The cultural diversity found in America today presents unique challenges before the health care community. Communication is one of the biggest concerns. The 1990 US Census estimated that 14 million people living in the United States have limited English proficiency (Baker, et al. 1996). These figures would no doubt be even higher now, given the recent rate of immigration and the high birth rate of many immigrant groups. Health care providers are therefore increasingly finding it necessary to communicate with patients with whom there is a significant language barrier.

The Joint Commission of the Accreditation of Hospital Organizations has recognized this and has addressed it in its 1996 Comprehensive Accreditation Manual for Hospitals. In this manual standards are set requiring hospitals to "provide effective communication for each patient served, including the hearing and speech impaired." (Accreditation Manual for Hospitals 1996). Examples of Implementation for this are given and include access to interpreter/translator services, telecommunications for the deaf, and bilingual signs posted in areas of need (Accreditation Manual for Hospitals 1996). Despite these examples, there are no actual guidelines for implementation. The phrasing, it seems, is purposefully broad and vague in order that each institution could adapt the standards to meet its own needs. It is therefore up to the hospitals themselves to determine those needs and to create policies accordingly.

This study focuses on the ways in which the hospitals in Omaha, Nebraska have faced this challenge. Using a qualitative research method, the policies and procedures of each institution regarding interpreter/translator services are examined. Similarities and differences in the various policies are noted and explored. Finally, recommendations are made regarding improvements that could be made to meet the need more effectively.

A review of the literature related to interpreter and translator services in healthcare revealed several themes including need, use, selection, roles, styles, effectiveness, problems, and recommendations. Virtually all the articles found discuss the need for interpretation services in today’s health care settings. D’Avanzo (1992), Spring, Ross, Etkin, and Deinard (1995), and Brooks (1990) all focus on the needs of specific populations and the ways in which the language barrier impeded the delivery of health care to them.

Baker et al. (1996) reports a lack of interpreter use in an emergency department despite a perceived need by patients and shows that interpreter use greatly affected patient’s understanding of their disease and recommended treatment.

Poss and Rangel (1995) emphasize the importance of choosing a qualified interpreter and discuss numerous things to look for when hiring one. These will be mentioned later in the recommendations section of this paper. McIvor (1995) mentions the unique problems faced by refugees coming to the U.S. and notes that in the field of psychiatry, it is important to chose an interpreter with a particular knowledge of the political and cultural background from which such patients come.

Hatton (1992) and Hatton and Webb (1993) also emphasize the importance of interpreters as cultural bridges and go even further to define the role of interpreters, specifically in the field of community health nursing. They also provide a distinction between interpreter and translator that is quite useful. A study by Murphy, Anderson, and Lyons (1993) examines the vital role language interpretation plays in diabetic education with non-English speaking patients. They point out that culture is especially relevant in the management of a chronic disease such as diabetes due to the lifelong course of the disease and the focus on behaviors which are quite often culturally influenced. The role of the interpreter as health advocate is put forth by Parsons and Day (1992). Their findings suggest that this role may be an effective mechanism to address some of the adverse obstetrical outcomes observed in ethnic minorities.

Different styles of interpreting are identified and explained by Hatton and Webb (1993). They report that "collaboration", which allowed the health care provider and the interpreter to act more as colleagues, was the style felt by the majority of those studied to be the most effective type of interaction.

Vasquez and Javier (1991) put forth some problems encountered when working with interpreters. They enumerate five common errors interpreters make--omission, addition, condensation, substitution, and role exchange--and give case examples to illustrate them. Their recommendation then is for clinicians to watch for indications of these errors which may distort communication. Friend (1991) describes a case involving a bioethical dilemma in which the transfer of information between patient and physician was distorted due to the personal views of the interpreter.

Guidelines and recommendations are put forth by Poss and Rangel (1995). As stated above, they list numerous qualifications for interpreters to meet. In addition, they give guidelines for working with interpreters and make suggestions for novice interpreters. These will be further discussed in the recommendations section of this paper.

In summary, the literature included several themes including need, use, selection, roles, styles, effectiveness, problems, and recommendations regarding interpretation services. However, no study was found which looked at the services provided for interpretation at each hospital in a particular community to examine similarities and differences, strengths and weaknesses. Such is the intent of this study.

