CPHQ Candidate Handbook

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The key takeaways are that the document outlines the vision, mission, and overview of the CPHQ certification program including the exam administration process and requirements.

The purpose of the CPHQ certification is to establish standards for quality management professionals and recognize individuals who meet these standards based on their knowledge of quality principles and practices.

The eligibility requirements for taking the CPHQ exam include having a minimum of two years of full-time experience in a healthcare setting within the last five years, with at least 1,000 hours of work experience in quality health care or a related field.

Candidate

examination handbook
April 2010

CPHQ Examination
Program Administered by the
Healthcare Quality Certification Board of
the National Association for Healthcare Quality

World Class. Certified. Professional.


TAB L E O F C ONTENT S

Vision Statement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   2 General Information


Mission Statement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   2 Fees. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Affiliation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   2 Scores Canceled by HQCB or AMP. . . . . . . . . . . . . . . . . . . 11
Accreditation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   2 Disciplinary Policy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Statement of Nondiscrimination . . . . . . . . . . . . . . . . . . . . . . . . . .   2 Pass/Fail Score Determination. . . . . . . . . . . . . . . . . . . . . . . . 12
If You Pass the Examination . . . . . . . . . . . . . . . . . . . . . . . . . 13
CPHQ Program Overview
Continuing Education Credit. . . . . . . . . . . . . . . . . . . . . . . . . 13
Introduction to the CPHQ Program. . . . . . . . . . . . . . . . . . . .   3
Verification of CPHQ Status. . . . . . . . . . . . . . . . . . . . . . . . . . 13
Management and Examination Services. . . . . . . . . . . . . . . .   3
If You Do Not Pass the Examination . . . . . . . . . . . . . . . . . . . 13
Objectives of Certification. . . . . . . . . . . . . . . . . . . . . . . . . . .   3
Appeals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Definition of the Quality Management Professional. . . . . . . .   4
Duplicate Score Report. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Certification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   4
Preparation for the CPHQ Certification Examination. . . . . . . 14
Recertification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   4
International Terminology Crosswalk. . . . . . . . . . . . . . . . . . . 14
Eligibility Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   4
About the Examination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   5 CPHQ Examination Content Outline. . . . . . . . . . . . . . . . . . . . . 15

The CPHQ Examination CPHQ Examination Blueprint Matrix . . . . . . . . . . . . . . . . . . . . 18

Examination Administration . . . . . . . . . . . . . . . . . . . . . . . . . .  6 Additional Sample Questions with Performance Detail. . . . . 19


International Examination Services. . . . . . . . . . . . . . . . . . . .   6
Instructions for Completing the CPHQ Examination
Assessment Center Locations. . . . . . . . . . . . . . . . . . . . . . . .   6
Application Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Holidays. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   6
Special Arrangements for Candidates with Disabilities. . . . .  6 Application Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Telecommunication Devices for the Deaf. . . . . . . . . . . . . . .   7
Request for Special Examination Accommodations. . . . . . . 27
Applying for / Scheduling an Examination . . . . . . . . . . . . . .   7
Rescheduling or Canceling an Examination. . . . . . . . . . . . .   7 Documentation of Disability-Related Needs. . . . . . . . . . . . . . 28
Missed Appointments and Cancellations . . . . . . . . . . . . . . .   8 Request for Duplicate CPHQ Examination Score Report . . . 29
No Refunds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   8
Inclement Weather, Power Failure or Emergency. . . . . . . . .   8 Request to Change Mailing or E-mail Address. . . . . . . . . . . . 31

Board and Committee Member List. . . . . . . . . . . . . . . . . . . . . 33


Rules for Computerized Testing
Taking the Examination. . . . . . . . . . . . . . . . . . . . . . . . . . . . .   9
Identification. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   9
Assessment Center Security. . . . . . . . . . . . . . . . . . . . . . . . .   9
Examination Restrictions. . . . . . . . . . . . . . . . . . . . . . . . . . . .   9
Misconduct. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  9
Copyrighted Examination Questions. . . . . . . . . . . . . . . . . . . 10
Practice Examination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Timed Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Candidate Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Following the Examination. . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Copyright © 2010 by Healthcare Quality Certification Board; All Rights Reserved.


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C P H Q e x a m i n at i o n c a n d i d at e h a n d b o o k 1
CPHQ T H E MA R K O F DI S TIN C TION IN H EA LT H C A R E Q U A L IT Y

IT IS YOUR RESPONSIBILITY TO READ AND UNDERSTAND


Vision Statement
THE CONTENTS OF THIS HANDBOOK BEFORE APPLYING
The Healthcare Quality Certification Board raises the standard
FOR THE EXAMINATION.
for healthcare quality professionals by defining world-class
professional excellence through the international Certified
This Handbook contains current information about the certification
Professional in Healthcare Quality (CPHQ) certification.
examination developed by the Healthcare Quality Certification
Board (HQCB) as of November 1, 2009. It is essential that you
keep it readily available for reference until you are notified of your
Mission Statement
The Healthcare Quality Certification Board, by providing the only
performance on the examination. All previous versions of this
accredited international healthcare quality certification, improves
Handbook are null and void.
the quality of healthcare by advancing the theory, practice and
development of diverse quality professionals.
Direct all correspondence, address changes, requests for a
current Candidate Handbook, and for information about the
development and administration of the CPHQ examination, Affiliation
certification program and recertification to: The Healthcare Quality Certification Board (HQCB) of the National
Association for Healthcare Quality (NAHQ) was formed in 1976 to
HQCB
advance the profession of healthcare quality management through
P. O. Box 19604
the development of a certification program. The HQCB is the
Lenexa, Kansas 66285-9604, USA
certifying arm of NAHQ, a not-for-profit organization. The HQCB
913-895-4609
establishes policies, procedures and standards for certification
Toll Free 800-346-4722
and recertification in the field of international healthcare quality
Facsimile 913-895-4652
management. The granting of Certified Professional in Healthcare
E-mail: [email protected]
Quality (CPHQ) status by the HQCB recognizes professional and
www.cphq.org
academic achievement through the individual’s participation in this
voluntary international certification program.
Candidates taking the examination in the United States
can register for and schedule an examination online at
www.goAMP.com. Accreditation
The CPHQ certification program is fully accredited by the National
Commission for Certifying Agencies (NCCA), the accrediting arm
of the National Organization for Competency Assurance (NOCA),
Washington, D.C.

Statement of Nondiscrimination
The certification examination is offered to all eligible candidates,
regardless of age, gender, race, religion, national origin, marital
status or disability. Neither the HQCB nor AMP discriminates on
the basis of age, gender, race, religion, national origin, marital
status or disability.

2 C P H Q e x a m i n at i o n c a n d i d at e h a n d b o o k
P R O G R AM O V E R V IE W

Introduction to the CPHQ Program Management and


The purpose of certification in the international healthcare quality Examination Services
management field is to promote excellence and professionalism. The HQCB contracts with Applied Measurement Professionals,
The program certifies individuals who demonstrate they have Inc. (AMP) to provide management and examination services.
acquired a body of knowledge and expertise in this field by AMP provides administrative support for the certification process
passing a written international examination. The CPHQ designation and Board operations. AMP maintains Board records, handles
provides the healthcare employer and the public with the finances, processes examination applications, recertification
assurance that certified individuals possess the necessary skills, materials, and requests for continuing education approvals.
knowledge and experience in healthcare quality management to Contracting with a management services firm provides a stable
perform competently. base from which the voluntary HQCB operates and serves as a
conduit of information between certified professionals, candidates,
The high standards of the certification program are ensured by and the HQCB.
the close working relationships among the National Association for
Healthcare Quality (NAHQ), the Healthcare Quality Certification AMP also provides examination services to assist HQCB. AMP
Board (HQCB), healthcare quality management professionals, carefully adheres to industry standards for development of
and testing experts. The HQCB adheres to standards of the practice-related, criterion-referenced examinations to assess
National Commission for Certifying Agencies (NCCA) in the competency. AMP offers a full range of services, including:
development and implementation of its certification program, as practice analyses and development of examination specifications,
well as guidelines issued by the Equal Employment Opportunity psychometric guidance to committees of content experts during
examination question writing, development of content-valid
Commission (EEOC) and the Standards for Educational and
examination instruments, publishing, examination administration,
Psychological Testing (1999) prepared by the Joint Committee
scoring, and reporting examination results.
on the Standards for Educational and Psychological Testing of
the American Educational Research Association (AERA), the Applied Measurement Professionals, Inc. (AMP)
American Psychological Association (APA), and the National 18000 W. 105th Street
Council on Measurement in Education (NCME). Olathe, KS 66061-7543, USA
913-895-4600
The certification program is not designed to determine who is Facsimile 913-895-4650
E-mail: [email protected]
qualified or who shall engage in healthcare quality management
www.goAMP.com
activities. The goal is to promote excellence and professionalism
by documenting individual performance as measured against a
predetermined level of knowledge about quality management. Objectives of Certification
A cooperative effort by the HQCB, Applied Measurement The objectives of the certification program for quality management
Professionals, Inc. (AMP), and practicing healthcare quality professionals are to:
management professionals has resulted in the definition of tasks   1. promote professional standards and improve the practice of
significant to the practice of quality management. It is these international quality management;
competencies that are included in the certification examination.   2. give special recognition to those professionals who
The examination materials are developed by practicing quality demonstrate an acquired body of knowledge and expertise
management professionals and the HQCB. in the field through successful completion of the examination
process;
  3. identify for employers, the public and members of allied
professions individuals with acceptable knowledge of the
principles and practice of healthcare quality management;
and
  4. foster continuing competence and maintain the professional
standard in healthcare quality management through the
recertification program.

