Occupations and Terms of Reference › Internal auditor
Universal terms of reference · POS-015 · version 1.0 · status: draft · next review 2027-10-27
Internal auditor
To give independent assurance to the board and management that controls, risk management and governance work, and to report weaknesses clearly so they are fixed.
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 provide independent assurance. You plan and carry out audits of finance, operations, quality and information controls, and report findings to management and the board audit committee until they are fixed.
Reports to: Chief financial officer; reports functionally to the board audit committee.
Leads or supervises: No direct reports (may lead audit assistants).
What you do on a typical day
- Carry out planned audits from the annual audit plan.
- Test controls and collect evidence.
- Write audit reports and agree actions with managers.
- Follow up on open actions.
- Report to the audit committee each quarter.
Working conditions and demands
- Independence is essential; must not audit own work.
- Handles confidential financial and patient information.
- Often reviews sensitive matters.
What good looks like
- Audit plan delivered on time.
- Findings are agreed and fixed within agreed dates.
- The audit committee gets clear, honest reports.
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-015 |
| ISCO-08 | 2411 (skill level 4) |
| ESCO | to map |
| Department | Governance |
| Facility types | Hospital, Ambulatory, Transport, Medevac, Fitness, Aesthetic |
3. Reporting line and working relationships
Reports to: POS-007. Supervises: .
| Works with | Nature of the relationship |
|---|---|
| Chief financial officer | Financial audits and controls. |
| Board audit committee | Reports audit findings independently. |
| Chief quality and safety officer | Risk and quality audits. |
4. Key accountabilities
| Domain | Accountability | Evidence of delivery | Checked | Linked competencies | Linked trainings | Linked policies | Standards |
|---|---|---|---|---|---|---|---|
| Audit plan | Delivers the annual audit plan with independence and objectivity. | Audit plan delivered; reports issued | Annually | C-01 | T-06 | – | 1 |
| Controls | Tests controls and gives assurance on their design and operation. | Testing evidence on file | Quarterly | C-02 | T-06 | POL-INC | 1 |
| Follow-up | Follows up open audit actions until they are closed. | Open actions reported to the audit committee | Quarterly | C-03 | T-08 | – | 1 |
| Concerns | Investigates concerns raised through whistleblowing channels when asked, and reports fairly. | Investigations recorded and reported | Quarterly | C-01 | T-08 | POL-WHISTLE | 2 |
5. Decision rights
| The post holder decides | Consults or escalates |
|---|---|
| Audit methods and testing approach | Significant control failures or fraud (audit committee and CEO) |
| Scope of individual audits within the plan | Management refusal to accept high-priority audit findings (audit committee) |
6. Qualifications and experience
| ID | Qualification | Mandatory | Validity |
|---|---|---|---|
| Q-01 | Professional audit qualification (IIA, ACCA, CIA or national equivalent) | Yes | Lifetime |
| Q-02 | Degree in accounting, finance or a related field | Yes | Lifetime |
| ID | Experience | Minimum years | Mandatory |
|---|---|---|---|
| E-01 | Internal or external audit experience, including health or regulated services | 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 | – |
| T-06 | Governance, accountability and assurance | recommended | periodic | Every 3 year(s) | – | C-01 · C-02 |
| T-07 | Emergency and major incident command | essential | annual | Every 1 year(s) | POL-INC | – |
| T-08 | Speaking up, inclusion and equality leadership | essential | periodic | Every 2 year(s) | POL-WHISTLE · POL-EQUAL | C-03 |
8. Health, fitness and language
| ID | Requirement | Frequency | Tier | Minimum in low-resource settings |
|---|---|---|---|---|
| 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 | Audit planning and testing | Follows audit steps | Plans and runs an audit | Designs the audit programme | Audit file review | Every 12 months | T-06 |
| C-02 | Risk and control evaluation | Identifies control gaps | Evaluates control design | Advises on the risk and control framework | Peer review | Every 12 months | T-06 |
| C-03 | Audit reporting and communication | Writes clear findings | Presents findings to managers | Reports to the audit committee with clear priorities | Report review | Every 12 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 | Audit plan delivered | 100% | audit plan tracker | Annually |
| PI-02 | High-priority findings closed on time | 100% | action tracker | Quarterly |
| PI-03 | Audit reports issued within agreed time | 100% | audit register | Quarterly |
| PI-04 | Audit committee attendance | 100% | committee minutes | Quarterly |
11. Career ladder and promotion
| Level | Role | Minimum experience to move on | Qualifications | Competency minimums | Trainings required | Assessment |
|---|---|---|---|---|---|---|
| Executive | Internal auditor | 5 years (recommended) | Q-01 | C-01 expert, C-03 practitioner | T-06 | 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 |