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: 06/30/2025
2025 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); Did Not Measure (used for hospitals that report not measuring certain measures on the Leapfrog Hospital Survey); 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 2025 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 2025: fact-finding questions regarding opportunities for financial assistance in Section 1B: Billing Ethics, fact-finding question on soliciting feedback about a hospital's informed consent process in Section 1D: Informed Consent (note that the non-optional questions in Section 1D are scored), Section 2B: EHR Application Information, Section 6D: Diagnostic Excellence, and Section 6E: Hospital Boarding in the Emergency Department (ED). Therefore, this data will not be displayed on the Hospital Details Page.
Important Note 4:
Important Note 4: A list of subsections that will not be scored but will be publicly reported is available in the 2025 Leapfrog Hospital Survey Scoring Algorithms.
Questions? Contact the Help Desk.
| Section 1: Patient Rights and Ethics |
| Measure | Scoring Details | Performance Category | Reporting Period | Displayed on Public Website as: |
| Basic Facility Information | ||||
| Rapid Response Team Protocol | Yes | Rapid Response Protocol | ||
| Reported Concerns Policy | Yes | Patient-Reported Conerns Policy | ||
| Billing Ethics | Achieved the Standard | Billing Ethics | ||
|
Billing Statement |
Yes | |||
|
Contact Billing Representative |
Yes | |||
|
Legal Action |
No | |||
| Health Care Equity | Considerable Achievement | Health Care Equity | ||
|
Demographic Data Collected |
Race, Ethnicity, Spoken language, Written language, Gender identity | |||
|
Train Staff |
Yes | |||
|
Stratify Quality Measures |
Yes | |||
|
Identified Disparities |
Yes, disparities were identified | |||
|
Disparities Quality Improvement |
Yes | |||
|
Share Efforts on Web |
No | |||
|
Share Efforts with Board |
Yes | |||
| Informed Consent | Considerable Achievement | Informed Consent | ||
|
Train Staff |
Yes | |||
|
Review Expected Difficulties |
Yes | |||
|
Identify Personnel |
Yes | |||
|
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 | 04/2025 | Safe Medication Ordering |
| CPOE Evaluation Tool Score | Full Demonstration of National Safety Standard for Decision Support | |||
| BCMA Units | 100% | Achieved the Standard | 04/2025 | Safe Mediation Administration |
| BCMA Compliance | 99% | |||
| BCMA Decision | 5 out of 5 | |||
| BCMA Workarounds | 8 out of 8 | |||
| Medication Reconciliation | Unable to Calculate Score | 06/2025 | 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 | 12/31/2024 | Carotid Endarterectomy | ||
|
Carotid Endarterectomy Privileging |
|||||
|
Mitral Valve Repair and Replacement Volume |
Does Not Apply | 12/31/2024 | Mitral Valve Repair and Replacement | ||
|
Mitral Valve Repair and Replacement Privileging |
|||||
|
Mitral Valve Repair and Replacement - Participation in STS ACSD |
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|
Mitral Valve Repair and Replacement - STS Composite Score |
|||||
|
Open Aortic Procedures Volume |
Does Not Apply | 12/31/2024 | Open Aortic Procedures | ||
|
Open Aortic Procedures Privileging |
|||||
|
Lung Resection for Cancer Volume |
Does Not Apply | 12/31/2024 | Lung Resection for Cancer | ||
|
Lung Resection for Cancer Privileging |
|||||
|
Esophageal Resection for Cancer Volume |
Does Not Apply | 12/31/2024 | Esophageal Resection for Cancer | ||
|
Esophageal Resection for Cancer Privileging |
|||||
|
Pancreatic Resection for Cancer Volume |
Does Not Apply | 12/31/2024 | Pancreatic Resection for Cancer | ||
|
Pancreatic Resection for Cancer Privileging |
|||||
|
Rectal Cancer Surgery Volume |
Does Not Apply | 12/31/2024 | Rectal Cancer Surgery | ||
|
Rectal Cancer Surgery Privileging |
|||||
|
Bariatric Surgery Volume |
73 | Achieved the Standard | 12/31/2024 | Bariatric Surgery for Weight Loss | |
|
Bariatric Surgery Privileging |
Yes | ||||
|
Total Knee Replacement Surgery Volume |
122 | Achieved the Standard | 12/31/2024 | Total Knee Replacement Surgery | |
|
Total Knee Replacement Surgery Privileging |
Yes | ||||
|
Total Hip Replacement Surgery Volume |
1 | Some Achievement | 12/31/2024 | Total Hip Replacement Surgery | |
|
Total Hip Replacement Surgery Privileging |
Yes | ||||
|
Norwood Procedure Volume |
Does Not Apply | 12/31/2024 | Congenital Heart Surgery for Infants (Norwood Procedure) | ||
|
Norwood Procedure Privileging |
