Quality Report


Quality Report

Presbyterian Hospital
HCO ID: 2775
1100 Central Ave. SE
Albuquerque, NM, 87106
(505) 841-1234
www.phs.org
Summary of Quality Information

Accreditation Programs

Gold Seal
Home Care
Accreditation Decision
Effective Date
5/11/2023
Last Full Survey Date
5/10/2023
Last On-Site Survey Date
5/10/2023
Gold Seal
Hospital
Accreditation Decision
Effective Date
12/20/2023
Last Full Survey Date
5/12/2023
Last On-Site Survey Date
2/1/2024

Advanced Certification Programs

Gold Seal
Certification Decision
Effective Date
1/18/2024
Last Full Survey Date
1/17/2024
Last On-Site Survey Date
1/17/2024

Core Certification Programs

Gold Seal
Certification Decision
Effective Date
1/20/2022
Last Full Survey Date
2/29/2024
Last On-Site Survey Date
2/29/2024
Gold Seal
Certification Decision
Effective Date
1/20/2022
Last Full Survey Date
2/29/2024
Last On-Site Survey Date
2/29/2024

Sites

PMG 528 Clinic
3777 Highway 528 NE
Rio Rancho, NM, 87144

Available Services

  • Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

  • PMG Family Medicine
  • PMG Internal Medicine

PMG Atrisco
3901 Atrisco NW
Albuquerque, NM, 87120

Available Services

  • Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

  • PMG FAMILY MEDICINE
  • PMG BEHAVIORAL HEALTH
  • PMG URGENT CARE

PMG Belen
609 South Christopher Rd
Belen, NM, 87002

Available Services

  • Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

  • PMG FAMILY MEDICINE
  • PMG BEHAVIORAL HEALTH
  • PMG INTERNAL MEDICINE
  • PMG PEDIATRICS
  • PMG Urgent Care

PMG Cedar
201 Cedar SE
Albuquerque, NM, 87106

Available Services

  • Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

  • PMG CARDIOLOGY
  • PMG EAR NOSE AND THROAT
  • PMG GENERAL SURGERY
  • PMG Neuro Surgery
  • PMG OB-GYN
  • PMG PEDIATRIC ENDOCRINOLOGY
  • PMG PEDIATRIC GASTROENTEROLOGY
  • PMG PEDIATRIC HEMATOLOGY AND ONCOLOGY
  • PMG PEDIATRIC NEUROLOGY
  • PMG PEDIATRIC PULMONOLOGY
  • PMG PEDIATRIC SURGERY
  • PMG Urology

PMG Gastroenterology
3715 Southern Blvd. SE
Rio Rancho, NM, 87124

Available Services

  • Anesthesia (Outpatient )
  • Perform Invasive Procedure (Outpatient )
  • Single Specialty Practitioner (Outpatient )

PMG High Resort (4005)
4005 High Resort Blvd. SE
Rio Rancho, NM, 87124

Available Services

  • Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

  • PMG FAMILY MEDICINE
  • PMG INTERNAL MEDICINE
  • PMG PEDIATRICS

PMG High Resort (4100)
4100 High Resort Blvd SE
Rio Rancho, NM, 87124

Available Services

  • Anesthesia (Outpatient )
  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Other Clinics/Practices Located at This Site:

  • PMG Endocrinology
  • PMG Neurology
  • PMG Pain and Spine Clinic
  • PMG Rheumatology
  • PMG Urgent Care

PMG Kaseman
8300 B Constitution Ave. NE
Albuquerque, NM, 87111

Available Services

  • Administration of Blood Product (Outpatient )
  • Administration of High Risk Medications (Outpatient )
  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Other Clinics/Practices Located at This Site:

