Summary
Overview
Work History
Education
Skills
Certification
Personal Information
Timeline
Generic

Cynthia Joseph

Nashville

Summary

Regulatory professional with a reputation for maintaining high standards and a results-driven approach. Extensive experience in healthcare quality, regulatory compliance, and accreditation processes. Demonstrated ability to navigate complex regulatory environments and implement effective compliance strategies. Skilled in leading healthcare organizations through The Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS), and state regulatory surveys, ensuring adherence to the highest standards of patient care and safety. Committed to fostering team collaboration and adapting to evolving regulatory requirements. Recognized for expertise in regulatory research and compliance monitoring, known for reliability and flexibility.

Overview

20
20
years of professional experience
1
1
Certification

Work History

Senior Accreditation and Regulatory Specialist

Vanderbilt University Medical Center
05.2020 - Current


  • Ensures organizational compliance with all applicable federal and state regulations independently
  • Initiates requests for data analytics to identify potential regulatory risks
  • Optimized internal audit processes, identifying areas for improvement in regulatory adherence.
  • Drafts and implements corrective action plans along with unit leadership
  • Worked closely with legal counsel to address any concerns related to noncompliance or regulatory investigations.
  • Assists with policy drafts and revisions
  • Conducted thorough risk assessments to identify potential compliance issues and develop effective mitigation strategies.
  • Facilitates and leads the review, response, and documentation of complaints received from external parties
  • Led training initiatives to increase organizational understanding of evolving regulations and industry best practices.
  • Facilitates obtaining additional licenses, accreditations and certification across the health systems
  • Strengthened relationships with regulatory authorities through transparent communication and proactive engagement.
  • Trains new staff members on department processes and procedures
  • Managed complex regulatory projects, ensuring timely completion and optimal outcomes.
  • Independently conducts and assists with regulatory visits
  • Provided expert guidance on regulatory requirements, supporting the development of compliant products and services.
  • The responsibilities listed are a general overview of the position and additional duties may be assigned


Medical Laser Safety Officer

Vanderbilt University Medical Center
01.2024 - Current

Skilled Medical Laser Safety Officer ensuring laser safety compliance in clinical and surgical settings. Expertise in regulatory compliance, risk assessment, and laser safety training for healthcare professionals. Passionate about patient and staff safety, with a strong track record of implementing laser safety protocols , reducing incidents, and improving operational efficiency.

  • Conducted regular safety inspections and audits to identify potential hazards and prevent accidents and injuries.
  • Laser Safety Program Development
  • ANSI Z1323 Compliance and OSHA Standards
  • Staff Training and Credentialing
  • Equipment Inspection and Maintenance
  • Conducted Organization assessment for 3 critical access hospitals and XX clinics.
  • Responded to any incident reportings and achieved mitigation to ensure future patient and staff laser safety
  • Recognized, documented, and advised on removal of hazards.
  • Promoted a culture of safety through engaging workshops and training sessions for employees on various topics such as hazard identification, PPE usage, and incident reporting.
  • Streamlined accident reporting procedures, resulting in more accurate data for analysis and prevention efforts.
  • Collaborated with management to develop site-specific safety policies, ensuring alignment with federal and state requirements.

Accreditation and Regulatory Affairs Service Associate

Duke University Hospital
04.2019 - 03.2020
  • Ensures organizational compliance with all applicable federal and state regulations independently
  • Initiated requests for data analytics to identify potential regulatory risks
  • Drafted and implemented corrective action plans along with unit leadership
  • Assisted with policy drafts and revisions
  • Facilitated and led the review, response, and documentation of complaints received from external parties
  • Facilitated obtaining additional licenses, accreditations and certification across the health systems
  • Collaborated with Quality Improvements teams with various projects throughout the healthcare system
  • Assisted with regulatory visits

Accreditation and Regulatory Specialist

Vanderbilt University Medical Center
01.2018 - 03.2019
  • Ensured organizational compliance with all applicable federal and state regulations under occasional guidance
  • Implemented proactive data analytics to identify potential regulatory risks
  • Helped draft and implement corrective action plans along with unit leadership
  • Assisted in initiation and advisement on policy drafts and revisions
  • Facilitated the review, response, and documentation of complaints received from external parties with occasional guidance
  • Facilitated obtaining additional licensures, accreditations, and certification across the health systems
  • Assisted with regulatory visits

RN II, Circulating Nurse

Monroe Carell Jr Children’s Hospital at Vanderbilt
09.2016 - 01.2018
  • Delivered pediatric patient care services before, during, and after surgery, preparing patients for surgery, providing emotional support, and assisting the surgeon
  • Maintained a sterile environment in the operating room, ensuring the OR team provides patients with best possible care and anticipating the needs of the surgical team
  • Acted as second assistant to Cardiac Surgeons
  • Served as a member of the Nursing Council and Nursing Policy Committee

