This document outlines the topics covered in the CPHQ certification exam, including quality management foundations, using data for improvement, leadership strategies, continuous improvement processes, change management, patient safety, and a final assessment. Key areas covered are process analysis tools, statistical techniques, performance measures, quality program oversight, process improvement teams, risk management, medical record review, and integrating quality initiatives throughout hospital operations and governance. The goal of the certification is to demonstrate expertise in driving quality and safety in healthcare.

1. CPHQ: Practice to be the best
1. Introduction and Test Taking Tips:
What is Quality and why
What is CPHQ and why to certify
Test taking strategy
2. Foundation, Techniques and Tools:
Process analysis tools (e.g., fishbone, Pareto chart, run chart,
scatter gram, control chart)
Statistical techniques to describe data (e.g., mean, standard
deviation)
Statistical process control (e.g., common and special cause
variation, random variation, trends)
Statistical techniques to evaluate data (e.g., t-test, regression)
Communication
3. Using Data for Improvement:
Confidentiality of performance improvement activities,
records, and reports
Information for committee meetings (e.g., agendas, reports,
minutes)
Customer needs/expectations (e.g., surveys, focus groups,
teams)
Data inventory listing activities (i.e., what is available from
which sources?)
Data collection methodology and Analysis
Computerized systems for data collection and analysis
Epidemiological theory in data collection and analysis
Comparative data, benchmarking , outcomes
Incident/occurrence reports
Decision making
4. Strategy and Leadership:

2. leadership values and commitment
the organization’s quality culture
organization-wide strategic planning
Identify internal / external customer/supplier relationships
organizational vision and mission statement
goals and objectives
performance measures (e.g., balanced scorecards, dashboards,
core measures)
lines of authority/accountability
performance improvement models (e.g., FOCUS, PDCA, Six
Sigma)
national/international excellence/quality models
accreditation process
financial benefits of a quality program
performance improvement oversight group (e.g., Quality
Council, Steering Council, QM Committee)
performance improvement team or teams and team structure
(e.g., cross functional, self-directed)
Quality champions (e.g., process owners, quality, and patient
safety)
performance measures/indicators
written plan for a risk management program
survey processes (i.e., accreditation, licensure, Certification)
cost analysis and departments budget
5. Continuous Improvement:
process improvement activities and Teams
performance improvement action plans and projects
process and outcome measures
evidence-based practice guidelines
external quality awards (e.g., Malcolm Baldrige, Magnet)
credentialing and privileging process
medication usage review

3. medical record review
infection control processes
peer review
service specific review (e.g., pathology,radiology, pharmacy,
nursing)
patient advocacy (e.g., patient rights, ethics)
risk management: prevention and identification
mortality review
failure mode and effects analysis
quality department
Education and Training
Integration between:
 performance improvement incorporated into the
employee performance appraisal system
 findings from performance improvement incorporated
into the credentialing/appointment/privilege delineation
process
 data analysis results incorporated into the performance
improvement process
 outcome of risk management assessment incorporated
into the performance improvement process
 outcome of utilization management assessment
incorporated into the performance improvement process
 quality findings incorporated into governance and
management activities (e.g., bylaws, administrative
policies, and procedures)
 accreditation and regulatory recommendations
incorporated into the organization
Evaluation of:
 measures, teams, projects, Surveys, Accreditation
 performance/productivity reports
 patient/member/customer satisfaction
 practitioner profiling
 complaint analysis

4. 6. Change Management and Innovation:
Organization quality and safety culture
ISO, Lean and Six sigma
Interpersonal relationship
Integrate quality concepts within the organization
organizational values and commitment among staff
7. Patient Safety:
Patient safety culture – goals and program
Technology and patient safety program
Risk management
Incident report
Sentinel/unexpected event
Root cause analysis
8. Wrap-up/Evaluation: Final assessment quiz
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