Occupations and Terms of Reference › Chief executive officer (CEO)
Universal terms of reference · POS-003 · version 1.0 · status: draft · next review 2027-10-27
Chief executive officer (CEO)
To lead the whole organisation, deliver its mission and standards, be accountable to the board for safety, quality and finances, and build a leadership team that can run the services well.
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 lead the whole organisation. You set the strategy with the board, make sure patient safety and quality come first, keep the finances sound, and build a leadership team that runs the services well. You are the final point of accountability for the organisation's standards and accreditation.
Reports to: The board of directors.
Leads or supervises: The executive team (COO, CMO, CNO, CFO, CQO, CHRO, CIO, CSO), and the legal, data protection, compliance and communications leads.
What you do on a typical day
- Weekly executive meeting: review safety, quality, finance and workforce dashboards, and decide actions.
- Review serious incidents and complaints with the quality lead, and confirm that actions are complete.
- Meet senior clinicians and managers on site, and hear directly from staff and patients.
- Prepare and attend board meetings; report performance, risks and decisions clearly.
- Hold a one-to-one with each executive each month; set and review their objectives.
- Represent the organisation to regulators, partners, funders and the community.
Working conditions and demands
- Long hours and travel between sites; available out of hours for serious incidents.
- High public and regulatory visibility; decisions may be published.
- Responsible for staff wellbeing at the top of the organisation.
What good looks like
- Safety and quality indicators are reviewed at every board meeting, and improvement is visible.
- Each executive knows their objectives, and the board trusts the reporting.
- Staff say they can speak up, and concerns are answered.
- The organisation meets its licensing and accreditation requirements without surprises.
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-003 |
| ISCO-08 | 1120 (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-001. Supervises: POS-004, POS-005, POS-006, POS-007, POS-008, POS-009, POS-010, POS-011, POS-016, POS-017, POS-018, POS-020.
| Works with | Nature of the relationship |
|---|---|
| Board of directors | Accountable to the board for performance, safety and strategy; reports at each board meeting. |
| Executive team | Leads the executive team; sets priorities and resolves conflicts. |
4. Key accountabilities
| Domain | Accountability | Evidence of delivery | Checked | Linked competencies | Linked trainings | Linked policies | Standards |
|---|---|---|---|---|---|---|---|
| Strategy and governance | Leads the strategy, governance and performance of the whole organisation, and is accountable to the board for it. | Board-approved strategy; governance framework in place; reports on time | Each board meeting | C-01 · C-02 | T-06 | POL-WHISTLE | 2 |
| Patient safety and quality | Makes sure patient safety and quality are measured, owned and improved in every service, and that serious incidents are learned from. | Safety dashboard reviewed monthly; serious incidents reviewed with actions completed | Monthly | C-03 | T-05 · T-07 | POL-INC | 2 |
| Finance and resources | Keeps the organisation financially sound and makes sure resources follow patient need. | Balanced budget; audited accounts; risk register reviewed | Quarterly | C-04 | T-06 | – | 2 |
| People and culture | Builds leadership capacity and a culture in which staff can speak up. | Staff survey results; speaking-up cases handled within the policy timeframe | Annually | C-05 | T-08 | POL-WHISTLE · POL-EQUAL | 2 |
| Legal and regulatory | Makes sure licensing, regulatory and accreditation duties are met, and that any breach is reported to the board and, where required, the regulator. | Licences current; accreditation requirements tracked; no unreported breach | Quarterly | C-02 | T-06 | POL-DATA | 2 |
5. Decision rights
| The post holder decides | Consults or escalates |
|---|---|
| Strategic priorities and the annual budget within board approval | Changes to the strategy or structure (board decision) |
| Appointment of executive team members, with board approval | Serious safety events with legal or public consequences |
| Response to serious incidents, including external reporting decisions | Matters outside delegated financial limits |
6. Qualifications and experience
| ID | Qualification | Mandatory | Validity |
|---|---|---|---|
| Q-01 | Degree in health management, public health, medicine or a related field | Yes | Lifetime |
| Q-02 | Postgraduate qualification in health management or business administration (MBA or equivalent) | No | Lifetime |
| ID | Experience | Minimum years | Mandatory |
|---|---|---|---|
| E-01 | Senior leadership experience in a health service or comparable complex 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 · C-04 |
| 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-05 |
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 | Strategic leadership and vision | Contributes to strategy | Leads a service strategy | Sets organisational strategy with the board | 360 feedback and board review | Every 24 months | T-06 |
| C-02 | Governance, accountability and board reporting | Prepares accurate reports | Presents performance and risk to the board | Designs governance and assurance for the whole organisation | Board evaluation | Every 24 months | T-06 |
| C-03 | Patient safety leadership | Knows the safety systems | Leads safety improvement across services | Sets the safety culture and holds the system to account | Safety culture survey and incident review | Every 12 months | T-05 · T-07 |
| C-04 | Financial stewardship | Reads management accounts | Manages a budget and explains variances | Sets financial strategy and manages risk to sustainability | Finance review | Every 12 months | T-06 |
| C-05 | Workforce and culture leadership | Supports team development | Develops and appraises leaders | Builds a learning and speaking-up culture across the organisation | Staff survey and appraisal | 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 | Serious incidents reviewed with actions completed | 100% | incident register | Monthly |
| PI-02 | Staff survey: staff feel safe to speak up | set by board | staff survey | Annually |
| PI-03 | Budget performance against plan | within agreed tolerance | finance reports | Quarterly |
| PI-04 | Regulatory and accreditation actions completed on time | 100% | compliance tracker | Quarterly |
11. Career ladder and promotion
| Level | Role | Minimum experience to move on | Qualifications | Competency minimums | Trainings required | Assessment |
|---|---|---|---|---|---|---|
| Executive | Chief executive officer (CEO) | 10 years (recommended) | Q-01 | C-01 expert, C-03 expert | T-06 · T-07 | Board appointment process 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 |