|||||
|
Norwood Procedure - Participation in STS CHSD |
|||||
| Limited Data Footnote for Adult and Pediatric Complex Surgery | |||||
| Safe Surgery Checklist - Inpatient | Achieved the Standard | 04/2025 | 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 | 12/31/2024 | Cesarean Sections | |
| Limited Data Footnote | ||||
| Episiotomy | Does Not Apply | 12/31/2024 | Episiotomies | |
| Limited Data Footnote | ||||
| Newborn Bilirubin Screening Prior to Discharge | Does Not Apply | 12/31/2024 | Screening Newborns for Jaundice Before Discharge | |
| Limited Data Footnote | ||||
| Appropriate DVT Prophylaxis in Women Undergoing Cesarean Delivery | Does Not Apply | 12/31/2024 | Preventing Blood Clots in Women Undergoing Cesarean Section | |
| Limited Data Footnote | ||||
| Operating a NICU | ||||
| High Risk Deliveries Volume | Does Not Apply | High-Risk Deliveries | ||
| Limited Data Footnote | ||||
| 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 test was performed to help hospitals understand if the NTSV C-sections rate among different racial/ethnic categories differs significantly when compared to the reference population (the non-Hispanic White category). The Fisher’s Exact Test was used if any numerator or denominator was equal to or less than 10 cases and noted with an asterisk (*) in the results below. If less than 10 cases were reported for the denominator, the interpretation is reported as “Interpretation is Not Available”. In addition, if the calculated rate is greater than or equal to 75% for the reference or any comparison population, the interpretation is reported as “Potentially inaccurate results.” 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: Physician and Nurse Staffing |
| Measure | Scoring Details | Performance Category | Reporting Period | Displayed on Public Website as: |
| Adult ICU Physician Staffing | Achieved the Standard | 04/2025 | Specially Trained Doctors Care for Adult Critical Care Patients | |
| Pediatric ICU Physician Staffing | Does Not Apply | 04/2025 | Specially Trained Doctors Care for Pediatric Critical Care Patients | |
| Nursing Workforce | ||||
|
Nursing Cohort |
Non-teaching (includes hospitals that do not join Leapfrog's NHSN Group) | |||
|
Total Nursing Care Hours per Patient Day |
8.76 | Considerable Achievement | 12/31/2024 | Nursing and Bedside Care for Patients |
|
Total Nursing Care Hours (numerator) |
58,731.87 | |||
|
Total Patient Days (denominator) |
6,707.72 | |||
|
NQF SP 9 Applied |
Not Applied | |||
|
Limited Data Footnote |
||||
|
RN Hours per Patient Day |
5.86 | Considerable Achievement | 12/31/2024 | Nursing for Patients |
|
RN Hours (numerator) |
39,323.44 | |||
|
Total Patient Days (denominator) |
6,707.72 | |||
|
NQF SP 9 Applied |
Not Applied | |||
|
Limited Data Footnote |
||||
|
Nursing Skill Mix |
66.95% | Considerable Achievement | 12/31/2024 | Percentage of Nursing Staff who are Registered Nurses (RNs) |
|
Total Productive Hours Worked by RNs (numerator) |
39,323.44 | |||
|
Total Productive Hours Worked by All Nursing Staff (denominator) |
58,731.87 | |||
|
NQF SP 9 Applied |
Not Applied | |||
|
Limited Data Footnote |
||||
|
Percentage of RNs who are BSN-Prepared |
Did Not Measure | 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) |
| 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 | 120.00 | Achieved the Standard | Latest 12 months prior to Survey submission | Effective Leadership to Prevent Errors |
| NQF SP 2 Culture Measurement, Feedback, and Intervention | 120.00 | Achieved the Standard | Latest 12 or 24 months prior to Survey submission | Staff Work Together to Prevent Errors |
| 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 | ||
|
Apologize to Patient |
Yes | |||
|
Report the Event |
Yes | |||
|
Root Cause Analysis |
Yes | |||
|
Waive all Costs |
Yes | |||
|
Policy Available |
Yes | |||
|
Interview Patients and Families |
Yes | |||
|
Inform on Actions Taken |
Yes | |||
|
Protocol on Support for Caregivers |
Yes | |||
|
Compliance Annual Review |
Yes | |||
| CLABSI | Unable to Calculate Score | 12/31/2024 | 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 | 01/2025 | 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) | Achieved the Standard | 12/31/2024 | Radiation Dose for Head Scans | |
| Median DLP for Head CT Scans (1 to 4) | ||||
| Median DLP for Head CT Scans (5 to 9) | ||||
| Median DLP for Head CT Scans (10 to 14) | 392 | |||
| Median DLP for Head CT Scans (15 to 17) | 392 | |||
| Limited Data Footnote | ||||
|
