | No | Lifetime |
| ID | Experience | Minimum years | Mandatory |
|---|---|---|---|
| E-01 | Senior clinical experience as a consultant or equivalent, including clinical leadership | 8 | Yes |
7. Training requirements
Recommended common practice. Each facility adapts the list to its national law. Essential items apply in every setting; recommended items apply where resources allow.
| ID | Training | Tier | When | Validity | Linked policies | Linked competencies |
|---|---|---|---|---|---|---|
| T-01 | Facility induction | essential | at_entry | Once | POL-WHISTLE · POL-EQUAL · POL-DATA | – |
| T-02 | Safeguarding adults | essential | periodic | Every 3 year(s) | POL-SAFEG | – |
| T-03 | Safeguarding children | essential | periodic | Every 3 year(s) | POL-SAFEG | – |
| T-04 | Data protection and confidentiality | essential | annual | Every 1 year(s) | POL-DATA | – |
| T-05 | Incident reporting and open disclosure | essential | periodic | Every 2 year(s) | POL-INC | C-01 · C-02 · C-03 |
| T-06 | Governance, accountability and assurance | recommended | periodic | Every 3 year(s) | – | – |
| T-07 | Emergency and major incident command | essential | annual | Every 1 year(s) | POL-INC | C-01 · C-03 |
| T-08 | Speaking up, inclusion and equality leadership | essential | periodic | Every 2 year(s) | POL-WHISTLE · POL-EQUAL | C-04 · C-05 |
8. Health, fitness and language
| ID | Requirement | Frequency | Tier | Minimum in low-resource settings |
|---|---|---|---|---|
| H-01 | Immunity to vaccine-preventable diseases relevant to the setting, documented at entry | At entry or as set | essential | Documented hepatitis B status at entry |
| H-02 | Tuberculosis screening at entry, then as the national rule requires | At entry or as set | essential | Symptom screening at entry and after exposure |
| H-03 | Fitness-to-work assessment at entry and after serious illness or injury | Every 12 months | recommended | Fitness check at entry |
| Language | Level | Mandatory |
|---|---|---|
| Official language of the country of practice | professional | Yes |
| English | working | Yes |
9. Competencies by level
| ID | Competency | Foundation | Practitioner | Expert | Assessed by | Revalidate | Linked trainings |
|---|---|---|---|---|---|---|---|
| C-01 | Clinical leadership and decision-making | Makes sound clinical decisions | Leads clinical decisions in a service | Sets clinical standards across the organisation | Case review and peer review | Every 12 months | T-05 · T-07 |
| C-02 | Clinical governance and audit | Takes part in audit | Leads clinical audit | Designs the clinical governance system | Clinical governance review | Every 12 months | T-05 |
| C-03 | Patient safety and incident learning | Reports and learns from incidents | Leads incident reviews | Builds a just learning system for medical errors | Incident review audit | Every 12 months | T-05 · T-07 |
| C-04 | Professional standards and revalidation | Keeps own licence current | Supports colleagues' revalidation | Sets medical professional standards and assures them | Revalidation audit | Every 24 months | T-08 |
| C-05 | Leading doctors and multidisciplinary teams | Works in a team | Leads a multidisciplinary team | Leads medical workforce planning across the organisation | 360 feedback | Every 24 months | T-08 |
10. Performance evaluation
- Probation: 6 months, with a sign-off review (recommended value).
- Appraisal: every 12 months against the competencies and indicators below.
| ID | Indicator | Target | Data source | Frequency |
|---|---|---|---|---|
| PI-01 | Clinical incidents reviewed with actions completed | 100% | incident register | Monthly |
| PI-02 | Doctors with a current licence and revalidation | 100% | HR and licence register | Quarterly |
| PI-03 | Clinical audit cycles completed on time | set by facility | audit register | Quarterly |
| PI-04 | Mortality and morbidity reviews held | set by facility | governance minutes | Monthly |
11. Career ladder and promotion
| Level | Role | Minimum experience to move on | Qualifications | Competency minimums | Trainings required | Assessment |
|---|---|---|---|---|---|---|
| Executive | Chief medical officer (CMO) | 8 years (recommended) | Q-01, Q-02 | C-01 expert, C-02 expert | T-07 · T-08 | Executive appointment and performance review |
12. Policies the post holder follows
Each policy is a standard template that the facility adopts and adapts. Templates are maintained centrally, so every facility works from the same version.
POL-SAFEG · Safeguarding adults and children
Purpose: Protect patients from abuse, neglect and harm, and make sure every concern is recognised and acted on.
Scope: All staff, volunteers and contractors.
Key rules:
Scope: All staff, volunteers and contractors.
Key rules:
- Recognise signs of abuse and neglect and record them factually.
- Report every concern to the designated safeguarding lead the same shift.
- Do not investigate alone.
- Share information only as the safeguarding procedure allows.
POL-DATA · Data protection and confidentiality
Purpose: Keep patient and staff information private, secure and used only for care and legal purposes.
Scope: All staff who access records or systems.
Key rules:
Scope: All staff who access records or systems.
Key rules:
- Access only the records needed for your work.
- Keep records secure; do not leave screens or paper unattended.
- Do not share information without a lawful basis.
- Report any breach to the data protection officer within 24 hours.
Linked trainings: T-10 · Review every 12 months · Template 0.1 (draft)
POL-WHISTLE · Speaking up (whistleblowing)
Purpose: Let staff raise patient safety or conduct concerns without fear of reprisal.
Scope: All staff.
Key rules:
Scope: All staff.
Key rules:
- Raise a concern with your line manager or the named speaking-up officer.
- If that route fails, escalate to the board or the national regulator.
- Retaliation against anyone who speaks up is a disciplinary offence.
- Concerns are recorded, investigated and the outcome given to the person raising them.
Linked trainings: T-01 · Review every 12 months · Template 0.1 (draft)
POL-EQUAL · Equality, diversity and inclusion
Purpose: Give every patient and colleague fair access, respectful treatment and reasonable adjustments.
Scope: All staff and patients.
Key rules:
Scope: All staff and patients.
Key rules:
- Treat every person with dignity regardless of background.
- Make reasonable adjustments, including interpreters, for language and disability.
- Report discrimination through the speaking-up route.
- Monitor access and outcomes by group.
Linked trainings: T-01 · Review every 24 months · Template 0.1 (draft)
POL-INC · Incident reporting and open disclosure
Purpose: Report and learn from incidents and near misses, and tell patients honestly when things go wrong.
Scope: All staff.
Key rules:
Scope: All staff.
Key rules:
- Report every incident and near miss the same shift.
- Give the patient and family an honest account and an apology where appropriate (open disclosure).
- Take immediate action to protect others.
- Learn: contribute to the review and follow the agreed actions.
13. Standards that name this role
14. Record history
| Date | Change | Approved by |
|---|---|---|
| 2026-10-27 | Draft record, batch 1 of the position build | Awaiting approval |