Assistant Director, Accreditation and Regulatory Affairs

Assistant Director, Accreditation and Regulatory Affairs

The Assistant Director, Accreditation and Regulatory is responsible for leading system accreditation and regulatory programs at Duke University Health System (DUHS). This role involves collaboration with leadership, staff, and medical staff to ensure compliance with accreditation, regulatory, and disease-specific certification requirements.

This role requires a systems thinker with strong experience in policy management, including the use of policy management software and the ability to train others on its use. The Assistant Director will be responsible for supporting and enforcing use of the designated policy platform, ensuring policies are developed, maintained, and approved through the appropriate governance channels. This includes engaging leaders and stakeholders to gain buy-in for standardized policy processes and ensuring consistent adoption of the system's governance and committee review framework.

The Assistant Director also brings expertise in regulatory standards and improvement methodologies and promotes cross-entity collaboration to align priorities, elevate system-wide effectiveness, and ensure a consistent approach to policy management and compliance.

Key responsibilities include:

• Interpretation and application of regulatory and accreditation standards
• Oversight of policy and document management infrastructure
• Stakeholder education and communication
• Enforcement of policy governance processes, including committee approvals and software utilization

Continuous Readiness Efforts:

• Lead the entity in evaluating, planning, and supporting continuous compliance and readiness infrastructure.
• Oversee pre-survey, on-site survey, and post-survey activities for accreditation, regulatory, and certification programs.
• Collaborate with leaders and departments to assess policies, evaluate workflows, and observe clinical care to identify gaps and ensure compliance.
• Partner with Patient Safety, Quality, Professional Practice, Risk Management, Legal, and other departments to assess regulatory functions and maintain compliance.
• Conduct ongoing monitoring, measurement, and analysis of survey data and trends; communicate results to appropriate departments and leadership.
• Develop and maintain a comprehensive accreditation project plan.

Resource Development and Management:

• Create and maintain toolkits, educational resources, and reference materials to support readiness.
• Deliver training and presentations related to regulatory, accreditation, and certification requirements.
• Ensure regulatory resources are up to date and communicate changes to leadership and staff.
• Collaborate with clinical and administrative departments to implement changes that enhance compliance and improve patient outcomes.

Survey Coordination:

• Serve as the primary liaison between accreditation/regulatory bodies and the entity.
• Develop, maintain, and implement an entity-specific unannounced survey plan.
• Manage on-site surveys, including communications, agendas, and logistics.
• Support the development and execution of corrective action plans in response to survey findings.
• Oversee reporting requirements for state and federal regulatory agencies.

Program Management:

• Manage the accreditation and certification budget plan.
• Develop and manage Accreditation Readiness Committee meetings and activities.
• Monitor changes in federal and state regulations and accreditation standards; communicate updates to leadership and staff.
• Enhance continuous improvement activities by teaching performance and process improvement methodologies.
• Champion cross-entity collaboration to align priorities and standardize practices across the health system.

Knowledge, Skills, and Abilities:

• Highly self-motivated and independent thinker with sound judgment.
• Knowledge of accrediting organization standards and regulatory compliance.
• Strong problem-solving, analytical, and negotiation skills.
• Ability to prioritize and accomplish goals effectively.
• Excellent interpersonal, facilitation, coaching, written, and verbal communication skills.
• Flexible and adaptable to changing processes and procedures.
• Experience working in complex organizations with multiple stakeholders.
• Demonstrated ability to manage conflict, mentor teams, and recognize behaviors that contribute to success.

Minimum Qualifications:

• Education: Bachelor's degree in Nursing, Business, Healthcare Administration, or a related field. Master's degree preferred.
• Experience: Minimum of 7 years of experience in accreditation, certification, quality, risk management, patient safety, or clinical operations. Knowledge of quality improvement methodologies, project management, and regulatory standards (CMS, TJC, DNV, TJC, JACO, DHHS, DHSR, DOH). Experience with auditing, data analytics, staff training, and creative problem-solving preferred. Must be able to work on-site to ensure readiness for unannounced surveys. Preferred: Management experience in clinical operations, project management systems, and accreditation readiness.
• Licensure/Certifications: RN or other clinical professional licensure preferred. Preferred certifications: CPHQ, Certified Quality Technician (ASQ), HACP, or CSHA.

Duke is an Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex (including pregnancy and pregnancy related conditions), sexual orientation, or military status.

Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideasan exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.

Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.