Lovelace Westside Hospital

Hospital ID: 88-6915
CMS Certification Number: 32-0074
Address: 10501 Golf Course Road NW, Albuquerque, NM 87114-5000
Teaching Hospital Status: Non-Teaching
Survey Submit Date: 06/28/2024

2024 Leapfrog Hospital Survey Details Page

This Hospital Details Page includes important scoring information. Most all of the information on this page is publicly reported on Leapfrog's website: ratings.leapfroggroup.org. However, some of the scoring details on this page are not publicly reported. Scoring details that are not publicly reported are highlighted in yellow. Print a copy of this page for your records.

For the purpose of public reporting, performance on each measure on the Leapfrog Hospital Survey is placed into one of four performance categories: Achieved the Standard (displayed as four filled bars); Considerable Achievement (displayed as three filled bars); Some Achievement (displayed as two filled bars); or Limited Achievement (displayed as one filled bar).

Additional scoring terms include: Does Not Apply (used for hospitals that report not performing a particular procedure, not having a particular unit, or are not applicable for a particular measure); Unable to Calculate Score (used for hospitals that report a sample size that does not meet Leapfrog’s minimum reporting requirements, or for facilities that do not participate with CMS or do not have a measure score published by CMS for the Patient Follow-Up measures in Section 9D (Safety of Procedures)); Declined to Respond (used for hospitals that do not submit a Survey or a section of the Survey); or Pending Leapfrog Verification (used for hospitals that have Survey responses undergoing Leapfrog's standard verification process).

For more information about the scoring algorithms used in each section below, please download a copy of the 2024 Leapfrog Hospital Survey Scoring Algorithms.

Important Note 1:

Leapfrog will begin sending out Data Verification messages in July. Primary, Secondary, and System Survey Contacts should watch their email for any Data Verification messages. More information about verifying the accuracy of our results is available on our website.

Important Note 2:

Hospitals will be scored and publicly reported as "Declined to Respond" (described above) for any remaining sections of the Survey that are not submitted. Hospitals are encouraged to submit all sections prior to November 30 (the Late Submission Deadline).

Important Note 3:

The following questions will not be scored or publicly reported in 2024: new fact-finding questions regarding financial assistance in Section 1B: Billing Ethics, the new fact-finding question on soliciting feedback about a hospital's informed consent process in Section 1D: Informed Consent (note that the other questions in Section 1D are scored), Section 2B: EHR Application Information, the new fact-finding question regarding evidence-based precautions to reduce the spread of C. difficile in Section 6D: Hand Hygiene, and Section 6E: Diagnostic Excellence. Therefore, this data will not be displayed on the Hospital Details Page.

Questions? Contact the Help Desk.

Section 1: Patient Rights and Ethics

Measure	Scoring Details	Performance Category	Reporting Period	Displayed on Public Website as:
Billing Ethics		Achieved the Standard		Billing Ethics
Billing Statement	Yes
Contact Billing Representative	Yes
Legal Action	No
Health Care Equity		Achieved the Standard		Health Care Equity
Informed Consent		Some Achievement		Informed Consent
Train Staff	Yes
Solicit Feedback	No
Review Expected Difficulties	Yes
Identify Personnel	No
Write Forms at 6th Grade Reading Level	No, all forms are at a 9th grade reading level or lower
Use Medical Interpreters	Yes
Use Teach Back Method	Yes

Section 2: Medication Safety

Measure	Scoring Details	Performance Category	Reporting Period	Displayed on Public Website as:
CPOE Implementation Status	85% or greater	Achieved the Standard	04/2024	Safe Medication Ordering
CPOE Evaluation Tool Score	Full Demonstration of National Safety Standard for Decision Support	Achieved the Standard	04/2024	Safe Medication Ordering
BCMA Units	100%	Achieved the Standard	04/2024	Safe Mediation Administration
BCMA Compliance	96%
BCMA Decision	5 out of 5
BCMA Workarounds	8 out of 8
Medication Reconciliation	0.245	Some Achievement	05/2024	Medication Reconciliation

