Guide to Healthcare Quality & Patient Safety Certifications

Healthcare quality is an umbrella term encompassing all the processes, knowledge sets, competencies, and professional skills focused on ensuring safe and effective care. Care should also center around the patient, be delivered promptly, and be accessible equitably. More simply, healthcare quality is concerned with creating improvements in the system that ensure patients can access customized, effective, systemically cost-effective care.

Certain professionals engage with healthcare quality intentionally or through leadership behaviors. According to the National Association for Healthcare Quality (NAHQ), healthcare quality professionals are those who enhance the delivery of care, improve patient outcomes, and optimize the cost of care. They achieve this through leadership concerning patient safety, regulation and accreditation, improved data analytics, and an understanding of population health.

Professional certification is the process by which any professionals, including those in healthcare, voluntarily choose to demonstrate proficiency in their craft through specialized training, followed by passing exams focused on essential knowledge sets or skills. Because formalized training and professional experience create a wide range of variability upon which to judge a job candidate, professional certification is useful to employers because it provides a universal set of standards against which to judge the quality of candidate proficiency.

Healthcare quality certifications are available to clinicians (RNs, NPs, MDs, etc.), non-clinicians, administrators, and support staff. Regardless of one’s role in healthcare, pursuing certification can lead to promotions or greater responsibility, higher salaries, and a stronger presence in the job market.

Although functionally, healthcare quality certificates and certifications offer professionals the ability to hone knowledge and skills regarding improving the healthcare system, there is a distinction between the two.

Healthcare quality certificate programs are offered by universities at the post-baccalaureate or post-graduate level. Each university determines the subject matter; no two certificate programs are the same. Within a certificate program, the courses a student can take are often flexible to fulfill requirements. At completion, graduates receive a certificate, which is similar in function to a degree or diploma. While some certificate programs are specifically designed to help graduates sit for certification exams, they do not lead to certification on their own.

Certification is offered by non-academic organizations that focus on researching and compiling universal professional competencies within the general healthcare quality arena or within a specific sub-discipline of healthcare quality.

A generalized healthcare quality certification, the most common healthcare quality certification (HCQ), indicates that a healthcare quality professional can perform job functions related to a wide range of healthcare quality measures.

Generalist HCQ certifications prove that a professional understands the breadth of the ecosystem of healthcare quality. Although many of these certifications stress that those who earn certification will be capable of management, even non-management professionals can pursue these to benefit their careers and the institutions where they are employed.

Generalized healthcare quality certifications can be earned through the following organizations:

Eligibility

There are no eligibility requirements to sit for the Certified Professional in Healthcare Quality (CPHQ) exam. The NAHQ allows each candidate to determine if they are ready to sit for the exam. However, they caution that this exam is not an entry-level test and should only be attempted after two years of work experience in healthcare.

Testing

The CPHQ consists of 140 multiple-choice questions, 125 of which are scored. This exam costs $479 for NAHQ members and $579 for non-members. Topics covered include organizational leadership, health data analytics, performance and process improvement, and patient safety.

Renewal

The CPHQ certification must be renewed every two years. The renewal cost is between $175 and $330, depending on membership status and when the application is submitted. Candidates must also submit 30 hours of continuing education to renew.

Eligibility

The ABQAURP offers the Certification in Health Care Quality and Management (HCQM). To be eligible to sit for this exam, candidates must hold an unrestricted license to practice as applies to their profession, have two letters of recommendation, submit documentation of active involvement in health care quality of at least 208 hours over the past five years, and complete 25 hours of ABQAURP continuing education hours or the ABQAURP Core Body of Knowledge course in the past five years. Candidates must also demonstrate competency in the English language.

Testing

The fee to take this exam is $645 for members and $745 for non-members. This exam consists of 175 multiple-choice questions that must be answered in four hours. It covers:

• Quality improvement, quality management, and quality assurance
• Patient safety
• Physician advisor roles in HCQM
• Transitions of care
• Case management
• Insurance and managed care
• Workers’ compensation education
• Clinical resource management
• Regulatory environment
• Accreditation organizations
• Credentialing and privileging
• Legal and ethical issues in risk management

Renewal

The HCQM certification must be renewed every two years. The application to renew must include 8 hours of ABQAURP-approved continuing medical education. Certification holders must maintain ABQAURP membership to be eligible for renewal. Recertification costs up to $150.

