Director Regulatory and Accreditation - Systems

System Director Of Regulatory And Accreditation

The System Director of Regulatory and Accreditation provides strategic leadership and operational oversight for regulatory compliance and accreditation readiness across TMC Health. This role ensures that all entities maintain continuous compliance with the Joint Commission (TJC), CMS Conditions of Participation, and applicable state and federal regulations. The Director drives a proactive culture of safety, accountability, and high reliability through system-wide education, monitoring, and performance improvement initiatives. This position will guide the development of policy and guidelines as they relate to the hospital and compliance with regulatory and accreditation guidelines and assist in the interpretation of these policies.

Essential Functions :

• Develops and implements a system-wide regulatory and accreditation strategy aligned with enterprise TMC Health risk and quality goals.
• Serves as the primary liaison with accrediting and regulatory agencies.
• Leads TMC Health's response to regulatory changes and ensures timely implementation of new requirements.
• Designs and manages a continuous readiness program across all facilities.
• Conducts mock surveys, tracers, and audits to identify gaps and drives corrective actions.
• Develops and delivers training programs for leaders and frontline staff on regulatory standards and survey preparedness.
• Promotes a culture of transparency, learning, and proactive compliance.
• Partners with Quality, Risk, Infection Prevention, Nursing, and operational leaders to align compliance efforts.
• Leads system-wide regulatory readiness committees and workgroups.
• Monitors and reports on compliance trends, survey outcomes, and regulatory risks.
• Develops dashboards and KPIs to track performance and drive accountability.
• Provides central expertise regarding accreditation and licensure standards. Identify, plan for, communicate, monitor and evaluate actions to comply with existing and new regulations, standards and accreditation requirements throughout the organization.
• Implements a periodic organizational needs assessment for regulatory compliance including Intra-cycle Monitoring (ICM), using the Focused Standards Assessment (FSA) Tool required by The Joint Commission.
• Identify areas of vulnerability and assist area leaders in developing corrective action plans; also identify and communicate areas of success to celebrate and encourage promotion of best practices.
• Review, assess, and work to revise relevant medical center policies and procedures and / or recommend and assist with the development of new policies and procedures to ensure compliance with regulatory, accreditation, and professional standards.
• Provides documentation and other information as required or requested on time to assure compliance for regulating and accreditation agencies. Maintain and organize all critical documentation support in compliance with requirements; oversee the development of delivery and follow-up documentation (i.e. reports, plans, appeals, measures, etc.).
• Manage all agency site visits to include scheduling, logistics and communication within the organization.
• Provides consultation to all departments on the interpretation and application of TJC accreditation standards and Centers for Medicare and Medicaid Services (CMS) Conditions of Participation to maintain ongoing readiness.
• Development of mandatory educational material to meet periodic requirements.
• Assist area leaders in the development of specific educational material to address areas of vulnerability for compliance with standards or unique requirements for special accreditations; assist the medical center in the review of all educational materials for regulatory or accreditation compliance to assure they reflect medical center practice and congruency with each other.
• Adheres to and supports team members in exhibiting TMCH values of integrity, community, compassion, and dedication.
• Adheres to TMCH organizational and department-specific safety and confidentiality policies and standards.

Performs related duties as assigned.

Minimum Qualifications

Education : Bachelor's degree in Nursing, Healthcare Administration, Public Health, or related field from an accredited institution, Master's Degree preferred. An equivalent combination of relevant education and experience may be substituted for these educational requirements.

Experience : Five (5) ten (10) years nursing experience in a hospital setting.

Licensure or Certification : If an RN, current RN licensure permitting work in the state of Arizona. CJCP, CPHQ, or CHC preferred.

Knowledge, Skills and Abilities :