Section 3: Adult and Pediatric Complex Surgery

Measure	Scoring Details	Performance Category	Reporting Period	Displayed on Public Website as:
Hospital and Surgeon Volume
Carotid Endarterectomy Volume		Does Not Apply	12/31/2023	Carotid Endarterectomy
Carotid Endarterectomy Privileging		Does Not Apply	12/31/2023	Carotid Endarterectomy
Mitral Valve Repair and Replacement Volume		Does Not Apply	12/31/2023	Mitral Valve Repair and Replacement
Mitral Valve Repair and Replacement Privileging			12/31/2023
Mitral Valve Repair and Replacement - Participation in STS ACSD
Mitral Valve Repair and Replacement - STS Composite Score
Open Aortic Procedures Volume		Does Not Apply	12/31/2023	Open Aortic Procedures
Open Aortic Procedures Privileging		Does Not Apply	12/31/2023	Open Aortic Procedures
Lung Resection for Cancer Volume		Does Not Apply	12/31/2023	Lung Resection for Cancer
Lung Resection for Cancer Privileging		Does Not Apply	12/31/2023	Lung Resection for Cancer
Esophageal Resection for Cancer Volume		Does Not Apply	12/31/2023	Esophageal Resection for Cancer
Esophageal Resection for Cancer Privileging		Does Not Apply	12/31/2023	Esophageal Resection for Cancer
Pancreatic Resection for Cancer Volume		Does Not Apply	12/31/2023	Pancreatic Resection for Cancer
Pancreatic Resection for Cancer Privileging		Does Not Apply	12/31/2023	Pancreatic Resection for Cancer
Rectal Cancer Surgery Volume		Does Not Apply	12/31/2023	Rectal Cancer Surgery
Rectal Cancer Surgery Privileging		Does Not Apply	12/31/2023	Rectal Cancer Surgery
Bariatric Surgery Volume	55	Achieved the Standard	12/31/2023	Bariatric Surgery for Weight Loss
Bariatric Surgery Privileging	Yes	Achieved the Standard	12/31/2023	Bariatric Surgery for Weight Loss
Total Knee Replacement Surgery Volume	100	Achieved the Standard	12/31/2023	Total Knee Replacement Surgery
Total Knee Replacement Surgery Privileging	Yes	Achieved the Standard	12/31/2023	Total Knee Replacement Surgery
Total Hip Replacement Surgery Volume	4	Some Achievement	12/31/2023	Total Hip Replacement Surgery
Total Hip Replacement Surgery Privileging	Yes	Some Achievement	12/31/2023	Total Hip Replacement Surgery
Norwood Procedure Volume		Does Not Apply	12/31/2023	Congenital Heart Surgery for Infants (Norwood Procedure)
Norwood Procedure Privileging			12/31/2023
Norwood Procedure - Participation in STS CHSD
Safe Surgery Checklist		Achieved the Standard	05/2024	Safe Surgery Checklist - Complex Surgery

Section 4: Maternity Care

Measure	Scoring Details	Performance Category	Reporting Period	Displayed on Public Website as:
Cesarean Birth		Does Not Apply	12/31/2023	Cesarean Sections
Episiotomy		Does Not Apply	12/31/2023	Episiotomies
Newborn Bilirubin Screening Prior to Discharge		Does Not Apply	12/31/2023	Screening Newborns for Jaundice Before Discharge
Appropriate DVT Prophylaxis in Women Undergoing Cesarean Delivery		Does Not Apply	12/31/2023	Preventing Blood Clots in Women Undergoing Cesarean Section
High Risk Deliveries Volume		Does Not Apply		High-Risk Deliveries
High Risk Deliveries Outcomes
High Risk Deliveries Outcomes - VON Volume
High Risk Deliveries Outcomes - VON SMR 95% Lower Bound
High Risk Deliveries Outcomes - VON SMR Shrunken
High Risk Deliveries Outcomes - VON SMR 95% Upper Bound

Section 4: Maternity Care - NTSV Cesarean Birth Stratified by Race/Ethnicity
The table below includes NTSV C-section data stratified by race/ethnicity. This information will not be scored or publicly reported, but aggregated results will be used in a national report published this fall. To aid in the interpretation of results, a chi-square analysis was performed to help hospitals understand if the rate of NTSV C-sections among the different racial/ethnic categories differs significantly when compared to the reference population (the non-Hispanic White category). For the purposes of analysis, numerators and rates are not provided if less than 10 cases were reported for the denominator and the interpretation will be reported as “Interpretation is Not Available.” In addition, interpretations are reported as “Interpretation is Not Available” if the numerator or the number of women without a c-section is less than 5 for the Non-Hispanic white category or comparison group due to limitations of the chi-square test. Note: For the purposes of this analysis, the non-Hispanic White category was used as the reference population.