RN II, Cardiac Float Pool

Monroe Carell Jr Children’s Hospital at Vanderbilt
07.2014 - 09.2016
  • Recruited to join the newly created unit, providing specialized cardiac care across the hospital on an as-needed basis and fostering collaboration with physicians and other healthcare professionals
  • Specialized units include PCICU, ECMO, Cardiac Step-down unit, Pediatric Cardiovascular Operating Room, Electrophysiology Lab, and Cath Lab
  • Met the specialized physiological and psychological needs of children in the areas of health maintenance, chronic illness, and disease management
  • Performed patient assessments, recording physical findings, communicating changes to the healthcare team, and using findings to create interdisciplinary care

Clinical Care Coordinator / Field Supervisor

ELK VALLEY HEALTH SERVICES
07.2013 - 07.2014
  • Supervised nurses and other healthcare professionals providing pediatric care in a home environment, completing patient assessment reports and managing staffing issues including scheduling
  • Collaborated with the healthcare team to create a plan of care, documenting and submitting to insurers as well as using it as basis for home care

Travel RN

AMERICAN MOBILE HEALTHCARE
01.2013 - 12.2013
  • Delivered nursing care to pediatric patients in PICU, interpreting orders and evaluating diagnostic tests to identify and assess clinical status and care needs
  • Worked closely with physicians and other healthcare professionals, serving as an interdisciplinary team member for comprehensive treatments and best options to maximize patient outcomes

Travel RN

Rady Children’s Hospital
01.2013 - 12.2013
  • Provided direct pediatric patient care in a collaborative model, floating across a variety of units including PICU and PCCU
  • Assessed patient conditions and administered medications, educating families about patient conditions and providing support as needed

Travel RN

AMERICAN MOBILE HEALTHCARE
01.2009 - 12.2010
  • Managed life support equipment and administration of IV fluids and medication in PICU, as well as monitoring telemetry and responding to codes

RN II, PICU, PCICU

MONROE CARELL JR CHILDREN’S HOSPITAL AT VANDERBILT
01.2007 - 12.2009
  • Cared for critically ill patients in pediatric ICU, utilizing effective nursing processes to optimize patient outcomes and providing exceptional physician support

RN / Charge Nurse, PICU, PCICU

DUKE UNIVERSITY CHILDREN’S HOSPITAL
01.2005 - 12.2007
  • Communicated effectively with high volume of diverse patients and family members while establishing rapport with patients and medical staff

Education

Masters of Jurisprudence - Health Law

Loyola University of Chicago, School of Law
08.2021

Bachelor of Science - Nursing

South University
12.2015

Diploma - Nursing

Watts School of Nursing, Duke Healthcare System
05.2005

Skills

  • Comprehensive Knowledge of Federal and State Health Regulations
  • Accreditation survey preparation and response
  • Incident Command Leadership
  • Policy development and implementation
  • Regulatory risk assessment and mitigation
  • Continuous survey readiness strategies
  • Incident reporting and corrective action planning
  • Cross-department collaboration with nursing, medical staff, and administration
  • Data driven decision-making and reporting
  • Engaging with external regulatory bodies and surveyors
  • Conducting mock surveys and readiness assessments
  • Proficient in healthcare quality software and electronic health records (Verge, Tableau, Epic)

Certification

  • Certified Professional in Healthcare Quality (CPHQ)
  • Registered Nurse, Tennessee, # RN0000170472
  • Accreditation Professional Orientation Certificate Program, Vizient
  • Basic Life Support (BLS)
  • Pediatric Advanced Life Support (PALS)
  • Neonatal Resuscitation Program (NRP)

Personal Information

Title: RN, BSN, M.J.

Timeline

Medical Laser Safety Officer

Vanderbilt University Medical Center
01.2024 - Current

Senior Accreditation and Regulatory Specialist

Vanderbilt University Medical Center
05.2020 - Current

Accreditation and Regulatory Affairs Service Associate

Duke University Hospital
04.2019 - 03.2020

Accreditation and Regulatory Specialist

Vanderbilt University Medical Center
01.2018 - 03.2019

RN II, Circulating Nurse

Monroe Carell Jr Children’s Hospital at Vanderbilt
09.2016 - 01.2018

RN II, Cardiac Float Pool

Monroe Carell Jr Children’s Hospital at Vanderbilt
07.2014 - 09.2016

Clinical Care Coordinator / Field Supervisor

ELK VALLEY HEALTH SERVICES
07.2013 - 07.2014

Travel RN

AMERICAN MOBILE HEALTHCARE
01.2013 - 12.2013

Travel RN

Rady Children’s Hospital
01.2013 - 12.2013

Travel RN

AMERICAN MOBILE HEALTHCARE
01.2009 - 12.2010

RN II, PICU, PCICU

MONROE CARELL JR CHILDREN’S HOSPITAL AT VANDERBILT
01.2007 - 12.2009

RN / Charge Nurse, PICU, PCICU

DUKE UNIVERSITY CHILDREN’S HOSPITAL
01.2005 - 12.2007

Bachelor of Science - Nursing

South University

Diploma - Nursing

Watts School of Nursing, Duke Healthcare System

Masters of Jurisprudence - Health Law

Loyola University of Chicago, School of Law
Cynthia Joseph