The major goal of this study was to discover what language interpretation services are currently being provided in Omaha hospitals. A secondary goal was then to explore what, if any, improvements could be made in these services.

The researchers included a member of the University of Nebraska Medical Center’s family medicine faculty, one of the program coordinators in the UNMC department of family medicine, and a senior medical student. Together they designed the interview questions and the format for the study. The student conducted the interviews and compiled the information which was then analyzed by the rest of the research team.

Approval of the University of Nebraska Medical Center’s Institutional Review Board was obtained prior to interview conduction.

The subjects were selected according to the duties of their position within the institutions studied. In each hospital the person whose job it was to handle and arrange for language interpretation services was sought and interviewed within a period of two weeks. This was more difficult at some institutions than others. Some hospitals have a specific position designated to directly handle these issues. At other hospitals, it was quite difficult to ascertain whose job it was, and often the person who seemed most knowledgeable about interpretation issues had a very broad job description which included many other unrelated duties. Participants therefore included five persons in Human Resource departments, two in Social Services, one in Patient Services, one in the Communications Center, and one with the title of Staff Development Coordinator.

The authors chose an exploratory qualitative field approach using individual in-depth interviews (see Crabtree and Miller, 1991; Crabtree and Miller, 1992) to gather information. Using McCracken’s approach (1989), the research team first reviewed the literature on the topic of language interpretation and translation. Members also discussed personal experiences on the subject and any preconceptions they may have had. Using this information, the team then developed an interview guide that included the following five major questions along with appropriate probes and prompts:

Interview Questions

1. What is your job as it relates to services to non-English speaking patients?

2. What interpretation/translation services are currently provided at your institution?

3. What limits interpreter availability/use?

4. Do you provide interpreter training?

The student researcher obtained informed consent from all those interviewed. The interviews were each 20-35 minutes in length and were audiotaped for later verbatim transcription by the program coordinator. Persons from four of the eleven hospitals refused to be interviewed in person. Two were then interviewed over the telephone, one requested the questionnaire but failed to return it, and one gave minimal information but refused an interview or questionnaire of any sort. All those interviewed were assured that the identification of both themselves and the institution they represented would be kept confidential and would not appear anywhere on the report.

The research team analyzed the verbatim transcripts of the interviews using the method outlined by Crabtree and Miller (1991). In this approach, researchers individually reviewed the transcripts, highlighted passages they felt to be significant, and then met as a group to compare notations and interpretations of each passage. Similarities and differences were noted. Common themes were identified.

The findings of this study will be divided into common themes and noted differences from the interviews.

Each institution represented recognized the need for services to non-English speaking patients. Although cultural diversity seemed to be emphasized more in some hospitals than others, they were universally aware that Omaha has undergone demographic changes that now require more of them in the way of patient communication. The areas of greatest need within the hospital were commonly identified as the emergency department, pediatric units, labor and delivery, and admitting. One of those interviewed additionally mentioned outpatient surgery as an area in which interpreters were needed and utilized. The need for future growth and improvement in the area of interpretation services was also acknowledged by all those interviewed. There seemed to be a universal feeling that this is an issue that the hospitals struggle with, and changes will continually need to be made.

Every person interviewed made some mention of the reality of limited finances. One stated that "Interpreters are very expensive, you know," and another remarked, "There are only so many resources." The services provided at each institution are clearly based on the number of patients seen requiring a particular service. Volume demonstrates need, and need determines where money will be spent. Whomever is responsible for coordination interpretation services has to be able to justify these services by the number of people served. Also, the time of the managerial personnel may be viewed as a limited resource. Those in charge of supervising and coordinating interpreters were often very difficult to locate. They all have numerous other duties as part of their job, and many told the interviewer outright that they are severely overworked. Their time is therefore a resource to be allocated as they feel appropriate, given the other demands on this time.

Each institution has some sort of policy in place regarding interpretation services. Some of those interviewed admitted that no such policy had been formulated previous to the Joint Commission standards in the most recent Manual for Hospitals; however, they had to create a policy in order to comply for accreditation. There are several common elements of these policies. One is the use of an employee language bank, in which each employee is asked when hired if she or he speaks another language and if she or he would volunteer if asked. Another is use of the AT&T Language Line, a telephone interpretation service in which a number can be called for an available interpreter for over 200 languages 24 hours a day. It is a three-way conference call which allows the health care provider to communicate with the patient through an interpreter over the phone. Hospitals differed in the reliance on this service, but virtually all of them reported using it to some extent. All institutions also made use of the TDD, the Telecommunication Device for the Deaf, and all interviewed were familiar with the Nebraska Commission for the Hearing Impaired to locate sign language interpreters. Finally, interpretation services were universally free; all those interviewed stated that the cost of providing any and all such services was not directly passed on to those requiring them.