Race/Ethnicity of Mother	Numerator	Denominator	Rate	Interpretation
Non-Hispanic White (reference population)				Reference population
Non-Hispanic Black
Non-Hispanic American Indian or Alaska Native
Non-Hispanic Asian or Pacific Islander
Hispanic
Non-Hispanic Other (including two or more races)
Unknown

Section 5: ICU Physician Staffing

Measure	Scoring Details	Performance Category	Reporting Period	Displayed on Public Website as:
ICU Physician Staffing		Achieved the Standard	05/2024	Specially Trained Doctors Care for Critical Care Patients

Section 6: Patient Safety Practices

Measure	Scoring Details	Performance Category	Reporting Period	Displayed on Public Website as:
NQF SP 1 Culture of Safety Leadership Structures and Systems	110.77	Considerable Achievement	12 months prior to 2024 Survey submission	Effective Leadership to Prevent Errors
NQF SP 2 Culture Measurement, Feedback, and Intervention	120.00	Achieved the Standard	12 or 24 months prior to 2024 Survey submission	Staff Work Together to Prevent Errors
Nursing Workforce
Nursing Cohort	Non-teaching (includes hospitals that do not join Leapfrog's NHSN Group)
Total Nursing Hours per Patient Day	9.23	Considerable Achievement	12/31/2023	Nursing and Bedside Care for Patients
Total Nursing Hours (numerator)	52,766.19
Total Patient Days (denominator)	5,716.53
NQF SP 9 Applied	Not Applied
RN Hours per Patient Day	5.60	Considerable Achievement	12/31/2023	Nursing for Patients
RN Hours (numerator)	31,985.03
Total Patient Days (denominator)	5,716.53
NQF SP 9 Applied	Not Applied
Nursing Skill Mix	60.62%	Considerable Achievement	12/31/2023	Percentage of Nursing Staff who are Registered Nurses (RNs)
Total Productive Hours Worked by RNs (numerator)	31,985.03
Total Productive Hours Worked by All Nursing Staff (denominator)	52,766.19
NQF SP 9 Applied	Not Applied
Percentage of RNs who are BSN-Prepared		Limited Achievement	Latest 12 months prior to Survey submission	Percentage of Registered Nurses (RNs) who have a Bachelor's Degree in Nursing
Total employed RNs who are BSN-prepared (numerator)
Total employed RNs (denominator)
Hand Hygiene		Achieved the Standard		Handwashing
Hand Hygiene Monitoring	Met
Hand Hygiene Monitoring - Use of an Electronic Compliance Monitoring System	No
Hand Hygiene Monitoring - Count	200
Hand Hygiene Monitoring - Frequency	Monthly
Hand Hygiene Feedback	Met
Hand Hygiene Training and Education	Met
Hand Hygiene Infrastructure	Met
Hand Hygiene Culture	Met

Section 7: Managing Serious Errors

Measure	Scoring Details	Performance Category	Reporting Period	Displayed on Public Website as:
Never Events		Achieved the Standard		Responding to Never Events
CLABSI		Unable to Calculate Score	06/30/2024	Infection in the Blood
CAUTI		Unable to Calculate Score		Infection in the Urinary Tract
MRSA		Unable to Calculate Score		MRSA Infection
CDI	0.000	Achieved the Standard		C. difficile Infection
SSI Colon		Unable to Calculate Score		Surgical Site Infection after Colon Surgery

Section 8: Pediatric Care

Measure	Scoring Details	Performance Category	Reporting Period	Displayed on Public Website as:
CAHPS - Communication with Parents About Meds		Does Not Apply	05/2024	Experience of Children and Their Parents
CAHPS - Communication with Parents About Child's Care
CAHPS - Nurse Communication with Children
CAHPS - Doctor Communication with Children
CAHPS - Preventing Mistakes and Reporting Concerns
Median DLP for Head CT Scans (< 1 year)		Limited Achievement	12/31/2023	Radiation Dose for Head Scans
Median DLP for Head CT Scans (1 to 4)	535
Median DLP for Head CT Scans (5 to 9)	615
Median DLP for Head CT Scans (10 to 14)	901
Median DLP for Head CT Scans (15 to 17)	788
Median DLP for Abdomen/Pelvis CT Scans (< 1 year)		Considerable Achievement	12/31/2023	Radiation Dose for Abdomen/Pelvis Scans
Median DLP for Abdomen/Pelvis CT Scans (1 to 4)
Median DLP for Abdomen/Pelvis CT Scans (5 to 9)	211
Median DLP for Abdomen/Pelvis CT Scans (10 to 14)	337
Median DLP for Abdomen/Pelvis CT Scans (15 to 17)	343

