Auto req ID
113888BR
Duke Entity
DUKE HOSPITAL
Job Code
5102 STRATEGIC SERVICES ASSOCIATE
Job Description
Job Title: DIRECTOR OF ACCREDITATION & REGULATORY AFFAIRS

General Description:
Responsible for supervision, oversight and monitoring of the hospital’s compliance with, state, federal and local regulatory requirements and all accreditation/certification standards such as The Joint Commission. Establishes a quality assurance system to ensure procedures and protocols are consistent with requirements to achieve constant readiness for regulatory site visits and surveys.
 
Duties and Responsibilities:
Provides leadership in the development and implementation of strategies regarding regulatory compliance.  
 
Directs and coordinates accreditation, policy, and regulatory affairs initiatives for the hospital; serves as the organizational liaison with Joint Commission and other pertinent regulatory agencies.
 
Assesses compliance with accreditation standards and regulations. Identifies areas of vulnerability related to accreditation standards and regulations.
 
Develops and monitors actions to address individual and aggregate trends to ensure adherence to all regulatory compliances. Evaluates effectiveness of corrective actions for identified problems and continuous quality improvement activities.
 
Coordinates quality reviews, identifies resources needed, people to be involved, and the logistics of accomplishing the project.
 
Monitors for and communicates changes in federal and state regulations, Joint Commission accreditation standards hospital leadership and staff.
Participates in State and Federal quality improvement projects to obtain comparative data on quality indicators, to use in assessing how well the institution is doing in relation to others and compliance with the Joint Commission standards.
 
Leads and participates in relevant DUH and DUHS committees such as Continual Readiness Committee and Performance Improvement Oversight Committee.
 
Develops and updates policies and procedures as needed to remain in compliance. Responsible for the flow of policies and once approved posts on the DUHS intranet website.
 
Provides in-services and continuing education for staff.
 
Supervises staff responsible for coordinating compliance with accreditation and regulatory standards.
 
Serves as the representative for external interactions with accrediting and regulatory bodies.
 
Performs other duties as assigned.
 
Location
Durham
Requisition Number
401603733
Position Title
DIRECTOR OF ACCREDITATION & REGULATORY AFFAIRS
Shift
Rotating
Job Family Level
G2
Full Time / Part Time
FULL TIME
Regular / Temporary
Regular
Department Name
CHIEF NURSING OFFICER PATIENT CARE SVCS
Minimum Qualifications
Duke University is an Affirmative Action/Equal Opportunity Employercommitted to providing employment opportunity without regard to anindividual's age, color, disability, gender, gender expression, genderidentity, 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 robustexchange of ideas—an exchange that is best when the rich diversity ofour perspectives, backgrounds, and experiences flourishes. To achievethis exchange, it is essential that all members of the community feelsecure and welcome, that the contributions of all individuals arerespected, and that all voices are heard. All members of our communityhave a responsibility to uphold these values.
Essential Physical Job Functions:Certain jobs at Duke University and Duke University Health System mayinclude essential job functions that require specific physical and/ormental abilities. Additional information and provision for requests forreasonable accommodation will be provided by each hiring department.Required Qualifications at this Level:
Education: 
Bachelor's degree in health-related field required.
 
Experience
Five years of experience in healthcare regulatory and auditing activities required which includes two years leadership experience. 
 
Licensure or Certification:
Registered Nurse or other Clinical Professional with current licensure/certification preferred.
 
Knowledge, Skills, and Abilities
 

Knowledge of state and federal regulations, and the Joint Commission standards and practices for acute care hospitals is required.

Must demonstrate a broad-based knowledge of and an ability to coach implementation of total quality management in the hospital.

Knowledge of quality improvement and risk management.

Highly effective verbal and written communication skills are necessary to work with medical, nursing staff and external review agencies in monitoring and evaluating the quality of patient care.

Demonstrated ability to collaborate with multiple members of the health care and administrative leadership team.

Demonstrated ability to think critically, develop conceptual strategies.

Essential Physical Job Functions:
Requires the ability to sit or stand for long periods of time, occasional stooping, and reaching; May require lifting up to 25 pounds; requires a normal range of vision and hearing with or without accommodations.