Assistant Vice President of Survey Readiness & Accreditation

Ardent Health Services (AHS) is a national health care services company headquartered in Nashville, TN. Through its subsidiaries, Ardent owns and operates nearly 200 sites of care. Our subsidiaries own and operate hospitals and multispecialty physician practices in six states. Ardent includes 30 hospitals, 4,423 patient beds, 23,000 employees, and 1,700 employed physicians. Within the industry, we are noted for recognizing that every hospital is as unique as the community it serves. This in-depth understanding of how health care works at the local level is one of our great strengths.

POSITION SUMMARY

The Assistant Vice President, Survey Readiness and Accreditation is responsible for overseeing and ensuring the organization's preparedness for regulatory surveys, accreditation, and compliance assessments. This role leads efforts to maintain and enhance the organization's status with accrediting bodies such as The Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS), and other relevant state or federal regulatory entities. The AVP, Survey Readiness and Accreditation ensures that all departments adhere to applicable standards, federal and state regulations, and accreditation requirements, fostering a culture of continuous improvement in quality and safety.

• Lead the development and implementation of the organization's survey readiness strategy, including identifying key standards and regulations related to accreditation for assigned hospitals.
• Oversee the preparation and coordination of internal readiness assessments, mock surveys, and self-assessments to ensure compliance with accrediting and Centers for Medicare & Medicaid Services (CMS), State and/or The Joint Commission (TJC) regulatory bodies.
• Serve as the primary point of contact for all accreditation and survey activities, managing the logistics and coordination of surveys and site visits.
• Serve as primary point of contact for Joint Commission Resources (JCR) Tracers with AMP/Mock Survey Tools and resource.
• Monitor and evaluate the organization's readiness for upcoming surveys, ensuring corrective actions are taken where necessary to maintain compliance.
• Track and report on survey results, Centers for Medicare & Medicaid Services (CMS), State and/or The Joint Commission (TJC) regulatory requirements, and accreditation statuses to senior leadership and relevant stakeholders.
• Work with the Quality Improvement (QI) and Risk Management teams to integrate survey readiness and accreditation standards into daily operations and quality initiatives.
• Lead the development and implementation of action plans to address areas of non-compliance or improvement following internal audits or surveys.
• Facilitate the development and execution of corrective action plans in response to survey findings, ensuring timely resolution and ongoing compliance.
• Support the development and monitoring of key performance indicators (KPIs) related to accreditation standards, compliance, and quality measures.
• Develop and deliver educational programs, workshops, and training to staff and leadership on accreditation standards, regulatory bodies such as, Centers for Medicare & Medicaid Services (CMS) and The Joint Commission (TJC) requirements, and survey processes.
• Act as a liaison between departments and external accreditation and certification regulatory bodies to communicate and resolve survey or accreditation-related issues.

Education & Experience:

• Bachelor's degree in nursing or a related field.
• Master's degree in healthcare administration, Nursing, Public Health, or a related field preferred.
• 5+years of experience in healthcare accreditation, Centers for Medicare & Medicaid Services (CMS), State and/or The Joint Commission (TJC) regulatory compliance, or quality management, with significant experience in survey readiness and managing accreditation processes.
• Certified Professional in Healthcare Quality (CPHQ), preferred.
• Certified Accreditation Professional (CAP), preferred.
• Other relevant certifications in quality, compliance, or accreditation, preferred.