EDITIONEN·FR·ქართ

Accréditation Sans Frontières

International Accreditation of Healthcare Facilities

Occupations and Terms of Reference › IT manager

Universal terms of reference · POS-194 · version 1.0 · status: draft · next review 2027-10-27

IT manager

To run the day-to-day IT service, so that systems are available, users are supported, and changes are made safely.

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 run the IT service day to day. You manage the team, service availability, change control, supplier performance and user support.

Reports to: Chief information officer.

Leads or supervises: Systems, database, network and help desk teams.

What you do on a typical day

Working conditions and demands

What good looks like

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.

2. Identification

Item Detail
Position code POS-194
ISCO-08 1330 (skill level 4)
ESCO to map
Department Information technology
Facility types Hospital, Ambulatory, Transport, Medevac, Fitness, Aesthetic

3. Reporting line and working relationships

Reports to: POS-010. Supervises: POS-195, POS-196, POS-197, POS-199.

Works with Nature of the relationship
Chief information officer IT strategy and budget.
Data protection officer Access and data protection.
Clinical informatics specialist Clinical system changes.

4. Key accountabilities

Domain Accountability Evidence of delivery Checked Linked competencies Linked trainings Linked policies Standards
Service Runs the IT service to agreed levels. Service levels met 95% or more Monthly C-01 · C-02 T-08 – 2
Change Makes sure changes are approved and recorded. No unrecorded changes Monthly C-01 T-08 – 2
Security Keeps operations secure and access controlled. Access reviews completed Quarterly C-03 T-04 POL-DATA 2

5. Decision rights

The post holder decides Consults or escalates
Routine change approvals within policy Changes that risk a critical clinical system (CIO)
Priority of support tasks Security incidents with data at risk (CIO and data protection officer)

6. Qualifications and experience

ID Qualification Mandatory Validity
Q-01 Degree in computer science or information systems No Lifetime
Q-02 IT service management certificate (for example, ITIL) Yes Lifetime
ID Experience Minimum years Mandatory
E-01 IT operations or service management experience 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-03
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) – –
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-01 · C-02

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 Service management and change control Follows change steps Runs change control Designs service processes Service audit Every 12 months T-08
C-02 Systems operations and availability Monitors systems Manages availability Designs resilience Availability review Every 12 months T-08
C-03 IT security awareness Follows security rules Enforces security in operations Designs security operations Security audit Every 12 months T-04

10. Performance evaluation

ID Indicator Target Data source Frequency
PI-01 Service levels met 95% or more service report Monthly
PI-02 Changes recorded 100% change log Monthly
PI-03 Access reviews completed 100% access log Quarterly

11. Career ladder and promotion

Level Role Minimum experience to move on Qualifications Competency minimums Trainings required Assessment
Executive IT manager 5 years (recommended) Q-01, Q-02 C-01 expert, C-02 practitioner T-08 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:
  • 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.
Linked trainings: T-08 · T-09 · Review every 12 months · Template 0.1 (draft)
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:
  • 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:
  • 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:
  • 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:
  • 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.
Linked trainings: T-11 · T-05 · Review every 12 months · Template 0.1 (draft)

13. Standards that name this role

2

14. Record history

Date Change Approved by
2026-10-27 Draft record, batch 1 of the position build Awaiting approval

Back to all occupations · Health Occupations Map

© 2026 Accréditation Sans Frontières · PHIG · Sheni Network