The services each institution provides vary widely. Three of the ten hospitals employ full time Spanish interpreters to be available both in the hospital and the adjacent clinics. One of these has two full time and two part time staff paid by the hour in addition to a bilingual administrative assistant who sets up all appointments for Spanish-speaking patients. The other two each have one full time interpreter. This position is salaried at one hospital and is paid hourly at the other. The other seven institutions do not have Spanish interpreters on staff.

For languages other than Spanish, virtually all hospitals turn to their employee language bank in an attempt to find someone working at the hospital at the time who could take time away from their job to interpret. If that fails, there then are several different ways the need is met. Some institutions would call in an employee known to speak the needed language from home and pay them for their time. Others would go to a list of interpreters in the community. Still others would go directly to the AT&T Language Line for assistance. If the language needed is sign language, the Nebraska Commission for the Hearing Impaired is most often consulted.

On-call and after-hours needs are most often filled by employees who might happen to be working those shifts and could interpret. Although some institutions have a social worker on call who reportedly might be able to deal with interpreter requests, most of those interviewed reported that there is no interpreter designated to be "on-call" at any given time. One hospital does have Spanish interpreters on-call 24 hours a day seven days a week to cover emergency or unexpected situations anywhere in the hospital or clinic. These persons get paid three hours minimum each time they are called in and $1.00 an hour if they are not called in. Another hospital uses their salaried daytime interpreter if they need to during off-hours.

When those interviewed were asked,"What happens when a translator is not available?", several responses were given. Some stated that the AT&T Language Line is used in these circumstances. Others seek out members of the patient’s family or friends to interpret. One respondent stated that "We try to find someone working to interpret, and if no one is available to do that, then we just announce over the PA [public announcement] system that we need anyone who speaks such-and-such language to report to room such-and-such." Numerous respondents stated that they hadn’t run into the problem of not being able to find an interpreter very often. "It’s pretty rare that you just can’t find anybody that can help you out." One even went so far as to state, "That’s never happened."

Institutions also vary according to the other sorts of materials available to non-English speaking patients. Some places have written materials including procedural explanations and informed consent forms in other languages, most often Spanish. Videos and other sorts of visual aids are available in some hospitals as well. One respondent reported having a system of picture graphics and "point talk" for those who may be illiterate to communicate their basic needs.

The ways in which interpreters are selected and trained are also very different. Each of the three hospitals who hire Spanish interpreters to be on staff had advertised the position in the local newspaper and had formulated its own list of qualifications for the position. The representative of one of these hospitals stated that their hiring committee looks for a native speaker with a degree, preferably in a healthcare field, and experience in hospital work. Applicants are tested both orally and written for competence. Once hired, the interpreter is also sent through medical terminology training and must shadow another interpreter for a given number of hours to learn more about their position. The second institution prefers experience over education. This respondent stated that they looked for someone with prior interpreting experience but purposely did not seek out those with a degree because, "...we felt that if someone had a degree in that area, they probably would not be challenged by the day-to-day activities that are offered in translating and would want more in their job." No training is given to the interpreters beyond the 90 day orientation required for all employees of the institution. The person from the third hospital stated that their hiring committee looks for a bachelor’s degree in language or equivalent experience "because if somebody has been speaking Spanish as their native tongue for 20 years, that would be considered equivalent experience." The person then added that professionalism, organizational skills, and well-roundedness were also emphasized in the interview process. No specific training is provided upon hiring.

The interpreters used at one of the mental health inpatient facilities are selected with a quite different set of qualifications. There the respondent replied that behavioral health knowledge was valued and said that some of the interpreters used actually have counseling degrees and so are very knowledgeable about the appropriate terminology and approaches. The subject further stated,

"You want to have someone who’s compassionate, who is able to provide that warmth that you would provide in a therapy session. And someone who is knowledgeable about the disease process and is not going to be shocked or frightened about mental health in general because there’s a stigma that’s still out there in society and we need someone who feels comfortable in that sort of setting."

