As the U.S. immigrant population increases, many hospitals are seeking ways to improve their interpreter services, but there is "no clearly identified game plan for hospitals to decide what mix of language services to provide, by whom and how," United Press International reports. Nearly 90% of hospitals recently surveyed by the American Hospital Association said they were combining bilingual staff, telephone interpretation services and full-time interpreters to serve the needs of patients, who speak more than 80 different languages. Previous studies have found that inadequate communication with patients negatively effects quality and efficiency of care, including decreased use of primary care and increased use of expensive diagnostic tests and emergency departments. Don Schinske, executive director of the California Healthcare Interpreting Association, said there is little agreement on what level of training is sufficient for the medical interpreter providing the services. Interpretation services "were largely provided on an ad hoc basis by family members and bilingual staff," but now community colleges offer yearlong courses and some employers send staff to weeklong training sessions, UPI reports. Washington is the only state that offers an official certification for medical interpreters, according to Schinske. Many interpreters in other states are not evaluated to see if they have specialized vocabulary and communications skills that are appropriate to a hospital setting, according to UPI. Interpreters also might not be familiar with other best practices, such as repeating information back to a patient or giving physician instructions to a patient using first person, Schinske said (Pierce, United Press International, 10/13).