C P H Q e x a m i n at i o n c a n d i d at e h a n d b o o k 3
CPHQ pr o gr a m o v e rv i e w

Definition of the Quality Each successful candidate will receive a certificate that is suitable
for framing, identification card, CPHQ pin and recertification
Management Professional information approximately 6-8 weeks after completing the
The practice of quality management occurs in all healthcare
examination.
settings, is performed by professionals with diverse clinical and
non-clinical educational and experience backgrounds, and
involves the knowledge, skills and abilities needed to perform
Recertification
Following successful completion of the certification examination,
the tasks significant to practice in the CPHQ examination content
the CPHQ is required to maintain certification by fulfilling
outline. (Refer to the Examination Content Outline found later in
continuing education (CE) requirements, which are reviewed and
this Handbook.)
established by the HQCB annually. The current requirements
include obtaining and maintaining documentation of thirty (30)
A Certified Professional in CE hours over the two-year recertification cycle and payment of
Healthcare Quality (CPHQ) is ... a recertification fee. All continuing education must relate to areas
covered in the most current examination content outline. Current
an individual who has passed the HQCB’s accredited,
employment in the quality management field is not required
international examination, demonstrating competent
to maintain active CPHQ status. The process for obtaining
knowledge, skill and understanding of program development
recertification is described on the website at www.cphq.org and
and management, quality improvement concepts,
is provided to each CPHQ upon initial certification and at the
coordination of survey processes, communication and
beginning of each subsequent recertification cycle.
education techniques, and departmental management.

Eligibility Requirements
The examining board’s goal is to produce examinations that test All candidates have complete access to the examination process.
generic concepts that can be applied to any healthcare setting Those who aspire to excel and demonstrate their competency in
globally. Candidates who pass the CPHQ examination must the field of healthcare quality management have a chance to do
also understand how all of these important elements of quality so and achieve certification.
management, case/care/disease/utilization management and
risk management, as well as data management and general After years of extensive experience in testing research and
management skills integrate together to produce an effective development and after observing the extraordinarily diverse
and efficient system to monitor and improve care. backgrounds of exceptional candidates who have been successful
on the examination and as CPHQs, the Board is confident that the

Certification carefully crafted international CPHQ examination will differentiate

To become certified, each quality management professional between candidates who are able to demonstrate competence

must pass the CPHQ examination. The examination is available and those who are not. It is with this confidence that the Board

in computer-based format at Assessment Centers in the United celebrates the elimination of barriers such as minimum education

States and multiple international locations. Certified professionals and/or experience requirements that are not objectively linked to

are entitled to use the designation “CPHQ” after their names. success on the examination and effectiveness as a healthcare

Certification in quality management is effective on the date quality professional.

you pass the examination. The credential is valid from that


date through a two-year period which begins on the 1st day of
January of the year following the date you pass the examination.
Candidates who do not achieve a passing score or whose cycle
of eligibility has expired must submit a new application and be
determined eligible again for a subsequent testing cycle.

4 C P H Q e x a m i n at i o n c a n d i d at e h a n d b o o k
Each candidate must take time to assess and judge his/her own About the Examination
readiness to apply to take the CPHQ examination, particularly if The international quality management certification examination
you have not worked in the field for at least two years. A careful is the only fully accredited, standardized measurement of the
review of all available information about the tasks covered in knowledge, skills and abilities expected of competent quality
the CPHQ examination content outline, the sample examination management professionals. The examination is available in
questions, reference list and any other available data is essential a computerized format on a daily basis at AMP Assessment
before you make the decision to apply for the examination. centers.

The Examination Committee develops and writes the examination The certification examination is an objective, multiple-choice
to test the knowledge, skills and abilities of effective quality examination consisting of 140 questions. 125 of these questions
management professionals who have been performing a are used in computing the score, as discussed later in this
majority of the tasks on the examination outline for two Handbook. The HQCB uses the following percentage guidelines
years. The examination does not test at the entry level and is in selecting the three types of questions that appear on each
not appropriate for entry-level candidates. If you are new to examination: 32% recall, 53% application, and 15% analysis.
healthcare quality management, have worked in the field less Recall questions test the candidate’s knowledge of specific facts
than two years or your experience as a quality manager was and concepts. Application questions require the candidate to
not specifically related to healthcare, the HQCB cautions interpret or apply information to a situation. Analysis questions test
that you may not be ready to attempt the examination. Refer to the candidate’s ability to evaluate, problem solve or integrate a
the content outline later in this Handbook for detailed content variety of information and/or judgment into a meaningful whole.
information and other tools to assess your readiness.

Pretest Questions on the Examination


In addition to the 125 scored questions, CPHQ examinations also
include an additional 15 pretest questions. You will be asked to
answer these questions, however, they will not be included in the
scored examination result. Pretest questions will be disbursed
within the examination, and you will not be able to determine
which of the questions are being pretested and which will be
included in your score. This is necessary to assure that candidates
answer pretest questions in the same manner as they do scored
questions. This allows the question to be validated as accurate
and appropriate before it is included as a measure of candidate
competency.

The examination content is based upon an international practice


analysis conducted to ensure the content is current, practice-
related and representative of the responsibilities of quality
management professionals internationally. Participants in the
international practice analysis survey must have completed a
minimum of one year working in healthcare quality, case/care/
disease/utilization and/or risk management for their responses to
be included in the research.

C P H Q e x a m i n at i o n c a n d i d at e h a n d b o o k 5
CPHQ T H E C P H Q EXAMINATION

Examination Administration Holidays


Examinations are delivered by computer at over 170 AMP Examinations will not be offered on the following holidays:
Assessment Centers located throughout the United States. January 1, 2010 – New Year’s Day
The examination is administered by appointment only Monday January 18, 2010 – Martin Luther King Jr. Day
through Friday at 9:00 a.m. and 1:30 p.m. Evening and Saturday February 15, 2010 – President’s Day
appointments may be scheduled based on availability. Available April 2, 2010 – Good Friday
dates will be indicated when scheduling your examination. May 31, 2010 – Memorial Day
Candidates are scheduled on a first-come, first-served basis. July 5, 2010 – Independence Day
September 6, 2010 – Labor Day
International Examination Services October 11, 2010 – Columbus Day
HQCB and AMP are making available international computerized November 11, 2010 – Veteran’s Day
examinations. For information regarding the availability of November 25-26, 2010 – Thanksgiving Holiday
international computerized Assessment Centers please visit December 23-24, 2010 – Christmas Holiday
the AMP website at www.goAMP.com. AMP is continuing to December 30-31, 2010 – New Year’s Holiday
expand its international locations and more locations are being
added throughout the year. If you are an international candidate Special Arrangements for
you will need to submit a completed application form and the
application fee. If you do not have a Social Security number or
Candidates with Disabilities
AMP complies with the Americans with Disabilities Act and strives
social insurance number, a unique identifying number will be
to ensure that no individual with a disability as defined by the
assigned to you when your application is processed. All other
ADA as a person who has a physical or mental impairment that
rules and regulations regarding the computerized examination
substantially limits one or more major life activities, a person who
apply to international examination candidates. All examinations
has a history or record of such an impairment, or a person who
will be given in computerized format only. International candidates
is perceived by others as having such an impairment is deprived
will not receive instant score reports. Results will be sent within
of the opportunity to take the examination solely by reason of
3-5 business days after completion of the examination to the
that disability. AMP will provide reasonable accommodations
candidate’s address of record.
for candidates with disabilities. Candidates requesting special
accommodations must call AMP at 888-519-9901 to schedule
Assessment Center Locations their examination.
AMP Assessment Centers have been selected to provide
1. Wheelchair access is available at all established Assessment
accessibility to the most candidates in all states and major
Centers. Candidates must advise AMP at the time of
metropolitan areas. A current listing of AMP Assessment Centers,
scheduling that wheelchair access is necessary.
including addresses and driving directions, may be viewed at
AMP’s website located at www.goAMP.com. Specific address 2. Candidates with visual, sensory, physical or learning
information will be provided when you schedule an examination disabilities that would prevent them from taking the
appointment. examination under standard conditions may request special
accommodations and arrangements and will be reviewed by
AMP.

Verification of the disability and a statement of the specific type


of assistance needed must be made in writing to AMP at least
45 calendar days prior to your desired examination date by
completing the Request for Special Examination Accommodations
and Documentation of Disability-Related Needs forms. AMP will
review the submitted forms and will contact you regarding the
decision for accommodations.