  • PMG ENDOCRINOLOGY
  • PMG FAMILY MEDICINE
  • PMG GENERAL SURGERY
  • PMG INTERNAL MEDICINE
  • PMG ONCOLOGY/HEMATOLOGY
  • PMG PULMONOLOGY
  • PMG RHEUMATOLOGY
  • PRESBYTERIAN M.D. ANDERSON RADIATION TREATMENT CENTER

PMG Kaseman Behavioral Medicine
1325 Wyoming N.E.
Albuquerque, NM, 87110

Available Services

  • Behavioral Health (Non 24 Hour Care - Adult )
  • Chemical Dependency (Non 24 Hour Care - Adult )
  • Chemical Dependency (Non-detox - Adult )

PMG Kaseman Child & Adolescent Behavioral Medicine
8312 Kaseman Ct. NE
Albuquerque, NM, 87110

Available Services

  • Behavioral Health (Non 24 Hour Care - Child/Youth )

PMG Las Estancias
3630 Las Estancias Dr SW
Albuquerque, NM, 87121

Available Services

  • Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

  • Behavioral Health
  • Family Practice
  • Internal Medicine
  • OB Services
  • Pediatric Urgent Care
  • Pediatrics
  • Urgent Care

PMG Los Lunas Clinic
200 Emilio Lopez Rd
Los Lunas, NM, 87031

Available Services

  • Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

  • PMG BEHAVIORAL HEALTH
  • PMG FAMILY MEDICINE
  • PMG OBSTETRICS AND GYNECOLOGY

PMG Montgomery
8800 Montgomery Blvd. NE
Albuquerque, NM, 87111

Available Services

  • Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

  • PMG BEHAVIORAL HEALTH
  • PMG FAMILY MEDICINE
  • PMG INTERNAL MEDICINE

PMG Northside
5901 Harper NE
Albuquerque, NM, 87109

Available Services

  • Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

  • PMG FAMILY MEDICINE
  • PMG NORTHSIDE URGENT CARE
  • PMG PEDIATRICS
  • PMG PODIATRY

PMG Northside OB/GYN
6100 Pan American Freeway NE, Suite 450
Albuquerque, NM, 87109

Available Services

  • Outpatient Clinics (Outpatient )

PMG Northside Primary Care
6100 Pan American Freeway NE Suite 390
Albuquerque, NM, 87109

Available Services

  • Outpatient Clinics (Outpatient )

PMG Paradise
4588 Paradise Blvd NW
Albuquerque, NM, 87114

Available Services

  • Outpatient Clinics (Outpatient )

PMG San Mateo
401 San Mateo SE
Albuquerque, NM, 87108

Available Services

  • Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

  • PMG BEHAVIORAL HEALTH
  • PMG FAMILY MEDICINE
  • PMG INTERNAL MEDICINE
  • PMG OBSTETRICS AND GYNECOLOGY
  • PMG PEDIATRICS

PMG Wyoming
5550 Wyoming Blvd. NE
Albuquerque, NM, 87109

Available Services

  • Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

  • PMG BEHAVIORAL HEALTH
  • PMG FAMILY MEDICINE

Presbyterian Healthcare
DBA: PRESNOW 24/7 Urgent and Emergency Care Isleta/Rio Bravo
3436 Isleta Blvd. SW
Albuquerque, NM, 87105

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Anesthesia (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Presbyterian Healthcare
DBA: PresNow 24/7 Urgent and Emergency Care Center
6400 Paseo Del Norte NE
Albuquerque, NM, 87113

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Anesthesia (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Presbyterian Healthcare
DBA: PRESNow 24/7 Urgent and Emergency Care Coors/Western Trail
4515 Coors Blvd. NW
Albuquerque, NM, 87120

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Anesthesia (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Presbyterian Healthplex
6301 Forest Hills Dr. N.E.
Albuquerque, NM, 87109

Available Services

  • Outpatient Clinics (Outpatient )

Presbyterian Home Health and Hospice
8100 Constitution Place NE #400
Albuquerque, NM, 87110

