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Forward2025 Required Annual Education for Credentialed Medical Staff
The purpose of this initiative is to implement a standardized, system-wide process that ensures consistency, compliance, and alignment with accreditation and regulatory expectations.
This course is required for all Baptist Health credentialed medical staff members with privileges.
Click on Register below to start the course.
Target Audience
Who should complete the Required Annual Education for Credentialed Medical Staff course?
- This course should be completed annually by all credentialed medical staff with privileges.
- Honorary and Affiliate medical staff members are exempt.
- This includes both employed and non-employed providers, including BHMG physicians.
Required annually for credentialed medical staff with privileges in the following professions:
- Employed and non-employed medical staff members including physicians, advanced practice registered nurses, physician assistants/physician associates, certified registered nurse anesthetists, nurse midwives, podiatrists, dentists, psychologists, and allied health professionals.
Learning Objectives
Overall Learning Objective 
Identify and apply key safety, regulatory, and clinical protocols—including infection prevention, medication and biologics administration, emergency preparedness, ethical compliance, and high-risk care escalation—in all patient care settings, to satisfy annual regulatory and accreditation requirements and ensure patient safety.
Organ, Eye, and Tissue Donation
- Describe the organ and tissue donation process, including the roles of healthcare providers and the Organ Procurement Organization (OPO) in facilitating donation.
- Recognize clinical triggers—such as severe neurological injury or imminent death—that require timely referral to the OPO, under CMS Conditions of Participation and institutional policy.
- Identify and apply the clinical criteria and confirmatory tests used to determine brain death, ensuring alignment with national standards and hospital protocols.
- Demonstrate knowledge of hospital policy and federal regulations (e.g., CMS Conditions of Participation) related to donor referral, brain death declaration, and documentation requirements.
Use of Restraints
- Articulate the key components of the BHSF Restraint Policy and the relevant regulatory requirements set forth by CMS and DNV NIAHO, emphasizing their implications for clinical practice.
- Apply, monitor, and document the use of both violent and non-violent restraints following institutional protocols and regulatory standards.
Infection Prevention and Control
- Explain the key components of standard precautions.
- Recognize the appropriate use and indications for transmission-based precautions.
- Implement evidence-based bundle practices to reduce healthcare-associated infections.
- Review the principles of antimicrobial stewardship and its role in preventing the development of multidrug-resistant organisms.
- Adhere to the bloodborne exposure control protocols and procedures.
Abuse, Neglect, and Suicide Prevention
- Explain suicide screening and assessment using C-SSRS, an evidence-based screening tool, and the application of precautions based on risk level.
- Explain policies and procedures related to a Baker Act for Baptist Health.
- Review abuse and neglect reporting requirements for vulnerable populations.
Resources
HIPAA/ Privacy: Best Practices for Physicians
Maren Gordon
Privacy Manager, Baptist Health South Florida
Shannon Martin
Lead, Governance, Risk & Compliance Security Analyst
Technology & Digital
The Importance of Preventing Fraud, Waste, and Abuse (FWA)
Ana Navarrete, MSN, R.N., CHC
Corporate Compliance Director
Emergency Management and Safety
Edgar Fandino
Director, Environmental Health, and Safety
Luis Collado
AVP Business Continuity, Emergency Management, and Safety
Jose Lopez
Director, Emergency Preparedness
Surgical and Operating Room Fire Safety
Edgar Fandino
Director, Environmental Health, and Safety
Organ, Eye, and Tissue Donation
Rabbi Claudio J. Kogan, M.D., MBE, M.Ed.
Director, Bioethics Program
Medication Management, Medication Reconciliation, and Antimicrobial Stewardship
Estela Trimino, Pharm.D., MBA, BCPS
AVP Acute Care Southern Region | Pharmacy
Obstetric Hypertensive Crisis and Maternal Hemorrhage Plan
Yvonne Johnson, M.D.
Vice President & Chief Medical Officer
Abuse, Neglect and Suicide Prevention
Mily Selgas, R.N., MSN, MBA, HC
Corporate V.P. of Clinical Log EBC Case Management
Use of Restraints
Pua Cooper MSN, R.N., FHIMSS, CHCIO, CDH-E
AVP of Corporate Quality/Accreditation, Patient Safety BHMG Analytics, BHMG Quality/Performance Improvement, & Clinical Informatics Liaison
Christina M. Rodriguez, MSN, R.N., CPHQ, CPPS, NE-BC
Corporate Director
Accreditation Services at Baptist Health South Florida
Infection Prevention and Control
Jessica Garciga, R.N., BSN, CIC, CSPDT
Director of Infection Prevention & Control
Denise Payne R.N., MSN, MBA, CIC, CPHQ, CPPS, CJCP, FACHE, NEA-BC
AVP, Quality, Infection Prevention & Public Reporting
Workplace Health – Annual Health Requirements
Maribeth Rouseff, MBA
Assistant Vice President
Workplace Health & Wellness
Disclosures and Resolution of Conflict of Interest
Zulma Berrios, M.D., Luis Collado, Pua Cooper, MSN, R.N., Jessica Garciga, R.N., Rabbi Claudio Kogan, M.D., Edgar Fandino, Yvonne Johnson, M.D., Jose Lopez, Ana Navarrete, R.N., Denise Payne, R.N., Christina M. Rodriguez, MSN, R.N., Maribeth Rouseff, MBA, Mily Selgas, R.N., and Esty Timino, Pharm.D., faculty of this educational activity, have no relevant financial relationships with ineligible companies* to disclose, and have indicated that the presentations or discussions will not include off-label or unapproved product usage.
Non-faculty contributors and others involved in the planning, development, and editing/review of the content have no relevant financial relationships with ineligible companies* to disclose.
*Ineligible companies - Companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
Baptist Health South Florida is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. Baptist Health has been re-surveyed by the ACCME and awarded Commendation for 6 years as a provider of CME for physicians.
Baptist Health South Florida designates this enduring material for a maximum of 1.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
American Board of Surgery - Maintenance of Certification (MOC) - Accredited CME- General Surgery
Successful completion of this CME activity, which includes participation in the evaluation component, enables the learner to earn credit toward the CME of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.
Your participation information will be shared with specialty boards through the ACCME's PARS reporting system. Submissions are recorded in approximately 48 hours. You will receive an email when your credits have been processed.
Available Credit
- 1.25 ABS Accredited CME
- 1.25 AMA PRA Category 1 Credit™
- 1.25 General certificate of attendance
- 1.00 Florida Board of Dentistry
- 1.25 Nurse Practitioners
- 1.25 Florida Board of Podiatric Medicine
Have a Question?
Please contact the appropriate Medical Staff Office for any questions regarding credentials at a Baptist Health South Florida facility.
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Register for a Course Please email [email protected] with a print screen of the error message, browser name and version, username and URL where the error occurred. You can expect a response within 48 hours.
Continuing Medical Education Department
Office Hours: Monday - Friday, 7:30 a.m. - 3:30 p.m.
Excludes federal holidays. Appointments only.
Phone: 786-596-2398
Required Hardware/Software
PC/Mac Users
This site is supported on the most recent stable releases of the following browsers:
Google Chrome
Microsoft Edge
Safari
Mozilla Firefox
Mobile Users
This site is supported on the following mobile devices:
- Apple iOS mobile devices running iOS 10 or later
- Android mobile devices running Android 4.4 or later, with the latest release of Google Chrome or Mozilla Firefox
Technical Support
If you are experiencing technical difficulties or have received an error message, please send an email to [email protected] and include a print screen of the error message, your browser name and version, username and URL where the error occurred. You can expect a response within 48 hours.