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About Us

Quality & Patient Safety at Martha’s Vineyard Hospital

Martha's Vineyard Hospital (MVH) has an extensive internal network of processes that act as checkpoints and yardsticks for monitoring and measuring quality standards.

About Us

Quality & Patient Safety at Martha’s Vineyard Hospital

Government agencies, national sanctioning bodies, state associations, and private independent survey firms regularly evaluate MVH’s quality of care performance across a wide range of criteria. Some of these criteria go beyond just facts and figures to measure how well a hospital manages the interpersonal aspects of patient care.
In some instances, these evaluations are compared with performance data from other hospitals across the state or country. In other cases, sanctioning bodies establish quality and safety benchmarks, which hospitals are required to meet or exceed in order to earn and maintain accredited status.

The Joint Commission

The Joint Commission is an independent, not-for-profit body that established standards for quality and standards. The Joint Commission conducts regular, on-site surveys of hospitals, evaluating a wide range of criteria. The results of these surveys determine whether a hospital earns accreditation from the Joint Commission. This accreditation process includes unannounced surveys of hospitals which ensures that the hospital is always striving to be its best in terms of safety and quality of care.

The Joint Commission granted Martha’s Vineyard Hospital full accreditation for a 36-month cycle beginning in September 2018.

Hospitals are required to post an announcement that an accreditation survey may be imminent and to allow the public to provide input.

Baby-Friendly Hospital

In December 2017, Martha’s Vineyard Hospital earned its designation as a Baby-Friendly Hospital through The Baby-Friendly Hospital Initiative (BFHI) – a global program launched by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) to encourage and recognize hospitals and birthing centers that offer an optimal level of care for infant feeding and mother/baby bonding.

To be designated as a Baby-Friendly Hospital, MVH successfully completed a rigorous development, planning, and implementation schedule that culminated in an on-site assessment by BFHI in September, followed by the awarding of the designation this December. Baby-Friendly USA is the accrediting body for BFHI in the United States.

Patient Centered Medical Home (PCMH)

After a yearlong initiative, in cooperation with Massachusetts General Hospital/Mass General Brigham, the Primary Care Practices of Martha’s Vineyard Hospital have earned National Committee for Quality Assurance(NCQA) Recognition as a Patient Centered Medical Home.

This medical home model of care strives for continuous quality and patient experience improvement. Spearheaded by practice leadership and executed by care team physicians, nurse practitioners, nurses, medical assistants and administrative support professionals, we set and meet goals to improve quality measures, improve resource stewardship, improve appointment availability and improve disparities in care services.

ACR Lung Cancer Screening Center Designation

Martha’s Vineyard Hospital has been designated a Lung Cancer Screening Center by the American College of Radiology (ACR). The ACR Lung Cancer Screening Center designation is a voluntary program that recognizes facilities that have committed to practice safe, effective diagnostic care for individuals at the highest risk for lung cancer.

In order to receive this elite distinction, facilities must be accredited by the ACR in computed tomography in the chest module, as well as undergo a rigorous assessment of its lung cancer screening protocol and infrastructure. Also required are procedures in place for follow-up patient care, such as counseling and smoking cessation programs.

Age-Friendly Health System- Committed to Care Excellence

Martha’s Vineyard Hospital has been recognized as an Age-Friendly Health System- Committed to Care Excellence. The Age-Friendly Health Systems initiative was launched in 2017 by The John A. Hartford Foundation and the Institute for Healthcare Improvement, in partnership with the American Hospital Association and Catholic Health Association of the US, with a commitment to make 20 percent of hospitals and health systems in the United States age-friendly by 2020.

An Age-Friendly Health System is one in which clinical care settings reliably implement four geriatric care practices (4Ms: What Matters, Medications, Mentation, Mobility) in a manner consistent with evidence-based best practice. The 4Ms are defined, and examples of how to implement them, are featured in the Age-Friendly Health Systems Guide to Using the 4Ms in the Care of Older Adults. Recognition is given at the hospital or practice level.

Get the Facts

Did You Know?

Over 2,000

new patients join our practice every year.

Quality and Patient Safety

Supporting the Martha’s Vineyard Hospital culture of safety and the people behind it is a carefully designed system of processes that reinforce, cross-check and quality care initiatives’ status. These processes represent checklists and benchmarks that analyze the progress of maintaining and raising quality throughout every care aspect.

As a patient, you will have expectations and want reassurances about the quality of care you receive. Our quality processes are among the many ways to ensure we deliver both.

In our continuing effort to improve the quality of care we provide, we ask our patients to complete a survey about their experience at Martha’s Vineyard Hospital. This survey is conducted through email or via telephone.

At Martha’s Vineyard Hospital, our goal is to provide the best healthcare and medical service possible. Sometimes we exceed expectations. Now and then, however, we might not meet our patients’ or families’ expectations. We want to learn from your experience- good or bad. The Quality and Patient Safety Department welcomes your compliments or concerns. We are also here to help you resolve a problem.

Director of Quality and Patient Safety: 508-684-4553

Patient Advocacy:

Phone: 508-957-9497

Email: MVHPatientAdvocate@Partners.org

For more about Patient Advocacy, click here.

Quarterly Reports on MVH ICU Registered Nurse-to-Patient Ratio

This information is reported to the Massachusetts Department of Public Health to ensure that Martha’s Vineyard Hospital does not exceed the maximum patient assignment of two patients per nurse.

July 1, 2019 – September 30, 2019

April 1, 2019 – June 30, 2019

January 1, 2019 – March 31, 2019

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Did You Know?


inpatients were seen at MVH in 2019.