Accreditation & Quality Assurance
Government agencies, national sanctioning bodies, state associations, and private independent survey firms regularly evaluate Martha’s Vineyard Hospital’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 across the 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 an accredited status.
Finally, Martha's Vineyard Hospital has an extensive internal network of processes and mechanisms that act as checkpoints and yardsticks for monitoring and measuring quality standards.
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 2015 and is due to be surveyed again sometime in 2018.
Hospitals are required to post an announcement that an accreditation survey may be imminent and to give the public an opportunity to provide input.
Visit the Joint Commission website.
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.
Visit the Baby Friendly Website.
Patient Centered Medical Home (PCMH)
After a yearlong initiative, in cooperation with Massachusetts General Hospital/Partners HealthCare, 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.
Learn more here.
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.
For more information about the Lung Cancer Screening Center designation, visit: acr.org
Supporting the Martha’s Vineyard Hospital culture of quality and the people behind it, is a carefully designed system of processes that reinforce, cross check and monitor the status of quality care initiatives. These processes represent checklists and benchmarks that analyze the progress of maintaining and raising quality throughout every aspect of care.
In much the same way, you as a patient 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 form is given or mailed to all patients.
If you have not received a survey, and/or wish to contact us with your comments or suggestions click here.
Below you will find the links to the quarterly reports which have been provided to the Massachusetts Department of Public Health on the ICU Registered Nurse-to-Patient ratio beginning in January 2016. This reporting ensures that Martha's Vineyard Hospital is not exceeding 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
October 1, 2018 - December 31, 2018
July 1, 2018 - September 30, 2018
April 1, 2018 - June 30, 2018
January 1, 2018 - March 31, 2018
October 1, 2017 - December 31, 2017
July 1, 2017 -September 30, 2017
April 1, 2017 - June 30, 2017
January 1, 2017 - March 31, 2017
At Martha’s Vineyard Hospital, our goal is to provide the best healthcare and medical service possible. Sometimes we exceed expectations. Every now and then, however, we might not meet our patients’ or families’ expectations. We want to learn from your experience, good or not so good. The Quality Improvement Office welcomes your compliments or concerns. We are also here to help you resolve a problem.