Eligibility

The Certified in Healthcare Quality (CHQ) certification from AIHQ is earned by completing an online course and passing an exam on the topics covered. This course costs $500.

Testing

The CHQ course covers:

• Overview of the healthcare systems around the world
• The concept of healthcare quality
• Current issues of healthcare quality
• Planning and organizing for healthcare quality
• Historical evolution of quality in healthcare
• Dissemination of healthcare quality
• Quality improvement and quality assurance
• Measuring and monitoring quality
• Data collection, analysis, and management
• Economics of healthcare quality
• Quality cost and cost containment
• Regulations, accreditations, and licensure

Upon completing the course, candidates will take an exam that allows them to demonstrate competency in the topics covered.

Renewal

Certificates are valid for three years. To renew, candidates must submit proof of 80 hours of continuing education, provide an updated resume or CV, and pay a $150 renewal fee. If candidates let their certificate lapse, they will not be eligible for renewal and will have to retake the exam and potentially the entire course.

Patient safety is how healthcare organizations ensure patients are protected from preventable adverse outcomes, including injuries, infections, errors, and accidents. Patient safety certifications ensure professionals have adequate competency to apply practical strategies for improving conditions for safety.

Topics for patient safety certifications include understanding the scope and scale of risk, involving patients in safety, creating teams that foster safety and communication with one another and with patients, and using quantitative skills (measurement, compliance monitoring systems, reporting, etc.). Patient safety certifications are available from several organizations, including:

Eligibility

Candidates for the Certified Professional in Patient Safety credential (CPPS) from IHI must hold a bachelor’s degree, three years of work experience in health care, or an associate’s degree and five years of work experience in health care.

Testing

The CPPS exam consists of 100 questions that must be answered in two hours. The exam costs between $449 to $549, depending on IHI membership status. This exam covers patient safety culture, leadership, patient safety risk and solutions, measuring and improving performance, systems thinking and design, and human factors.

Renewal

CPPS certification holders must recertify every three years. To recertify, candidates must complete 45 hours of continuing education or pass the CPPS exam again. Recertification costs $175 to $225, depending on the level of IHI membership held.

Eligibility

To be eligible for the Certified Healthcare Safety Professional (CHSP) credential from the IBFCSM candidate must have eight years of work experience in patient safety or a combination of work experience and education totaling eight years. Thirty credits of college coursework are equivalent to one year of work experience.

Testing

First, candidates must apply to take the exam. They must submit eligibility documentation and pay a $145 application fee. Once approved to take the test, they must pay a $250 examination fee and schedule their exam. This exam consists of 100 to 150 multiple-choice questions on management, leadership, hazard control practices, and compliance.

Renewal

CHSP certifications are valid for five years, however, certificate holders must pay a $135 annual fee to maintain their certification. At the five-year recertification, certificate holders must provide documentation of 5,000 hours of professional practice and 50 hours of continuing education.

Eligibility

There are no eligibility requirements to take the Certified Professional in Quality and Patient Safety (CPQPS) course through the AIHQ. The course costs $500 and takes at least 28 hours to complete.

Testing

Upon completion of the CPQPS course, students can sit for the final exam. This exam demonstrates competence in the topics covered in the course, such as:

• Introduction to quality, healthcare quality
• Quality & healthcare quality gurus and theories
• Leadership and management in healthcare quality
• Strategic management and planning in healthcare
• Statistics in healthcare quality
• Healthcare quality statistical tools
• Key performance measures in healthcare quality
• Performance improvement
• Root cause analysis
• Risk management and FMEA
• Health information systems
• Accreditation and healthcare quality institutions and awards
• Introduction to patient safety history
• Systems thinking, design, and human factors engineering
• Healthcare-associated errors
• Team and group building
• Accreditation and patient safety
• Workforce safety, credentialing, privileging, and licensing
• Patient empowerment and disclosure

Renewal

Renewals for the CPQPS certification must be completed every three years. Certificate holders must submit proof of 80 hours of continuing education and pay a $150 fee.

Patient safety officers are healthcare professionals who utilize data, global perspectives on healthcare, communication skills, knowledge about patient safety standards and regulatory requirements, and change management skills to bring patient safety programs to healthcare organizations or improve patient safety programs that already exist within healthcare organizations.

Patient safety officer certification differs from patient safety certification in that the officers are responsible for designing and implementing new systems. Patient safety officer certifications are available from:

Eligibility

To be eligible to sit for the Certified Patient Safety Officer (CPSO) exam candidate must have eight years of relevant work experience or a combination of work experience and education that totals eight years. The IBfCSM considers 30 credit hours of college education equivalent to one year of work experience.

