System Director, Accreditation and Regulatory Affairs

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Work arrangement - Onsite Duke University Hospital, Duke South, Green Zone 

General Description of the Job Class

The System Director of Accreditation & Regulatory Affairs provides strategic leadership and operational oversight for accreditation, regulatory compliance, and policy management across Duke University Health System (DUHS), which includes acute care and ambulatory settings. This role is responsible for maintaining continuous readiness for all accreditation and regulatory requirements; ensuring the organization is prepared for planned and unannounced surveys; and partnering with executive and clinical leaders to promote a culture of safety, quality, and compliance.

The System Director serves as DUHS’s primary system leader and expert for external accreditation and regulatory bodies, including The Joint Commission, Centers for Medicare & Medicaid Services (CMS), North Carolina Department of Health and Human Services, and other federal and state investigative and oversight agencies. The role has authority to work across organizational lines and influence practices, priorities, and behaviors to ensure regulatory compliance across all DUHS entities.

This position leads and oversees the centralized Accreditation & Regulatory Affairs team, currently ensuring consistent standards, processes, and compliance expectations across all DUHS hospitals and ambulatory locations.

Duties and Responsibilities of this Level

Accreditation & Regulatory Leadership

• Provide systemwide leadership and subject matter expertise on accreditation and regulatory requirements, including Joint Commission standards, CMS Conditions of Participation, and applicable federal and state regulations.
• Oversee ongoing continuous readiness activities for hospitals and ambulatory practices through assessments, process monitoring, and review of compliance data.
• Interpret and communicate regulatory updates and oversee enterprise implementation of required changes.
• Partner with entity-based Accreditation & Regulatory leaders, who manage site-specific regulatory visits, while providing system oversight and ensuring alignment, consistency, and shared best practices.

Regulatory Oversight & Compliance Infrastructure

• Oversee DUHS’s enterprise framework for regulatory preparedness, documentation, communication, and follow-up.
• Guide and support local leaders in responding to regulatory findings, including the development and evaluation of corrective action plans and the monitoring of resolution.
• Ensure timely and accurate organizational responses to external agencies.
• Oversee required federal and state reporting, ensuring a consistent, reliable systemwide process applicable across hospital and ambulatory settings.

Policy Management Leadership

• Provide system leadership and oversight for DUHS’s enterprise policy management program.
• Oversee development, review, revision, dissemination, and publication of systemwide policies.
• Ensure processes for policy creation and approval are standardized, timely, and aligned across all entities.
• Direct communication of new and revised policies to employees and stakeholders in clear and accessible formats.

Team Leadership & Development

• Lead a centralized accreditation and regulatory team across the health system.
• Establish program goals, clarify roles, and promote collaborative, cross-campus work rather than siloed efforts.
• Provide coaching, professional development, and performance management for team members, including mid-year and annual evaluations.
• Lead recurring team meetings, including weekly virtual meetings and monthly in-person sessions.

Strategic, Operational, and Executive Collaboration

• Serve as the primary system liaison for accreditation and regulatory agencies, ensuring consistent representation of DUHS interests.
• Develop and maintain policies and workflows that guide DUHS’s response to federal and state auditor or investigative visits (e.g., CMS, HHS-OIG, FDA, NCDHHS).
• Collaborate with hospital presidents, medical staff leadership, quality and patient safety leaders, compliance, legal counsel, performance services, and risk management.
• Lead or support systemwide initiatives and projects related to regulatory updates, accreditation changes, and process improvement.
• Provide reports, analysis, and counsel to senior leadership on emerging regulatory trends, risks, and opportunities.

Program Development & Continuous Improvement

• Build and enhance the Accreditation & Regulatory Affairs infrastructure, filling historical gaps and establishing sustainable, scalable systemwide processes.
• Evaluate and implement tools, technology, and processes that support monitoring, tracking, and communication of compliance activities.
• Identify opportunities for process improvements that enhance reliability, efficiency, and readiness across DUHS hospitals and ambulatory sites.

Financial Management

• Develop, manage, and oversee the budget for the Accreditation & Regulatory Affairs department.
• Monitor expenditures, ensure financial stewardship, and plan for program growth aligned with organizational priorities.

Minimum Qualifications

Education

Master's degree in a health-related field preferred.

Experience

Minimum of five years of experience in healthcare accreditation and regulatory affairs with demonstrated success in leading accreditation activities, regulatory compliance, team supervision, and organizational readiness programs. Experience in a complex academic health system is strongly preferred.

Degrees, Licensure, and/or Certification

Preferred certifications: Certified Professional in Healthcare Quality (CPHQ), Healthcare Accreditation Certification Programs (HACP), Certified Professional Patient Safety (CPPS); other relevant certifications may be considered

Knowledge, Skills, and Abilities

• Expert knowledge of accreditation standards, regulatory requirements, and policy formulation.
• Strong leadership, communication, and team-building skills.
• Excellent organizational, analytical, and problem-solving abilities.
• Ability to work collaboratively with leaders and staff at all levels of the organization and with external regulatory partners.
• Ability to influence practice and behavior across multiple settings and entities