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 Limit—Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit—Not 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 Limit—Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit—Not 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 Limit—Not available
SSI - Abdominal Hysterectomy: Upper Confidence Limit—Not available
SSI - Abdominal Hysterectomy: Number of Procedures53Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.409Not available
SSI - Abdominal Hysterectomy: Observed Cases3Not available
SSI - Abdominal Hysterectomy—Not available
MRSA Bacteremia: Lower Confidence Limit—Not available
MRSA Bacteremia: Upper Confidence Limit—Not available
MRSA Bacteremia: Patient Days8745Not available
MRSA Bacteremia: Predicted Cases0.211Not available
MRSA Bacteremia: Observed Cases0Not available
MRSA Bacteremia—Not 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 patients—Not available—
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate3.8Same as national202
Death rate for heart attack patients—Not available—
Death rate for CABG surgery patients—Not available—
Death rate for COPD patients—Not available—
Death rate for heart failure patients11Same as national29
Death rate for pneumonia patients12.9Same as national58
Death rate for stroke patients—Not available—
Pressure ulcer rate0.52Same as national462
Death rate among surgical inpatients with serious treatable complications—Not 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 patients—Not 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 chemotherapy—Not available—
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy—Not available—
Ratio of unplanned hospital visits after hospital outpatient surgery1.3Same as national276
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate—Not available—
Rate of readmission for CABG—Not available—
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients—Not available—
Heart failure (HF) 30-Day Readmission Rate19.2Same as national32
Rate of readmission after hip/knee replacement—Not 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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