Testing

Candidates interested in sitting for the CPSO exam must demonstrate their eligibility by completing an application. They must also pay a $145 application fee. They can book their exam and pay the $250 exam fee upon approval. This exam consists of 100 to 150 questions and covers patient safety fundamentals, patient safety hazards and risks, and patient safety compliance.

Renewal

CPSO certificate holders must pay an annual renewal fee of $135 and complete a recertification process every five years. To recertify, candidates must provide proof of 5,000 hours of professional work experience in the past five years and 50 hours of continuing education credits.

Eligibility

It is up to each candidate to determine if they are ready to take the Certified Patient Safety Officer (CPSO) course offered through the AIHQ, as there are no eligibility requirements. Candidates simply have to register and pay the $500-course fee.

Testing

Once candidates have completed the course are eligible to take the CPSO exam. This exam is on the topics covered in the class and includes:

• Patient safety overview
• The interaction between patient safety and risk management
• Principles of national and international patient safety goals
• Implementing patient safety goals in a hospital
• Techniques to improve patient safety
• Patient safety indicators towards performance improvement
• Medical errors and adverse occurrences
• Medical errors management
• Ethics, the law, and patient safety
• Documentation and medical record
• Patient safety and quality tools
• Informed consent
• Designing and implementing patient safety programs in hospitals
• Quality, cost, access, and impact on patient safety

Renewal

Every three years, CPSO certificate holders must renew their certification. It costs $150 to renew this certification, and certificate holders must provide proof of 80 hours of continuing education.

Controlling infections within healthcare settings is a major part of healthcare quality. Proper infection control protects patients and providers, diminishes pathogens’ capacity to evolve into treatment-resistant superbugs, reduces the cost of care, and prevents infections from spreading into the greater community.

Earning a certification in infection control indicates that healthcare professionals understand common healthcare infections and how they spread, best practices for preventing infection, and the organization of an infection control program.

Certifications for infection control are offered through:

Eligibility

Anyone can take the Certified Professional in Infection Control (CPIC) course through AIHQ, as there are no eligibility requirements. Interested professionals just need to register online and pay the $500-course fee.

Testing

Part of the CPIC course is a comprehensive exam upon completing the modules. Passing the exam demonstrates competence in the following topics:

• Introduction to microbiology
• Basic concepts of epidemiology
• Common healthcare-associated infections
• Infection control within specific settings
• Infection control precautions
• Infection control standards, policies, and procedures
• Performance improvement and patient safety
• Applying the principles of infection control in a healthcare environment
• Organizing and managing an infection control program in a healthcare facility

Renewal

CPIC certifications are valid for three years. To renew, certificate holders must submit proof of 80 hours of continuing education and pay a $150 renewal fee.

Eligibility

The Certification in Infection Prevention and Control (CIC) certification is offered by the CBIC. Eligibility requirements include completing post-secondary education in a healthcare-related field and at least one year of full-time, two years of part-time, or 3,000 hours of work experience in infection control.

Testing

To sit for this exam, candidates must apply with their eligibility documentation and pay a $410 fee. Once eligibility is confirmed, candidates will be able to schedule to take the exam. The exam consists of 150 questions which must be answered in three and a half hours. Topics covered include:

• Identification of infectious disease processes
• Surveillance and epidemiologic investigation
• Preventing and controlling the transmission of infectious agents
• Employee and occupational health
• Management and communication
• Education and research
• Environment of care
• Cleaning, sterilization, and disinfection

Renewal

Every five years, CICs must renew their certification. They can either opt to renew by retaking the CIC exam and paying the $410 exam fee or by compiling a portfolio of 40 Infection Prevention Units (IPUs). If candidates choose to go the IPU route, the portfolio must be approved by the CBIC.

Similar in scope to a patient safety officer, a medication safety officer’s primary role is to reduce the risk of mortality and injuries related to medication use by creating or improving medication safety programs. Earning certification requires professionals to prove competency in topics including medication errors, prescription safety, administration safety, patient errors, compliance, staff training, medication management including transport, storing, and labeling, and medicines evaluation.

Organizations offering certifications for medical safety officers include:

Eligibility

Certified Medication Safety Officer (CMSO) certification through the AIHQ doesn’t have any eligibility requirements. Any professional in the field can pay the $500-course fee and complete the 28-hour program.