6 C P H Q e x a m i n at i o n c a n d i d at e h a n d b o o k
Telecommunication Devices for Depending on availability,
the Deaf If you contact AMP by
3:00 p.m. Central Time on...
your examination may be
scheduled as early as...
AMP is equipped with Telecommunication Devices for the Deaf
Monday Wednesday
(TDD) to assist deaf and hearing-impaired candidates. TDD calling
is available 8:30 a.m. to 5:00 p.m. (Central Time) Monday-Friday at Tuesday Thursday
913-895-4637. This TDD phone option is for individuals equipped Wednesday Friday/Saturday
with compatible TDD machinery. Thursday Monday
Friday Tuesday

Applying for / Scheduling an


Examination When you schedule your examination appointment, be prepared
1. Online Application/Scheduling: You may complete the to confirm a location and a preferred date and time for testing.
application and scheduling process online by visiting You will be asked to provide your unique identification number or
www.goAMP.com and selecting “Candidates.” The computer Social Security number. When you call or go online to schedule
will guide you through the application/scheduling process. your examination appointment, you will be notified of the time
After the application information and credit card payment to report to the Assessment Center and if an e-mail address is
(VISA, MasterCard, American Express, and Discover) have provided you will be sent an e-mail confirmation notice.
been submitted, eligibility will be confirmed or denied and you
will be prompted to schedule an examination appointment or If special accommodations are being requested, complete the
supply additional eligibility information. Request for Special Examination Accommodations form included
in this handbook and submit it to AMP at least 45 days prior to the
OR desired examination date.

2. Paper Application and Scheduling: Complete and mail Rescheduling or Canceling an


to AMP the paper application included in this handbook
Examination
with appropriate fee (credit card, cashier’s check or money
You may reschedule your appointment ONCE at no charge by
order). A paper application is considered complete only if
calling AMP at 888-519-9901 at least 2 business days prior to your
all information requested is complete, legible and accurate;
scheduled appointment. The following schedule applies.
if you are eligible for the examination; and if the appropriate
fee accompanies the application. A paper application that is You must call AMP by 3:00 p.m.
incomplete or late will be returned, unprocessed. If your examination Central Time to reschedule the
is scheduled on... Examination by the previous...
AMP will process the paper application and within Monday Wednesday
approximately two weeks will send a confirmation notice Tuesday Thursday
including a website address and toll-free telephone number Wednesday Friday
to contact AMP to schedule an examination appointment (see Thursday Monday
following table). If eligibility cannot be confirmed, notification
Friday Tuesday
why the application is incomplete will be sent. If a confirmation
of eligibility notice is not received within 4 weeks, contact AMP
at 888-519-9901.

C P H Q e x a m i n at i o n c a n d i d at e h a n d b o o k 7
CPHQ T H E C P H Q EXAMINATION

Missed Appointments and Inclement Weather, Power Failure or


Cancellations Emergency
In the event of inclement weather or unforeseen emergencies
You will forfeit your examination registration and all fees paid to on the day of an examination, AMP will determine whether
take the examination under the following circumstances. A new, circumstances warrant the cancellation, and subsequent
complete application and examination fee are required to reapply rescheduling, of an examination. The examination will usually not
for examination. be rescheduled if the Assessment Center personnel are able to
open the Assessment Center.
• You cancel your examination after confirmation of eligibility is
received.
You may visit AMP’s website at www.goAMP.com prior to the
• You wish to reschedule an examination but fail to contact examination to determine if AMP has been advised that any
AMP at least two business days prior to the scheduled testing Assessment Centers are closed. Every attempt is made to
session. administer the examination as scheduled; however, should an
• You wish to reschedule a second time. examination be canceled at an Assessment Center, all scheduled
candidates will receive notification following the examination
• You appear more than 15 minutes late for an examination. regarding rescheduling or reapplication procedures.
• You fail to report for an examination appointment.
If power to an Assessment Center is temporarily interrupted
during an administration, your examination will be restarted. The
No Refunds
responses provided up to the point of interruption will be intact,
Fees are nonrefundable. Credit card transactions that are declined
but for security reasons the questions will be scrambled.
will be subject to a $25 handling fee. A certified check or money
order for the amount due, including the handling fee, must be sent
to AMP to cover declined credit card transactions.

8 C P H Q e x a m i n at i o n c a n d i d at e h a n d b o o k
R U L E S F O R C OM P U TE R I Z ED TE S TIN G

Taking the Examination that has NOT been inspected may result in dismissal from the

Your examination will be given by computer at an AMP examination.


Assessment Center. You do not need any computer experience • No guests, visitors or family members are allowed in the testing
or typing skills to take your examination. On the day of your room or reception areas.
examination appointment, report to the Assessment Center no
• No personal items, valuables, or weapons should be brought to
later than your scheduled testing time. Look for signs indicating
the Assessment Center. AMP is not responsible for items left in
AMP Assessment Center check-in. IF YOU ARRIVE MORE THAN
the reception area.
15 MINUTES AFTER THE SCHEDULED TESTING TIME, YOU
WILL NOT BE ADMITTED.
Examination Restrictions
• Pencils will be provided during check-in.
Identification
To gain admission to the assessment center, you must present two • Possession of a cellular phone or other electronic devices
forms of identification, one with a current photograph. Both forms is strictly prohibited and will result in dismissal from the
of identification must be valid and include your current name and examination.
signature. You will also be required to sign a roster for verification • You will be provided with one piece of scratch paper at a time
of identity. You MUST bring one of the following: driver’s license to use during the examination, which must be returned to the
with photograph; state identification card with photograph; supervisor at the completion of testing, or you will not receive
passport; military identification card with photograph. The second a score report. No documents or notes of any kind may be
form of identification must display your name and signature for removed from the examination room.
signature verification (e.g., credit card with signature, social
• No questions concerning the content of the examination may
security card with signature, employment/student ID card with
be asked during the examination.
signature). If your name on these documents is different than it
appears on your identification, you must bring proof of your name • Eating, drinking or smoking will not be permitted in the
change (e.g., marriage license, divorce decree or court order). Assessment Center.
• You may take a break during the examination, but will not be
Assessment Center Security allowed additional time to make up for time lost during breaks.
AMP maintains examination administration and security standards
that are designed to assure that all candidates are provided the Misconduct
same opportunity to demonstrate their abilities. The Assessment Individuals who engage in any of the following conduct may
Center is continuously monitored by audio and video surveillance be dismissed from the examination, their scores will not be
equipment for security purposes. reported, and examination fees will not be refunded. Examples
of misconduct are when a candidate:
The following security procedures apply during the examination:
• creates a disturbance, is abusive, or otherwise uncooperative;
• Examinations are proprietary. No cameras, notes, tape
recorders, personal digital assistants (PDAs), pagers or • displays or uses electronic communications equipment such
cellular phones are allowed in the examination room. as pagers, cellular phones, PDAs in the examination room;

• Calculators are not necessary as all calculations found on the • talks or participates in conversation with other examination
examination can be performed without the aid of a calculator. candidates;
However, if you wish to do so you are permitted to bring a • gives or receives help or is suspected of doing so;
personal calculator and use it during the examination. The
• attempts to record examination questions or make notes;
only type of calculator permitted is a simple battery-powered
pocket calculator that does not have an alphanumeric • attempts to take the examination for someone else; or
keypad, and does not have the capability to print or to store • is observed with notes, books or other aids.
or retrieve data. You MUST present your calculator to the
examination proctor for inspection PRIOR to the start of
the examination. Using a calculator during the examination

C P H Q e x a m i n at i o n c a n d i d at e h a n d b o o k 9
CPHQ R U L E S F O R C OM P U TE R I Z ED TE S TIN G

Copyrighted Examination Questions Only one examination question is presented at a time. The

All examination questions are the copyrighted property of HQCB. question number appears in the lower right portion of the screen.

It is forbidden under federal copyright law to copy, reproduce, Choices of answers to the examination questions are identified as

record, distribute or display these examination questions by any A, B, C, or D. You must indicate your choice by either typing in the

means, in whole or in part. Doing so may subject the candidate to letter in the response box in the lower left portion of the computer

severe civil and criminal penalties. screen or clicking on the option using the mouse. To change an
answer, enter a different option by pressing the A, B, C, or D key
or by clicking on the option using the mouse. You may change
Practice Examination your answer as many times as you wish during the examination
Prior to attempting the timed examination, you will be given the
time limit.
opportunity to practice taking an examination on the computer.
The time used for this practice examination is NOT counted as
To move to the next question, click on the forward arrow (>) in
part of the examination time or score. When you are comfortable
the lower right portion of the screen or select the NEXT key. This
with the computer testing process, you may quit the practice
action will move you forward through the examination question by
session and begin the timed examination.
question. To review any question, click the backward arrow (<) or
use the left arrow key to move backward through the examination.
Timed Examination
Following the practice examination, the actual examination will An examination question may be left unanswered for return later in
begin. Before beginning, instructions for taking the examination the examination session. Questions may also be bookmarked for
are provided on-screen. later review by using the mouse and clicking in the blank square
to the right of the Time button. Click on the hand icon or select
the NEXT key to advance to the next unanswered or bookmarked
question on the examination. To identify all unanswered and
bookmarked questions, repeatedly click on the hand icon or press
the NEXT key. When the examination is completed, the number of
examination questions answered is reported. If not all questions
have been answered and there is time remaining, return to the
examination and answer those questions. Be sure to provide
an answer for each examination question before ending the
examination. There is no penalty for guessing.

