Occupations and Terms of Reference › Data protection officer
Universal terms of reference · POS-017 · version 1.0 · status: draft · next review 2027-10-27
Data protection officer
To make sure patient and staff personal data is protected and lawfully used, and to advise the organisation on privacy risk and data rights.
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 protect personal data. You advise on lawful processing, run data protection impact assessments, handle data subject requests and breach reporting, and train staff on confidentiality.
Reports to: Chief executive officer; reports directly to the board on data protection matters.
Leads or supervises: No direct reports.
What you do on a typical day
- Review new systems and projects for privacy risk.
- Advise staff on data requests and sharing.
- Handle data subject requests within legal timelines.
- Review and report data breaches within the legal timeframe.
- Run privacy training and awareness.
Working conditions and demands
- Must be independent and not instructed on how to perform the role.
- Handles sensitive health data.
- Deadlines set by law.
What good looks like
- Privacy assessments completed before new systems go live.
- Breaches reported within the legal timeframe.
- Staff know how to protect data.
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-017 |
| ISCO-08 | 2529 (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-003. Supervises: .
| Works with | Nature of the relationship |
|---|---|
| Chief information officer | Information security and system access. |
| Legal counsel | Data protection law and claims. |
| Chief quality and safety officer | Breach and incident reporting. |
4. Key accountabilities
| Domain | Accountability | Evidence of delivery | Checked | Linked competencies | Linked trainings | Linked policies | Standards |
|---|---|---|---|---|---|---|---|
| Privacy framework | Maintains the data protection policy and framework. | Policy reviewed annually | Annually | C-01 | T-04 | POL-DATA | 1 |
| Impact assessments | Runs data protection impact assessments for new systems and projects. | Assessments completed before go-live | Monthly | C-02 | T-04 | POL-DATA | 2 |
| Breaches | Leads breach response and makes sure notifications are made on time. | Breach register complete; reports within legal timeframe | Monthly | C-03 | T-04 · T-05 | POL-DATA · POL-INC | 2 |
| Rights and training | Handles data subject requests and runs privacy training. | Requests answered within timeframe; training compliance | Monthly | C-01 | T-04 | POL-DATA | 2 |
5. Decision rights
| The post holder decides | Consults or escalates |
|---|---|
| Advice on lawful processing and privacy risk | Notifiable breaches (CEO and regulator) |
| Responses to data subject requests within law | Disputes with the regulator (CEO and legal counsel) |
6. Qualifications and experience
| ID | Qualification | Mandatory | Validity |
|---|---|---|---|
| Q-01 | Degree in law, information governance, health informatics or a related field | Yes | Lifetime |
| Q-02 | Data protection professional certificate (for example, CIPP or national equivalent) | Yes | Lifetime |
| ID | Experience | Minimum years | Mandatory |
|---|---|---|---|
| E-01 | Data protection, information governance or privacy experience, ideally in health | 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 | C-01 · C-02 · C-03 |
| T-05 | Incident reporting and open disclosure | essential | periodic | Every 2 year(s) | POL-INC | 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 | – |
| 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-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 | Data protection law and principles | Applies data rules | Advises on lawful processing | Designs the data protection framework | Privacy audit | Every 12 months | T-04 |
| C-02 | Data protection impact assessment | Identifies data risk | Runs impact assessments | Sets risk standards for new systems | Assessment review | Every 12 months | T-04 |
| C-03 | Breach response and reporting | Reports suspected breaches | Leads breach investigations | Designs breach response across the organisation | Breach exercise | Every 12 months | T-04 · T-05 |
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 | Breaches reported within legal timeframe | 100% | breach register | Monthly |
| PI-02 | Impact assessments completed before go-live | 100% | assessment register | Quarterly |
| PI-03 | Data subject requests within timeframe | 100% | request log | Monthly |
| PI-04 | Staff privacy training compliance | 100% | training records | Quarterly |
11. Career ladder and promotion
| Level | Role | Minimum experience to move on | Qualifications | Competency minimums | Trainings required | Assessment |
|---|---|---|---|---|---|---|
| Executive | Data protection officer | 5 years (recommended) | Q-01, Q-02 | C-01 expert, C-03 practitioner | T-04 | 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 |