Table 1.

Themes, Descriptions, and Potential Health System Intervention Components

Theme	Description	Potential intervention components
Belief about the negative consequences (emotional and material) of not passing test	Concerns about not passing the test, such as feeling guilty about overusing language skills; worry that not passing would threaten personal or professional identity; uncertainty about consequences of not passing the exam, such as loss of privileges or opportunity to retake the test.	• Messaging incorporating champions and addressing the emotional barriers to assessment and the potential perceived threats to personal or professional identity • Transparency about assessment format, structure, and scoring, as well as opportunities for retaking the assessment • Resources to support improvement to reach passing threshold
Time constraints and competing demands	Prioritization of time and competing priorities as barriers to proficiency testing.	• Schedule time for new hires and existing employees to take assessment • Incorporate assessment into clinical schedule • Create and communicate clear policy for certification
Challenging test format and structure	Test not representative of a patient-clinician conversation; test register and difficulty too high; uniform content not applicable; dislike of testing in general.	• Informational materials about assessment format, structure, and scoring • Consider alternative assessment options such as validated approaches to direct observation • Recruit champions and opinion leaders to reinforce importance of assessment
Messaging consistent with professional ethos	Recommendations to appeal to clinicians’ professional identity or role, emphasizing patient-centered care, rather than punitive messaging.	• Messaging campaigns to encourage certification, emphasizing quality patient care
Organizational culture that values and incentivizes certification	Need for recognition, financial incentives, or support and resources; a clear mandate or policy for certification.	• Financial incentives and rewards to get certified and to see patients in non-English language once certified • Assessment guidelines for new bilingual hires and existing employees, with standardized procedures • Dashboard of clinicians’ non-English skills and certification which is made available to patients and employees • Visible recognition for certified bilingual clinicians, for example, an ID sticker, listing on a website
Reassurance and empowerment about personal language proficiency	Passing the test could serve as reassurance not to use an interpreter in clinical encounters or for a clinical supervisor to trust a trainee’s language skills; not passing the test could serve as reassurance to use an interpreter; reassurance that it is ok to use an interpreter when clinician feels one is needed, even after passing the test.	• Training sessions and guidance on appropriate use of interpreters • Messaging campaigns to encourage certification, emphasizing quality patient care • Guidance on accessing professional interpreters, regardless of certification status • Educational sessions about certification and ensuring language access
Individuals championing certification	Messaging from trusted individuals.	• Recruit champions and opinion leaders to reinforce importance of assessment • Messaging campaigns to encourage certification, emphasizing quality patient care