Candidate Comments
During the examination, comments may be provided for any
question by clicking on the button displaying an exclamation
point (!) to the left of the Time button. This opens a dialogue box
where comments may be entered. Comments will be reviewed, but
The computer monitors the time spent on the examination. You will individual responses will not be provided.
have three hours to complete the examination. The examination
will terminate if testing exceeds the time allowed. Click on the
“Time” box in the lower right portion of the screen or select the
Time key to monitor testing time. A digital clock indicates the time
remaining to complete the examination. The Time feature may be
turned off during the examination.

10 C P H Q e x a m i n at i o n c a n d i d at e h a n d b o o k
Following the Examination Fees
After you finish the examination, you are asked to complete a short Fees for the CPHQ examination are shown in the table that
evaluation of your testing experience. Then, you are instructed follows.
to report to the examination proctor to receive your score report. CPHQ Examination Fees
Scores are reported in printed form only, in person or by U.S. mail.
Special NAHQ
To assure confidentiality, no candidate examination scores
Examination member or NAHQ
will be reported over the telephone, by electronic mail or by Fee (In U.S. international society
facsimile. Neither the HQCB nor the testing agency will release dollars) affiliate member fee
a copy of individual score reports to employers, schools or other
All Examinations: $440 $370
individuals or organizations without your written authorization.
The special member fee applies to current or new National
The score report you receive as you leave the Assessment Association for Healthcare Quality (NAHQ) members or members
Center will include your photograph, taken prior to the start of the of a non-U.S. national society NAHQ affiliate. The special member
examination. The score report will reflect either “pass” or “fail,” fee does not apply to members of U.S. state NAHQ-affiliate
followed by a raw score indicating the number of questions you associations unless they are also members of NAHQ. If you wish
answered correctly. Additional detail is provided in the form of to join NAHQ you must send the separate membership application
raw scores by each of the four major content categories. This and dues directly to NAHQ, not to the HQCB. Contact NAHQ at
information is provided as feedback to help you understand 800-966-9392 or visit www.nahq.org.
your performance within the major content categories. Your
pass/fail status is determined by your overall raw score for the Fees may be paid by credit card, personal check, or money
entire examination. Even though the examination consists of 140 order for the total amount, payable to HQCB. Checks drawn on
questions, your score is based on 125 scored questions. Fifteen of non-United States banks must state “Payable in U.S. Dollars”.
the questions on the examination are “pretest” questions and are Please write your name on the face of your check. An additional
not included in the final score. $25 charge will be added for any returned checks or rejected
credit cards to cover additional handling fees and service charges
Failing candidates may reapply for subsequent examinations. imposed by the bank or credit card company. Your canceled
Candidates may test one time per 90-day period. There is no check or credit card receipt serve to document payment for the
limitation on the number of times the examination may be taken. examination.

Scores Canceled by HQCB or AMP


HQCB and AMP are responsible for the integrity of the scores they
report. On occasion, occurrences, such as computer malfunction
or misconduct by a candidate, may cause a score to be suspect.
HQCB and AMP are committed to rectifying such discrepancies
as expeditiously as possible. HQCB may void examination results
if, upon investigation, violation of its regulations is discovered.

C P H Q e x a m i n at i o n c a n d i d at e h a n d b o o k 11
CPHQ G ENE R A L IN F O R MATION

Disciplinary Policy Pass/Fail Score Determination


The HQCB shall undertake sanctions against applicants, HQCB is not able to release or discuss individual questions with
candidates or individuals already awarded the CPHQ designation candidates following the examination. To do so would require
only in relation to failure to meet Board requirements for initial elimination of that question from the item bank of pretested
certification or recertification. The HQCB certification program is a questions and deplete the number of pretested questions required
voluntary process, not required by law for employment in the field. to develop future versions of the examination.
Monitoring and evaluating actual job performance is beyond the
scope of the HQCB. The methodology used to set the minimum passing score is the
Angoff method, applied during the performance of a Passing Point
Applications may be refused, candidates may be barred from Study by a panel of experts in the field. The experts evaluated
future examinations, or candidates or individuals already certified each question on the examination to determine how many correct
may be sanctioned, including revocation of the CPHQ designation, answers are necessary to demonstrate the knowledge and skills
for the following reasons: required to pass this examination portion. Your ability to pass the
  1. attesting to false information on the application or on examination depends on the knowledge and skill you display, not
recertification documents or during the random audit on the performance of other candidates.
procedure
Passing scores may vary slightly for each version of the
  2. giving or receiving information to or from another candidate
examination. To ensure fairness to all candidates, a process of
during the examination
statistical equating is used. This involves selecting an appropriate
  3. removing or attempting to remove examination materials or mix of individual questions for each version of the examination
information from the testing site that meet the content distribution requirements of the examination
content blueprint. Because each question has been pretested,
  4. unauthorized possession and/or distribution of any official
a difficulty level can be assigned. The process then considers
testing or examination materials
the difficulty level of each question selected for each version of
  5. representing oneself falsely as a designated CPHQ the examination, attempting to match the difficulty level of each
version as closely as possible. To assure fairness, slight variations
in difficulty level are addressed by adjusting the passing score up
or down, depending on the overall difficulty level statistics for the
group of scored questions that appear on a particular version of
the examination.

12 C P H Q e x a m i n at i o n c a n d i d at e h a n d b o o k
If You Pass the Examination If You Do Not Pass the Examination
If you pass the HQCB examination, you are entitled to use the If you do not pass the certification examination, you may
designation Certified Professional in Healthcare Quality and reapply for subsequent examinations. You may test one time per
registered acronym “CPHQ”, with your name on letterheads, 90-day period. There is no limitation on the number of times the
business cards, and all forms of address. Certification is for examination may be taken. Repeat candidates must submit a new
individuals only. The CPHQ designation may not be used to imply application and full examination fee. Names of candidates who
that an organization, association, or private firm is certified. do not pass the examination are confidential and are not revealed
under any circumstances, except by legal compulsory process.
HQCB mails a congratulatory letter and information packet for
each new CPHQ, which includes an identification card, certificate Appeals
and a CPHQ pin. You should expect to receive this packet Because the performance of each question on the examination
approximately one month following the end of the month that is included in the final score has been pretested, there are no
within which you took and passed the examination. appeal procedures to challenge individual examination questions,
answers, or a failing score.
HQCB reserves the right to recognize publicly any candidate who
has successfully completed a CPHQ certification examination, Actions by the Board affecting eligibility of a candidate to take
thereby earning the certification credential. the examination may be appealed. Additionally, appeals may be
considered for alleged inappropriate examination administration
Replacement certificates can be purchased by sending a written procedures or environmental testing conditions severe enough to
request and the required $15 fee to the HQCB. Replacement or cause a major disruption of the examination process and which
extra CPHQ pins are available for $7. could have been avoided.

Continuing Education Credit All appeals must be submitted in writing. Equivalency eligibility
Some organizations accept successful completion of a appeals must be received within thirty (30) days of the initial
certification examination for continuing education (CE) credit. HQCB action. Appeals for alleged inappropriate administration
Check with your licensure or registration board or association for procedures or severe adverse environmental testing conditions
acceptance and CE credits allowed. must be received within sixty (60) days of the release of
examination results.
Refer to the “Recertification” section in this Handbook for details
about CE requirements to maintain CPHQ status after passing the The HQCB Chair will respond within thirty (30) days of receipt of
examination. the appeal. If this decision is adverse, the candidate may file a
second-level appeal within thirty (30) days. A three-member panel
Verification of CPHQ Status of the HQCB will review the Chair’s decision and respond with a
Information on the current certification status of an individual will final decision within forty-five (45) days of receipt.
be provided to the public upon request. Employers who request
verification of CPHQ status must provide the individual’s name Duplicate Score Report
and social security number to assure correct identification in the You may purchase additional copies of your score report at a cost
CPHQ database. Annually, a listing of successful candidates will of $25 per copy payable to AMP. Requests must be submitted to
be published in the program newsletter and on the CPHQ website AMP, in writing, within ninety (90) days after the examination. The
(www.cphq.org). request must include your name, Social Security number, mailing
address, date of examination and authorization signature. Use the
form in the back of this Handbook to request a duplicate score
report. Duplicate score reports will be mailed approximately two
weeks after receipt of the request.