Available Services

  • Home Health Aides
  • Home Health, Non-Hospice Services
  • Hospice Care
  • Medical Social Services
  • Occupational Therapy
  • Physical Therapy
  • Speech Language Pathology

Presbyterian Hospital
1100 Central Southeast
Albuquerque, NM, 87106

Available Services

  • Cardiac Catheterization Lab (Surgical Services )
  • Cardiac Surgery (Surgical Services )
  • Cardiothoracic Surgery (Surgical Services )
  • Cardiovascular Unit (Inpatient )
  • Coronary Care Unit (Inpatient )
  • CT Scanner (Imaging/Diagnostic Services )
  • Dialysis Unit (Inpatient )
  • Ear/Nose/Throat Surgery (Surgical Services )
  • EEG/EKG/EMG Lab (Imaging/Diagnostic Services )
  • Gastroenterology (Surgical Services )
  • GI or Endoscopy Lab (Imaging/Diagnostic Services )
  • Gynecological Surgery (Surgical Services )
  • Gynecology (Inpatient )
  • Hematology/Oncology Unit (Inpatient )
  • Inpatient Unit (Inpatient )
  • Interventional Radiology (Imaging/Diagnostic Services )
  • Labor & Delivery (Inpatient )
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services )
  • Medical /Surgical Unit (Inpatient )
  • Medical ICU (Intensive Care Unit )
  • Neurosurgery (Surgical Services )
  • Normal Newborn Nursery (Inpatient )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Ophthalmology (Surgical Services )
  • Orthopedic Surgery (Surgical Services )
  • Orthopedic/Spine Unit (Inpatient )
  • Outpatient Clinics (Outpatient )
  • Pediatric Unit (Inpatient )
  • Plastic Surgery (Surgical Services )
  • Positron Emission Tomography (PET) (Imaging/Diagnostic Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Surgical Unit (Inpatient )
  • Thoracic Surgery (Surgical Services )
  • Transplant Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Joint Replacement - Hip
  • Joint Replacement - Knee
  • Primary Stroke Center

Other Clinics/Practices Located at This Site:

  • Presbyterian Infusion Center

Presbyterian Kaseman Hospital
8300 Constitution Avenue Northeast
Albuquerque, NM, 87110

Available Services

  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult )
  • Behavioral Health (24-hour Acute Care/Crisis Stabilization - Child/Youth )
  • Community Integration (Non 24 Hour Care )
  • Hospice Care

Other Clinics/Practices Located at This Site:

  • PMG PAIN AND SPINE CLINIC
  • Sleep Center

Presbyterian Outpatient GI Lab
301 Cedar SE
Albuquerque, NM, 87106

Available Services

  • Anesthesia (Outpatient )
  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Presbyterian Rust Medical Center
2400 Unser Blvd SE
Rio Rancho, NM, 87124

Available Services

  • Cardiac Catheterization Lab (Surgical Services )
  • CT Scanner (Imaging/Diagnostic Services )
  • Dialysis Unit (Inpatient )
  • Ear/Nose/Throat Surgery (Surgical Services )
  • EEG/EKG/EMG Lab (Imaging/Diagnostic Services )
  • Gastroenterology (Surgical Services )
  • Gynecological Surgery (Surgical Services )
  • Gynecology (Inpatient )
  • Hematology/Oncology Unit (Inpatient )
  • Inpatient Unit (Inpatient )
  • Interventional Radiology (Imaging/Diagnostic Services )
  • Labor & Delivery (Inpatient )
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services )
  • Medical /Surgical Unit (Inpatient )
  • Medical ICU (Intensive Care Unit )
  • Normal Newborn Nursery (Inpatient )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Orthopedic Surgery (Surgical Services )
  • Orthopedic/Spine Unit (Inpatient )
  • Pediatric Unit (Inpatient )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Surgical Unit (Inpatient )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )

Organization Commentary

Mr. Tim Johnsen, CHIEF OPERATING OFFICER

Response to JCAHO Quality Report August 3, 2004 Presbyterian has set clear goals to become a national leader in safe, quality care. Our aim is to be in the top ten percent of all hospitals in patient safety. We also strive to be one of the top 100 heart care programs in the nation. To this end, we are one of a handful of hospitals in the country to invest in medication safety technology at every step of the medication administration process. Presbyterian is also a participant in the Institute of Healthcare Improvement’s Impact Collaborative, where we are one of 108 hospital systems sharing ideas and information to make healthcare delivery safer and stronger across the nation. We have recently established a Quality Institute that is implementing process improvements and treatment requirements that will further decrease mortality and medical errors that harm patients. Presbyterian’s voluntary participation in the Joint Commission accreditation process continues to foster evaluation of patient care for improvement. As a healthcare system dedicated to continuous improvement on behalf of our patients, we are not satisfied with the results in this Joint Commission report. Presbyterian regrets that the data we provided to the Joint Commission was not of the quality to accurately reflect the care we deliver every day to patients in our hospital. The data we supplied to the Commission relied on administrative data for these reports. While these records accurately reflect services rendered, they are not an exact match to a patient’s clinical record and, therefore, fail to capture many of the interventions that the Joint Commission seeks out. In 2004, Presbyterian implemented a new system to better capture clinical data, that will allow us to more accurately report public data reflective of our commitment to safe, high quality care.

National Patient Safety Goals and National Quality Improvement Goals

Symbol Key

  • starThis organization achieved the best possible results
  • plusThis organization's performance is better than the target range/value
  • checkThis organization's performance is similar to the target range/value
  • minusThis organization's performance is worse than the target range /value
  • naThis measure is not applicable for this organization
  • ndNot displayed

Measures Footnote Key

  1. The measure or measure set was not reported.
  2. The measure set does not have an overall result.
  3. The number is not enough for comparison purposes.
  4. The measure meets the Privacy Disclosure Threshold rule.
  5. The organization scored above 90% but was below most other organizations.
  6. The measure results are not statistically valid.
  7. The measure results are based on a sample of patients.
  8. The number of months with measure data is below the reporting requirement.
  9. The measure results are temporarily suppressed pending resubmission of updated data.
  10. Test Measure: a measure being evaluated for reliability of the individual data elements or awaiting National Quality Forum Endorsement.
  11. There were no eligible patients that met the denominator criteria.
  12. The measure rate is within optimal range.

Symbol Key

  • starThis organization achieved the best possible results
  • plusThis organization's performance is better than the target range/value
  • checkThis organization's performance is similar to the target range/value
  • minusThis organization's performance is worse than the target range/value
  • naThis measure is not applicable for this organization
  • ndNot displayed

Measures Footnote Key

  1. The measure or measure set was not reported.
  2. The measure set does not have an overall result.
  3. The number is not enough for comparison purposes.
  4. The measure meets the Privacy Disclosure Threshold rule.
  5. The organization scored above 90% but was below most other organizations.
  6. The measure results are not statistically valid.
  7. The measure results are based on a sample of patients.
  8. The number of months with measure data is below the reporting requirement.
  9. The measure results are temporarily suppressed pending resubmission of updated data.
  10. Test Measure: a measure being evaluated for reliability of the individual data elements or awaiting National Quality Forum Endorsement.
  11. There were no eligible patients that met the denominator criteria.
  12. The measure rate is within optimal range.

* This information can also be viewed at Hospital Compare.

**      Indicates per 1000 hours of patient care.
***   The measure was not in effect for this quarter.
----   Null value or data not displayed.

Hospital 2023 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Home Care 2023 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Reporting Period: January 2022 - December 2022
Perinatal Care National Comparison: nd 2 Statewide Comparison: nd 2

New Changes to Quarterly Measure

Download Quarterly Measure Results

* State results are not calculated for the National Patient Safety Goals.