Testing

Testing for CMSO certification is completed once candidates have finished their courses. The exam will cover the topics taught in the class, including:

• Introduction to medication management processes
• Standards of medication management and use
• Patient safety standards/goals
• Clinical risk management and management of medication
• Role of medication safety officer
• Role of pharmacy and therapeutics committee
• Role of quality improvement in medication management
• Evaluation of the medication management program
• Prevention and control of sentinel and adverse events

Renewal

Every three years, CMSO certificate holders must renew their credentials. Renewals are completed through an online application, and candidates must provide proof of 80 hours of continuing education and pay a $150 renewal fee.

Using a foundation of patient safety, a patient experience professional has the same roles as all other health quality professionals in improving care, reducing costs, and preventing errors. The lens through which a patient experience professional contributes to healthcare quality is specifically through patient engagement.

Certified patient experience professionals have proven skills in partnership and advocacy, the design of patient experience programs, high-level communication and customer service skills, and leadership capacity, specifically in empowering patients to make informed and autonomous choices about their care.

Certification organizations offering exams include:

Eligibility

The AIHQ offers certification as a Certified Patient Experience Catalyst (CPXC). This course can be taken by anyone who wishes to deepen their knowledge in this field.

Testing

Once students have completed the CPXC course, they must take a comprehensive exam. This exam demonstrates patient partnership and advocacy competency, analysis of patient experience, design of patient experience improvement programs, communications excellence, organizational culture, and leadership to drive a patient’s experience.

Renewal

The AIHQ requires CPXC certificate holders to renew their credentials every three years. To be eligible for renewal, professionals must submit 80 hours of continuing education and pay a $150 renewal fee.

Eligibility

Professionals working in patient experience can earn a Certified Patient Experience Professional (CPXP) certification through the PXI. To be eligible, candidates must have three years of work experience in patient experience or at least 30 Patient Experience Continuing Education Credits (PXEs).

Testing

The CPXP exam costs $475 and consists of 150 multiple-choice questions. The exam covers four main areas including:

• Partnership and advocacy
• Measurement and analysis
• Design and innovation
• Organizational culture and leadership

Renewal

Recertification for CPXP certificate holders is required every three years. Candidates must pay a $275 renewal fee and have 30 Patient Experience Continuing Education Credits (PXEs).

The facilities in which healthcare is delivered are vital to providing quality care to patients. Facility safety officers cultivate the expertise necessary to manage physical safety within buildings, security teams and technology, waste and hazardous materials management, equipment maintenance and repair, emergency preparations, and disaster readiness. Facility safety officers must also cultivate leadership and delegation skills, prepare for inspections, ensure compliance, and coordinate quality improvement strategies.

AIHQ and AMIHM provide general certifications for facility safety officers. Sub-specializations within facility safety officiating exist as well. For example, the National Fire Protection Association (NFPA) offers healthcare facility managers the opportunity to become Certified Life Safety Specialists (CLSS-HC). Continue reading to learn more about these certifications.

Eligibility

The Certified Facilities Safety Officer (CFSO) course from the AIHQ is open to anyone who wishes to enroll. There are no eligibility requirements. Students simply need to register online and pay a $500 application fee.

Testing

The 28-hour CFSO course culminates with a comprehensive exam allowing students to demonstrate competency in the course topics. These include:

• Overview of facility management and safety (FMS) in healthcare organizations
• Roles and responsibilities of an FMS officer
• FMS Standards for healthcare organizations
• Environmental safety plans
• Environmental tracers in healthcare organizations
• Facility inspection and periodic evaluations
• Role of quality management in FMS
• Leadership Role in FMS
• Delegated services oversight

Renewal

Every three years, CFSO certificate holders must apply for recertification. They must pay a $150 recertification fee and submit proof of 80 hours of continuing education.

Eligibility

The only eligibility requirement to sit for the Certified Life Safety Specialist (CLSS-HC) for Health Care Facility Managers exam through the NFPA is to have a high school diploma. This specialized certification helps those concerned with facility safety understand the main life challenges in healthcare facilities.

Testing

The CLSS-HC exam costs $399 and consists of 100 multiple-choice questions that must be answered in three hours. This exam is open book and covers the following topics:

• Protections
• Means of egress
• Operating features
• Building services
• General requirements
• Special provisions

Renewal

The CLSS-HC certification must be renewed every three years. Renewals cost $180. To renew, candidates must have ten points of professional development activities, which can include maintaining NFPA membership or completing continuing education courses.