C P H Q e x a m i n at i o n c a n d i d at e h a n d b o o k 13
CPHQ G ENE R A L IN F O R MATION

Preparation for the CPHQ 15. “A Dash through the Data! Using Data for Improvement”,
an educational DVD on the basics of using data for QI by
Certification Examination Sandra K. Murray, www.nahq.org
The HQCB neither sponsors, endorses nor financially
16. Quality Improvement Methods for Healthcare Manual.
benefits from any review courses or published materials for
www.hqq.co.uk/html/publications
the CPHQ certification examination. Examination questions
are written from a wide variety of publications and resources in 17. MacSherry, R and Pearce. P (2008) Clinical Governance:
the field. Some suggested preparation for the examination might A Guide to Implementation for Healthcare Professionals
include but should not be limited to the following resources: Blackwell Publishing (2nd Edition) ISBN 978-1-4051-3920-5
  1. The CPHQ Self Assessment Exam: This self assessment can
18. Patient Safety-Achieving a New Standard for Care: Quality
help identity areas of strength/improvements for the CPHQ
Chasm Series
examination. www.cphq.org
19. The Team Handbook-3rd Edition 2004
  2. Q-Solutions (NAHQ) www.nahq.org
20. The Lean Enterprises Memory Jogger. Richard L. Macinnes
  3. The Healthcare Quality Handbook: A Professional Resource
and Study Guide. Brown, Janet A. www.jbqs.com.

  4. To Err is Human: Building a Safer Health System. The Institute


International Terminology Crosswalk
Candidates are encouraged to review the terms listed on page 15
of Medicine. (2000).
which could be found on a CPHQ examination. This list includes
  5. Facilitation at a Glance: Your Pocket Guide to Facilitation. healthcare quality terms and words that may have different
Bens, Ingrid. (2008). 2nd Ed. meanings in different countries. For purposes of the CPHQ
  6. Measuring Quality Improvement in Healthcare: A Guide to examination, they are considered to have the same or equivalency
Statistical Process Control Applications. Carey, Raymond G. meaning in the context of individual examination questions.
(2001).
A translation of these terms from English to Arabic, Spanish
  7. Crossing the Quality Chasm: A New Health System for the
21st Century. Institute of Medicine. (2001). and Traditional Chinese can be viewed and printed from the
www.cphq.org website by clicking on “International.” The
  8. Preventing Medication Errors. Institute of Medicine. (2007). translation is provided as an aid to candidates for whom English
  9. The Six Sigma Way Team Fieldbook. Pande, Peter, Neuman, is not their primary language. These candidates may find it helpful
Robert, & Cavanagh, Roland. 2002. to familiarize themselves with the list and translation prior to taking
the examination.
10. Understanding Patient Safety. Wachter, Robert, 2008.

11. Improving Healthcare Using Toyota Lean Production Methods. The CPHQ Examination Committee uses this terminology
Chalice, Robert, 2007. crosswalk as a reference when reviewing and approving questions
for the examination. They may decide to include both or several
12. The Quality Toolbox, Tague, Nancy, 2005.
words that have a similar meaning in the context of an individual
13. Lean Six Sigma Pocket Toolbook. George, Michael, Rowlans, question, separated by a “slash” mark, to help candidates
David, Price, Mark & Maxey, John. 2005. understand the question and/or answer choices.
14. The Memory Jogger™ 2, 2nd Ed. Brassard, Michael.
www.goalqpc.com

14 C P H Q e x a m i n at i o n c a n d i d at e h a n d b o o k
Terminology Crosswalk of Terms • healthcare organization = healthcare entity
• HMO = health maintenance organization
• administrator = leader or facility (hospital) director
• legal standard = requirement of law
• aggregate = summarize (usually referring to data)
• LOS = length of stay (LOS)
• ambulatory care unit = outpatient care unit
• managed care setting = a facility with managed care contracts
• appointment = initial acceptance for membership in a
• “Meals on Wheels” = meals in home
healthcare service, such as a medical staff or medical group
• member = patient, in the context of a managed care program
• behavioral health = behavioral/mental health
• modality = type of service
• capitation = capitated = predetermined or pre-negotiated fee
• pathway = pathway/guideline
• case management = case/care/disease management
• performance improvement = quality improvement
• case mix = patient groupings
• proctor = mentor = coach = supervise = observe
• CEO = chief executive officer (CEO)
• providers/practitioners = physicians or other licensed
• charter = start = assign
independent practitioners
• clinical pathways = clinical/critical pathways/guidelines
• quality council = steering council = QM committee
• compensable = payable
• reappointment = renewal of membership in a healthcare service,
• CQI = continuous quality improvement (CQI) such as a medical staff or medical group
• credentialing = initial evaluation of credentials or initial • reappraisal = re-evaluate competency = periodic competency
credentialing process review
• credentials = qualifications (e.g., licenses, certifications, • recredentialing = periodic re-evaluation and renewing of
education, experience) credentials
• delinquency rate = non completion rate (usually referring to • senior management = directors = administrators
medical records) • sentinel event = sentinel/unexpected event
• deploy = implement = start = initiate • severity = mental or physical dependency = acuity
• DRG = the diagnosis related group (a method of categorizing • sues = takes legal action against
illnesses for purposes of payment or statistical analysis)
• third party payor = payer = insurance company
• ED = emergency department (ED)
• transcriptionist = secretary = typist
• equipment = device = supplies
• unit = unit/ward/floor
• FTE = full time equivalent = full time employee
• workers compensation = injured workers
• generic screening = concurrent screening
• “written off” = erased = waived (usually referring to a financial
• governing body = board of directors = board of trustees
obligation)
• H&P = history and physical

C P H Q e x a m i n at i o n c a n d i d at e h a n d b o o k 15
CPHQ G ENE R A L IN F O R MATION

The content validity of the CPHQ examination is based on an B. Operational


international practice analysis which surveyed QM professionals   1. Facilitate establishment of a performance
on the tasks they perform. Each question on the examination is improvement oversight group (e.g., Quality Council,
linked directly to one of the tasks listed below. In other words, Steering Council, QM Committee)
each question is designed to test if the candidate possesses the   2. Identify the need for a performance improvement
knowledge necessary to perform the task and/or has the ability to
team or teams
apply it to a job situation.
  3. Identify the appropriate team structure (e.g., cross
functional, self-directed)
Each of the tasks below was rated as significant to practice by
  4. Identify champions (e.g., process owners, quality,
QM professionals who responded to the survey. One decision rule
patient safety)
used by the International Practice Analysis Committee required
that a task be significant to practice in the major types and sizes   5. Monitor the activities of consultants (e.g., quality and
of healthcare facilities, including those employed in managed patient safety)
care. Thus the examination content is valid for this segment of QM   6. Assist in developing objective performance
professionals as well as those employed in hospital, clinic, home measures/indicators
care, behavioral/mental health or other care settings.   7. Contribute to development and revision of a written
plan for a risk management program
The following list of tasks is those which form the content outline   8. Contribute to development and revision of a written
of the CPHQ examination and to which the examination questions plan for a case/care/disease/utilization management
are linked: program
  9. Coordinate survey processes (i.e., accreditation,
1. Management and Leadership (28 items or 22%)
licensure, or equivalent)
A. Strategic
10. Participate in cost analysis
  1. Facilitate development of leadership values and
11. Participate in developing and managing a budget for
commitment
a department
  2. Facilitate assessment and development of the
organization’s quality culture 2. Information Management (30 items or 24%)
  3. Participate in organization-wide strategic planning A. Design and Data Collection
  4. Identify internal customer/supplier relationships   1. Maintain confidentiality of performance improvement
  5. Identify external customer/supplier relationships activities, records, and reports
  6. Participate in developing an organizational vision   2. Organize information for committee meetings
statement
(e.g., agendas, reports, minutes)
  7. Participate in developing an organizational mission
  3. Assess customer needs/expectations (e.g., surveys,
statement
focus groups, teams)
  8. Develop goals and objectives
  4. Perform or coordinate data inventory listing activities
  9. Develop and use performance measures (e.g.,
(i.e., what is available from which sources?)
balanced scorecards, dashboards, core measures)
  5. Perform or coordinate data definition activities
10. Determine lines of authority/accountability
11. Evaluate applicability of performance improvement   6. Perform or coordinate data collection methodology
models (e.g., FOCUS, PDCA, Six Sigma)   7. Assist with the evaluation of computer software
12. Evaluate applicability of national/international applications
excellence/quality models   8. Evaluate computerized systems for data collection
13. Facilitate evaluation and/or selection of appropriate and analysis
voluntary accreditation process(es)   9. Implement computerized systems for data collection
14. Develop a performance improvement plan and analysis
15. Link performance improvement activities with 10. Use epidemiological theory in data collection and
strategic goals analysis
16. Demonstrate financial benefits of a quality program 11. Collect qualitative and quantitative data
17. Facilitate change within the organization 12. Aggregate/summarize data for analysis

16 C P H Q e x a m i n at i o n c a n d i d at e h a n d b o o k
B. Measurement B. Implementation
  1. Use or coordinate the use of process analysis tools   1. Coordinate the performance improvement process
to display data (e.g., fishbone, Pareto chart, run   2. Lead performance improvement teams
chart, scattergram, control chart)   3. Facilitate performance improvement teams
  2. Use basic statistical techniques to describe data   4. Participate on performance improvement teams
(e.g., mean, standard deviation)   5. Participate in the credentialing and privileging
  3. Use or coordinate the use of statistical process process
control components (e.g., common and special
  6. Coordinate or participate in quality improvement
cause variation, random variation, trend analysis)
projects
  4. Use the results of statistical techniques to evaluate
  7. Participate in the process of:
data (e.g., t-test, regression)
a. medication usage review
C. Analysis
b. medical record review
  1. Use comparative data to measure or analyze
c. infection control processes
performance
d. peer review
  2. Interpret benchmarking data
  3. Interpret incident/occurrence reports e. service specific review (e.g., pathology,

