Regional AVP, Regulatory Performance

Shift: Day
Schedule: Full - Time Regular

Ardent Health Services invests in people, technology, facilities and communities, producing high-quality care and extraordinary results. Based in Nashville, Tennessee, Ardent’s subsidiaries own and operate 31 hospitals in seven states with more than 25,000 employees including 1,150 employed providers. Ardent facilities exceed national averages in Overall Hospital Quality Star Rating as ranked by the Centers for Medicare & Medicaid Services; 89 percent of its hospitals received a three-star rating or above in comparison with 73 percent of all hospitals ranked. Seven of the company's hospitals were recognized by Modern Healthcare as "Best Places to Work" in 2017 – more than any other system in the country. Ardent's corporate office was named "Top Work Places" for Nashville based companies in 2017.

Ardent Health Services invests in quality healthcare.  AHS makes considerable investments in people, technology, facilities, and communities, producing high quality care and extraordinary results. Since 2001, those investments total more than $835 million. From newly constructed facilities and expanded services, to lifesaving technology and outstanding opportunities for employees, AHS is committed to providing its hospitals and clinics the tools needed to succeed. 

Ardent’s work environment is built upon Behavior Standards, which include five key pillars: Service, Quality, People, Financial and Growth. These pillars represent who we are, what we do and how we operate. Our corporate office in Nashville, TN was recently named Best Places to Work by The Tennessean and seven of our hospitals were also named Best Places to Work by Modern Healthcare.

OUR MISSION: Ardent Health Services is a premier provider of health care services, delivered with compassion for patients and their families, with respect for employees, physicians, and other health professionals, with accountability for our fiscal and ethical performance, and with responsibility to the communities we serve.

OUR PHILOSOPHY: Every action we take at AHS is built on three key tenets:

  • Ardent recognizes that each hospital is as unique as the community it serves.
  • We believe in working with employees and physicians to improve the quality of care, patient safety and customer service and we measure all three continuously.
  • We reinvest in our facilities – helping our hospitals expand services, enhance technology and add new programs that fulfill their missions.

We believe it is this mix of corporate support and local autonomy that equips our facilities for success.

OUR POSITION: We have an exciting opportunity to join our quality team as a Regional AVP, Regulatory Performance.

General Responsibilities:

  • Accountable for coordinating the regional accreditation and regulatory activities.
  • Serves as a liaison and contact to accrediting organizations.
  • Serves as a Subject Matter Expert (SME) for accreditation, certification, regulations and standards.
  • Oversees the development and implementation of mock surveys
  • Provides direction, leadership and mentoring to personnel involved with mock surveys.
  • Conducts assessments throughout the to assess and evaluate an organization’s actual performance of functions and processes aimed at continuously improving patient outcomes and their ability to provide safe, high reliable quality care.
  • Insure completion of pre-survey facility assessments for survey readiness prior to each hospital’s anticipated survey.
  • Serves as the Team Leader as needed for visits assisting with the assessment and improvement of accreditation and regulatory readiness.
  • Facilitates that organizations receive excellent customer service and that their accreditation and certification needs are met.
  • Applies systems analysis skills and inductive reasoning skills to determine health care organizations' degree of compliance with applicable standards and functionality of care delivery systems.
  • Engages health care organization staff in interactive dialogues on standards based issues in health care in order to assess compliance and to identify opportunities for improving compliance.
  • Prepares reports that clearly link individual standards deficiencies with potential systems vulnerabilities and related organization risk points.
  • Effectively communicates survey finding information to organization and division leadership in a constructive and collegial style.
  • Facilitate that hospital leaders and managers remain current on relevant accreditation standards, processes and requirements.
  • Works with key stakeholders to evaluate performance and outcome data in order to identify potential opportunities and/or evaluate the effectiveness of improvement initiatives.
  • Guides and supports organizations in the development and implementation of improvement plans.
  • Identities, develops, and disseminates helpful resources and best practices.
  • Provides consultative and educational support to hospitals relative to clinical quality, patient safety, infection control, and regulatory/accreditation compliance.
  • Provides oversight, guidance and coordination for Due Diligence reviews in relation to regulatory performance.
  • Prepares and presents pertinent educational programs using adult learning principles.
  • Prepares and provides reports to senior leadership at hospital, region and corporate level as needed.
  • Completes other duties as assigned.


  • Bachelor of Science in Nursing required
  • Current professional license in discipline required at time of hire and must be maintained
  • Current knowledge of relevant accrediting and certifying organizations, State, local and federal  regulations and standards, the survey and accreditation processes, and strategies for continuous standards compliance
  • Current knowledge of standards and guidelines from relevant professional organizations such as APIC and AORN.
  • Strong background in healthcare quality required
  • Minimum of 10 years of healthcare experience with at least 5 of those years served in a managerial/supervisory or leadership role
  • Critical thinking, interpersonal, problem solving, interviewing, teamwork, organizational, and written and verbal skills required.
  • Experience with team facilitation
  • Experience in Quality Management, including:
  1. Development and implementation of evidence based clinical practice guidelines
  2. Data analysis of key quality indicators and appropriate benchmarking
  3. Clinical profiling and working knowledge of provider performance evaluation process. 
  • Experience in development of continuing educational programming using Adult Learning Principles