Bottom quartile Middle Top quartile Percentile badges compare this hospital to all 5,426 hospitals nationally.

Overview

Address
516 E NIZHONI BLVD, GALLUP, NM 87301
Phone
(505) 722-1000
Hospital Type
Acute Care
Ownership
Government (Federal)
Emergency Services
Yes
Birthing Friendly
Yes
2 /5
CMS Overall Rating
p7
Acute Care — General medical and surgical hospital participating in Medicare IPPS. Subject to CMS quality reporting and payment adjustment programs (VBP, HRRP, HAC).

CMS Star Rating — Quality Domain Breakdown

CMS computes the overall star rating from five quality domains. Each domain compares this hospital's measures against national benchmarks.

Mortality 2 of 7 measures reported
2
Better No different Worse
30-day death rates for heart attack, heart failure, pneumonia, COPD, stroke, CABG, and kidney disease.
Safety of Care 3 of 8 measures reported
3
Better No different Worse
Healthcare-associated infections and patient safety indicators (PSI-90 composite).
Readmission 3 of 11 measures reported
3
Better No different Worse
30-day unplanned readmission rates for heart attack, heart failure, pneumonia, COPD, hip/knee replacement, and CABG.
Patient Experience 8 of 8 measures reported
8 measures reported (comparative data not available for this domain)
HCAHPS survey scores — patient-reported experience with communication, responsiveness, cleanliness, and discharge planning.
Timely & Effective Care 5 of 12 measures reported
5 measures reported (comparative data not available for this domain)
Process-of-care measures including flu immunization, blood clot prevention, and appropriate use of imaging.

Readmissions — Hospital Readmissions Reduction Program

The Excess Readmission Ratio (ERR) compares this hospital's 30-day readmission rate to expected, adjusting for patient mix. An ERR of 1.0 means readmissions are as expected; > 1.0 triggers a Medicare payment penalty (up to 3%).

This hospital has excess readmissions in at least one condition and is subject to HRRP payment reduction.
Acute Myocardial Infarction (Heart Attack) 0 discharges
— Not reported
Heart Failure
1.0301 p69
Pneumonia
0.9605 p25
COPD
— Not reported
Hip/Knee Replacement
— Not reported
CABG Surgery
— Not reported
Expected (1.0) National median

Value-Based Purchasing

The Hospital VBP Program adjusts Medicare payments based on clinical quality. The Total Performance Score (TPS) is a weighted composite of four domains, each worth 25%. This hospital's TPS is above the national median, suggesting a positive payment adjustment.

43.3 p86
Total Performance Score
National median: 29.5
Clinical Outcomes 25% weight
6.3 p58
Nat'l median: 5.0
Measures mortality rates for conditions like heart attack, heart failure, pneumonia, and COPD. Based on 30-day risk-standardized mortality.
Safety 25% weight
10.8 p53
Nat'l median: 10.0
Patient safety measures including healthcare-associated infections (CLABSI, CAUTI, SSI, MRSA, C. diff) and perioperative complications.
Person & Community Engagement 25% weight
1.3 p0
Nat'l median: 8.8
Based on HCAHPS patient experience survey results — communication with nurses and doctors, hospital cleanliness, pain management, discharge information.
Efficiency & Cost Reduction 25% weight
25.0 p96
Nat'l median: 2.5
Based on Medicare Spending Per Beneficiary (MSPB). Measures episode-of-care costs from 3 days before admission through 30 days after discharge.

CMS Payment Programs

Three Medicare programs adjust hospital payments based on quality performance. Hospitals can be penalized under multiple programs simultaneously.

Readmissions (HRRP)
Penalized
Worst ERR: 1.0301
Value-Based Purchasing
43.3 TPS
Above national median
HAC Reduction
No Reduction
HAC Score: 0.2326

Complications & Deaths

30-day mortality rates, patient safety indicators, and complication rates. "Better" means statistically significantly better than the national rate.