  4. Interpret outcome data radiology, pharmacy, nursing)

  5. Interpret data to support decision making f. patient advocacy (e.g., patient rights, ethics)
D. Communication   8. Perform or coordinate risk management:
  1. Interact with medical staff and support personnel a. risk prevention
regarding individual patient management issues b. risk identification
  2. Promote organizational values and commitment c. mortality review
among staff d. failure mode and effects analysis
  3. Compile and write performance improvement reports e. collaborate with quality department
  4. Integrate quality concepts within the organization   9. Perform or coordinate risk management: risk
  5. Coordinate the dissemination of performance prevention
improvement information within the organization C. Education and Training
  6. Ensure accuracy in public reporting activities (e.g.,   1. Develop organizational performance improvement
organizational transparency, website content) training (e.g., quality, patient safety)
  7. Facilitate communication with accrediting and   2. Provide performance improvement training
regulatory bodies   3. Evaluate effectiveness of performance improvement
3. Performance Measurement and Improvement training
(47 items or 38%)   4. Facilitate change within the organization through
A. Planning education
  1. Facilitate establishment of priorities for process   5. Develop/provide survey preparation training (e.g.,
improvement activities accreditation, licensure, or equivalent)
  2. Facilitate development of performance improvement D. Evaluation/Integration
action plans and projects   1. Evaluate team performance
  3. Facilitate development or selection of process and   2. Analyze/interpret performance/productivity reports
outcome measures   3. Analyze patient/member/customer satisfaction
  4. Facilitate evaluation or selection of evidence-based   4. Conduct or coordinate practitioner profiling
practice guidelines (e.g., for standing orders or as   5. Perform or coordinate complaint analysis
guidelines for physician ordering practice)
  6. Incorporate performance improvement into the
  5. Participate in the development of clinical/critical
employee performance appraisal system
pathways or guidelines
  7. Incorporate findings from performance improvement
  6. Aid in evaluating the feasibility to apply for external
into the credentialing/appointment/privilege
quality awards (e.g., Malcolm Baldrige, Magnet)
delineation process

C P H Q e x a m i n at i o n c a n d i d at e h a n d b o o k 17
CPHQ e x a m i n at i o n c o n t e n t o u t l i n e

  8. Integrate results of data analysis into the   1. Contribute to development and revision of a written
performance improvement process plan for a patient safety program
  9. Integrate outcome of risk management assessment   2. Coordinate a patient safety program
into the performance improvement process   3. Assess how technology can enhance the patient
10. Integrate outcome of utilization management safety program (e.g., computerized physician order
assessment into the performance improvement entering (CPOE), barcode medication administration
process (BCMA), electronic medical record (EMR))
11. Integrate quality findings into governance and   4. Integrate technology to enhance the patient safety
management activities (e.g., bylaws, administrative program
policies, and procedures)   5. Integrate patient safety goals into organizational
12. Integrate accreditation and regulatory activities (e.g., Joint Commission, JCI, NQF, IHI)
recommendations into the organization   6. Participate in the process of patient safety goals
review
4. Patient Safety (20 items or 16%)
  7. Perform or coordinate risk management
A. Strategic
a. incident report review
  1. Facilitate assessment and development of the
b. sentinel/unexpected event review
organization’s patient safety culture
c. root cause analysis
  2. Identify applicability of patient safety goals (e.g.,
Joint Commission, JCI, NQF, IHI) 125 TOTAL ITEMS
  3. Facilitate development of a patient safety program
  4. Link patient safety activities with strategic goals
  5. Integrate patient safety concepts within the
organization
  6. Integrate patient safety findings into governance and
management activities (e.g., bylaws, administrative
policies, and procedures)
B. Operational

CPHQ Examination Blueprint Matrix


# of questions in each of the three
cognitive levels on the exam
Content Category % of exam # of questions Recall Application Analysis
  1. Management and Leadership   22%   28   8 17   3
  2. Information Management   24%   30   9 14   7
  3. Performance Measurement and Improvement   38%   47 18 21   8
  4.  Patient Safety     16%   20   5 11   4
Total 100% 125 40 63 22
% of Total 100% 32% 50% 18%

18 C P H Q e x a m i n at i o n c a n d i d at e h a n d b o o k
The following ten questions have been removed from active use from the Certified Professional for Healthcare Quality (CPHQ) examination
item pool that is established, maintained and owned by the Healthcare Quality Certification Board (HQCB) of the National Association for
Healthcare Quality (NAHQ). The purpose of releasing these questions is to provide information that could assist prospective candidates
to prepare for the examination and to further their understanding of the examination process.

In releasing these questions, the HQCB has attempted to provide examples that represent a range of content and difficulty that would be
typical of an actual examination. However, HQCB emphasizes that this small number of sample questions does not provide a complete
depiction of the overall diversity that candidates should expect to encounter on an actual examination form.

Following each question is the correct response (key), the cognitive level (Cog) required for a response, the linkage to the current test
content outline (TCO), and a description of other relevant question characteristics and notes about the history of the question, where
applicable. Additional information about the CPHQ examination and certification program is available from a variety of other sources.
These sources include but are not limited to: other sections in this Handbook, the HQCB worldwide website (www.cphq.org), the
HQCB-sponsored item writing workshop (“Secrets of Competency Testing: Writing Questions for the CPHQ Examination”) presented at
the annual NAHQ conference or in co-sponsorship with NAHQ-affiliated state associations, and course work offered by NAHQ or other
educational providers independently from and without endorsement by the HQCB.

Abbreviations used in the sample questions below are defined as


Key = the letter of the correct answer.
Cog = cognitive level required for a response (recall, application or analysis).
TCO = task on the test content outline to which the question is linked.

  1. The primary benefit of adopting a countrywide or global uniform set of discharge data is to

A. facilitate computerization of data.


B. validate data being collected from other sources.
C. facilitate collection of comparable health information.
D. assist medical records personnel in collecting internal data.
Key: C Cog: Application
TCO: IIA7

  2. In order to perform a task for which one is held accountable, there must be an equal balance between responsibility and

A. authority.
B. education.
C. delegation.
D. specialization.
Key: A Cog: Recall
TCO: IA10

  3. A patient was in the operating room when a piece of a surgical instrument broke off and was left in the patient’s body. The patient
was readmitted for removal of the foreign object. Which of the following would most likely apply in this situation?

A. res ipsa loquitur


B. contributory negligence
C. contractual liability
D. tort liability
Key: A Cog: Application
TCO: IVB9b

C P H Q e x a m i n at i o n c a n d i d at e h a n d b o o k 19
CPHQ e x a m i n at i o n c o n t e n t o u t l i n e

  4. Which of the following types of budgets itemizes the major equipment to be purchased in the next year?

A. capital
B. variable
C. operating
D. fixed
Key: A Cog: Recall
TCO: IB11

  5. A quality professional needs to assign a staff member to assist a medical director in the development of a quality program for a
newly established service. Which of the following staff members is MOST appropriate for this project?

A. a newly hired staff member who has demonstrated competence and has time to complete the task
B. a knowledgeable staff member who works best on defined tasks
C. a motivated staff member who is actively seeking promotion
D. a competent staff member who has good interpersonal skills
Key: D Cog: Application
TCO: IIIB6

  6. A surgeon’s wound infection rate is 32%. Further examination of which of the following data will provide the MOST useful information
in determining the cause of this surgeon’s infection rate?

A. mortality rate
B. facility infection rate
C. use of prophylactic antibiotics
D. type of anesthesia used
Key: C Cog: Application
TCO: IIIB7e

  7. Pharmacy and Nursing are having difficulty developing an action plan for medication errors. Pharmacy Services states that Nursing
Services causes the majority of the problems related to errors, while Nursing Services states the opposite. The quality professional’s
role in resolving this problem is to

A. provide them with directives on how to solve the problem.


B. facilitate discussion between the groups to enable them to assume ownership of their portions of the problem.
C. assign the task to an uninvolved manager.
D. refer the problem to the facilitywide quality council.
Key: B Cog: Application
TCO: IIIC2

20 C P H Q e x a m i n at i o n c a n d i d at e h a n d b o o k
a d d i t i o n a l s a m pl e qu e s t i o n s w i t h p e rf o r m a n c e d e ta i l

  8. Which of the following is MOST likely to be a benefit of concurrent ambulatory surgical case review?

A. decreased medical record review at discharge


B. an increase in the number of cases failing screening criteria
C. an increase in reviewer competence
D. decreased medical record requests

Key: A Cog: Application


TCO: IIA6

  9. A well-designed patient safety program should include all of the following EXCEPT

A. an annual patient safety committee meeting.


B. planned response to adverse events.
C. orientation and continuing education on patient safety issues.
D. review of patient safety policies and procedures for all departments.

