Occupations and Terms of Reference › Compliance officer
Universal terms of reference · POS-018 · version 1.0 · status: draft · next review 2027-10-27
Compliance officer
To make sure the organisation meets its legal, regulatory and accreditation obligations, and that compliance risks are found and managed before they become problems.
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 make sure the organisation meets its obligations. You maintain the compliance calendar, check licences and permits, track regulatory change, and support teams to comply.
Reports to: Chief executive officer.
Leads or supervises: No direct reports.
What you do on a typical day
- Maintain the compliance obligations register.
- Check licences, permits and inspections are current.
- Track regulatory changes and brief leaders.
- Support teams preparing for inspections.
- Report compliance status to the board each quarter.
Working conditions and demands
- Works across all services and sites.
- Must be independent of the activity it checks.
- Deadlines set by regulators.
What good looks like
- All licences and permits are current.
- Inspections are passed with few findings.
- Regulatory changes are briefed to leaders in time.
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-018 |
| ISCO-08 | 2611 (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 |
|---|---|
| Legal counsel | Regulatory interpretation. |
| Chief quality and safety officer | Accreditation and quality standards. |
| Internal auditor | Joint review of controls. |
4. Key accountabilities
| Domain | Accountability | Evidence of delivery | Checked | Linked competencies | Linked trainings | Linked policies | Standards |
|---|---|---|---|---|---|---|---|
| Obligations register | Maintains the register of legal and regulatory obligations. | Register reviewed quarterly | Quarterly | C-01 | T-06 | – | 1 |
| Licences | Makes sure licences, permits and certificates are current. | Licence register complete; expiry alerts issued | Monthly | C-01 | T-06 | – | 1 |
| Inspection readiness | Prepares services for inspections and surveys. | Preparation plans agreed; findings closed | Quarterly | C-02 | T-06 | POL-INC | 2 |
| Change | Briefs leaders on regulatory change within agreed time. | Briefings issued within 30 days of change | Quarterly | C-03 | T-06 | – | 1 |
5. Decision rights
| The post holder decides | Consults or escalates |
|---|---|
| Compliance monitoring approach | Non-compliance with a licence or legal duty (CEO and legal counsel) |
| Priorities for compliance checks within the plan | Serious licence breaches that need regulator contact (CEO) |
6. Qualifications and experience
| ID | Qualification | Mandatory | Validity |
|---|---|---|---|
| Q-01 | Degree in law, health management or a related field | Yes | Lifetime |
| Q-02 | Compliance or regulatory certificate (for example, CCP or national equivalent) | No | Lifetime |
| ID | Experience | Minimum years | Mandatory |
|---|---|---|---|
| E-01 | Compliance, regulatory or quality experience in a regulated organisation | 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 · C-03 |
| 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 | Regulatory obligations and licensing | Knows key obligations | Maintains compliance records | Designs the compliance framework | Compliance audit | Every 12 months | T-06 |
| C-02 | Compliance monitoring and inspection readiness | Supports inspections | Leads inspection preparation | Designs monitoring across services | Inspection review | Every 12 months | T-06 |
| C-03 | Regulatory change management | Notes changes | Briefs teams on change | Leads change in the compliance system | Change review | Every 12 months | T-06 |
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 | Licences and permits current | 100% | licence register | Monthly |
| PI-02 | Inspection findings closed on time | 100% | action tracker | Quarterly |
| PI-03 | Regulatory changes briefed on time | 100% | briefing log | Quarterly |
| PI-04 | Obligations register reviewed | 100% | register review | Quarterly |
11. Career ladder and promotion
| Level | Role | Minimum experience to move on | Qualifications | Competency minimums | Trainings required | Assessment |
|---|---|---|---|---|---|---|
| Executive | Compliance officer | 5 years (recommended) | Q-01 | C-01 expert, C-02 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 |