Estes 1

Katie Estes

Professor Babcock

ENGL 138T, Section 002

17 April 2023

Addressing Language Barriers in American Healthcare

“Dr J is a second-year emergency department (ED) resident physician who, during an

unusually busy shift, sees MM, a 13-year-old girl, accompanied by her father; this is their third

visit to the ED this week. MM, rubbing her belly, appears somewhat uncomfortable but in no

apparent distress. After 15 minutes of fumbling with an interpreter via phone, Dr J realizes that

MM and her father speak a language or dialect not available via the interpreter phone service.

The 3 navigate a broken English dialogue that seems to reveal that, for 5 days, MM has had

decreased appetite and abdominal pain, which was most severe yesterday and since then has

improved. Dr J’s physical examination of MM reveals mild, diffuse, nonspecific abdominal

tenderness that seems most consistent with acute gastroenteritis. Dr J leaves MM’s room and

confers with Dr C about a treatment plan. Dr J returns to MM, suggesting she take

acetaminophen for pain, and arranges for MM’s discharge from the ED before moving on to

another patient.

Two days later, MM returns to the ED with an abdominal abscess from a ruptured

appendix, in septic shock, and requiring urgent surgical intervention. Dr J wonders what she

might have done differently.”i

 Estes 2

This story is just one representation of the various barriers that prevent non-English

speaking patients from receiving equitable healthcare in the United States. Miscommunication

can be frustrating in any industry, but it is dangerous in medicine. Imagine the stress of rushing

to the emergency department, only to face the additional confusion of being unable to

comprehend the words of those trying to help. Without effective communication, providers

cannot properly treat patients. Being that health professionals should strive to “do no harm,”

overcoming language barriers is an urgent requirement for fulfilling this goal.

Language barriers specifically refers to the difficulty for people who speak different

languages to understand each other. These barriers cause poorer health outcomes, lower quality

of care, and reduced access to medical services for patients and families with limited English

proficiency (LEP).ii How can America’s healthcare system work to overcome language

disparities and minimize the inequities faced by linguistic minorities in the population?

The solution to this problem may seem simple: use interpreters and translators. However,

language barriers are a multi-dimensional issue, making solutions complicated to implement

correctly. Consider a true account from a 2017 graduate of Penn State College of Medicine.

While a medical student serving on Hershey Medical Center’s psychiatry service, he met a

patient who was referred to the emergency room by her family doctor for “acute suicidal

ideations.” The patient spoke Mandarin, so the med student used a remote video interpreter to

communicate with her. During this interaction, the interpreter determined that the referring

physician confused a word for a sensation in the chest and thought the patient wanted to stab

herselfiii. Although this misunderstanding was eventually corrected and the patient was not

physically harmed, she spent multiple hours in the emergency room with no explanation of why
 Estes 3

she was there. This anecdote shows how even simple communication errors can snowball into

significant misunderstandings.

Figure 1iv
The two previous cases illustrate both the direct and indirect consequences of language

barriers in healthcare. In the first situation, deficits in a healthcare organization’s interpretation

services led to misdiagnosis and acute patient harm that could have been easily avoided in the

absence of language barriers. This concept applies to similar situations – such as instances where

the patient is unable to communicate information such as family history or drug allergies – in

which the patient received the wrong treatment or experiences a life-threatening allergic reaction

because the provider made decisions without considering the complete picture.
 Estes 4

On the other hand, the second story demonstrates indirect consequences that stem from

misunderstanding. Here, a physician’s misinterpretation induced a confusing, time-consuming

chain of events. It makes sense why non-English-speaking populations often feel alienated by the

American healthcare system: lack of effective communication between providers and patients

often undermines trust and deters them from seeking care.v Thus, even if language barriers do not

result in direct physical harm, they still negatively impact the healthcare experience of America’s

LEP population.

Furthermore, despite widespread research indicating the efficacy of professional medical

interpreters at improving care for patients with LEPvi and the presence of federal and state

regulations, healthcare practices often fail to provide these resources for patients.vii Use of

professional medical interpreters has been shown to result in fewer communication errors,

improved patient comprehension, and improved overall patient satisfaction.viii Nevertheless,

medical interpreters remain underutilized in clinical settings despite widespread

acknowledgement of their benefits.ix Solutions to increasing access to interpreters in healthcare

would therefore focus on ways on enforcing policy that already exists. Cultural competency in

healthcare systems would also help non-English-speaking populations feel more comfortable,

represented, and understood.

