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The System Director for Regulatory and Accreditation has the authority and responsibility for coordinating and ensuring ongoing compliance with accreditation and other regulatory activities for the hospitals and clinical entities in the Duke University Health System (DUHS). Also has the authority to cross lines of accountability and to influence and/or change the behavior of individuals within the organization. The Director oversees and facilitates compliance with health system mandates regarding standardization and cost-effective use of resources as well as manages the financial performance of this health system function.
Duties and Responsibilities of this Level
Communicates up-to-date and comprehensive knowledge of accreditation/regulatory guidelines, trends, issues, and other pertinent information useful in the development, implementation, and accomplishment of a successful continuous readiness program, as assessed through observation and feedback.
Oversees the review and revision, if necessary, of each entity's continual readiness processes at least biannually.
Serves as liaison with accreditation and regulatory agencies for the health system representing and communicating the health system's position.
Serves as an expert resource for health system accreditation and regulatory personnel.
Manages the DUHS policy and procedure manual.
Works collaboratively with accreditation managers at each entity within DUHS.
Collaborates with DUHS Risk Management, Accreditation, Performance Services, Compliance and Internal Auditing departments as needed in matters related to regulatory compliance, policy planning, and implementation.
Plans for, implements, and communicates policy/process revisions as required by changes in regulatory agency policies/laws.
Develops strategies for compliance and auditing to ensure compliance.
Trends and analyzes accreditation/regulatory performance measures (i.e., compliance with National Patient Safety Goals) and reports trended data to each hospital's senior leadership and the health system leadership.
Provides entities with updates related to changes in accreditation and regulatory standards/ requirements.
Serves as DUHS representative for external interactions with accrediting and regulatory bodies. - Reviews/directs/approves communication/interactions with external accrediting and regulatory bodies. - Assure corrective action plans are adequate and measurable. - Assures entities are responsive to accreditation/regulatory agencies promptly (e.g. PPR, RFIs, corrective action plans).
Determines fiscal requirements and directs preparation of budgetary recommendations at the corporate and entity levels; monitors verifies, and reconciles expenditure of budgeted funds.
Determines tools needed to assist in maintaining and monitoring compliance with standards.
Required Qualifications at this Level
Education
Master's degree in a health-related field preferred.
Experience
Minimum of five years' experience in healthcare accreditation and regulatory affairs with a successful track record of effective accreditation and regulatory affairs activities and outcomes. Also experience in budgeting, staffing, and supervision of personnel.
Knowledge, Skills, and Abilities
Expert knowledge of accreditation standards, healthcare regulations, and policy formulation. Excellent organizational, oral, and written communication skills, problem-solving, program development, computer skills, strong leadership, and team-building skills. The ability to work with a variety of disciplines and levels of staff across departments and health systems as well as personnel from outside organizations is required. Ability to work with a variety of disciplines and levels of staff across departments and the health system is required.
Duke is an Affirmative Action/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, sexual orientation, or veteran 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 essentialjob 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.