Median DLP for Abdomen/Pelvis CT Scans (< 1 year) |
Achieved the Standard | 12/31/2024 | 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) |
145 | |||
| Median DLP for Abdomen/Pelvis CT Scans (10 to 14) | 229 | |||
| Median DLP for Abdomen/Pelvis CT Scans (15 to 17) | 275 | |||
| Limited Data Footnote |
| Section 9B: Medical, Surgical, and Clinical Staff |
| Measure | Scoring Details | Performance Category | Reporting Period | Displayed on Public Website as: |
| Certified Clinicians Present While Adult Patients are Recovering | Yes | Achieved the Standard | Latest 3 months prior to Survey submission | Elective Outpatient Surgery Recovery Staffing - Adult |
| Certified Clinicians Present While Pediatric Patients are Recovering | 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 |
0 | 12/31/2024 | Anterior Segment Eye Procedures | |
|
Posterior segment eye procedures |
0 | Posterior Segment Eye Procedures | ||
|
Ocular adnexa and other eye procedures |
1 | 1 | Other Eye Procedures | |
| Orthopedics | ||||
|
Finger, hand, wrist, forearm, and elbow procedures |
22 | 1 | 12/31/2024 | Finger, Hand, Wrist, Forearm, and Elbow Procedures |
|
Shoulder procedures |
58 | 0 | Shoulder Procedures | |
|
Spine procedures |
0 | Spine Procedures | ||
|
Hip procedures |
0 | Hip Procedures | ||
|
Knee procedures |
11 | 0 | Knee Procedures | |
|
Toe, foot, ankle, and leg procedures |
133 | 7 | Toe, Foot, Ankle, and Leg Procedures | |
|
General orthopedic procedures |
1 | 0 | General Orthopedic Procedures | |
| Otolaryngology | ||||
|
Ear procedures |
37 | 119 | 12/31/2024 | Ear Procedures |
|
Mouth procedures |
20 | 3 | Mouth Procedures | |
|
Nasal/sinus procedures |
297 | 73 | Nasal and Sinus Procedures | |
|
Pharynx/adenoid/tonsil procedures |
290 | Pharynx, Adenoid, and Tonsil Procedures | ||
| Gastroenterology | ||||
|
Upper GI endoscopies |
1391 | 12/31/2024 | Upper GI Endoscopies | |
|
Lower GI endoscopies |
1306 | Lower GI Endoscopies | ||
| General Surgery | ||||
|
Cholecystectomies and common duct explorations |
68 | 12/31/2024 | Cholecystectomies and Common Duct Explorations | |
|
Hemorrhoid procedures |
12 | Hemorrhoid Procedures | ||
|
Inguinal and femoral hernia repairs |
65 | Inguinal and Femoral Hernia Repairs | ||
|
Other hernia repairs |
104 | Other Hernia Repairs | ||
|
Laparoscopies |
3 | Laparoscopies | ||
|
Lumpectomies or quadrantectomy of breast procedures |
56 | Lumpectomies or Quadrantectomies of Breast | ||
|
Mastectomies |
89 | Mastectomies | ||
| Urology | ||||
|
Circumcisions |
12/31/2024 | Circumcisions | ||
|
Cystourethroscopies |
Cystourethroscopies | |||
|
Male genital procedures |
Male Genital Procedures | |||
|
Urethra procedures |
Urethra Procedures | |||
|
Vaginal repair procedures |
Vaginal Repair Procedures | |||
| Neurological Surgery | ||||
|
Spinal fusion procedures |
12/31/2024 | Spinal Fusion Procedures | ||
| Obstetrics and Gynecology | ||||
|
Cervix procedures |
0 | 12/31/2024 | Cervix Procedures | |
|
Hysteroscopies |
7 | Hysteroscopies | ||
|
Uterus and adnexa laparoscopies |
12 | Uterus and Adnexa Laparoscopies | ||
| Plastic and Reconstructive Surgery | ||||
|
Breast repair or reconstructive procedures |
188 | 12/31/2024 | Breast Repairs and Reconstructions | |
|
Skin graft/reconstruction procedures |
37 | Skin Grafts and Repairs | ||
| Limited Data Footnote for Volume of Procedures | ||||
| 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 an Outpatient Colonoscopy | 14.6 | Some Achievement | 12/31/2023 | Unplanned Hospital Visits After Colonoscopy |
| Safe Surgery Checklist for Adult and Pediatric Outpatient Procedures | Achieved the Standard | 04/2025 | 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 | Achieved the Standard | 12/31/2024 | Medication Documentation for Elective Outpatient Surgery Patients | |
|
Home Medications |
97% | |||
|
Visit Medications |
100% | |||
|
Allergies and Adverse Reactions |
97% | |||
| Limited Data Footnote |
| Section 9F: Patient Experience (OAS CAHPS) |
| Measure | Scoring Details | Performance Category | Reporting Period | Displayed on Public Website as: |
| Patient Experience (OAS CAHPS) | Unable to Calculate Score | 04/2025 | Experience of Patients Undergoing Elective Outpatient Surgery | |
|
Facilities and Staff |
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|
Communication About Your Procedure |
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|
Patients’ Rating of the Facility |
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|
Patients Recommending the Facility |