Assistant Director, Accreditation and Regulatory Affairs

At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together.

About Duke Health
At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together.

Position Summary
The Assistant Director, Accreditation & Regulatory Affairs - Policy Management directs Duke University Health System's (DUHS) enterprise-wide Policy Management Program. This position is responsible for ensuring a consistent, compliant, and effective approach to policy governance across all hospitals, clinics, and service lines.

This role partners with leadership, staff, and medical staff to ensure policies align with accreditation and regulatory requirements. The Assistant Director is a strategic, systems-level thinker with demonstrated expertise in policy management, including leading cross-functional meetings, facilitating governance processes, and using policy management software to drive adoption and compliance.

Key responsibilities include overseeing the designated policy platform, ensuring policies move through appropriate governance channels, and engaging stakeholders to standardize processes. The Assistant Director also applies knowledge of regulatory standards and performance improvement methodologies to promote alignment, efficiency, and compliance across the health system.

Key Responsibilities

Policy & Governance Leadership

• Direct the DUHS Policy Management Program, including governance processes, approvals, and software utilization.
• Interpret and apply accreditation and regulatory standards in policy development and administration.
• Educate stakeholders on policy processes, compliance requirements, and the use of policy management tools.
• Monitor and report on policy compliance metrics, ensuring timely review and updates.

Accreditation & Regulatory Support

• Collaborate with leaders and departments to ensure policies support compliance with accreditation, certification, and regulatory requirements.
• Partner with Patient Safety, Quality, Professional Practice, Risk Management, Legal, Compliance and other stakeholders to evaluate policies and workflows for compliance.
• Provide support for announced and unannounced surveys and participate in relevant pre-survey, on-site, and post-survey activities.
• Support data collection, analysis, and reporting related to policy and accreditation metrics.

Education & Communication

• Develop and deliver training, toolkits, and resources on policy management and its link to accreditation and regulatory requirements.
• Communicate changes in regulations, accreditation standards, and policy governance processes to leadership and staff.

Program & Resource Management

• Maintain a comprehensive project plan for system-wide policy management and accreditation readiness.
• Support related committees, including preparation of materials and facilitation of discussions.
• Champion continuous improvement and standardization of policy processes across DUHS.

Knowledge, Skills, and Abilities

• In-depth knowledge of accrediting organization standards (e.g., TJC, DNV, CMS) and regulatory compliance.
• Proven expertise in policy governance, software platforms, and change management.
• Strong analytical, problem-solving, facilitation, and negotiation skills.
• Exceptional interpersonal, written, and verbal communication abilities.
• Ability to lead in a complex organization with multiple stakeholders and priorities.
• Experience mentoring teams, managing conflict, and building collaborative relationships.
• Ability to prioritize and accomplish goals effectively.

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, 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 Experience:

Management experience in clinical operations, project management systems, and accreditation readiness.

Policy Management software experience (Policy Stat (RLDatix), Policy Tech (NAVEX), Policy Manager (MCN Solutions)

Demonstrated experience managing policy lifecycle processes using electronic policy management software, including training end users and ensuring compliance with system-wide workflows.

Licensure/Certifications:
RN or other clinical professional licensure preferred.
Preferred certifications: Certified Professional in Healthcare Quality (CPHQ), Healthcare Accreditation Certification Programs (HACP). Lean Six Sigma or Project Management Professional (PMP) certification

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.