Duke University

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Position Summary

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 who can lead system/entity efforts to achieve the highest compliance with accreditation and certification standards, aiming not only to meet but to exceed benchmarks for patient care excellence. The Assistant Director is instrumental in shaping and supporting the infrastructure for sustained accreditation success by applying deep expertise in regulations, standards, and improvement methodologies. This position also champions cross-entity collaboration to align priorities and drive standardization in accreditation and regulatory practices, elevating system-wide effectiveness and readiness.

The Assistant Director operationalizes an effective continuous readiness framework that supports and sustains the DUHS Accreditation and Regulatory Program's core goals of:

1. Standard interpretation
2. Standard compliance
3. Education and communication
4. Survey operations

Work Performed

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 onthe robust exchange of ideas—an 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.