The healthcare industry is mediated by a vast web of laws, regulations, rules, and guidelines, and a compliance officer’s purpose is to ensure that their healthcare organization operates within the scope of these boundaries.

In addition to understanding regulations, compliance officers create programs, including implementing internal compliance reviews, preparing for external audits, and engaging in risk assessment. Depending on the size of the practice, compliance officers are responsible for educating staff about practices for compliance or managing entire compliance teams who ensure that every aspect of a larger-scale healthcare facility is operating within the scope of compliance.

Every healthcare facility must have a compliance program as per the Affordable Care Act regulations, and compliance officers are the professionals who create them. Organizations offering certifications for compliance officers include:

Eligibility

Eligibility requirements for the Certified in Healthcare Compliance (CHC) certification through the HCCA are:

• One year or at least 1,500 hours of work experience in compliance-related job duties
• 20 hours of continuing education approved by the Compliance Certification Board (CCB)

Testing

The CHC exam costs $275 for HCCA members and $375 for non-members. Candidates must complete the 120-question multiple-choice exam in two hours. Content covered on the exam includes:

• Standards, policies, and procedures
• Compliance program administration
• Screening and evaluation of employees, physicians, vendors, and other agents
• Communication, education, and training on compliance issues
• Monitoring, auditing, and internal reporting systems
• Discipline for non-compliance
• Investigations and remedial measures

Renewal

The HCCA requires CHC certificate holders to renew every two years. To renew they must pay a renewal fee of $115 for members and $225 for non-members. Also, candidates must complete 40 CCB CEUs, of which 20 CEUs must be from live training or events.

Eligibility

Compliance officers can earn a Certified Professional Compliance Officer (CPCO) through the AAPC. There are no eligibility requirements; however, the AAPC highly recommends that candidates have at least two years of work experience in compliance.

Testing

The CPCO exam is a 100-question multiple-choice test that must be completed in four hours. It costs $399 for one attempt and $499 for two attempts. Candidates are tested on the:

• Healthcare compliance program history
• OIG compliance program guidance for small practices
• Compliance program guidance for third-party billing and clinical laboratories
• IG supplemental compliance program guidance for hospitals
• Key and other risk areas
• Fraud and abuse laws
• Other laws and regulations
• Investigations process/audits
• References/resources

Renewal

To renew, candidates must pay a yearly membership renewal fee of $180. Every two years CPCO certificate holders must submit 36 hours of continuing education, of which 16 hours must be in compliance.

Evidence-based, data-driven decision-making is an instrumental part of cultivating quality in healthcare. With most healthcare organizations using electronic medical records (EMR) systems, data is abundant. However, with most EMRs providing non-specific reporting, a healthcare performance improvement (HPI) professional is there to idealize custom systems by which collected data is analyzed and used to create consistent healthcare outcomes and create plans for systemic improvement.

In addition to data-focused initiatives, healthcare performance improvement professionals also have a high-level understanding of interpersonal, management, and organizational methodologies (Six Sigma, FOCUS-PDCA, etc.) that can be used for systems improvement. Organizations that certify professionals in healthcare performance improvement include:

Eligibility

Anyone who wants to earn a credential in this field can earn the Certified in Healthcare Performance Improvement (CHPI) through the AIHQ. There are no eligibility requirements other than registering for the course and paying a $500 fee.

Testing

Candidates will complete 28 hours of education in healthcare performance improvement and take a comprehensive exam. The course covers:

• Performance improvement (PI) models
• Setting standards and developing measures
• Communicating measures
• Compliance monitoring systems
• Identifying improvement opportunities
• Aggregating and analyzing PI data
• Use of PI tools
• FMEA
• Six Sigma
• Communicating pi recommendations
• Measuring customer satisfaction
• Medical staff and organizing for PI
• Navigating accreditation, certification, and licensure processes

Renewal

The AIHQ requires CHPI certificate holders to renew every three years by paying a $150 fee and submitting proof of 80 hours of continuing education.

In addition to those listed above, the International Board for Certification of Safety Managers (IBFCSM) offers several unique healthcare safety certifications, including:

• Certified Hazard Control Manager (CHCM)
• Certified Healthcare Emergency Professional (CHEP)
• Certified Healthcare Fire Safety Professional (CHFSP)
• Certified Emergency Disaster Professional (CEDP)
• Certified Product Safety Manager (CPSM)