Occupations and Terms of Reference › Medical director
Universal terms of reference · POS-012 · version 1.0 · status: draft · next review 2027-10-27
Medical director
To lead the day-to-day medical practice of the organisation, so that doctors deliver safe, effective and well-documented care under agreed clinical standards.
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 run medical practice day to day. You lead the doctors, make sure clinical standards are applied, handle medical incidents and complaints, and support doctors with difficult cases.
Reports to: Chief medical officer.
Leads or supervises: Doctors and clinical leads, and the ethics committee secretary.
What you do on a typical day
- Review medical incidents and complaints with the clinical governance lead.
- Check medical rotas and cover for each service.
- Support doctors with complex cases.
- Chair or attend clinical meetings and agree actions.
- Review clinical protocols and check adherence.
Working conditions and demands
- On call for serious medical incidents.
- Balances clinical work with management.
- Works across the organisation's clinical services.
What good looks like
- Doctors are licensed, competent and supported.
- Clinical incidents lead to visible learning.
- Protocols are current and followed.
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-012 |
| ISCO-08 | 1342 (skill level 4) |
| ESCO | to map |
| Department | Governance |
| Facility types | Hospital, Ambulatory |
3. Reporting line and working relationships
Reports to: POS-005. Supervises: POS-019, POS-014.
| Works with | Nature of the relationship |
|---|---|
| Chief medical officer | Sets the medical strategy; medical director delivers it. |
| Chief nursing officer | Joint care pathways and safety. |
| Chief quality and safety officer | Clinical audit and incident learning. |
4. Key accountabilities
| Domain | Accountability | Evidence of delivery | Checked | Linked competencies | Linked trainings | Linked policies | Standards |
|---|---|---|---|---|---|---|---|
| Medical practice | Makes sure doctors apply clinical standards and protocols. | Audit results reviewed; protocol adherence reported | Quarterly | C-01 · C-02 | T-05 | POL-INC | 2 |
| Medical incidents | Leads review of medical incidents and complaints, and makes sure learning is shared. | Incidents reviewed within policy timeframe | Monthly | C-03 | T-05 · T-07 | POL-INC | 2 |
| Doctor support | Supports doctors' competence, rotas and wellbeing. | Rota cover checked weekly; appraisals completed | Quarterly | C-04 | T-08 | POL-EQUAL · POL-WHISTLE | 2 |
| Ethics | Supports the ethics committee and makes sure consent and ethical review are followed. | Ethics reviews recorded and actioned | Quarterly | C-01 | T-05 | POL-WHISTLE | 2 |
5. Decision rights
| The post holder decides | Consults or escalates |
|---|---|
| Clinical protocols within the approved clinical standards | Clinical changes with budget or service impact (CMO) |
| Medical rota decisions within budget | Serious medical incidents with legal or public consequences (CMO and CQO) |
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 |
| ID | Experience | Minimum years | Mandatory |
|---|---|---|---|
| E-01 | Senior clinical experience as a consultant or equivalent, with some clinical leadership | 6 | 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-03 |
| T-08 | Speaking up, inclusion and equality leadership | essential | periodic | Every 2 year(s) | POL-WHISTLE · POL-EQUAL | C-04 |
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 decision-making and case management | Makes sound decisions in own practice | Manages complex cases in a service | Sets case-management standards across services | Case review | Every 12 months | T-05 |
| C-02 | Clinical audit and protocol adherence | Takes part in audit | Leads an audit | Designs the audit and protocol programme | Audit review | Every 12 months | T-05 |
| C-03 | Incident review and learning | Reports incidents | Leads incident reviews | Leads a just learning culture for medical incidents | Incident review audit | Every 12 months | T-05 · T-07 |
| C-04 | Leading doctors | Works in a team | Leads a medical team | Develops medical leadership across services | 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 | Medical incidents reviewed within timeframe | 100% | incident register | Monthly |
| PI-02 | Doctors with current licence and competence assessment | 100% | licence and HR register | Quarterly |
| PI-03 | Clinical audits completed on time | set by facility | audit register | Quarterly |
| PI-04 | Ethics reviews recorded | 100% | ethics register | Quarterly |
11. Career ladder and promotion
| Level | Role | Minimum experience to move on | Qualifications | Competency minimums | Trainings required | Assessment |
|---|---|---|---|---|---|---|
| Executive | Medical director | 6 years (recommended) | Q-01, Q-02 | C-01 expert, C-03 practitioner | T-05 · T-07 | 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 |