Section 9B: Medical, Surgical, and Clinical Staff

Measure	Scoring Details	Performance Category	Reporting Period	Displayed on Public Website as:
ACLS trained clinician, plus a second clinician, present at all times and immediately available in building while adult patient is present in the hospital outpatient department	Yes	Achieved the Standard	Latest 3 months prior to Survey submission	Elective Outpatient Surgery Recovery Staffing - Adult
PALS trained clinician, plus a second clinician, present at all times and immediately available in building while pediatric patient is present in the hospital outpatient department	Yes	Achieved the Standard	Latest 3 months prior to Survey submission	Elective Outpatient Surgery Recovery Staffing - Pediatric

Section 9C: Volume of Procedures

Procedure	Adult Volume	Pediatric Volume	Reporting Period	Displayed on Public Website as:
Ophthalmology
Anterior segment eye procedures			12/31/2023	Anterior Segment Eye Procedures
Posterior segment eye procedures				Posterior Segment Eye Procedures
Ocular adnexa and other eye procedures				Other Eye Procedures
Orthopedics
Finger, hand, wrist, forearm, and elbow procedures	198	6	12/31/2023	Finger, Hand, Wrist, Forearm, and Elbow Procedures
Shoulder procedures	145	0		Shoulder Procedures
Spine procedures	0			Spine Procedures
Hip procedures	0			Hip Procedures
Knee procedures	65	1		Knee Procedures
Toe, foot, ankle, and leg procedures	179	7		Toe, Foot, Ankle, and Leg Procedures
General orthopedic procedures	4	0		General Orthopedic Procedures
Otolaryngology
Ear procedures	33	149	12/31/2023	Ear Procedures
Mouth procedures	20	2		Mouth Procedures
Nasal/sinus procedures	230	51		Nasal and Sinus Procedures
Pharynx/adenoid/tonsil procedures		204		Pharynx, Adenoid, and Tonsil Procedures
Gastroenterology
Upper GI endoscopies	1273		12/31/2023	Upper GI Endoscopies
Lower GI endoscopies	1479			Lower GI Endoscopies
General Surgery
Cholecystectomies and common duct explorations	43			12/31/2023	Cholecystectomies and Common Duct Explorations
Hemorrhoid procedures	1		Hemorrhoid Procedures
Inguinal and femoral hernia repairs	43		Inguinal and Femoral Hernia Repairs
Other hernia repairs	65		Other Hernia Repairs
Laparoscopies	2		Laparoscopies
Lumpectomies or quadrantectomy of breast procedures	61		Lumpectomies or Quadrantectomies of Breast
Mastectomies	66		Mastectomies
Urology
Circumcisions	0		12/31/2023	Circumcisions
Cystourethroscopies	0			Cystourethroscopies
Male genital procedures	0			Male Genital Procedures
Urethra procedures	0			Urethra Procedures
Vaginal repair procedures	2			Vaginal Repair Procedures
Neurological Surgery
Spinal fusion procedures			12/31/2023	Spinal Fusion Procedures
Obstetrics and Gynecology
Cervix procedures	0		12/31/2023	Cervix Procedures
Hysteroscopies	27			Hysteroscopies
Uterus and adnexa laparoscopies	36			Uterus and Adnexa Laparoscopies
Plastic and Reconstructive Surgery
Breast repair or reconstructive procedures	128		12/31/2023	Breast Repairs and Reconstructions
Skin graft/reconstruction procedures	36		12/31/2023	Skin Grafts and Repairs

Section 9D: Safety of Procedures (Patient Follow-up and Safe Surgery Checklist for Adult and Pediatric Outpatient Procedures)

Measure	Scoring Details	Performance Category	Reporting Period	Displayed on Public Website as:
Rate of Unplanned Hospital Visits After Outpatient Colonoscopy	14.4	Some Achievement	12/31/2022	Unplanned Hospital Visits After Colonoscopy
Safe Surgery Checklist		Achieved the Standard	05/2024	Safe Surgery Checklist - Elective Outpatient Surgery

Section 9E: Medication Safety for Outpatient Procedures

Measure	Scoring Details	Performance Category	Reporting Period	Displayed on Public Website as:
Medication and Allergy Documentation		Limited Achievement	12/31/2023	Medication Documentation for Elective Outpatient Surgery Patients
Home Medications
Visit Medications
Allergies and Adverse Reactions

Section 9F: Patient Experience (OAS CAHPS)

Measure	Scoring Details	Performance Category	Reporting Period	Displayed on Public Website as:
Patient Experience (OAS CAHPS)		Limited Achievement	05/2024	Experience of Patients Undergoing Elective Outpatient Surgery
Facilities and Staff	58%
Communication About Your Procedure	69%
Patients’ Rating of the Facility	65%
Patients Recommending the Facility	66%