The Problem-Based Approach to CPHQ Exam Preparation

A problem-based approach to CPHQ exam preparation is more compatible with adult learning concepts compared to other learning approaches, and, according to the best available evidence, far superior in helping candidates pass the CPHQ examination.

Consider this. You’ve finally scored your dream job: Director of Quality & Patient Safety at New Horizon Hospital, a large multidisciplinary hospital that is only 4 months away from completion. Recognizing your experience and skills in the field, the Board has asked you to develop a comprehensive quality management plan that will set the platform for services at New Horizon Hospital to rival the best in the nation.

  • What are your priorities for the next few months?
  • How would you go about developing a plan? Is it too early to do so?
  • Should you wait till the hospital has opened?
  • What do you absolutely need to know at this stage?
  • What are the issues you anticipate?

These questions may (or may not) be relevant to a healthcare quality professional. But they sure are to a CPHQ candidate. Why? Because the thought processes to answer them need to be correct – more so than the final answers – for someone preparing to take the CPHQ exam.

This post will give you a snippet (i.e. it’s not the whole story) of how I teach healthcare quality to adult learners. It may seem a little unconventional, only because people are more accustomed to a predominantly didactic delivery of content.

However, the methodology I shall discuss below has been used extensively with my private students and with satisfactory results (also discussed below). Perhaps more importantly, the approach to teaching and learning described below may give you an idea of how you could modify the way think about preparing for the CPHQ exam.

The Common Approach

I have never attended a CPHQ exam preparation course (excluding the ones I conduct), though I’ve participated in numerous ones related to healthcare quality (especially), patient safety, epidemiology, biostatistics, management, and leadership.

Nevertheless, I’d hazard a guess that the teaching methods used in any CPHQ exam prep course (excluding the ones I conduct) are the same (read: boring), conservative (read: safe), and user-friendly (read: aimed-to-meet-expectations) ones employed since sermons were given from the pulpit.

For example, if the same content was meant to be delivered as in the case at the top of this post, it might go something like this:

Let’s talk about the steps in developing a healthcare quality management plan.

Step 1: Do this.
Step 2: Do that.
Step 3: Do something else.

Well, there’s nothing wrong with this approach (almost). After all, with the help of some PowerPoint slides and a lot of bullet points, who could fault anyone for delivering the material in this way? (It’s “safe,” remember?) The “lectures” must be done in a certain way to meet the expectations of the customer, right? Isn’t healthcare quality boring anyway? How else could it be taught to make it less dry?

The Common Approach: The Good

It is easy to prepare a series of didactic lectures and to recite/read the material to an audience. Almost too easy. With some textbooks and amateurish Googling skills, one could probably put together sufficient content to call it a “course” or “workshop.”

And every month, people do exactly this in different parts of the world for a fee the customer is willing to pay.

Does it add value? Probably. But to the wrong audience.

Didactic lecture-style presentations are best suited to elementary content, such as definitions. Examples: “What does RCA stand for?” “What is FMEA?” “What is accreditation?” Such questions are basic; they will never be asked in this manner on the CPHQ exam. On the other hand, I might ask such questions on an end-of-module test for my Health Care Quality 101 course. Didactic lectures are useful for delivering pure “recall” content, of which there is plenty on a basic study course.

The Common Approach: The Not-So-Good

By far, most didactic material given at CPHQ exam prep courses and workshops is so basic that it is assumed for CPHQ certification.

Most questions on the CPHQ exam are applied questions, not recall ones.

For example, a question testing your applied knowledge of root cause analysis (RCA) might provide a scenario describing an undesirable variation in a key care process and test your ability to distinguish whether RCA is appropriate or not. There is almost no way of preparing for such questions using the didactic approach. There are numerous other examples that I’ve come across over the years in which the didactic method of teaching simply fails to do the job.