Measure Score vs. National Denominator
COMP_HIP_KNEE
Hybrid_HWM 4.20 No Different Than the National Rate 205
MORT_30_AMI Number of Cases Too Small
MORT_30_CABG
MORT_30_COPD Number of Cases Too Small
MORT_30_HF 10.80 No Different Than the National Rate 31
MORT_30_PN 14.80 No Different Than the National Rate 78
MORT_30_STK Number of Cases Too Small
PSI_03 0.50 No Different Than the National Rate 742
PSI_04
PSI_06 0.20 No Different Than the National Rate 972
PSI_08 0.31 No Different Than the National Rate 990
PSI_09 2.31 No Different Than the National Rate 79
PSI_10
PSI_11
PSI_12 3.44 No Different Than the National Rate 83
PSI_13
PSI_14 1.75 No Different Than the National Rate 32
PSI_15 1.05 No Different Than the National Rate 50
PSI_90 0.96 No Different Than the National Value

Patient Experience (HCAHPS)

Hospital Consumer Assessment of Healthcare Providers and Systems — standardized patient survey measuring satisfaction with care.

Measure Score Star Rating
H_COMP_1_A_P: Nurses "always" communicated well 59%
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 15%
H_COMP_1_U_P: Nurses "usually" communicated well 26%
H_COMP_1_LINEAR_SCORE: Nurse communication - linear mean score
H_COMP_1_STAR_RATING: Nurse communication - star rating 1
H_NURSE_RESPECT_A_P: Nurses "always" treated them with courtesy and respect 61%
H_NURSE_RESPECT_SN_P: Nurses "sometimes" or "never" treated them with courtesy and respect 13%
H_NURSE_RESPECT_U_P: Nurses "usually" treated them with courtesy and respect 26%
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 60%
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 14%
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 26%
H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand 56%
H_NURSE_EXPLAIN_SN_P: Nurses "sometimes" or "never" explained things so they could understand 17%
H_NURSE_EXPLAIN_U_P: Nurses "usually" explained things so they could understand 27%
H_COMP_2_A_P: Doctors "always" communicated well 68%
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 7%
H_COMP_2_U_P: Doctors "usually" communicated well 25%
H_COMP_2_LINEAR_SCORE: Doctor communication - linear mean score
H_COMP_2_STAR_RATING: Doctor communication - star rating 2
H_DOCTOR_RESPECT_A_P: Doctors "always" treated them with courtesy and respect 71%
H_DOCTOR_RESPECT_SN_P: Doctors "sometimes" or "never" treated them with courtesy and respect 5%
H_DOCTOR_RESPECT_U_P: Doctors "usually" treated them with courtesy and respect 24%
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 69%
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 7%
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 24%
H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand 65%
H_DOCTOR_EXPLAIN_SN_P: Doctors "sometimes" or "never" explained things so they could understand 10%
H_DOCTOR_EXPLAIN_U_P: Doctors "usually" explained things so they could understand 25%
H_COMP_5_A_P: Staff "always" explained 54%
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 22%
H_COMP_5_U_P: Staff "usually" explained 24%
H_COMP_5_LINEAR_SCORE: Communication about medicines - linear mean score
H_COMP_5_STAR_RATING: Communication about medicines - star rating 2
H_MED_FOR_A_P: Staff "always" explained new medications 59%
H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications 16%
H_MED_FOR_U_P: Staff "usually" explained new medications 25%
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 48%
H_SIDE_EFFECTS_SN_P: Staff "sometimes" or "never" explained possible side effects 28%
H_SIDE_EFFECTS_U_P: Staff "usually" explained possible side effects 24%
H_COMP_6_N_P: No, staff "did not" give patients this information 19%
H_COMP_6_Y_P: Yes, staff "did" give patients this information 81%
H_COMP_6_LINEAR_SCORE: Discharge information - linear mean score
H_COMP_6_STAR_RATING: Discharge information - star rating 2
H_DISCH_HELP_N_P: No, staff "did not" give patients information about help after discharge 25%
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge 75%
H_SYMPTOMS_N_P: No, staff "did not" give patients information about possible symptoms 14%
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms 86%
H_CLEAN_HSP_A_P: Room was "always" clean 55%
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 15%
H_CLEAN_HSP_U_P: Room was "usually" clean 30%
H_CLEAN_LINEAR_SCORE: Cleanliness - linear mean score
H_CLEAN_STAR_RATING: Cleanliness - star rating 2
H_QUIET_HSP_A_P: "Always" quiet at night 50%
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 21%
H_QUIET_HSP_U_P: "Usually" quiet at night 29%
H_QUIET_LINEAR_SCORE: Quietness - linear mean score
H_QUIET_STAR_RATING: Quietness - star rating 2
H_HSP_RATING_0_6: Patients who gave a rating of "6" or lower (low) 21%
H_HSP_RATING_7_8: Patients who gave a rating of "7" or "8" (medium) 26%
H_HSP_RATING_9_10: Patients who gave a rating of "9" or "10" (high) 53%
H_HSP_RATING_LINEAR_SCORE: Overall hospital rating - linear mean score
H_HSP_RATING_STAR_RATING: Overall hospital rating - star rating 1
H_RECMND_DN: "NO", patients would not recommend the hospital (they probably would not or definitely would not recommend it) 12%
H_RECMND_DY: "YES", patients would definitely recommend the hospital 42%
H_RECMND_PY: "YES", patients would probably recommend the hospital 46%
H_RECMND_LINEAR_SCORE: Recommend hospital - linear mean score
H_RECMND_STAR_RATING: Recommend hospital - star rating 1
H_STAR_RATING: Summary star rating 2

