Executive Director, Compliance Programs and Quality Assurance

The mission of The University of Texas MD Anderson Cancer Center is to eliminate cancer in Texas, the nation, and the world through outstanding programs that integrate patient care, research and prevention, and through education for undergraduate and graduate students, trainees, professionals, employees and the public.

The primary purpose of the Executive Director, Compliance Programs and Quality Assurance (CPQA), is to provide the strategic vision for, management of, and facilitation of critical elements of MD Anderson’s Institutional Compliance Program, based on legal and regulatory guidance, UT System guidance, and emerging trends in compliance enforcement.  With respect to the quality assurance responsibilities, the Executive Director will lead the development, implementation, and oversight of quality assurance initiatives within the Institutional Compliance Program. This includes ensuring the integrity, consistency, and effectiveness of compliance investigations and related processes.  These responsibilities reinforce MD Anderson’s commitment to excellence, accountability, and continuous improvement in Institutional Compliance operations.

KEY FUNCTIONS

Strategic Vision

The Executive Director, CPQA, is responsible for providing the strategic vision for the operation of the Institutional Compliance Program’s education, outreach, and policy governance functions; risk assessment initiatives; investigation efforts; intern program; executive reporting; compliance committees; publications and communications; reporting and audit response; and the Institutional Compliance Program’s annual Work Plans.  

The Executive Director, CPQA, serves as a member of Institutional Compliance’s Leadership Committee, comprising the Chief Compliance and Ethics Officer; the Deputy Chief Compliance Officer; the Senior Legal Officers for Privacy and Information Security, Billing and Reimbursement, Research Compliance, Data Governance, and Corporate Compliance and Ethics.

The Executive Director, CPQA, co-chairs the Institutional Mandatory Training Steering Committee, which considers proposals and revisions to Institution-wide education requirements including the annual Employee Education Event and the New Employee Orientation Program; and also is responsible for oversight and direction of all general compliance educational activities, including Faculty Compliance Orientation, the annual Employee Education Event, and other general Institution-wide educational activities such as Compliance Training for Managers. These responsibilities include strategy, deployment, content development, event planning and management, event assessment and tracking, and enforcement initiatives.

The Executive Director, CPQA, serves on the Institutional Regulatory and Public Safety Work Group to strategize and review software proposals and projects in support of MD Anderson’s regulatory goals.

Serves as, or oversees, Institutional Compliance’s involvement in the Institutional Patient Safety Committee to stay abreast of patient safety efforts and issues, and to provide Institutional Compliance support and direction.

The Executive Director, CPQA, serves on the Institutional Safety Committee to stay abreast of Institution-wide safety efforts and trends, and to provide Institutional Compliance support and direction.

The Executive Director, CPQA, assesses, proposes enhancements to, and facilitates programmatic changes for all Institutional Compliance Program elements.

The Executive Director, CPQA will also assist senior legal officer (SLO) teams on consults and investigations, as needed.

Compliance Program Activities

The Executive Director, CPQA,  is responsible for strategy, leadership for, and management of the following Compliance Program Elements:

Federal Healthcare Compliance Program Training and Education: Responsible for strategy, oversight, and management of specialized compliance educational activities related to HHS-OIG General Compliance Program Guidance and Industry Specific Guidance, OIG Special Advisory Bulletins, OIG Opinions, Corporate Integrity Agreements, and other sub-regulatory guidance.

General (Enterprise) Compliance Education: Directly manages and develops strategies for the Institution-wide Sustainable Ethics Educational Program, working with educational leaders in Education and Training; Integrated Ethics; Nursing; the School of Health Professions; the MD Anderson UTHealth Graduate School; and Academic and VISA Administration.

Specialized Compliance Education: Responsible for strategy, oversight, and management of specialized compliance educational activities. These activities include proposing and strategizing compliance education and outreach efforts; reviewing investigation trending data to develop or assist Senior Legal Officers and Project Managers in the development of targeted education and training; ensuring that educational initiatives, outreach activities, and related projects remain within the departmentally approved budget leading the Executive Outreach Program; strategizing, scripting, (and assisting with storyboarding, shooting, and producing) videos and computer-based training courses in support of Institution-wide education efforts related to compliance; and serving as a content liaison with Human Resources – Employee Development and Talent Management Systems to strategize and facilitate compliance education efforts.

Compliance Outreach and Awareness: Develops strategies for all compliance awareness activities, including ad hoc compliance outreach; compliance publications; the periodic Chat with Compliance event; the annual Compliance Awareness Week event; the annual Data Defenders Week event; and the biennial Compliance Awareness Survey (typically required by the UT System), and other similar initiatives.

Communications: Serves as the compliance liaison with Internal and External Communications.

Compliance Program Documents and Publications: Responsible for development and maintenance of all major Institutional Compliance Program documents, including MD Anderson’s Standards of Conduct: Do the Right Thing publication; MD Anderson’s Code of Conduct; compliance posters; compliance brochures; and all other compliance publications.

Institutional Compliance Program Website, Internet, and SharePoint Content: Oversees management of all Institutional Compliance online content. Sets review cycles and ensures staff are up-to-date with house style and brand standards.

Compliance Liaison and Ambassador: Serves as the Institutional Compliance liaison in reviewing and revising MD Anderson’s Annual Security Report, required by the Clery Act and Title IX legislation. Serves as a liaison with UT System and is responsible for responding to all requests by the UT System throughout the fiscal year. Serves as the primary liaison for external auditors and reviewers with responsibility for reviewing compliance program activities, and serves as the primary compliance representative on a number of Institutional committees, such as the Medical Practice Committee, the Executive Committee of the Medical Staff, Joint Commission-related committees, the Information Services Subcommittee - Institutional Regulatory and Public Safety, and other committees as assigned.