In case it isn’t obvious to you, I should emphasize the didactic approach of the vast majority of trainers is very similar to someone reading a book to the learner. The content may be summarized in bullet points, but the delivery is effectively reading those points. There is very little “processing” by the teacher or the learner, very little “checking” (challenge, if you like) by either side, and virtually no reinforcement (positive or negative) given by either party during the entire “interaction.” In truth, there is minimal interaction and the process may be regarded as a passive one: the teacher says what he/she has to say, and the learner/participant/attendee listens and tries to absorb as much as she is able to.

How about taking out a big textbook/manual/“handbook” filled with bullet points and reading it? Same story. The learner is “reading” the text, but how much processing is there? Is it all being read but interpreted incorrectly? How do we know if the learner really gets it? How does the learner ask questions? (she can’t) How does the learner get positive or negative reinforcement during her learning process? (she can’t)

To summarize: The outcomes of attending a series of didactic lectures and reading a book on your own are almost the same, i.e. didactic lectures = reading book. The difference is this: in one case, you are paying someone to read the stuff to you, and the other you’re doing it on your own. Some people find value in listening to someone else “read” the points to them. However, this should not be a case of method A versus B (as many people wish to think).

Rather, I suggest you start thinking of:

  • Method A versus what is required to pass the CPHQ exam, and, separately,
  • Method B versus what is required to pass the exam.

If both methods A and B are ineffective relative to helping you pass the exam, don’t pick either (as opposed to picking the better of the two evils/failures).

With few exceptions (e.g. highly motivated individuals), the reality is that most people who attend courses that give didactic lectures become bored easily and start thinking about the next coffee break, watch the clock, and/or play with their iPhone, usually by mid-morning of the first day. So why do they even bother showing up? Most of them have the best of intentions – they want to pass the CPHQ exam – but insufficient consideration is given to type of thought processes required to optimally prepare for the exam.

“How about reading a book?”, you might ask. Same thing. Most people buy a book (and sometimes more) with the intention of becoming better prepared for the exam. However, many of them do not think about how the book might or might not help them pass the exam. The commonest reason people give me for buying Janet Brown’s handbook or HQ Solutions is because many others seem to have done the same. How rational is that?

It might be a different story if they could explain how the book would improve their score on the CPHQ exam in a scientific way or if they provided results of a study that showed people who read the book were more likely to pass the exam than those who didn’t read the book. (There is no such study, by the way.) Herd mentality, on the other hand, rarely leads to outstanding results.

Both listening to a didactic lecture and reading a book are one-size-fits-all approaches. The learner is only sometimes, if ever, able to relate the information to her set of circumstances. Naturally, if she is a highly experienced healthcare quality professional, the task of creating a mental picture to apply the basic information being received is much easier. What about the candidate who has very little working experience, or who has slight inkling of how healthcare and healthcare quality management is practiced in the US setting? In other words, didactic lectures and books may not be suitable for persons who require more background information/knowledge/experience and who need more opportunity to clarify their understanding of concepts and principles.

The common approach to healthcare quality training builds on “fundamentals.” Just as in elementary school. Which is exactly my point: we’re not trying to teach elementary school kids how to get a master’s degree in three months. Here’s another pertinent analogy: Try writing a 250-word essay on why you love or hate this post. You’d have to start by deciding whether you love or hate it. Then figure out your reasons. You might list the reasons in order of strength. And then formulate a cogent argument in a concise manner. You’d have to think about things like your audience, tone of language, jargon to use or avoid, etc. The common approach to teaching healthcare quality is akin to starting with the alphabet, i.e. “OK, boys and girls, today we’re going to learn the alphabet. We hope we can get you to write a 250-word essay to say why you love or hate an article in three months. Let’s begin: A, B, C,…”

Another problem with the didactic approach (or reading a book) is that it gives a false sense of security. People who attend didactic lectures rarely recall much content but they expect the material covered in the course/workshop/program will get them ready to answer all or almost all the questions on the exam. I have lost count of the number of people who have complained they failed the exam despite “studying very hard” from Janet Brown’s book or from HQ Solutions. (I doubt their scores would have been much different if they had used any other book. A bad player blames his instrument. I think the root cause of their problem was more likely to be a sub-optimal preparation process/method, rather than any inadequacies of the book they used.)

