Health Accreditation Certification Program
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Quick Look: Accreditation-Specific Certifications

HCPro, Briefings On Accreditation and Quality, April 2019
By Dan Egli, PhD, Roman Healthcare Group
Motivated professionals are usually lifelong learners. Often they pursue niche certifications as part of their professional improvement and growth. Hospital quality leaders who find themselves growing more skilled and successful in continuous survey readiness (CSR) activities now have two accreditation-specific certifications available to them. This article and accompanying chart will provide you with a way to compare and contrast these certifications across 30 parameters.
One of the certifications is from Joint Commission Resources (JCR), and the other is from the Center for Improvement in Healthcare Quality (CIHQ). The JCR certification is called the Certified Joint Commission Professional (CJCP), while CIHQ offers the Healthcare Accreditation Certified Professional (HACP) credential.
As a quality services consultant, I’ve spoken with more than 50 professionals nationally, from quality directors to vice presidents, who’ve taken point on numerous surveys in their hospitals and hospital systems. All of these individuals have gone on to earn either the CJCP or the HACP certification (or both). In some cases the employer paid for the exam fee, but in no instance was there any financial incentive to get the certification.
When asked why they wanted to pursue an accreditation-specific certification, these professionals gave a range of responses, including:
  • Enhanced confidence in ongoing CSR and survey outcomes
  • Collegial respect, especially when presenting or publishing
  • Career advancement
  • Increased opportunities for promotion and salary increase
  • Evidence and recognition of cutting-edge expertise in regulatory standards
  • Improved quality of care, patient safety, and risk reduction
  • Personal satisfaction of achieving new goals in one’s field
Twenty hospitals indicated they either required or preferred someone with an accreditation certification when seeking to fill a quality services role. The hospitals listed unsatisfactory survey results and a desire to improve survey readiness and outcomes as reasons. They stated they’d have greater confidence in a quality services candidate if that person had either a CJCP or HACP certification. This included candidates for quality director, chief quality officer, and vice president of quality. Hospitals also indicated they were excited to have this person educate staff as part of a hospital, or system-wide optimization of CSR activities—pre-survey, on-site, and post-survey.
The majority of quality service professionals in acute care hospitals have a wide scope of responsibilities. Each of these seven “lanes” of quality services come with their own respective certifications:
  • Quality: CPHQ
  • Health information & technology: CPHIMS and CAHIMS
  • Patient safety: CPPS
  • Risk management: CPHRM
  • Infection prevention: CIC
  • Performance/process improvement: Certified Lean/Six Sigma (CLSS)
  • Regulatory compliance/accreditation: CJCP and HACP
In some cases, other areas are added to these “lanes,” such as medical staff or employee health. However, the foundation for all these activities is a strong knowledge base in accreditation and the CMS Conditions of Participation, as well as industry rules, regulations, and standards.
Accreditation-Specific Certifications
Lead Writer: Dan Egli, PhD, The Roman Healthcare Group
Contributors: Julie Brown, CJCP, HACP, Director, Regulatory Compliance; Palmetto Health, Jodi Eisenberg, MHA, CPHQ, CPMSM, Senior Director, Programs, Vizient, Matt Kutz, BS, Kutz Technology Services
  The Joint Commission:
Certified Joint Commission Professional (CJCP)
Healthcare Accreditation Certified Professional (HACP)
Eligibility 1. A bachelor’s degree and two years of regulatory compliance/accreditation experience
2. An associate's degree or RN credentials plus five years of regulatory compliance/accreditation experience
Active or recent hospital employment and two years of regulatory compliance/accreditation experience. Inpatient experience preferred.
Initial Fee $375 • $275 or $225 for CIHQ facilities
• $345 for a prep course and proctored exam or $275 for CIHQ facilities
Recertification Fee $350 • Continuing education unit = $180
• Online = $205
• Prep course and proctored exam = $275
Certification Valid For Three Years Two Years
Exam Content The Joint Commission survey process and standards per the Comprehensive Accreditation Manual for Hospitals (CAMH) CMS surveys, certification process, and Conditions of Participation (CoP)
Exam Length Three Hours Three Hours
Number of Questions 150 120
2018 Passing Score 78% in 2018 70%
Pass Rate More pass than fail; the results haven't been released yet by JCR • 90% pass online
• 98% pass the proctored exam
Grading Time Results available immediately after exam Results available immediately after exam for online; within 24 hours for proctored exam
Score Reports Provided Yes Yes
Test Frequency Quarterly:
• January
• April
• July
• October
• Online year-round
• Annual in-person exam
# Professionals Certified 501 980–1,150
CE Hours Needed 20 exclusively from TJC; 10 at the discretion of the CJCP 24
CE Frequency At discretion of CJCP within three-year term At discretion of HACP within two-year term
Accepts CEs from the Other Certification Allows 10 out of 30 CEs to be from HACP Accepts CEs from CJCP
Exam Prep Training workshops, books, and modules are available at JCR:
Study guides and practice exams are available at CIHQ:
Testing Sites Over 600 sites in U.S. and 1,600 globally One site
Proctored Exam Yes Yes
Testing Agency PSI Services LLC ( • Exam Builder online (with protocols to prevent open-book testing)
• Proctored on-site
Passing Point sStudy/Cut Assessment Yes, they annually determine the cutoff passing score with a psychometric review Yes, they annually determine the cutoff passing score without a psychometric review
Retesting Option Yes, the next testing month Yes
Recertification Loyalty 75% stay with CJCP (comprehensive % since launch date) 85% stay with HACP (comprehensive % since launch date)
Psychometric Team/Psychometrist Yes No
Exam Updates Annually Annually
Demographics The majority of the CJCP cadre represents RN's with Master's Degrees and 7-10 years of direct survey process experience. However, CJCP recipients come from the ranks of many different hospital professionals. Unknown
Created In 2012 2009
Source Susan Murray Hanscom, MS, Associate Director, CJCP Program, JCR Richard Curtis, RN, MS, CEO, Executive Director, CIHQ
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