Occupations and Terms of Reference › Theatre manager
Universal terms of reference · POS-299 · version 1.0 · status: draft · next review 2027-10-27
Theatre manager
To run the operating theatres safely and efficiently, so that patients are safe, comfortable and get the right care at the right time.
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 are a theatre manager. You run the operating theatres safely and efficiently, document your care, and escalate changes in patient condition at once.
Reports to: Head of surgery.
Leads or supervises: No direct reports.
What you do on a typical day
- Plan the theatre list and staffing.
- Assess patients and record observations.
- Give treatment and medicines within protocol.
- Obtain consent and explain care.
- Escalate deterioration and incidents at once.
Working conditions and demands
- Shift work, nights and weekends.
- Cancelled lists and staffing gaps.
- High and changing workload.
What good looks like
- Patients are assessed and cared for to standard.
- Deterioration is escalated early.
- Records are complete and accurate.
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-299 |
| ISCO-08 | 1342 (skill level 4) |
| ESCO | to map |
| Department | Nursing |
| Facility types | Hospital |
3. Reporting line and working relationships
Reports to: POS-038. Supervises: .
| Works with | Nature of the relationship |
|---|---|
| Head of department (per specialty) | Clinical direction and escalation. |
| Head of department (per specialty) | Ward rota and standards. |
4. Key accountabilities
| Domain | Accountability | Evidence of delivery | Checked | Linked competencies | Linked trainings | Linked policies | Standards |
|---|---|---|---|---|---|---|---|
| Assessment | Assesses patients in theatre services and plans care with the patient. | Care plan audit at standard | Weekly | C-01 | T-05 | POL-SAFEG | 2 |
| Care | Gives treatment and medicines within protocol and checks each one. | Medicines and protocol audit at standard | Monthly | C-02 | T-05 | POL-SAFEG | 2 |
| Escalation | Escalates deterioration and reports incidents the same shift. | Escalations and incidents logged same shift | Daily | C-03 | T-05 | POL-INC | 2 |
| Records and consent | Obtains consent and keeps complete, accurate records. | Records and consent audit passed | Monthly | C-02 | T-05 | POL-DATA | 2 |
5. Decision rights
| The post holder decides | Consults or escalates |
|---|---|
| Daily nursing care plan for each theatre services patient, within protocol | Deterioration or care needs beyond the theatre services scope (head of surgery) |
| Timing of routine observations and care tasks | Serious incidents and complaints (nurse manager) |
6. Qualifications and experience
| ID | Qualification | Mandatory | Validity |
|---|---|---|---|
| Q-01 | Nursing licence, current | Yes | per regulator |
| Q-02 | Theatre management certificate | Yes | Lifetime |
| ID | Experience | Minimum years | Mandatory |
|---|---|---|---|
| E-01 | Nursing practice in theatre services | 6 | 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-01 · C-02 · C-03 |
| 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 | – |
8. Health, fitness and language
| ID | Requirement | Frequency | Tier | Minimum in low-resource settings |
|---|---|---|---|---|
| H-01 | Immunity to vaccine-preventable diseases relevant to the setting, documented at entry | At entry or as set | essential | Documented hepatitis B status at entry |
| H-02 | Tuberculosis screening at entry, then as the national rule requires | At entry or as set | essential | Symptom screening at entry and after exposure |
| 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 | Nursing assessment and care planning in theatre services | Assesses routine patients under supervision | Assesses and plans care independently | Leads complex assessment and teaches others | Care record audit | Every 12 months | T-05 |
| C-02 | Nursing care and treatment in theatre services | Gives routine care within protocol | Gives complex care and manages treatment | Designs care protocols | Care audit | Every 12 months | T-05 |
| C-03 | Escalation, incident reporting and safety | Recognises and reports deterioration | Escalates and manages incidents | Leads safety and learning review | 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 | Care plans audited at standard | 100% | care plan audit | Weekly |
| PI-02 | Escalations made same shift | 100% | escalation log | Daily |
| PI-03 | Records and consent complete | 100% | records audit | Monthly |
11. Career ladder and promotion
| Level | Role | Minimum experience to move on | Qualifications | Competency minimums | Trainings required | Assessment |
|---|---|---|---|---|---|---|
| Executive | Theatre manager | 6 years (recommended) | Q-01, Q-02 | C-01 practitioner, C-02 practitioner, C-03 practitioner | T-05 | 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 |