Because they believe the scope of questions are confined to the narrow limits of a publication or course/workshop/program, they are often poorly prepared for practice-based questions (like those at the top of this post) and, by extension, the questions on the actual test.

One final point about the “common” approach before I describe an alternative. Spare a thought for the trainer. Can you imagine how boring it will be to prepare slide after slide in PowerPoint and regurgitating the material to a largely silent (and possible half-sleeping) audience? As mentioned above, a lot of people do it. But I made a conscious decision this style of teaching was not for me more than 10 years ago. At least not for the individuals whom I now teach, most of whom are mid- to senior-level healthcare professionals. I prefer to keep my work challenging and fun, and I believe this is reflected in the value I’m able to deliver for the people who trust me with preparing them properly for the CPHQ exam (or in any other engagement for that matter).

The Problem-Based Approach: The Good

The idea of problem-based learning is not new. When I was in medical school, two different but overlapping ways of learning were espoused by separate camps.

The traditional method involved learning by discipline, i.e. “everything” about Anatomy, “everything” about Physiology, “everything” about “Biochemistry”, “everything” about Pharmacology, “everything” about Internal Medicine, “everything” about Surgery. The content was largely based on what we could find in textbooks.

In the clinical years of medical school, things became more interesting because I could see “real” patients, and I was introduced to a problem-based approach. When a patient came in with a community-acquired pneumonia, I could focus on the relevant anatomy (not “everything”), relevant physiology (not “everything”), relevant pathology (not “everything”), relevant pharmacology (not pharmacodynamics and pharmacokinetics of 10,000 different drugs), physical examination of the respiratory system, etc.

The learning, I believe was extremely effective because it was targeted to a real problem and a real patient. Retention, i.e. remembering things, was also much easier when I could see how the various aspects (anatomy, physiology, biochemistry, clinical management, etc.) related to the clinical problem. So, about 15 years ago, I started documenting case studies in healthcare quality management for the purpose of teaching the topic in an organized way. The cases were based on actual experience in the hospital, not random products of my imagination.

I embellished the case scenarios at every opportunity to improve learning for my students. What started out as an experiment with a small group of middle managers turned out to be a huge success. To keep things organized, I had a set of learning objectives for each of these case scenarios, which acted as checkpoints for me. This was important to avoid drifting too far away from the main message, while providing ample opportunity to identify gaps in basic knowledge and fixing them.

Using the analogy of the alphabet above, I might be amenable to correcting one or two spelling errors while reading the short essay, or point out that some words are spelled differently in American English and British English and that the author might wish to be sensitive to such differences. Using the problem-based approach, the level of engagement for both participants and trainer is invariably higher than what can be offered by a didactic session. Unless the individual had not had sufficient sleep the night before (e.g. due to an overnight flight), I am confident of keeping the attention of the audience for at least four consecutive hours before lunch and another four afterwards. Most, if not all, participants who participate in my problem-based learning sessions have given overwhelmingly positive feedback about their experience.

There are also a lot of opportunities for reinforcement and for participants to challenge the points I make. Over the years, I’ve found these exchanges invaluable because they help me to communicate better and to be sensitive to things such as cultural issues and local customs and practices. (Most of my career had been spent in Western countries, so my foray into international arena nearly two decades ago was certainly an education.) In the past 10 years, I’ve been able to customize the case scenarios in my database such that they are extremely realistic for participants. In general, the closer the “problem” is to reality, the better the learning.

The Problem-Based Approach: The Not-So-Good

The problem-based approach of teaching healthcare quality may be seen as the “easy” way. It’s not.

It requires a variety of skills to perform successfully and sufficiently broad knowledge to address the multitude of issues that may arise even from a relatively “simple” scenario as the one at the top of this post. There is no way of preparing for a highly interactive session the night before the workshop or even days in advance. The “preparation” comes from many years of experience dealing with different situations, different organizations, different personalities. This experience is the true value that I bring to my students’ exam preparation.