Key: A Cog: Recall


TCO: IVA3

10. Discharge planners regularly monitor the number of inappropriate referrals, the timeliness of discharge planning, and the number
of days of discharge delays. What additional monitor should be added to evaluate the appropriateness of discharge planning
interventions?

A. adequacy of documentation in progress notes


B. attainment of discharge planning goals
C. timeliness of referrals to discharge planning
D. number of discharge planning referrals from nursing

Answer: B Cog: Analysis


TCO: IIIB7

11. A primary purpose of an information management system is to allow an organization to

A. save time.
B. centralize demographics.
C. reduce cost.
D. evaluate data.

Answer: D Cog: Recall


TCO: IIA9

12. Which part of a job description should be used in a criteria-based performance evaluation?

A. salary grade
B. duties and responsibilities
C. working conditions
D. qualifications

Answer: B Cog: Application


TCO: IIID6

C P H Q e x a m i n at i o n c a n d i d at e h a n d b o o k 21
CPHQ ADDITIONA L S AM P L E Q U E S TION S W IT H P E R F O R MAN C E DETAI L

13. Which of the following monitors provides patient outcome information?

A. healthcare-acquired infection rate


B. nursing care documentation compliance
C. antibiotic therapy discontinuation compliance
D. equipment malfunction rate

Answer: A Cog: Application


TCO: IIIA3

14. One major difference between traditional quality assurance (QA) and quality improvement (QI) is that QI

A. stresses peer review, while QA focuses on the customer.


B. focuses on individuals, while QA focuses on team synergy.
C. stresses team management, while QA stresses team collaboration.
D. focuses on the process, while QA focuses on individual performance.

Answer: D Cog: Application


TCO: IIIB6

22 C P H Q e x a m i n at i o n c a n d i d at e h a n d b o o k
HQCB Handbook, page 23

Instructions for Completing the CPHQ Examination Application Form


  1. Last/Family Name – Print your last/family name in the boxes Zip/Postal Code – Starting with the box on the left, print your
provided. This is the way your name will appear on your zip or postal code.
certificate if you pass the examination. If you have a double Country – Print your country of residence (if United States,
last name, e.g. Smith Jones, leave a blank box between the print USA).
names. If you have a hyphenated last name, put a hyphen (-)
E-mail – Clearly print your full e-mail address, including the
in the box between the two names.
@ sign between your e-mail address and the Internet service
First/Surname – Follow the directions above. If you use two provider (e.g., @aol.com, etc.) and include the appropriate
first names, e.g. Mary Lou, leave a blank box between the provider end designation (e.g., .com, .net, .org, .edu, etc.).
names. Please be certain to write clearly.
Middle Initial – Print the first letter of your middle name; Telephone – Print the area or country code, city code
only one (1) letter is allowed in this field. (if applicable), and telephone number for work, home
  2. Membership Status – Check the appropriate box to and facsimile, including extension numbers if applicable.
indicate whether you are a current or new member of the   5. Gender – (optional) Check the appropriate box so that
National Association for Healthcare Quality (NAHQ) or of a we may send future correspondence to you using the
non-U.S. organization that has formally affiliated with NAHQ. appropriate form of address.
Both categories are eligible to take advantage of the special
member fee for the examination. New members must send   6. Primary Place of Employment – Select the category from
a membership application and the current member dues the list which most closely matches the setting in which you
payment directly to NAHQ or call 800-966-9392 or visit currently spend the majority of your work time; enter that
www.nahq.org. two-digit code in the boxes provided.

  3. Social Security Number – Fill in your United States-   7. Educational level – Select the highest academic level you
issued social security number. This will be your confidential have completed from the list provided; enter that two-digit
examination identification number. Your social security code in the boxes provided.
number is required for us to verify CPHQ status for   8. Years of experience in healthcare quality management
employers. HQCB will assign a confidential examination – Select the category from the list provided to indicate
identification number for candidates who do not have a social the number of years of experience you have completed
security number. performing QM/CM/UM/RM activities, by the application
  4. Preferred Mailing Address – Print one number or letter of deadline for the examination.
your street address in each box and leave a blank box for   9. Previous Examination date – If you have taken the
each space between words or numbers. This is the address examination before, enter the month and year of the
to which all examination information and post examination examination taken most recently.
materials will be mailed, including certificates and pins for
passing candidates. HQCB recommends candidates use 10. Fees – Indicate the correct member or non-member fee, in
their home address (not a business address) to assure mail is the box(s) provided. Add the amounts you have entered, if
forwarded if your address changes. needed, and fill in the appropriate total amount in the box.

City – Print the name of the city of your mailing address. 11. Licenses or Registrations – Check the appropriate box to
State/Province – Print the two-letter initials for your state or indicate any license(s) or registration(s) you currently hold.
province for your mailing address.

Apply online at www.goAMP.com or mail the completed application and appropriate fee
(checks payable to HQCB) or credit card information to:
Applied Measurement Professionals, Inc.
18000 W. 105th Street
Olathe, KS 66061-7543

If paying by credit card, applications may be sent by facsimile to 913-895-4652.

(Note: If sending by facsimile, do not mail the original as this may result in a duplicate entry and duplicate charge to your credit card. If
paying by check, you must mail your application and check; do NOT also send it by facsimile as this may result in a duplicate entry.)
HQCB Handbook, page 24
HQCB Handbook, page 25

APPLICATION FORM
The Certified Professional in Healthcare Quality (CPHQ) Examination
HEALTHCARE QUALITY CERTIFICATION BOARD
  1. PRINT Last/Family
Name USE BLACK INK ONLY
FULL
NAME First Name

Middle Initial

  2. Are you a member of NAHQ or a non-U.S. national quality society NAHQ-affiliate? (State, regional, local or non-affiliated national association
membership does not equal NAHQ membership.)
  No (Non-member exam fee applies)   Yes; NAHQ or affiliate member ID # ___________________________ or
  Yes; new member; dues sent to NAHQ on _____________________ (date) (Member exam fee applies; call NAHQ at 800-966-9392 to join.)
  3. SOCIAL – –
SECURITY NUMBER
Required to verify CPHQ status for U.S. employers) (AMP will assign ID number for candidates without SS #s)

  4. PREFERRED Street
MAILING
ADDRESS City
Use of home State;
Province Zip/Postal Code –
address
recommended Country
Home
Work Phone – Phone –
Area/Country City Code Number Area/Country City Code Number
Code (If applicable) Code (If applicable)

Fax – – *E-mail

  5. GENDER (optional)
Male Female

  6. Primary place of employment:   8. Years of full-time and/or part time experience in healthcare quality,
(01) college or university (non-hospital case/care/disease/utilization and/or risk management activities:
(02) outpatient/specialty facility or clinic (01) fewer than two years
(03) consultant (02) two to five years
(03) more than five but not more than 10 years
(04) extended care facility
(04) more than 10 years
(05) hospital or medical center
(06) private review agency/third party payer/HMO/PPO/MMO/   9. Have you previously taken the CPHQ examination?
insurance company   Yes  No If yes, most recent date:
(07) government agency (non-hospital) Month Year

(08) home health/hospice 10. FEES: Examination fee:


(09) corporate/regional or network headquarters Non-NAHQ member fee: . . . . . . . . . . . . . . . . . . $440 USD
(10) licensing or accrediting body NAHQ/affiliate member fee: . . . . . . . . . . . . . . . . $370 USD
(includes members of non-U.S. national society NAHQ-affiliates)
(11) behavioral/mental health
(12) other (specify)___________________________________________ Total amount paid/authorized:  $ USD
METHOD OF PAYMENT
  Check #______________   Money order (If rebilling is necessary,
  7. Educational Level:
(indicate the highest level)   MasterCard   Visa   American Express a $25 fee will be added.)

(01) Licensed practical nurse (LVN/LPN) ______________________________________________________________


Print Credit Card Holder Name Account Number
(02) Registered Health Info. Technician (RHIT)
______________________________________________________________
(03) Registered Health Info. Administrator (RHIA) Expires (mo/yr) Signature of Credit Card Holder
(04) Diploma in Nursing (Registered Nurse)
11. License(s) and/or Registration(s) (current or inactive):
(05) Associate Degree
(06) Bachelor’s/Final Degree   RN   RHIA  MD  DPM
(07) Master’s Degree   LVN/LPN   RHIT  DO  Other license (specify type)
(08) Doctoral Degree (other than medical doctor) _________________________
(09) Medical Doctor (MD, DO) 12. Where did you hear about the CPHQ Examination?
(10) Other (specify)___________________________________________  AHIMA  NAHQ  IHI  ASHRM
 NPSF   Website  Other _________________________
OVER
HQCB Handbook, page 26

13. Declaration
AGREEMENT OF AUTHORIZATION and CONFIDENTIALITY
I authorize the Healthcare Quality Certification Board (HQCB) to make whatever inquiries and investigations that it deems necessary to verify my credentials and
professional standing. Further, I understand that the HQCB will treat the contents of this application as well as all documents relating to certification as confidential,
except when required by legal compulsory process, with the following exception. If I successfully pass the examination and attain the CPHQ designation, I
authorize the HQCB to release my name and address to the National Association for Healthcare Quality and its affiliated organizations for the purpose of mailing me
association information. I also authorize HQCB to use information from my application and subsequent examination for the purpose of statistical analysis, provided
my personal identification with the information has been deleted. I understand that the initial certification period is two calendar years following successfully passing
the examination and agree to meet current requirements if I wish to maintain active certification status thereafter. I further understand that the governing body has
the authority to change requirements to attain and maintain certification from time to time.
I have read and understand the information provided in the Candidate Handbook or on the cphq.org website. Under penalties of perjury, I declare that the
foregoing statements are true.
I understand that false information may be cause for denial or loss of the credential. I understand that I can be disqualified from taking or continuing to sit for an
examination or from receiving examination scores if the HQCB determines through either proctor observation or statistical analysis that I engaged in collaborative,
disruptive, or other prohibited behavior during the administration of the examination.