Issue Statement

Language barriers are obstacles to providing equitable healthcare in America. Language-

discordant encounters, in which the patient and health professional do not speak the same

language, have been shown to result in “worse health outcomes, reduced access to health

information, and decreased satisfaction with care.”x,xi Therefore, it is important to take immediate
 Estes 5

action toward eliminating these linguistic to improve healthcare for America’s marginalized

group of culturally diverse people.

Context

Before examining solutions to overcoming language barriers, it is important to

understand crucial background information on the problem. The United States is a country with

high linguistic diversity, making language barriers more prominent in the U.S. than most other

nations. America does not have an official language, but English is the most commonly spoken.xii

Even so, the proportion of people who speak a language other than English at home or have

Limited English Proficiency (LEP) has increased significantly over the past few decades,

increasing the demand for solutions to overcome these issues (Figure 1).xiii According to the

national census, nearly sixty eight million Americans spoke a language other than English at

home in 2019.xiv Spanish is the most common non-English language: sixty two percent of

Americans who do not speak English at home speak Spanish.xv Also, three-fourths of U.S. born

individuals with LEP and two-thirds of immigrants with LEP speak Spanish.xvi It is especially

urgent to implement solutions to language barriers in the U.S. considering America’s

proportionately high language diversity compared to other nations.

 Estes 6

Figure 2xvii
Current policy surrounding language barriers is another crucial component of

understanding language barriers in American healthcare. To begin, Title VI of the Civil Rights

Act of 1964 is a federal non-discrimination policy that prohibits discrimination on the basis of

race, color, and national origin for programs that receive government funding.xviii This includes

programs such as Medicare and Medicaid.xix It is important to acknowledge that healthcare

practices with the monetary flexibility to operate without federal financial aid are not mandated

to uphold this policy.

On the statewide level, Pennsylvania does not enforce additional policy, but there are

guidelines that have been developed to help clinics adhere to the federal requirements. The most

prominent guidelines are the National Standards for Culturally and Linguistically Appropriate

Services (CLAS). These recommendations outline manageable steps for implementing language

appropriate care in medical settings.xx Examples of standards include providing language

 Estes 7

assistance free of charge, informing patients that language assistance is available (in their

preferred language), and ensuring the competency of the individuals providing language

assistance.xxi This includes avoiding ad hoc interpreters, such as family members, minors, or

bilingual staff.xxii CLAS also recommends providing easy-to-understand print and multimedia

materials in the languages commonly used by the populations in the service area.xxiii

Although these standards exist, many hospitals do not comply with them. For

perspective, one study found that 13% of hospitals met all four of CLAS’s language-related

standards, whereas 19% met none.xxiv This shows that, despite public access to these standards,

there are widespread barriers to properly implementing them. Healthcare organizations

commonly face the challenges of inadequate interpreter staffing, functional limitations with

video or telephone services, and interpretation errors.xxv Interpretation services may be

unavailable in less common languages, or clinicians may lack the proper training to use

them.xxvi,xxvii It is also difficult to gauge issues and progress related to language barriers because

there is limited data collection and documentation of clinician language skills.xxviii

Ultimately, these barriers to implementation exacerbate the lower satisfaction scores and

decreased comprehension of at-home care routines in LEP communities.xxix Thus, a multi-

dimensional approach to overcoming language barriers is necessary to compensate for the variety

of factors that play into linguistic disparities in healthcare.

Identifying Solutions

One of the best ways to combat language barriers in healthcare is to increase access to

interpreters and translators. How is this accomplished? A major step involves increasing

exposure to interpreters in medical training. All healthcare organizations should adopt programs
 Estes 8

that allow them to a) incorporate interpreter training into the curriculum for prospective

healthcare providers, b) integrate updated training into Continuing Medical Education (CME)

credits for current providers and c) train bilingual staff as medical interpreters.

Healthcare providers can play their part by helping establish an Interpretation Services

Policy if their practice does not have one. There are many online resources, including an example

policy created by U.S. Department of Health and Human Services, that outlines specific steps

organizations should take to ensure equitable access to services for LEP individuals.xxx This

policy specifically breaks the task down into five key steps: identifying LEP individuals and their

language, obtaining a qualified interpreter, providing written translations, providing notice to

LEP individuals, and monitoring language needs and implementation.xxxi This is just one example

of the plethora of public resources that are available for healthcare professionals to implement

into their institutions to achieve tangible progress.