The relative difficulty of teaching healthcare quality management using a problem-based approach means that the copycats have been kept at bay since I founded my own consulting firm in 2009. Some people have tried to video and voice record my interactive workshops (with my permission) but none so far have successfully been able to conduct a workshop on their own. The reason for this is obvious – each workshop, each scenario, each interaction, each lesson is unique and will never be repeated in exactly the same way to a different audience because every participant and group of participants is different (each with a different set of requirements).

For each workshop, my goal is to, as quickly as possible, identify the greatest areas for improvement, and to focus on them using whatever tools at my disposal. Needless to say, it takes (much) more than simply giving a scenario and speaking to it to help candidates pass the CPHQ exam. So, unless you are prepared to demonstrate a wide range of skills and experience in healthcare quality, I suggest you stick to giving your PowerPoint presentations filled with bullet points. You must know what you’re doing or else you will fail to deliver value to the customer, i.e. the CPHQ candidate. If you are thinking of conducting problem-based training on your own, I strongly suggest you carefully examine your skills set because, as alluded to earlier, a problem-based workshop will also be an opportunity for participants to challenge your understanding and therefore expose gaps in your own knowledge. It could be a highly embarrassing exercise for all parties concerned.

Done properly, a problem-based teaching method will cover all the essential points needed to meet the learning objectives. This includes preparing an individual adequately for the CPHQ exam. However, in the wrong hands, I suspect there will be too many gaps left unaddressed for candidates to pass the exam. Over the years, I have found problem-based learning unsuitable for a subset of CPHQ candidates, or people who say they want to become CPHQs. These individuals may have one or more of the following issues: lack of commitment, lack of experience in the field, lack of understanding of what it takes to become a CPHQ. However, a common pattern is the absence of a firm grasp of the basics of healthcare quality management, or quality management for that matter.

From my point of view, it is worry when a self-professed CPHQ candidate has trouble describing the PDCA cycle, for example. CPHQ certification is widely regarded as the gold standard in healthcare quality management, and my CPHQ exam preparation workshops are designed for people at that level or fairly close to it. If you are aiming to win Wimbledon in a fortnight, I expect you to have played tennis at a high level for at least several years, and not to have picked up a tennis racquet for the first time yesterday. (Then again, I’ve devised a program to accelerate the process… but that’s a different story.)


Despite the logic as outlined above, you might have your doubts about the problem-based approach, possibly from its breakaway from conventional methods.

Is it all hogwash? The best evidence for the effectiveness of a problem-based approach is derived from my private students (of course) because I have the opportunity to work with them on the hundreds of different case scenarios from my database ad nauseam.

Compared to traditional approaches that yield an overall 68% pass rate for the CPHQ exam (at best), the pass rate among my students is 100%. No one individual who has gone through the entire private coaching program has ever scored less than 103/125 on the CPHQ exam.

Do I carefully select the individuals I admit to the program? Yes.

Do I use other time-tested, self-devised tactics and proprietary tools to help them pass? Of course.

Nevertheless, problem-based learning features more prominently in my private coaching CPHQ program than any other program I teach, and its success is quite telling: a 100% pass rate versus anything between 20% and 68% for any other formal training program/course/workshop that purports to help individuals pass the CPHQ exam.

Implications for You

If you are now sitting in front of your personal computer or iPad wondering what all this means practically, let me summarize the key message.

The CPHQ exam is a professional exam, one that tests your ability in practice, not how much academic minutiae you can remember. It tests your skills, judgment, and balance in decision-making (for all of which problem-based learning is far more suitable).

Think independently and critically when deciding on what products you need to prepare properly for the exam. Whenever possible, use real-life scenarios to enhance your learning and exam preparation. Look at the tasks on the CPHQ exam content outline – try and identify the things you are doing at work which are associated with those tasks. Work on these things and study around them. In this way, your “study” can be more “real” as opposed to purely theoretical.

Dr Andy Teh is the owner and principal of Teh & Associates, an international healthcare quality consulting firm he founded in 2009. Dr Teh provides innovative education and training solutions to a diverse range of persons (both in the US and elsewhere) preparing to take the CPHQ exam.

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