Over the past several decades, the United States has become an increasingly multilingual society. This is a marked transformation from the previous "melting pot" ideal, where immigrants and even Native Americans were encouraged to shed their native languages and adopt English.

Since 1990, the number of Americans whose primary language is not English has nearly doubled, from 32 million to over 60 million. America, a country that once took pride in being an "English-only" nation has scrambled to adapt.

The American healthcare industry has been under particular pressure to respond to a huge uptick in demand for services by non-English speaking patients. According to the most recent United States census, 80 percent of hospitals encounter patients with limited English proficiency on a frequent basis.

With people’s lives quite literally at stake, the need for healthcare providers to communicate in languages beyond English is greater than ever. Title VI of the Civil Rights Act prohibits discrimination on the grounds of race, color or national origin connected to any programs or activities receiving federal assistance.

Not providing qualified language services to patients constitutes a clear violation of Title VI, as patients of all backgrounds must receive the same standard of care, even if that must be done in a language other than English. More recently, the Affordable Care Act provides additional incentive for providers to expand their language capabilities (Section 3025).

Despite these laws, however, there is often confusion or even a complete lack of awareness in the medical community about what needs to be done. To this day, many hospitals and other healthcare providers rely on bilingual relatives of the patient or employees who are perceived to be fluent in more than one language.

The dangers of using such ad hoc interpreters cannot be overstated, particularly in a field where lives are at stake. As with any other specialized skill, taking someone's own opinion of their skill level carries major risks.

A study published by the Joint Commission in 2007 found that when patients with limited English proficiency have a medical issue, they are three times as likely to suffer a serious outcome. The same study shows that non-English-speaking patients experience more limited access to care and preventive services, longer hospital stays and unnecessary testing.

When healthcare providers are unable to accurately ascertain their patients' medical histories due to a language barrier, it is not surprising that these same patients would not receive the same quality of care.

A number of organizations have stepped up to the challenge of creating certification programs for medical interpreters, such as the International Medical Interpreters Association (IMIA), the country's oldest and largest such organization.

According to Izabel Arocha, executive director of the IMIA, their rigorous interpreter certification, overseen by the National Board of Certification for Medical Interpreters (National Board) was the first to offer national medical interpreter certification in 2009 and became accredited by the National Commission of Certifying Agencies in 2012.

The National Board offers certification for interpreters of Spanish, Russian, Mandarin, Cantonese, Korean and Vietnamese, as well as a certified medical interpreter credential (CMI), awarded only upon passing both a written and an oral performance exam.

Developed by interpreters for interpreters, the exam established a baseline of competency. It should be noted that some of the individuals who have been unable to pass the certification exams have had years of practice in the field, enabled simply by their own self-assessment and assumptions made by the institutions employing them.

As a further precaution, to ensure that interpreters have a high enough level of proficiency in each language, candidates must take an oral language proficiency test prior to sitting for the national certification test. They must score at the Advanced Mid level or higher (based on proficiency guidelines developed by American Council on the Teaching of Foreign Languages) in both English and their target language.

The Certification Commission for Healthcare Interpreters (CCHI) is the first national organization certifying healthcare interpreters to receive accreditation from the National Commission for Certifying Agencies (NCCA). CCHI offers a complete certification program that includes a core knowledge credential available in all languages, except Spanish, Arabic and Mandarin, and certification for interpreters of Spanish, Arabic and Mandarin.

The program was developed based on a comprehensive job task analysis of some 2,500 interpreters in the field to determine precisely what interpreting skills were needed to be successful. Unlike the IMIA, CCHI does not require a proficiency assessment as a prerequisite to taking the exam. Rather, candidates must complete at least 40 hours of healthcare interpreter training in order to be eligible to take the certification test.

"CCHI is very proud of its first 1000 certified and credentialed interpreters," said Kathleen K. Diamond, commissioner and vice-chair for outreach at CCHI. "In order to support them going forward, we have launched a continuing education accreditation program which will assess, analyze and accredit continuing education for healthcare interpreters."

Despite the efforts of the IMIA, CCHI and other organizations, providing non-English-speaking patients with qualified assistance continues to be a stumbling block for many, if not most, healthcare providers. Even hospitals and other healthcare providers that have Title VI compliance to ensure that medical interpreters are available when necessary find that staff members lack awareness about what actual compliance entails.

Lack of coordination between clinics and patient services department, for example, can lead to extremely inefficient and inadequate use of a hospital's interpretation services. Perhaps the biggest obstacle facing providers today is a continuing lack of awareness of what the legal ramifications of not having qualified language skills are.

To many physicians, it is far easier and more expedient to simply rely on their own or other employees' self-assessed language skills when interpretation is necessary. Naturally, this opens them up to liability issues — for example, how can you obtain informed consent from a patient that cannot understand what they are consenting to?

According to Bruce Adelson, CEO of Federal Compliance Consulting and a former senior attorney for the Department of Justice, many healthcare providers' existing programs to ensure Title VI compliance are not consistent with federal law. Even the best plans, however, can be rendered meaningless if staff do not receive the required training to understand what is required of them.

A major weak link in the area of Title VI compliance for hospitals is found among support staff, e.g. billing, reception, etc. Adelson says that awareness of Title VI among support staff continues to be astonishingly low, and even senior executives in the healthcare industry often are completely uninformed when it comes to compliance with the law.

For many providers, having support staff who self-assess as bilingual is a bonus, but not something they are actively seeking out. Without an independent verification of an employee's language skills, healthcare providers may be leaving open the door to liability, in addition to providing poor customer service.

It is critical to understand that even if a facility has medical interpreters available for physicians, not having qualified bilingual support staff means that it is not complying with Title VI.

Although some hospitals have now started having employees get certified through a number of private translation companies, Arocha of the IMIA says that many of these tests have not been extensively researched and validated, which could also jeopardize providers’ efforts to expand their multilingual capacities..

While the U.S. healthcare industry has undoubtedly made progress in the field of strengthening its language capabilities, the task of bringing healthcare providers into compliance continues to be a daunting one.

The ever-growing demand for these services makes it more critical than ever for healthcare providers to take action to care for non-English speaking patients. Providers who fail to do so run the risk of facing serious ethical and legal issues.