Research identifies health professionals’ lack of training in how to use interpreters as a

major contributing factor to language barriers. The first step of overcoming this obstacle is

modifying the curriculum of medical, nursing, physician assistant, and other professional schools

to require training for graduation. This training would include instruction on how to work

interpreters integrated throughout the existing curriculum, followed by a skill-based evaluation

where the student completed a simulated appointment with a non-English speaking patient.

Considering the existing requirements in most health professional schools, it would be

reasonable to educate students about how to effectively work with interpreters and interpretation

services as part of their required training.

In 2022, Mayo Clinic’s medical school implemented a program like the one described

above.xxxii The creators of this program emphasized the need for hands-on experience instead an
 Estes 9

online training course because students were able to improve by learning from their mistakes.

For example, after completing her simulation, one medical student learned that it was important

to speak in short sentences and pose each question individually for the interpreter to translate.xxxiii

Another student realized the importance of body positioning: introductions should take place

with herself, the interpreter, and the patient standing in a circle, but she should talk directly to the

patient for the remainder of the appointment.xxxiv These stimulated encounters provided students

with personal experience interacting with interpreters and identified individualized areas for

growth that would not have been available in an online training.

Additionally, there must be an option to educate currently practicing clinicians that have

already completed professional school. A feasible place to implement this training would be in

existing Continuing Medical Education (CME) requirements, which serve to “maintain, develop,

or increase the knowledge, skills, and professional performance” of new areas in their field.xxxv

Pennsylvania requires that physicians complete one hundred CME credits every two years.xxxvi

Because the specific breakdown of CME requirements is subject to change, it would be practical

to add interpretation training to the list. Without this training, many providers may continue to

lack the complete knowledge to know when, how, and why to use professional interpreters, or

they may attempt to use their own limited language skills to “get by” without using a

professional interpreter.xxxvii,xxxviii,xxxix

A potential disadvantage with the suggestions outlined above is that health providers may

be hesitant to add more work to their already busy schedules. Burnout is a significant issue that

has come to greater attention in the past few years, and it is foreseeable that providers may be

tempted to click through an online course without genuinely completing it. This would not be out

of malintent, but simply due to the fact there are already many required training courses in place
 Estes 10

designed to improve competencies in other areas of healthcare. Compensating for this would

require that the training be interactive and in-person instead of online. Even this option has its

drawbacks because it requires participants to take extra time out of their day. Overall, though,

this relatively small investment would significantly benefit the experiences of LEP patients with

healthcare and warrant mandated integration into both training for prospective and current

healthcare providers.

An additional solution includes training existing bilingual staff as medical interpreters.

This would capitalize on resources that are already present in healthcare organizations.

Furthermore, it is important to certify bilingual individuals in medical interpretation because

knowing how to speak a language and how to communicate meaning are two separate abilities

Certification reduces common interpretation errors – omission, false fluency, substitution,

editorialization, and addition – and teaches interpreters how to stay neutral.xl Two organizations

that offer recognized certification in medical interpretation are the Certification Commission for

Healthcare Interpreters and the National Board of Certification for Medical Interpreters.xli,xlii

Hershey Medical Center implemented a program like this with their bilingual medical students,

and it was highly successful. The students were able to gain valuable cultural competency

experience while also helping the hospital manage demand for interpreters.xliii It makes sense to

take advantage of current resources by using bilingual staff while also ensuring that they are

competent at providing correct care.

 Estes 11

xliv

Figure 3
Moreover, incorporate interpreter training into the curriculums of health professional

schools, CME requirements for current providers, and existing bilingual staff seem to be

effective approaches to combating language barriers by increasing access to interpreters in the

American healthcare system.

