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Kirby Bates Associates has been exclusively retained by Duke University Health System (DUHS) to conduct the search for the next System Director, Accreditation & Regulatory Affairs. The System Director, Accreditation & Regulatory Affairs will provide strategic leadership and operational oversight for accreditation, regulatory compliance, and policy management across all DUHS hospitals and ambulatory sites. This key system leader will serve as the organization’s subject matter expert for The Joint Commission, CMS, state and federal investigative agencies, and all regulatory bodies—ensuring that Duke maintains continuous readiness and a proactive, collaborative approach to compliance, safety, and quality. This role reports to senior system leadership and leads a centralized team responsible for driving alignment, consistency, and enterprise-wide regulatory preparedness.
Job Responsibility:
Provide strategic leadership and operational oversight for accreditation, regulatory compliance, and policy management across all DUHS hospitals and ambulatory sites
Serve as the organization’s subject matter expert for The Joint Commission, CMS, state and federal investigative agencies, and all regulatory bodies
Ensure that Duke maintains continuous readiness and a proactive, collaborative approach to compliance, safety, and quality
Report to senior system leadership and lead a centralized team responsible for driving alignment, consistency, and enterprise-wide regulatory preparedness
Shape systemwide accreditation and regulatory strategy
Serve as the primary system liaison to external agencies including The Joint Commission, CMS, NCDHHS, and federal oversight bodies
Lead continuous readiness efforts across DUHS’s hospitals and ambulatory practices
Build and refine an enterprise accreditation and regulatory framework
Partner with senior executives and clinical leaders
Influence organizational culture, promoting transparency, safety, quality, and system-wide effectiveness
Requirements:
Master’s degree in a health-related field required
Minimum of five years of experience in healthcare accreditation and regulatory affairs, including demonstrated success in leading compliance programs and accreditation activities
Experience in a complex academic health system strongly preferred
Preferred certifications: CPHQ, HACP, CPPS, or other relevant credentials
Expert knowledge of regulatory and accreditation standards
Nice to have:
Experience in a complex academic health system strongly preferred
Preferred certifications: CPHQ, HACP, CPPS, or other relevant credentials
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