System Director, Accreditation & Regulatory Affairs

System Director, Accreditation & Regulatory Affairs
Duke University Health System
Durham, NC

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.

Opportunity Highlights: 

• Shape systemwide accreditation and regulatory strategy across one of the nation’s most respected academic health systems.
• 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, ensuring proactive compliance and seamless preparation for planned and unannounced surveys.
• Build and refine an enterprise accreditation and regulatory framework, strengthening infrastructure, processes, tools, and communication systems across all sites.
• Partner with senior executives and clinical leaders—including hospital presidents, medical staff, quality and patient safety, compliance, legal, and performance services.
• Lead a high-impact, centralized team, fostering shared best practices, cross-campus consistency, and a cohesive approach to regulatory oversight.
• Influence organizational culture, promoting transparency, safety, quality, and system-wide effectiveness in every aspect of regulatory and policy management.

 Qualifications:

• 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.

To learn more about this exciting opportunity, please contact:

 EEO Statement

Kirby Bates Associates is an EEO/AA Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sexual orientation, gender, gender identity and expression, national origin, age, disability or protected veteran status. We celebrate diversity and are committed to creating an inclusive environment for all of our associates.