Dealing with Disadvantages

The chief barrier preventing healthcare practices from offering adequate language

assistance services is lack of funding. Hiring professional medical interpreters can be too

expensive for organizations to afford, especially if they only serve a very small LEP population

or operate a smaller practice in a rural area.xlv As a relatively large academic institution, Hershey

Medical Center is able to hire the services of Language Line, a professional interpreting and
 Estes 12

translation service.xlvi Language line provides both over-the-phone and video remote

interpretation at the Med Center. The phone service is available twenty-four-seven in 240

languages/dialects while the video interpretation, administered through an iPad (Figure 3), offers

forty languages/dialects as well as American Sign Language interpretation.xlvii The Medical

Center also has in-person Spanish medical interpreters and medical document translation

services, including English and Spanish brail translation.xlviii

Figure 4xlix
It is evident that smaller practices would not have access to the financial resources

necessary to purchase this scale of language assistance for their patients. The most promising

source of this much-needed funding for these institutions is in the form of government grants.

Examples of grants options include the Rural Emergency Hospital Technical Assistance Center,

which has awarded up to two-and-a-half-million-dollars, Rural Health Services Outreach

Program, which typically offers two-hundred fifty-thousand-dollar awards, and the Small Health

Care Program Improvement Program, which issues two-hundred-thousand-dollar awards.l,li,lii

 Estes 13

Health professionals could apply for these grants, and many others, to acquire additional

financial assistance for increasing access to interpreters at their practice.

There are other ways to overcome language barriers in healthcare. Creating pamphlets

that summarize common medical conditions and medical terminology could be beneficial in

primary care and general practice settings. However, ensuring adequate access to interpreters

should be prioritized because it would have a much more profound effect on improving the

experiences of LEP individuals in the healthcare system. Also, although pamphlets have the

capacity to work well in primary care and pediatric medicine, there are many specialties with too

many unique conditions for a simple pamphlet to be effective.

Like many ideas for change, these proposed solutions have disadvantages. However,

there are practical ways to compensate for these difficulties that make these solutions

implementable into current practice.

Conclusion

It is evident that language barriers are an urgent problem threatening the health and

wellbeing of limited English proficiency (LEP) individuals in America. Research continues to

sow how these barriers impede access to healthcare, compromise quality of care, and increase the

risk of adverse health outcomes for LEP patients.liii Despite federal policy that mandates non-

discriminatory policy, many healthcare institutions lack appropriate language services. Overall,

this leads to inequitable care for non-English-speaking groups of people and contributes to

language disparities within the healthcare system. Combating these obstacles is most effectively

achieved by increasing awareness of the problem. This includes properly training all healthcare

professionals to be proficient at working with interpreters (whether they are in-person, video
 Estes 14

remote, or on the phone) and initiating official medical interpretation certification for bilingual

staff. With resources such as government grants available to provide supplemental funding these

action plans are the most effective steps toward improving linguistically diverse healthcare in

America. More importantly, combating this specific inequity is part of the larger goal to

eliminate all disparities across healthcare and foster equitable opportunities for everyone.
 Estes 15

