JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Presbyterian Santa Fe Medical Center

5 / 5

At a glance

Presbyterian Santa Fe Medical Center carries a 5-star CMS overall rating — above the national norm.

Healthcare-Associated Infections

lower is better · 36 measures reported

Rates of infections patients can acquire while receiving care, such as central-line and catheter-associated infections, MRSA, and C. difficile.

MeasureScoreCompared to national
Central Line Associated Bloodstream Infection (ICU + select Wards): Lower Confidence LimitNot available
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence LimitNot available
Central Line Associated Bloodstream Infection: Number of Device Days256Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases0.172Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases1Not available
Central Line Associated Bloodstream Infection (ICU + select Wards)Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence LimitNot available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence LimitNot available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days385Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases0.212Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases0Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards)Not available
SSI - Colon Surgery: Lower Confidence Limit0.025Same as national
SSI - Colon Surgery: Upper Confidence Limit2.473Same as national
SSI - Colon Surgery: Number of Procedures82Same as national
SSI - Colon Surgery: Predicted Cases1.994Same as national
SSI - Colon Surgery: Observed Cases1Same as national
SSI - Colon Surgery0.502Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures53Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.409Not available
SSI - Abdominal Hysterectomy: Observed Cases3Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitNot available
MRSA Bacteremia: Upper Confidence LimitNot available
MRSA Bacteremia: Patient Days8745Not available
MRSA Bacteremia: Predicted Cases0.211Not available
MRSA Bacteremia: Observed Cases0Not available
MRSA BacteremiaNot available
Clostridium Difficile (C.Diff): Lower Confidence Limit0.229Same as national
Clostridium Difficile (C.Diff): Upper Confidence Limit2.448Same as national
Clostridium Difficile (C.Diff): Patient Days8160Same as national
Clostridium Difficile (C.Diff): Predicted Cases3.335Same as national
Clostridium Difficile (C.Diff): Observed Cases3Same as national
Clostridium Difficile (C.Diff)0.900Same as national

Complications & Deaths

lower is better · 20 measures reported

Rates of serious complications (like hip/knee replacement problems or accidental cuts during surgery) and 30-day mortality rates for common conditions.

MeasureScoreCompared to nationalSample
Rate of complications for hip/knee replacement patientsNot available
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate3.8Same as national202
Death rate for heart attack patientsNot available
Death rate for CABG surgery patientsNot available
Death rate for COPD patientsNot available
Death rate for heart failure patients11Same as national29
Death rate for pneumonia patients12.9Same as national58
Death rate for stroke patientsNot available
Pressure ulcer rate0.52Same as national462
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.21Same as national652
In-hospital fall-associated fracture rate0.27Same as national601
Postoperative hemorrhage or hematoma rate2.29Same as national148
Postoperative acute kidney injury requiring dialysis rate1.65Same as national64
Postoperative respiratory failure rate8.56Same as national65
Perioperative pulmonary embolism or deep vein thrombosis rate3.23Same as national161
Postoperative sepsis rate5.85Same as national59
Postoperative wound dehiscence rate1.74Same as national46
Abdominopelvic accidental puncture or laceration rate1.02Same as national81
CMS Medicare PSI 90: Patient safety and adverse events composite0.95Same as national

Unplanned Hospital Visits & Readmissions

lower is better · 14 measures reported

How often patients return to the hospital unexpectedly within 30 days of discharge — a marker of care quality and discharge planning.

MeasureScoreCompared to nationalSample
Hospital return days for heart attack patientsNot available
Hospital return days for heart failure patients-35.4Not available32
Hospital return days for pneumonia patients0.8Not available53
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.1Same as national259
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)13.4Same as national478
Rate of inpatient admissions for patients receiving outpatient chemotherapyNot available
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapyNot available
Ratio of unplanned hospital visits after hospital outpatient surgery1.3Same as national276
Acute Myocardial Infarction (AMI) 30-Day Readmission RateNot available
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patientsNot available
Heart failure (HF) 30-Day Readmission Rate19.2Same as national32
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate15.8Same as national53

Patient Experience (HCAHPS)

higher is better · 9 measures reported

What patients say about their hospital stay — communication with nurses and doctors, responsiveness, cleanliness, pain management, and whether they would recommend the hospital.

MeasureScoreSample
Nurse communication - star rating3321
Doctor communication - star rating3321
Communication about medicines - star rating2321
Discharge information - star rating2321
Cleanliness - star rating3321
Quietness - star rating3321
Overall hospital rating - star rating3321
Recommend hospital - star rating4321
Summary star rating3321

Timely & Effective Care

higher is better (unless a wait time) · 30 measures reported

How consistently hospitals follow recommended care processes — for example, giving heart-attack patients aspirin on arrival, or the average time spent in the emergency department.

MeasureScoreSample
Emergency department volumemedium
Global Malnutrition Composite Score
Global Malnutrition Composite Score: Malnutrition Diagnosis Documented
Global Malnutrition Composite Score: Malnutrition Risk Screening
Global Malnutrition Composite Score: Nutrition Assessment
Global Malnutrition Composite Score: Nutritional Care Plan
Hospital Harm - Severe Hyperglycemia
Hospital Harm - Severe Hypoglycemia
Hospital Harm - Opioid Related Adverse Events01301
Healthcare workers given influenza vaccination77570
Average (median) time all patients spent in the emergency department before leaving from the visit, including psychiatric/mental health patients and patients who were transferred to another facility. A lower number of minutes is better229457
Average (median) time patients spent in the emergency department before leaving from the visit, excluding patients transferred to another facility or psychiatric care/mental health patients. A lower number of minutes is better226429
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better27420
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better
Left before being seen422367
Head CT results
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients9979
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing10724
Appropriate care for severe sepsis and septic shock4379
Septic Shock 3-Hour Bundle6015
Septic Shock 6-Hour Bundle
Severe Sepsis 3-Hour Bundle6879
Severe Sepsis 6-Hour Bundle7642
Discharged on Antithrombotic Therapy
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 2
Venous Thromboembolism Prophylaxis
Intensive Care Unit Venous Thromboembolism Prophylaxis97329

Maternal Health

lower is better · 4 measures reported

Measures of maternal outcomes and safe delivery practices, including severe complications during childbirth.

MeasureScoreSample
Cesarean Birth
Risk Adjusted Severe Obstetric Complications (All)
Risk Adjusted Severe Obstetric Complications (excluding blood-transfusion-only cases)
Maternal Morbidity Structural MeasureYes

Frequently asked questions

How is Presbyterian Santa Fe Medical Center rated?
Presbyterian Santa Fe Medical Center has a 5 out of 5 CMS overall star rating as of the latest CMS release.
Does Presbyterian Santa Fe Medical Center have emergency services?
Yes. Presbyterian Santa Fe Medical Center operates a 24/7 emergency department.
Where is Presbyterian Santa Fe Medical Center located?
Presbyterian Santa Fe Medical Center is located at 4801 Beckner Road, Santa Fe, NM 87507.
What type of hospital is Presbyterian Santa Fe Medical Center?
Presbyterian Santa Fe Medical Center is classified by CMS as a Acute Care Hospitals facility (Voluntary non-profit - Private).

Data as of 2026-06-14. Source: CMS Provider Data Catalog. This is public data provided for informational purposes only and is not medical advice. See our methodology and editorial policy.

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