Institutional Policies and Procedures

Institutional Policy Program.  Activities include preparing or overseeing the preparation of the initial drafts of Institutional policies and attachments as requested by MD Anderson executives and management; creating and reviewing Executive Summaries for Institutional policies that require Governing Body approval; preparing reports expressing opinions on new or revised policies; performing literature searches, research, and assisted legal research; and developing strategies for the content and platform for MD Anderson’s Handbook of Operating Procedures (“Handbook”), including revising policies and coordinating with appropriate members of MD Anderson’s Information Services Division.  

In collaboration with the Associate Director, Institutional Compliance, is responsible for monitoring and improving processes for preparing, reviewing, and approving MD Anderson policies and maintaining the Handbook.

Serves as the administrative manager for the Institution’s Institutional Policy Framework and Institutional Policy Councils, providing oversight, updating bylaws, and ensuring accurate minutes and action items are maintained for council activities.

Assurance Activities

Compliance Hotline and related activities.  Leads Institutional Compliance investigation process and tracking; Compliance Hotline reporting; and Institutional Compliance Exit Survey process for separating employees. The Executive Director CPQA is responsible for triaging all incoming reports of potential non-compliance and makes recommendations to the CCEO and DCCO for appropriate disposition.

Compliance Plans.  Maintains all of the Institutional Compliance Program’s compliance plans and internal policies and procedures to ensure compliance with federal and state law, accrediting agencies, third-party payors, and The University of Texas System. The Executive Director, CPQA also is required to ensure the review and updating of all compliance documents on a quarterly, annually, or other periodic basis, as appropriate.

Risk Assessment.  Working in close collaboration with the department SLOs, leads the development of the annual Institutional Compliance Risk Assessment and corresponding workplans.

UT System Reporting.  Leads biannual reporting efforts for The University of Texas System, amassing required information, reviewing for accuracy, and securing approval from the CCEO and the DCCO prior to submission.

Compliance Committee Structure.  In close collaboration with department SLOs and their other designees, ensures that all compliance-related have appropriate governance and structure (e.g., committee charters, cadence, minutes, etc.).  Prepares such content and guidance, as necessary.

Supervisory Functions

Supervises all staff assigned to the Institutional Compliance Program team, including Associate Directors, Managers, Program Executive Directors, Policy Managers, Program Managers, and Program Coordinators. Manages and conducts performance evaluations for Institutional Compliance Program staff.

Departmental Responsibilities

Works with departmental leadership to identify annual departmental goals. Develops, facilitates, and monitors the activities related to annual goals.

Shares key program metrics with departmental leaders through briefings and other mechanisms.

Coordinates with relevant stakeholders to develop new technologies to streamline core departmental functions.

Provides departmental training and support for adoption of emerging platforms across the organization. Designs and leads brown bag sessions as appropriate to develop knowledge, expand skillsets, and increase engagement.

Works with the CCEO and DCCO to identify guest speaks for monthly staff meetings. Aids in development of staff meeting materials including presentations and handouts, and related content to department members.

Manages any department retreats. Schedules dates, develops proposed agendas, and documents outcomes.

Special Projects and Collaborative Efforts

Supports and facilitates all special projects assigned by the CCEO and DCCO. Works with colleagues across the organization to ensure prompt and thorough completion of such efforts.

Supports and facilitates collaborative efforts identified by Executive Leadership, working with leaders across the organization to meet goals. Examples could include the Campus Carry biennial review and reporting requirements, and the annual Texas Department of Information Resources curricula development, approval, and deployment.

Participates in and helps prepare responses to regulatory surveys (Joint Commission, Centers for Medicare and Medicaid Services) and audits. Serves as, or oversees, the Institutional Compliance representative in the Command Center for on-site surveys and audits.

Quality Assurance Responsibilities

Investigation Quality Oversight. Responsible for ensuring investigations are conducted thoroughly, objectively, and in alignment with institutional standards. This includes reviewing documentation for completeness and clarity, assessing investigative methodologies, ensuring all allegations have been addressed, and findings are supported by evidence.  Provides coaching and feedback to investigative teams to promote consistency and effectiveness.
Corrective and Preventative Action Plan (CAPA) Management. The Executive Director will ensure that root cause analyses (RCAs) are conducted as part of the investigative process, with a focus on identifying underlying systemic issues.  Oversees the development and implementation of CAPs resulting from RCAs and investigations. Ensures CAPs are actionable, measurable, and aligned with institutional risk mitigation strategies. Tracks CAP progress and conducts follow-up reviews to verify business partner implementation and effectiveness.
External Audit and Survey Quality Control.   The Executive Director will ensure that external audits, investigations, and surveys with which Institutional Compliance is providing support and assistance are responded to thoroughly, accurately, and completely.  This includes such activities as assistance with collation and review of evidence binders, preparing and editing allegations of compliance, and providing supplemental and ad hoc responses to surveyors, regulators, and accreditation bodies.
Metrics and Reporting. Develops and maintains quality assurance metrics related to investigations and CAPs. Provides regular reports to the Chief Compliance and Ethics Officer and other executive stakeholders, highlighting performance, trends, and opportunities for improvement.
Training and Capacity Building. Leads training initiatives for compliance staff and investigators focused on quality standards, documentation practices, and CAP development. Ensures continuous improvement through feedback loops and lessons learned.
Policy and Process Enhancement. Reviews and recommends updates to Institutional policies based on RCAs and investigations.
Continuous Improvement and Innovation.  Establishes a continuous improvement cycle for compliance processes, incorporating stakeholder feedback, audit findings, and performance metrics. Facilitates innovation in documentation practices, CAP tracking systems, and investigation workflows to enhance efficiency and effectiveness.