Notes
i
Espinoza, Jason, and Sabrina Derrington. “How Should Clinicians Respond to Language
Barriers That Exacerbate Health Inequity?” Journal of Ethics | American Medical Association,
American Medical Association, 1 Feb. 2021, https://journalofethics.ama-assn.org/article/how-
should-clinicians-respond-language-barriers-exacerbate-health-inequity/2021-02.
ii
Ibid
iii
“College of Medicine Students Take on Interpreter Roles.” Penn State Health News, 4 Dec.
2019, https://pennstatehealthnews.org/topics/college-of-medicine-students-take-on-interpreter-
roles/.
iv
“The Health Care Language Barrier #Infographic: Language Barrier, Health Care, Infographic.”
Pinterest, 29 Sept. 2014, https://nl.pinterest.com/pin/the-health-care-language-barrier-
infographic--87820261459743736/.
v
Espinoza, Jason, and Sabrina Derrington. “How Should Clinicians Respond to Language
Barriers That Exacerbate Health Inequity?” Journal of Ethics | American Medical Association,
American Medical Association, 1 Feb. 2021, https://journalofethics.ama-assn.org/article/how-
should-clinicians-respond-language-barriers-exacerbate-health-inequity/2021-02.
vi
Karliner LS;Jacobs EA;Chen AH;Mutha. “Do Professional Interpreters Improve Clinical Care
for Patients with Limited English Proficiency? A Systematic Review of the Literature.” Health
Services Research, U.S. National Library of Medicine,
https://pubmed.ncbi.nlm.nih.gov/17362215/.
vii
Chen, Alice Hm, et al. “The Legal Framework for Language Access in Healthcare Settings: Title
VI and beyond - Journal of General Internal Medicine.” SpringerLink, Springer-Verlag, 24 Oct.
2007, https://link.springer.com/article/10.1007/s11606-007-0366-2.
viii
Karliner LS;Jacobs EA;Chen AH;Mutha. “Do Professional Interpreters Improve Clinical Care
for Patients with Limited English Proficiency? A Systematic Review of the Literature.” Health
Services Research, U.S. National Library of Medicine,
https://pubmed.ncbi.nlm.nih.gov/17362215/.
ix
Ibid
x
Diamond, Lisa, et al. “A Systematic Review of the Impact of Patient-Physician Non-English
Language Concordance on Quality of Care and Outcomes.” Journal of General Internal
Medicine, U.S. National Library of Medicine, Aug. 2019,
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6667611/.
xi
“Scoping Review: Definitions and Outcomes of Patient-Provider Language Concordance in
Healthcare.” Patient Education and Counseling, Elsevier, 24 May 2020,
https://www.sciencedirect.com/science/article/pii/S0738399120302913?via%3Dihub.
xii
“Official Language of the United States.” USAGov, https://www.usa.gov/official-language-of-us.
xiii
Hernandez, Sandy Dietrich and Erik. “Nearly 68 Million People Spoke a Language Other than
English at Home in 2019.” Census.gov, 13 Dec. 2022,
https://www.census.gov/library/stories/2022/12/languages-we-speak-in-united-states.html.
xiv
“2015 Language Map App.” LEP, https://www.lep.gov/maps/lma2015/Final.
xv
Hernandez, Sandy Dietrich and Erik. “Nearly 68 Million People Spoke a Language Other than
English at Home in 2019.” Census.gov, 13 Dec. 2022,
https://www.census.gov/library/stories/2022/12/languages-we-speak-in-united-states.html.
xvi
Jie Zong, Jeanne Batalova Jie Zong and Jeanne Batalova. “The Limited English Proficient
Population in the United States in 2013.” Migrationpolicy.org, 27 June 2022,
https://www.migrationpolicy.org/article/limited-english-proficient-population-united-states-2013.
xvii
Bureau, US Census. “Language Use.” Census.gov, 6 July 2022,
https://www.census.gov/topics/population/language-use.html.
xviii
“Title VI of the Civil Rights Act of 1964.” The United States Department of Justice, 9 Apr.
2023, https://www.justice.gov/crt/fcs/TitleVI.
xix
“ASL Interpretation Services.” Department of Human Services,
https://www.dhs.pa.gov/Services/Assistance/Pages/ASL%20Interpretation
%20Services.aspx#:~:text=Medical%20Assistance%20%28MA%29%20doctors%20must
%20give%20free%20access,Assistance%20Programs%20expects%20all%20MA%20doctors
%20to%20comply.
xx
“Clas Standards.” CLAS Standards | Achieving Health Equity, https://www.cms.gov/Outreach-
and-Education/MLN/WBT/MLN1857916-OMH-AHE/OMHAHE/ahe/lesson01/09/index.html.
xxi
Ibid
xxii
Ibid
xxiii
Ibid
xxiv
From the *Department of Health Policy Research. “Do Hospitals Measure up to the National
Culturally and... : Medical Care.” LWW,
https://journals.lww.com/lww-medicalcare/Fulltext/2010/12000/Do_Hospitals_Measure_up_to_t
he_National_Culturally.6.aspx.
xxv
