The CPHQ Exam Content Outline 2015–2017 (CPHQ Exam Specifications 2015–2017), effective from January 1, 2015 through December 31, 2017, is found below. Note: This exam content outline became obsolete on January 1, 2018, when it was replaced by the 2018 CPHQ Exam Content Outline.

Quality Leadership and Structure

A. Leadership

  1. Support organizational commitment to quality
  2. Align quality and safety activities with strategic goals
  3. Engage stakeholders
  4. Provide consultative support to the governing body and medical staff regarding their roles and responsibilities (e.g., credentialing, privileging, quality oversight)
  5. Participate in the integration of environmental safety programs within the organization (e.g., air quality, infection control practices, building, hazardous waste)
  6. Assist with survey or accreditation readiness
  7. Evaluate and integrate external quality innovations (e.g., resources from IHI, WHO, AHRQ, NQF)
  8. Promote population health and continuum of care (e.g., handsoff, transitions of care, episode of care, utilization)

B. Structure

  1. Assist in developing organizational measures (e.g., balanced scorecards, dashboards)
  2. Assist the organization in maintaining awareness of statutory and regulatory requirements (e.g., OSHA, HIPAA, PPACA)
  3. Assist in selecting and using performance improvement approaches (e.g., PDCA, Six Sigma, Lean thinking)
  4. Facilitate development of the quality structure (e.g., councils and committees)
  5. Communicate the impact of health information management on quality (e.g., ICD10, coding, electronic health record, meaningful use)
  6. Assure effective grievance and complaint management
  7. Facilitate selection of and preparation for quality recognition programs and accreditation and certification options (e.g., Magnet, Baldrige, TJC, DNV, ARF, ISO, NCQA)
  8. Communicate the financial benefits of a quality program
  9. Recognize quality initiatives impacting reimbursement (e.g., capitation, pay for performance)

Information Management

A. Design and Data Collection

  1. Maintain confidentiality of performance/quality improvement records and reports
  2. Apply sampling methodology for data collection
  3. Coordinate data collection
  4. Assess customer needs/expectations (e.g., surveys, focus groups, teams)
  5. Participate in development of data definitions, goals, triggers, and thresholds
  6. Identify or select measures (e.g., structure, process, outcome)
  7. Assist in evaluating quality management information systems
  8. Identify external data sources for comparison (e.g., benchmarking)
  9. Validate data integrity

B. Measurement and Analysis

  1. Use tools to display data or evaluate a process (e.g., fishbone, Pareto chart, run chart, scattergram, control chart)
  2. Use statistics to describe data (e.g., mean, standard deviation)
  3. Use statistical process controls (e.g., common and special cause variation, random variation, trend analysis)
  4. Interpret data to support decision making
  5. Compare data sources to establish benchmarks
  6. Participate in external reporting (e.g., core measures, patient safety indicators)

Performance Measurement and Process Improvement

A. Planning

  1. Assist with establishing priorities
  2. Facilitate development of action plans or projects
  3. Participate in selection of evidence-based practice guidelines
  4. Identify opportunities for participating in collaboratives
  5. Identify process champions

B. Implementation and Evaluation

  1. Establish teams and roles
  2. Participate in monitoring of project timelines and deliverables
  3. Evaluate team effectiveness (e.g., dynamics, outcomes)
  4. Participate in the process for evaluating compliance with internal and external requirements for:
    1. clinical practice (e.g., medication use, infection prevention)
    2. service quality
    3. documentation
    4. practitioner performance evaluation (i.e., peer review)
  5. Perform or coordinate risk management activities (e.g., identification, analysis, prevention)

C. Education and Training

  1. Design organizational performance/quality improvement training (e.g., quality, patient safety)
  2. Provide training on performance/quality improvement, program development, and evaluation concepts
  3. Evaluate effectiveness of performance/quality improvement training
  4. Develop/Provide survey preparation training (e.g., accreditation, licensure, or equivalent)

D. Communication

  1. Facilitate conversations with staff regarding quality issues
  2. Compile and write performance/quality improvement reports
  3. Disseminate performance/quality improvement information within the organization
  4. Facilitate communication with accrediting and regulatory bodies
  5. Lead and facilitate change (e.g., change theories, diffusion, spread)
  6. Organize meeting materials (e.g., agendas, reports, minutes)

Patient Safety

A. Assessment and Planning

  1. Assess the organization’s patient safety culture
  2. Determine how technology can enhance the patient safety program (e.g., computerized physician order entering (CPOE), barcode medication administration (BCMA), electronic medical record (EMR), abduction/elopement security systems, human factors engineering)

B. Implementation and Evaluation

  1. Assist with implementation of patient safety activities
  2. Facilitate the ongoing evaluation of patient safety activities
  3. Participate in these patient safety activities:
    1. incident report review
    2. sentinel/unexpected event review
    3. root cause analysis
    4. failure modes and effects analysis (proactive risk assessment)
    5. patient safety goals review
    6. identification of reportable events for accreditation and regulatory bodies
  4. Integrate patient safety concepts throughout the organization
  5. Educate staff regarding patient safety issues