Occupations and Terms of Reference › Practice manager
Universal terms of reference · POS-229 · version 1.0 · status: draft · next review 2027-10-27
Practice manager
To run the ambulatory clinic day to day, so that patients are seen on time, the clinic is safe, and the team works 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 run the clinic. You manage staff rotas, patient flow, premises, supplies and complaints, and make sure the clinic meets its standards and budget.
Reports to: Medical director.
Leads or supervises: Reception, triage and patient flow staff.
What you do on a typical day
- Review clinic capacity and waiting times each morning.
- Plan staff rotas and cover.
- Handle complaints and patient concerns.
- Check premises, supplies and safety.
- Report clinic performance monthly.
Working conditions and demands
- Works with many clinicians and patients.
- On call for clinic problems.
- Balances cost and quality.
What good looks like
- Patients are seen on time.
- The clinic is safe and well run.
- Complaints are answered and learned from.
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 client or patient is assessed before they start any service, and the service is adjusted to their needs.
- Services stay within the scope of training and licence; anything beyond it is referred.
- Consent is informed and recorded before any procedure or programme.
- Adverse events and complaints are reported the same day and learned from.
- Clients' privacy and records are protected at all times.
- Prices, claims and promotions are honest and match what is delivered.
- Staff are trained and competent for their role before they work alone.
- Where the client's health or safety is at risk, work stops and the right person is called.
2. Identification
| Item | Detail |
|---|---|
| Position code | POS-229 |
| ISCO-08 | 1342 (skill level 4) |
| ESCO | to map |
| Department | Ambulatory clinic |
| Facility types | Ambulatory |
3. Reporting line and working relationships
Reports to: POS-012. Supervises: POS-230, POS-231, POS-236.
| Works with | Nature of the relationship |
|---|---|
| Medical director | Clinical standards. |
| Family physician (GP) lead | Clinical lists and cover. |
| Chief operating officer | Operating plan and budget. |
4. Key accountabilities
| Domain | Accountability | Evidence of delivery | Checked | Linked competencies | Linked trainings | Linked policies | Standards |
|---|---|---|---|---|---|---|---|
| Flow | Keeps clinic flow and waiting times within target. | Waiting times within target 90% or more | Weekly | C-01 | T-08 | – | 2 |
| Premises | Keeps premises and supplies safe. | Safety checks completed on schedule | Monthly | C-02 | T-05 | POL-SAFEG | 2 |
| Complaints | Handles complaints fairly and on time. | Complaints answered within policy timeframe | Monthly | C-01 | T-08 | POL-EQUAL · POL-WHISTLE | 2 |
5. Decision rights
| The post holder decides | Consults or escalates |
|---|---|
| Clinic rota decisions within budget | Serious clinic incidents (medical director and CQO) |
| Appointment slot allocation | Changes to clinic services (COO) |
6. Qualifications and experience
| ID | Qualification | Mandatory | Validity |
|---|---|---|---|
| Q-01 | Degree in health management or a related field | No | Lifetime |
| Q-02 | Practice management certificate | No | Lifetime |
| ID | Experience | Minimum years | Mandatory |
|---|---|---|---|
| E-01 | Clinic or practice management | 4 | 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-02 |
| 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 |
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 | Clinic operations and flow | Follows clinic plans | Runs a clinic | Designs clinic operations | Operations audit | Every 12 months | T-08 |
| C-02 | Clinic safety and premises | Checks safety | Leads safety checks | Designs premises safety | Safety audit | Every 12 months | 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 | Waiting times within target | 90% or more | clinic data | Weekly |
| PI-02 | Safety checks on schedule | 100% | check log | Monthly |
| PI-03 | Complaints answered on time | 100% | complaints log | Monthly |
11. Career ladder and promotion
| Level | Role | Minimum experience to move on | Qualifications | Competency minimums | Trainings required | Assessment |
|---|---|---|---|---|---|---|
| Executive | Practice manager | 4 years (recommended) | Q-01 | C-01 practitioner, 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:
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 |