Occupations and Terms of Reference › Board of directors
Universal terms of reference · POS-001 · version 1.0 · status: draft · next review 2027-10-27
Board of directors
To hold the organisation to account on behalf of its owners and the public: setting direction, approving the budget, appointing the chief executive, and making sure risk, quality and safety are governed properly.
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. The board is the highest governing body. It sets the vision and strategy, approves the budget and major investments, appoints and oversees the CEO, and makes sure risk, quality, safety and ethics are governed. Board members act in the interest of patients and the organisation, not of any individual.
Reports to: Shareholders or owners of the organisation.
Leads or supervises: Chief executive officer; the board chair leads the board.
What you do on a typical day
- Attend board meetings (at least quarterly) and read board papers beforehand.
- Review quality, safety and risk reports each quarter.
- Approve the annual budget and major investments.
- Review the CEO's performance annually.
- Declare conflicts of interest and recuse where needed.
Working conditions and demands
- Unpaid or part-paid roles with clear accountability.
- Must keep confidential patient and financial information.
- Accountable for decisions made collectively.
What good looks like
- Board decisions are recorded, and actions are tracked.
- Quality and safety are reviewed every quarter.
- Conflicts of interest are declared and managed.
- The board receives independent assurance.
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-001 |
| ISCO-08 | 1110 (skill level 4) |
| ESCO | to map |
| Department | Governance |
| Facility types | Hospital, Ambulatory, Transport, Medevac, Fitness, Aesthetic |
3. Reporting line and working relationships
Reports to: . Supervises: POS-003, POS-002.
| Works with | Nature of the relationship |
|---|---|
| Chief executive officer | Board receives reports and sets direction; CEO runs the organisation. |
| Internal auditor | Assurance reports to the audit committee. |
| Owners and shareholders | Board reports to owners on performance. |
4. Key accountabilities
| Domain | Accountability | Evidence of delivery | Checked | Linked competencies | Linked trainings | Linked policies | Standards |
|---|---|---|---|---|---|---|---|
| Direction | Sets the vision, strategy and values, and reviews them each year. | Strategy approved; minutes recorded | Annually | C-01 | T-06 | – | 1 |
| Oversight | Holds the CEO to account and reviews quality, safety and risk each quarter. | Quarterly quality and risk reports reviewed | Quarterly | C-01 · C-03 | T-05 · T-07 | POL-INC | 2 |
| Finance | Approves the budget and monitors financial performance. | Budget approved; variances reviewed quarterly | Quarterly | C-02 | T-06 | – | 1 |
| Integrity | Sets and follows the code of conduct, including conflicts of interest and speaking up. | Declarations register current; whistleblowing reports reviewed | Annually | C-04 | T-08 | POL-WHISTLE · POL-EQUAL | 2 |
5. Decision rights
| The post holder decides | Consults or escalates |
|---|---|
| Vision, strategy and annual budget | Matters reserved to owners or the law (owners and regulators) |
| Appointment, review and remuneration of the CEO | Changes to the constitution or governance structure (owners) |
| Major investments and partnerships |
6. Qualifications and experience
| ID | Qualification | Mandatory | Validity |
|---|---|---|---|
| Q-01 | Degree or equivalent professional experience relevant to governance | Yes | Lifetime |
| Q-02 | Governance or board training (for example, company directors' course) | No | Lifetime |
| ID | Experience | Minimum years | Mandatory |
|---|---|---|---|
| E-01 | Senior leadership or governance experience in a regulated organisation | 10 | 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-03 |
| 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 | 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-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 | Board governance and oversight | Reads board papers | Asks challenging questions | Leads the board in oversight of quality, risk and finance | Board review | Every 24 months | T-06 |
| C-02 | Financial oversight | Reads financial reports | Tests budget assumptions | Approves budgets and monitors financial risk | Board review | Every 24 months | T-06 |
| C-03 | Oversight of quality, safety and ethics | Reads safety reports | Asks about safety trends | Oversees the safety and ethics system | Board review | Every 24 months | T-05 · T-07 |
| C-04 | Conflicts of interest and integrity | Declares interests | Manages conflicts in decisions | Sets the board's standards of conduct | Board self-assessment | 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 | Board meetings held with quorum | 100% | minutes | Quarterly |
| PI-02 | Board decisions with recorded actions | 100% | action tracker | Quarterly |
| PI-03 | Declared conflicts managed | 100% | declarations register | Annually |
| PI-04 | Board self-assessment completed | 100% | self-assessment record | Annually |
11. Career ladder and promotion
| Level | Role | Minimum experience to move on | Qualifications | Competency minimums | Trainings required | Assessment |
|---|---|---|---|---|---|---|
| Executive | Board of directors | 10 years (recommended) | Q-01 | C-01 practitioner, 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 |