______________________________________________________________ ___________________________________
Candidate signature (Required) Date

Payment must be by credit card, check or money order payable in U.S. dollars to the “Healthcare Quality Certification Board”.
Please write your name on the face of the check. (HQCB/NAHQ tax ID #95-3062349)
No telephone or e-mail applications will be accepted. Completed forms may be sent by facsimile ONLY if paying by credit card.
Complete and mail this application with a check or credit card information to:
AMP/Examination Services
18000 W. 105th Street
Olathe, KS 66061-7543
913-895-4600
FAX 913-895-4650
HQCB Handbook, page 27

Request for Special Examination Accommodations

If you have a disability covered by the Americans with Disabilities Act, please complete this form and the Documentation of
Disability-Related Needs on the reverse side so your examination accommodations can be processed efficiently. The information you
provide and any documentation regarding your disability and your need for examination accommodations will be treated with strict
confidentiality.

Candidate Information
Social Security # __________ – _______ – ____________

__________________________________________________________________________________________________________
Name (Last, First, Middle Initial, Former Name)

__________________________________________________________________________________________________________
Mailing Address

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________
City State Zip Code

__________________________________________________________________________________________________________
Daytime Telephone Number

Special Accommodations
I request special accommodations for the _____________________________________________________________________ examination.

Please provide (check all that apply):


______  Reader
______ Extended examination time (time and a half)
______  Reduced distraction environment
______  Please specify below if other special accommodations are needed.

______________________________________________________________________________________________

______________________________________________________________________________________________
______________________________________________________________________________________________

Comments:____________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

Signed:_________________________________________________________________________  Date:_ _______________________________

Return this form with your examination application and fee to:
Examination Services Department, AMP, 18000 W. 105th Street, Olathe, KS 66061-7543.
If you have questions, call the Examination Services Department at 913-895-4600.
HQCB Handbook, page 28

HQCB Examination

Documentation of Disability-Related Needs

Please have this section completed by an appropriate professional (education professional, physician, psychologist, psychiatrist) to
ensure that AMP is able to provide the required examination accommodations.

Professional Documentation
I have known ___________________________________________________ since ______ / ______ / ______ in my capacity
                    Candidate Name             Date

_______________________________________________________________.
                Professional Title              

The candidate discussed with me the nature of the examination to be administered. It is my opinion that, because of this candidate’s
disability described below, he/she should be accommodated by providing the special arrangements listed on the reverse side.

Description of Disability:_________________________________________________________________________________________________

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

Signed:_________________________________________________________________________  Title:_________________________________

Printed Name:______________________________________________________________________________________________

Address:___________________________________________________________________________________________________

__________________________________________________________________________________________________________

Telephone Number:_ ________________________________________________________________________________________

Date:_ __________________________________________________  License # (if applicable):______________________________________

Return this form with your examination application and fee to:
Examination Services Department, AMP, 18000 W. 105th Street, Olathe, KS 66061-7543.
If you have questions, call the Examination Services Department at 913-895-4600.
HQCB Handbook, page 29

Request for Duplicate CPHQ Examination Score Report

Directions: You may use this form to ask the testing agency, AMP, to send you a duplicate copy of your score report. This request
must be postmarked no later than 90 days after the examination administration. Proper fees and information must be
included with the request. Please print or type all information in the form below. Be sure to provide all information and
include the correct fee, or the request will be returned.

Fees: $25 US Dollars per copy. Please enclose a check or money order payable in US Dollars to AMP. Do not send cash.
Write your test identification number on the face of your payment.

Mail to: Examination Services Department Amount enclosed: $___________________


Applied Measurement Professionals, Inc.
18000 W. 105th Street Examination Date: ____________________
Olathe, KS 66061-7543, USA

Print your current name and address:

Name________________________________________________ Candidate ID or Social Security Number_ __________________________

Street_ _______________________________________________________________________________________________________________

City___________________________________  State/Prov. ___________________  Zip/Postal Code_ ________________________________

Country_ _____________________________________________________________________________________________________________

Daytime Telephone (_______) _____________________________________   Fax (_______) ________________________________________

E-mail________________________________________________________________________________________________________________

If the above information was different at the time you were tested, please write the original information below:

Name________________________________________________ Candidate ID or Social Security Number_ __________________________

Street_ _______________________________________________________________________________________________________________

City___________________________________  State/Prov. ___________________  Zip/Postal Code_ ________________________________

Country_ _____________________________________________________________________________________________________________

Daytime Telephone (_______) _____________________________________   Fax (_______) ________________________________________

E-mail________________________________________________________________________________________________________________

Examination Date___________________________________________  Test Site__________________________________________________

I hereby request AMP to send a duplicate copy of my score report to the first address shown above.

Candidate’s Signature Date


HQCB Handbook, page 30
HQCB Handbook, page 31

Request to Change Mailing or E-mail Address


(All address and e-mail changes must be submitted in writing, either by mail or
facsimile, including an authorization signature and candidate ID number.)

You may use this form to request that HQCB enter a change of address, including e-mail address, into our database once you
have registered for the examination. To protect your confidential record and assure that no unauthorized person is able to alter your
record, we require that all address changes be submitted in writing and include your authorizing signature.

HQCB will forward your address change to the testing agency AMP. If you have questions, contact HQCB at 913-895-4609 or toll
free 800-346-4722 or e-mail: [email protected].

Mail or fax your request to: Healthcare Quality Certification Board (HQCB)
P. O. Box 19604
Lenexa, KS 66285-9604, USA
Facsimile 913-895-4652

Print your NEW name and address (use of home address recommended):

Name________________________________________________ Candidate ID or Social Security Number_ __________________________

Street_ _______________________________________________________________________________________________________________

City___________________________________  State/Prov. ___________________  Zip/Postal Code_ ________________________________

Country_ _____________________________________________________________________________________________________________

Work Telephone (_______) _ _________________________________   Home Telephone (_______) _________________________________

E-mail________________________________________________________________________________________________________________

Print your OLD information as it appeared on your application form:

Name________________________________________________ (if different from above)

Street_ _______________________________________________________________________________________________________________

City___________________________________  State/Prov. ___________________  Zip/Postal Code_ ________________________________

Country_ _____________________________________________________________________________________________________________

Daytime Telephone (_______) _____________________________________   Fax (_______) ________________________________________

E-mail________________________________________________________________________________________________________________

Examination Date___________________________________________  Test Site__________________________________________________

I hereby authorize HQCB and AMP to change my address in the examination database as shown above.


Candidate signature Date
HQCB Handbook, page 32
HQCB Handbook, page 33

2010 Healthcare Quality Certification Board


and Examination Committee Roster

Diana L. Martin, RN, MS, BSW, CPHQ, QMRP Greg Smith, MRC, CRC, CCM
Chair Public Member
Evanston, WY Cincinnati, OH
[email protected] [email protected]

Michael L. Greer, RN, MS, CPHQ, CMCN David S. Loose, MSN, CNAA, RN, CPHQ
Chair-Elect Past Chair
Brentwood, TN Alameda, CA
[email protected] [email protected]

Carrie L. Donovan, CPHQ Cathy Munn, MPH, RHIA, CPHQ


HQCB Secretary/Treasurer NAHQ Immediate Past President
Spearfish, SD Birmingham, AL
[email protected] [email protected]

Charlotte Burkhardt, BA, MBA, CPHQ, CHIM, CHE


Director Examination Committee Members
Guelph, ON CANADA All the members of the Board of Directors and
[email protected] the following:

Christina Ordonia, MPH, RHIA, CPHQ Anita Garrison, RN, MSN, CPHQ, FNAHQ, CMC
Director Memphis, TN
New Kent, VA [email protected]
[email protected]
Marie Kehoe, RGN, MScN, CPHQ
Terri Morris-Nichols, BHCA, RN, CPHQ Western Rd, Cork
Director [email protected]
Vancouver, WA
[email protected]
Healthcare Quality Certification Board
Of the National Association for Healthcare Quality
P.O. Box 19604, Lenexa, KS 66285
1-913-895-4609
Facsimile 1-913-895-4652
www.cphq.org
Toll free U.S./Canada 1-800-346-4722

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