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CPHQ Exam: Is the Door Closing on International Candidates?

As you are probably aware, the Healthcare Quality Certification Commission is expected to reintroduce questions on US-specific competencies (accreditation, regulations, healthcare reform, etc.) “as early as 2012.” In addition, the new CPHQ exam content outline will see a greater emphasis placed on patient safety. These changes will of course have a broad range of implications for the exam, (all) candidates, and indeed the entire CPHQ certification program.

Following our last few CPHQ exam preparation workshops (held in Asia), we sense a growing anxiety over the anticipated changes in the exam content outline among international candidates. We believe, in many cases, this concern is justified.

This article will discuss the likely impact of the proposed changes on international candidates’ chances of passing the exam, and how these persons might be able to overcome the challenges posed by the addition of questions that test US-specific competencies.

International Candidates: Doing It Tough

Let’s first recap the relevant statistics.

In the past, CPHQ candidates based outside of the US, in general, have been much less successful than their US counterparts in passing the exam. More precisely, only about one in three candidates pass the exam within a calendar year. It will be correct to assume that an even smaller proportion of candidates pass on their first attempt. By comparison, the pass rate among domestic (US-based) candidates was about 75%, regardless of number of attempts, in 2010.

There are several reasons for the relative underperformance by international candidates:

  • Lack of familiarity with terms and concepts on the CPHQ exam. Many international candidates, including those in Canada, continue to struggle in understanding concepts that are regularly examined and that are often second nature to the majority of US-based candidates. When discussing concepts such as managed care, DRG, and credentialing and privileging, we might as well be speaking Greek—some individuals truly have no clue what these terms mean, let alone possess any practical experience. So why do so many individuals around the world still pursue the CPHQ credential? There are a myriad of reasons why anyone might want to be certified; many of these reasons are actually valid (in our view)—see below.
  • Lack of understanding of what is being examined. Despite our repeated encouragement to peruse the CPHQ Candidate Examination Handbook, I still encounter a number of candidates who don’t have a firm grasp of what passing the exam entails. That’s unfortunate because it’s all well spelled out in the Handbook. Some pertinent points include the fact that the exam is a professional one, it does not test at the entry level, and it covers the list of tasks in the CPHQ exam content outline. It is possible that some candidates will require a more personal approach to learning what the exam is about; hence, we will announce an introductory course to the CPHQ exam shortly. The latter is designed to help fresh candidates (i.e. those who have recently decided to embark on the CPHQ program) understand the important aspects of the exam, how to prepare efficiently for the exam, and also what areas to (and not to) concentrate on. The program for this introductory course will be different to the exam preparation workshops that we usually conduct.
  • Language. We have assisted clients with a full range of English language skills, including some with borderline proficiency, pass the exam. Contrary to what many international candidates (and some US-based ones) assume, the CPHQ exam is not a word game or a test of semantics. Despite its weaknesses, the CPHQ exam does test one’s knowledge and skills in healthcare quality management.
  • Poor exam preparation. A person with above-average intelligence, professional experience, and scholarship should pass the exam, right? Not quite. A person might have excelled in his/her area of work, could have read tons of healthcare quality stuff over a period of months, and even attempted plenty of practice questions. However, all this does not guarantee success at the CPHQ exam, no matter where in the world they are based. We have amassed sufficient data on candidates’ performance to conclude that the amount of reading one does is not a major determinant for passing the CPHQ exam. While our research on the impact of other factors is ongoing, we are almost certain that many international candidates will benefit from proper assessment and instruction. One possible explanation for this is that they have a different frame of reference (compared to the people who write and select the questions), such that many incorrect assumptions are made about terms and conceptual models used in the exam. The latter is usually easily overcome by work experience in the US, but in the absence of this, independently (i.e. without assistance) developing an accurate understanding of some key concepts may prove challenging for a proportion of international candidates.
  • Overconfidence. We continue to meet a surprisingly large number of candidates who report being overconfident prior to sitting the exam, only to fail it. Part of this issue stems from the idea that quality management is “simple” (it’s not!), which is reinforced by parties who portray the CPHQ exam as a “textbook exam” (which it is also not).

Given these hurdles, the dismal pass rate among the pool of international candidates is hardly surprising, and looks like getting worse when the questions on the US-specific stuff are included. There seems to be acknowledgement of this fact in the e-mail from the HQCC.

Should International Candidates Pursue CPHQ Certification?

Candidates vary greatly in their motivation to take the exam.

For some, the CPHQ credential may be a way to gain employment as a healthcare professional in North America while they sort out licensing requirements.

Another reason why candidates might want CPHQ certification is career advancement in forward-looking healthcare organizations (located in Asia) that recognize its value. This could mean a significant boost in responsibilities, work satisfaction, and of course, compensation.

There are some candidates who join the program because they seek a more structured way to improve their skills in healthcare quality management, using the tasks in the CPHQ exam content outline as a guide. These persons tend to fare better than average. The mechanics for this observation are not easy to explain but most people will accept that there is an association between the nature and intensity of the motivation and success.

Do the benefits of achieving the goal (CPHQ certification)—and therefore one’s motivation to prepare for and take the exam—justify the work to overcome the challenges? The answer to this question is a very personal one.

Some people might even appreciate the experience of taking the journey, let alone reaching the end.

What International Candidates Can Do

Candidates based outside of the US can better prepare for the CPHQ exam by checking if any of the reasons for underperformance listed above apply to their situation.