Because this sort of individual is sought out and is often trained in the behavioral sciences, the respondent felt that such a person would have already had confidentiality and professional ethics training. Therefore, no specific training was given to those asked to interpret.

The volunteers who are used at each institution to interpret are selected only on their self-professed ability and willingness to interpret adequately and are universally given no training. Employees who are asked to interpret may have some familiarity with medical terms based on their position, for example a nurse or nurse’s aide; however, others may be in housekeeping or in other positions in which they would likely not have these skills. Those interpreters hired from within the community also receive no training at any of the hospitals interviewed.

When asked about the policy regarding the use of family members and children as interpreters, a variety of answers were given. Most of those people interviewed stated that family, friends, children-- indeed anyone brought in by a patient--are often used as interpreters. Many of them felt this was adequate and a good solution to the problem of communication. A few stated that they realized this wasn’t ideal, but was often easier and more practical than other options. One respondent stated,

"The policy...is that the patient has the right to receive information in the language they understand best. And they also have the right to any interpreter that they want to use. If they bring their own interpreter, then we will let them do that."

Two of those interviewed mentioned the dangers of using such persons as interpreters. One of them replied

"We have to be very careful when we use a child because some of the questions you need to ask for, history and medical conditions, are private and the parent doesn’t necessarily want to have the child translating that information. So we try not to use children unless it’s absolutely necessary and then we try to use them for just, you know, the bare necessities."

The other stated that "...we do really try and get a translator in there so they [family members] can remain in their role as mother or child or whatever and not have to take on that role of translator."

The overall attitude or tone regarding services to non-English speaking patients was quite different from hospital to hospital. Some of those representing the institutions seemed to view providing these services as a burden, while others saw it as an integral part of the greater mission of the hospital. One example involves the topic of cost. Some responses to the question, "In your view, how do interpreters affect hospital costs?" may illustrate this rather well. One person answered, "Some of those interpreters we have to bring in cost up to $40 an hour. This can really add up, and we never had to do worry about this or spend this money before we had so many people in Omaha who don’t learn English." The interviewer’s field notes from this encounter also showed that this person seemed resentful that the institution is having to spend time (her time) and resources on services for non-English speaking patients. There were those, however, who had a much different perspective. One of these stated,

"Obviously, we incur a cost to pay the interpreter for their time, but, at the same time, if a patient does not thoroughly understand pre or post op information or orders or follow-up care, or whatever, they are going to be more likely to end up back in the hospital because they don’t know how to care for themselves, so it’s a good service to offer and is cost effective."

Still another perspective regarding the cost effectiveness of interpreters involved that of marketing. This

person remarked,

"Well, based on the increase in Spanish population and the clientele that we have been able to acquire, I would say our full-time interpreter has been extremely cost effective...Having this service has assisted us in hiring Spanish speaking physicians because they will refer them [patients] to our hospital because they know we can take good care of them...So I’d say it’s been very cost effective because we’ve increased our Spanish clientele."

The latter two quotations reflect a willlingness and even an eagerness to provide interpretation services for two somewhat different reasons.

Responses to the interviews themselves were drastically different from person to person. Some of those contacted were less than helpful and even in some cases quite defensive when asked about this topic. One person openly refused any sort of formal interview and stated that the institution she was a part of had nothing to say on the subject. Others, however, were eager to discuss it and expressed great interest in learning more about how they could help their institution improve its services to non-English speaking persons. It must be kept in mind that those contacted and interviewed had various positions within the institutions. An effort was made to ascertain who at each hospital was the most knowledgeable and appropriate person to talk to regarding this topic, but certainly it was apparent that some of those interviewed worked more closely with the interpreter services than others and so had more knowledge and interest than others.

It also must be kept in mind that these persons may not have accurately reflected the attitude and/or tone of the hospitals they represent. Many of the institutions likely have very positive views on diversity and the challenges inherent in it, and yet the persons interviewed there projected quite a negative tone.

The results of this study show that while each institution recognizes some need for interpretation services, is limited by resources available, and has formulated some sort of policy on the subject, the services provided by each hospital vary considerably. This is not surprising when one considers that the need for such services also varies widely. Each institution has its own needs. Some will attract a greater non-English speaking population than others whether it be due to location, marketing, or other factors. For this very reason, the Joint Commission’s standards are very vague. Each hospital is allowed to access its own situation and need and address it accordingly. But whether an institution is called upon to provide interpretation services 20 times a day or once every two years, they must ensure that they make every effort to "provide effective communication for each patient served". (Accreditation Manual for Hospitals 1996).