Espinoza, Jason, and Sabrina Derrington. “How Should Clinicians Respond to Language
Barriers That Exacerbate Health Inequity?” Journal of Ethics | American Medical Association,
American Medical Association, 1 Feb. 2021, https://journalofethics.ama-assn.org/article/how-
should-clinicians-respond-language-barriers-exacerbate-health-inequity/2021-02.
xxvi
Ibid
xxvii
Hsieh, Elaine. “Not Just ‘Getting by’: Factors Influencing Providers' Choice of Interpreters -
Journal of General Internal Medicine.” SpringerLink, Springer US, 23 Oct. 2014,
https://link.springer.com/article/10.1007/s11606-014-3066-8.
xxviii
“Explore Scientific, Technical, and Medical Research on ScienceDirect.” ScienceDirect.com |
Science, Health and Medical Journals, Full Text Articles and Books.,
https://www.sciencedirect.com/.
xxix
Ramirez, Dorian, et al. “Language Interpreter Utilization in the Emergency Department Setting:
A Clinical Review.” Journal of Health Care for the Poor and Underserved, Johns Hopkins
University Press, 8 May 2008, https://muse.jhu.edu/article/236054.
xxx
(OCR), Office for Civil Rights. “Example of a Policy and Procedure.” HHS.gov, 1 Nov. 2021,
https://www.hhs.gov/civil-rights/for-providers/clearance-medicare-providers/example-policy-
procedure-persons-limited-english-proficiency/index.html.
xxxi
Ibid
xxxii
Mayo Clinic College of Medicine and Science. “Bridging the Language Gap: Medical Students
Use Interpreters to Better Connect with Patients - News Archive - Mayo Clinic College of
Medicine & Science.” Mayo Clinic College of Medicine and Science, Mayo Clinic College of
Medicine and Science, 6 June 2022, https://college.mayo.edu/about/news/news-archive/bridging-
the-language-gap-medical-students-use-interpreters-to-better-connect-with-patients/.
xxxiii
Ibid
xxxiv
Ibid
xxxv
“What Is CME Credit?” National Institutes of Health, U.S. Department of Health and Human
Services, 20 Mar. 2017, https://www.nih.gov/about-nih/what-cme-credit.
xxxvi
“Pennsylvania CME Requirements 2022.” Pennsylvania CME Requirements 2022,
https://www.giblib.com/blog/pennsylvania-cme-requirements-2022#:~:text=For
%20Pennsylvania%20MD%20physicians%2C%20you%E2%80%99ll%20need%20to
%20fulfill,prescribing%20or%20dispensing%20opioids%20%28For%20DOs%3A%20AOA
%201-A%29.
xxxvii
Ibid
xxxviii
Ibid
xxxix
“Errors in Medical Interpretation and Their Potential Clinical Consequences in Pediatric
Encounters.” Publications.aap.org, 2003,
https://publications.aap.org/pediatrics/article/111/1/6/28542/Errors-in-Medical-Interpretation-
and-Their?autologincheck=redirected.
xl
Ibid
xli
“Certification Commission for Healthcare Interpreters.” CCHI, 14 Apr. 2023,
https://cchicertification.org/.
xlii
Ibis
xliii
“College of Medicine Students Take on Interpreter Roles.” Penn State Health News, 4 Dec.
2019, https://pennstatehealthnews.org/topics/college-of-medicine-students-take-on-interpreter-
roles/.
xliv
Ibid
xlv
Schulson, Lucy B., and Timothy S. Anderson. “National Estimates of Professional Interpreter
Use in the Ambulatory Setting - Journal of General Internal Medicine.” SpringerLink, Springer
International Publishing, 2 Nov. 2020, https://link.springer.com/article/10.1007/s11606-020-
06336-6.
xlvi
“Language Assistance Services.” Penn State Health, https://www.pennstatehealth.org/language-
assistance-services.
xlvii
Ibid
xlviii
Ibid
xlix
“Laws Requiring Interpreters in Healthcare.” Certificate Interpreter Training Programs® -
Official Site, https://interpretertrain.com/laws-requiring-interpreters-in-healthcare/.
l
“Rural Emergency Hospital: Rural Health Redesign Center.” RHRCO,
https://www.rhrco.org/reh-tac#:~:text=As%20of%20September%202022%2C%20the
%20RHRCO%20has%20been,of%20the%20new%20Rural%20Emergency%20Hospital
%20provider%20designation.
li
“HRSA Electronic Handbooks.” Funding Cycle View | HRSA EHBs,
https://grants.hrsa.gov/2010/Web2External/Interface/FundingCycle/ExternalView.aspx?
fCycleID=b5aeff2a-c333-4ed2-9124-5b7b25384597#:~:text=This%20notice%20announces
%20the%20opportunity%20to%20apply%20for,underserved%20populations%20in%20the
%20local%20community%20or%20region.
lii
“Small Health Care Provider Quality Improvement Program Awards.” HRSA,
https://www.hrsa.gov/rural-health/grants/rural-community/small-health-care-provider-quality-
improvement-awards.
liii
Pennsylvania Patient Safety Authority. “Managing Patients with Limited English Proficiency:
Advisory.” Pennsylvania Patient Safety Authority,
http://patientsafety.pa.gov/ADVISORIES/Pages/201103_26.aspx.