  • Do you find some terms and concepts unfamiliar? Needless to say, nothing beats real-life work experience. However, this is not always feasible. If you’re in this position, you might like to seek assistance (not necessarily from Teh & Associates) to learn these new concepts. You might gain some comprehension by browsing the Internet but you can never be sure whether you have it right or sufficiently deep for the exam. We suggest that international candidates consider a course/workshop to help familiarize themselves with pertinent terms and concepts that commonly appear in the exam. One of our key advantages is the ability to transform real-world work experience in the US to models that non-US candidates, especially those based in Asia, can understand easily. Our workshop participants frequently tell us that they appreciate how we distill and simplify previously incomprehensible concepts for them. We are not aware of any other firm in the world that boasts the combination of:
    • Practical work experience within and without the US (together with expertise in US-centric competencies and colloquial terminology);
    • The ability to communicate the material being tested on the CPHQ exam content outline accurately and succinctly; and
    • Deep experience, backed by a superior track record, of helping candidates pass the CPHQ exam in a reasonable time frame.
  • Do you have a clear understanding of what the exam is about? Many parties around the world will try to make you think that the CPHQ exam is like a “textbook exam,” i.e. they give the impression that people can pass the exam by memorizing a body of information, either from a book, slides, or some other material. The CPHQ exam is a professional exam, and primarily tests applied knowledge and skills. But don’t take our word for it—read the CPHQ Candidate Examination Handbook carefully. You might have already been burnt on a previous attempt on the exam, in which case you will no doubt understand where we’re coming from. You might also wish to speak with people who have already undergone the CPHQ program and passed the exam (provided they have no vested interest)—read our article on the problem with seeking non-professional advice. “But hang on, don’t you also have a potential conflict of interest when giving these tips?,” you might ask. There might be a potential interest. But, as numerous people will attest, we:
    • Provide down-to-earth, commonsense advice. Often for free.
    • Turn away more potential clients, students, and workshop/program/course participants than we accept, in the interest of maintaining the high quality of our training programs.
    • We encourage people to evaluate the comparative value of the various services/products in helping them meet their desired goals (not in terms of presentation, marketese, and other non-value-adding activities and products).
    • We have been known to advise people not to pursue the CPHQ exam for various reasons.

    Our introductory course to the CPHQ exam is aimed at clarifying what the exam is really about and to correct any misconceptions.

  • Do you have a limited command of the English language? Many international candidates do not have strong English language skills. The good news is that they need not be English language professors. Although administered only in English, the CPHQ exam is not an English test. We know of some candidates with average English-language skills who have passed the CPHQ comfortably. Provided they understand the intended meaning of the questions on the exam, any deficiency in the English language should not be a major issue. However, if your English language skills are putting a ceiling on your performance for the exam, you should seek professional assistance.
  • Do you need help in getting ready for the exam? Inadequate exam preparation is the downfall of many candidates, both domestic and international. Some candidates tend to do better than others in this area. Those who might benefit from professional assistance with their CPHQ exam preparation include:
    • More matured candidates (who have not sat an exam for many years, e.g. 20–30 years);
    • Candidates who have failed the exam one or more times; and
    • People who have a history of performing poorly on standardized tests.
  • Are/were you overconfident? Overconfidence can be an issue for some people. Misinformation is often a contributor, in which case the solution to the problem should be obvious—get accurate facts (not opinion) so that you can make an informed appraisal of the exam!


With the reintegration of questions on US-specific competencies, the CPHQ exam will be even more difficult for the majority of international candidates to pass. Several things remain to be seen, e.g. how much more difficult the exam will be, the composition of question types (recall, application, analysis), and the specific tasks in the CPHQ exam content outline. We keenly anticipate the statistics related to the CPHQ exam for 2012 as it will give us some indication as to the pass rate among domestic and international candidates and the overall uptake of the exam in the two groups. These figures will only be published in mid 2013, and we won’t get a clear picture of the full effect of the anticipated changes until the end of 2013 (as a proportion of candidates will sit the exam before the changes are implemented in 2012). As mentioned elsewhere, we strongly advise all candidates to take the exam before the proposed changes are implemented as this route is associated with less uncertainty. However, if you are an international candidate who must sit the exam afterward, you may like to consider the suggestions listed above.

{ 3 comments… add one }
  • Nidal January 5, 2012, 12:28 am


    Really does the content will change this year? knowing that I am a candidate from Jordan and I have failed on October 9, 2012 and I prepare myself to retake the exam once again and really I insist to pass the exam?

    • Andy Teh January 5, 2012, 12:57 am

      @Nidal—Yes, questions on US-specific competencies will be reintroduced into the CPHQ exam, most likely in 2012 for a variety of reasons. I also expect the HQCC to give greater focus to some other areas. As mentioned above, the combined effect of these changes will probably increase the overall difficulty for the majority of international (i.e. non-US) candidates. Also, for reasons discussed in my article, you ought to consider some professional assistance at this stage of your exam preparation.

  • Andy Teh February 9, 2012, 8:16 pm

    The HQCC has confirmed that US-specific competencies questions have been undergoing pretesting since January 2012, and will continue to do so through the rest of 2012. Selected questions from pretesting are expected to be scored from January 1, 2013. More information can be found in a members-only article we published on January 30, 2012, “HQCC Sets Date of New CPHQ Exam Content” (protected content). I subsequently wrote a separate article, “Pretesting of US-Specific Competencies Questions: Why the HQCC Got It Wrong” (protected content), which discussed the issues that I foresee with the way in which the HQCC is conducting the pretesting.

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