The differences in who is selected to interpret are very interesting. Those who pay interpreters and have them on staff have qualifications for them, and they each emphasize different qualities. The area of mental health is particularly unique in its requirements. This is not surprising, due to the absolute reliance on communication found in the mental health field. Those hospitals which use only volunteer employees or other volunteers have no requirements these individuals must meet. This brings up the question whether or not these persons are truly qualified to interpret the information they are asked to interpret. The use of family members and children for interpretation is particularly troubling. Although it is undoubtedly tempting to use them as an easy resource, it can be very disruptive to the family dynamics and can often leave sensitive information uncovered. The policy at one hospital stating that it is the patients right to use whomever they wish may sound reasonable, and certainly patient rights are vital and necessary, but the question arises whether or not the patient has his or her options regarding interpretation fully explained before he or she makes such a decision to use family, friends, or children for this important task.

Only one institution in ten provides any sort of training for those called upon to interpret. This presents an array of problems. The role of the interpreter is incredibly important, perhaps much more so than the provider, and even the person interpreting, may recognize. Hatton writes, "Interpreters in these bilingual, bicultural settings have considerable power, for they possess what both the client and the health-care provider need--an understanding of the other’s language." (1992). To accurately interpret information related to health care often requires knowledge of terminology that is likely not used regularly in one’s native language, and certainly not in one’s second language. Untrained interpreters are additionally less likely to understand their role as an interpreter. Vasquez and Javier (1991) pointed out five basic errors that are commonly made: omission, addition, condensation, substitution, and role exchange. Each of these errors can be very damaging to the exchange of information and could be at least in part eliminated by some level of training. Confidentiality is also of the utmost importance in health care. Whether the person interpreting is one who is being paid to do so, is an employee in some other area of the hospital, or simply a person who answered the call over the PA system asking for an interpreter, that person is privy to the most intimate information a patient may give. Most will not be familiar with the strict code of confidentiality that is required of all health care professionals, and so sensitive information may be violated.

The overall tone presented by those interviewed was at times disappointing. One would hope that those handling or supervising interpretation services would be sensitive to appropriate issues and would show a true interest in such. Some of those interviewed were noticeably quite out-of-touch with the situation. It was obvious, for example, that the person who stated that interpreters with a degree "would not feel challenged" and "would want more from their job" does not understand what an incredibly complex job interpreting is. The remark, "That’s never happened," when asked what is done when an interpreter cannot be found, shows a clear sense of denial that there could be any problems with their current system. Perhaps this is in part due to the current competitive climate between health care providers. Each institution wants to market itself as the best for every need and so feels threatened when asked to evaluate an area of possible shortcoming.

This study had several limitations. Much of the information gathered dealt primarily with Spanish interpretation services. An effort was made to ask questions which were broad enough to cover all language interpretation, but most institutions had the greatest need for Spanish-speaking interpreters, and so that was their major focus. Many of those interviewed also mentioned sign language interpretation along with services to non-English speaking patients. Some of this information was presented in this paper; however, it was not the primary focus and so was not emphasized to any degree. Research which focused on this particular area would be necessary to truly understand the interpretation services available for the deaf.

As stated previously, the persons interviewed may or may not have been truly representative of the hospitals they serve. Therefore, any opinions, attitudes, or statements may simply be their own and not reflective of the institutions. Additionally, any lack of information regarding interpretation services provided at their respective hospitals may be due to a lack of knowledge on the part of those interviewed. Perhaps the interviewer was not directed to the appropriate person who could have most accurately answered the questions asked and so did not uncover all the information available.

The team size and the time constraints the study was conducted under also represent limitations. This study was a one month project start to finish, and so the data was collected and analyzed primarily by two team members within a relatively short amount of time.

