What are the responsibilities and job description for the System AVP, Accreditation & Regulatory Affairs position at University of Florida Health?
Overview
The System AVP, Accreditation & Regulatory Affairs provides enterprise leadership for accreditation readiness, regulatory compliance, and survey preparedness across UF Health. Reporting to the System Chief Nursing Officer, this executive leader is responsible for developing and implementing system-wide strategies, standards, and programs that ensure compliance with all applicable federal, state, and accreditation requirements.
This role serves as the organizational expert for accreditation and regulatory affairs, leading efforts to maintain continuous readiness across hospitals, ambulatory care settings, and other clinical entities. The System VP partners closely with executive leadership, clinical leaders, legal counsel, compliance, quality, and operational teams to strengthen organizational performance and minimize regulatory risk.
The position is responsible for establishing enterprise-wide accreditation and regulatory standards, monitoring performance, promoting best practices, and fostering a culture of continuous compliance. Through strong collaboration and influence, the System VP drives consistency, accountability, and operational excellence while supporting UF Health's commitment to delivering safe, high-quality patient care.
Responsibilities
- Develop and execute a comprehensive enterprise accreditation and regulatory readiness strategy for UF Health.
- Establish system-wide accreditation, licensure, and regulatory priorities, goals, and performance standards.
- Lead the development and implementation of programs that ensure ongoing compliance with Joint Commission, CMS, state licensure, and other regulatory requirements.
- Oversee accreditation and regulatory readiness across hospitals, ambulatory practices, and other clinical entities.
- Maintain organizational readiness for announced and unannounced surveys, inspections, audits, and accreditation reviews.
- Assess the effectiveness of accreditation and compliance activities and provide regular updates to executive leadership and governance committees.
- Serve as the system-wide resource and subject matter expert for accreditation, licensure, and regulatory requirements.
- Partner with facility leaders to develop corrective action plans and ensure timely resolution of findings identified through surveys and audits.
- Review and recommend improvements to policies, procedures, documentation, plans, and operational practices that impact regulatory compliance and accreditation readiness.
- Lead standardization efforts to reduce variation and strengthen compliance performance across the health system.
- Develop and oversee enterprise accreditation and regulatory reporting, benchmarking, dashboards, and performance monitoring programs.
- Analyze readiness metrics and identify opportunities for improvement and risk mitigation.
- Promote a culture of continuous readiness, accountability, and operational excellence across the organization.
- Develop educational programs and leadership initiatives that enhance accreditation knowledge and regulatory compliance capabilities.
- Partner with clinical and non-clinical leaders to strengthen engagement and accountability for accreditation and regulatory outcomes.
- Lead a system-wide network of accreditation and regulatory leaders and champions.
- Collaborate with stakeholders across quality, safety, nursing, medical affairs, operations, population health, digital health, and other functions to advance enterprise priorities.
- Represent UF Health in regional and national accreditation and regulatory organizations and professional forums.
Qualifications
Education
- Master’s degree in healthcare administration, Business Administration, Nursing, Public Health, Organizational Leadership, or a related field required.
Experience
- Minimum of five (5) years of progressive leadership experience in healthcare accreditation, regulatory compliance, healthcare operations, quality improvement, nursing leadership, physician practice operations, or a related healthcare field.
- Minimum of five (5) years of leadership experience within a complex health system, academic medical center, integrated delivery network, or comparable healthcare organization.
- Demonstrated success leading enterprise-wide accreditation, regulatory, or performance improvement initiatives with measurable results.
- Experience with survey readiness programs, compliance analytics, performance measurement, and continuous improvement methodologies.
- Proven ability to influence and lead across matrixed environments and multiple care settings.
Preferred Qualifications
- Experience leading accreditation and regulatory compliance programs across both inpatient and ambulatory care environments.
- Experience with accreditation readiness and compliance management platforms.
- Experience working within an academic health system or large multi-hospital integrated delivery network.
Certifications
- Healthcare Accreditation Certified Professional (HACP) or other relevant accreditation, compliance, quality, Lean, Six Sigma, or equivalent professional certification preferred.