Occupations and Terms of Reference › Clinical governance lead
Universal terms of reference · POS-014 · version 1.0 · status: draft · next review 2027-10-27
Clinical governance lead
To run the clinical governance system, so that clinical audit, incident learning, guidelines and medical standards are applied, measured and improved.
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 the clinical governance system day to day. You coordinate clinical audit, incident learning, guideline review and governance meetings, so that clinical standards are measured and improved across services.
Reports to: Chief medical officer.
Leads or supervises: No direct reports; coordinates clinical audit and governance teams.
What you do on a typical day
- Coordinate the clinical audit programme.
- Prepare the clinical governance meeting and track actions.
- Check guidelines are reviewed on time.
- Support incident reviews and learning.
- Report clinical governance indicators each month.
Working conditions and demands
- Works across all clinical services.
- Needs to keep actions moving without direct line authority.
- Handles confidential clinical information.
What good looks like
- Audits run on time with actions tracked to completion.
- Guidelines are current and used.
- Learning from incidents is visible.
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-014 |
| 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: .
| Works with | Nature of the relationship |
|---|---|
| Chief medical officer | Agrees the clinical governance plan. |
| Chief quality and safety officer | Joint quality and audit programme. |
| Medical director | Clinical incidents and protocols. |
4. Key accountabilities
| Domain | Accountability | Evidence of delivery | Checked | Linked competencies | Linked trainings | Linked policies | Standards |
|---|---|---|---|---|---|---|---|
| Governance meetings | Prepares and runs clinical governance meetings and tracks actions. | Minutes and actions issued within two working days | Monthly | C-01 | T-05 | POL-INC | 2 |
| Clinical audit | Coordinates the clinical audit programme. | Audit plan delivered; results reported | Quarterly | C-02 | T-05 | – | 2 |
| Guidelines | Makes sure guidelines and protocols are reviewed on time. | Guideline register current | Quarterly | C-01 | T-05 | – | 2 |
| Incident learning | Supports incident reviews and makes sure learning is shared. | Learning shared at governance meetings | Monthly | C-03 | T-05 · T-07 | POL-INC | 2 |
5. Decision rights
| The post holder decides | Consults or escalates |
|---|---|
| Audit schedule within the approved programme | Serious clinical incidents (CMO and CQO) |
| Agenda for clinical governance meetings | Guideline changes with budget or service impact (CMO) |
6. Qualifications and experience
| ID | Qualification | Mandatory | Validity |
|---|---|---|---|
| Q-01 | Degree in a clinical or health field | Yes | Lifetime |
| Q-02 | Clinical audit or governance qualification | Yes | Lifetime |
| ID | Experience | Minimum years | Mandatory |
|---|---|---|---|
| E-01 | Clinical governance, audit or quality experience in a health service | 5 | 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 | – |
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 governance systems | Follows governance procedures | Runs governance meetings | Designs governance across services | Governance audit | Every 12 months | T-05 |
| C-02 | Clinical audit methods | Takes part in audit | Leads audits | Designs audit programmes | Audit review | Every 12 months | T-05 |
| C-03 | Incident learning and reporting | Reports incidents | Facilitates incident reviews | Leads learning across services | Incident review audit | Every 12 months | T-05 · T-07 |
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 | Audits completed on time | set by facility | audit register | Quarterly |
| PI-02 | Governance actions closed on time | 100% | action tracker | Monthly |
| PI-03 | Guidelines reviewed on time | 100% | guideline register | Quarterly |
| PI-04 | Incident reviews held within timeframe | 100% | incident register | Monthly |
11. Career ladder and promotion
| Level | Role | Minimum experience to move on | Qualifications | Competency minimums | Trainings required | Assessment |
|---|---|---|---|---|---|---|
| Executive | Clinical governance lead | 5 years (recommended) | Q-01, Q-02 | C-01 expert, C-02 practitioner | T-05 | 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 |