There are a number of important questions regarding interpretation services that emerge from this research:

• How do health care providers feel about the services offered for communication with non-English speaking patients? Are they satisfied? Frustrated? What problems have they faced? How have they dealt with those problems? What changes do they think need to be made?
• How do interpreters themselves see the service they provide? Do they feel they are doing an adequate job of exchanging information between provider and patient? Are they overworked? What problems do they face? What solutions would they offer?
• How do patients who have used interpretation services feel about the help they received? Are they satisfied? Frustrated? Did they feel their words and feelings were sufficiently expressed to the health care provider? What complaints do they have regarding interpretation services? Were there instances in which they felt they needed interpretation and didn’t receive it? How do they use the telephone for communication with the hospital? Are they literate in their native language?
• How is the area of mental health different regarding interpretation needs? Why have they had less demand for these services? Why don’t more immigrants and/or refugees seek mental health care? Is it in part due to the language barrier?
• How do interpretation services affect hospital costs? Are they, or could they be, cost-effective?
• How do hospitals across Nebraska meet the challenge of communicating with non-English speaking patients? What particular problems do they have in providing services?
• How can hospitals around Nebraska provide better service to non-English speaking patients?

From the questions generated, it becomes apparent that other areas to be explored are those of the perspectives of the health care providers, interpreters and patients. This would provide a more complete picture of the interpretation needs and services. Additionally, research could be conducted throughout the rest of the state of Nebraska. A questionnaire of sorts could be sent out in a large mailing, with individual interviews conducted at selected sites around the state.

Studies could also be done to look at the true cost of providing interpretation services. The cost effectiveness question is one difficult to answer, but likely very important. Because a great deal of policy is unmistakably driven by dollars, this research could have a great impact on the future of services for non-English speaking patients.

The following are some recommendations for institutions providing care to non-English speaking patients:

1. Services. Each institution must access its own needs and decide how it will address them appropriately. In doing so, care must be taken to ensure that there is a system in place that, when needed, can be called upon to provide effective communication. This may involve an exploration of resources available in the community which can aide in the transfer of information. In addition to face-to-face interpreters, arrangements need to be made for telephone interpretation, written materials for education and informed consent, and resources for the illiterate such as videos and graphics. Some of these resources are available from vendors now, and you need only ask for them.

2. Interpreter Selection. Whether hired or volunteer, there are certain qualifications that interpreters should meet if at all possible. They should have adequate command of both languages involved. They should have some understanding of the patient’s cultural background and health care beliefs, so a bilingual and bicultural interpreter is ideal. In many cultures, using an interpreter of the opposite sex will cause problems, so an attempt should be made to find an interpreter of the same sex as the patient (Poss and Rangel, 1995). Family members, friends, and children should not be used except in the most extreme situations when no one else can be found or in the case of emergency when an interpreter cannot be waited for.

3. Training. There should be some sort of training provided for all those called upon to interpret. Topics covered should include confidentiality, objectivity, and the role of an interpreter. Ideally, training in medical terminology should also be addressed. Certainly for those hired as an interpreter who will be interpreting on a regular basis, such terminology must be taught, and proficiency tested written and orally. A shadowing experience as described at one institution in this study is also an excellent way for novice interpreters to learn their job from other interpreters.

Training for health care providers is also essential. Cultural awareness and sensitivity training can help create an understanding that is vital to good patient care. Basic foreign language classes are also helpful, although they do not substitute for providing qualified interpreters. Guidelines for working with interpreters should also be a part of provider training. Communicating through an interpreter is markedly different from exchanging information directly, and a few basic techniques can greatly facilitate the process and make all persons involved much more comfortable. Poss and Rangel (1995) offer numerous suggestions in this area.

4. Interpreter Focus Group. Some sort of focus groups both on the institutional level and the community level would likely be helpful for interpreters. These groups of interpreters could meet monthly or perhaps quarterly to discuss issues related to interpreting, problems encountered, and resources available for those they serve. There could also be information presented in the form of continuing education to improve their skills. The sharing of information that would take place would likely be very beneficial for them, for the institutions, and for the patients they serve.

This study of the language interpretation services provided by Omaha hospitals shows that each institution meets the challenge of communication in a unique way. There are common themes between the hospitals, such as need, limited resources, and a policy in place. There are distinct differences, however, in the services provided, the selection and training of interpreters, and the attitude or tone regarding these services projected during the interview. Recommendations are included to provide some suggestions for improvement in these areas. The cultural diversity found in America has changed the face of health care forever. Communication will no doubt continue to be a challenge as we move into the twenty first century, and the ways in which we meet that challenge will be crucial to providing quality health care for all.

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