Healthcare Associated Infections

Standardized Infection Ratios (SIR). A SIR < 1.0 means fewer infections than predicted based on national baseline data.

Measure Score (SIR) vs. National
HAI_1_CILOWER
HAI_1_CIUPPER
HAI_1_DOPC 210.000
HAI_1_ELIGCASES 0.171
HAI_1_NUMERATOR 0.000
HAI_1_SIR
HAI_2_CILOWER N/A No Different than National Benchmark
HAI_2_CIUPPER 2.111 No Different than National Benchmark
HAI_2_DOPC 1910.000 No Different than National Benchmark
HAI_2_ELIGCASES 1.419 No Different than National Benchmark
HAI_2_NUMERATOR 0.000 No Different than National Benchmark
HAI_2_SIR 0.000 No Different than National Benchmark
HAI_3_CILOWER
HAI_3_CIUPPER
HAI_3_DOPC 7.000
HAI_3_ELIGCASES 0.243
HAI_3_NUMERATOR 1.000
HAI_3_SIR
HAI_4_CILOWER
HAI_4_CIUPPER
HAI_4_DOPC 10.000
HAI_4_ELIGCASES 0.079
HAI_4_NUMERATOR 0.000
HAI_4_SIR
HAI_5_CILOWER
HAI_5_CIUPPER
HAI_5_DOPC 11384.000
HAI_5_ELIGCASES 0.275
HAI_5_NUMERATOR 0.000
HAI_5_SIR
HAI_6_CILOWER 0.720 No Different than National Benchmark
HAI_6_CIUPPER 2.379 No Different than National Benchmark
HAI_6_DOPC 10467.000 No Different than National Benchmark
HAI_6_ELIGCASES 8.036 No Different than National Benchmark
HAI_6_NUMERATOR 11.000 No Different than National Benchmark
HAI_6_SIR 1.369 No Different than National Benchmark

Timely & Effective Care

Process-of-care measures including ED wait times, treatment timeliness, and preventive care.

Measure Score Condition
EDV Emergency Department
GMCS Electronic Clinical Quality Measure
GMCS_Malnutrition_Diagnosis_Documented Electronic Clinical Quality Measure
GMCS_Malnutrition_Screening Electronic Clinical Quality Measure
GMCS_Nutrition_Assessment Electronic Clinical Quality Measure
GMCS_Nutritional_Care_Plan Electronic Clinical Quality Measure
HH_HYPER 13.0 Electronic Clinical Quality Measure
HH_HYPO 1.0 Electronic Clinical Quality Measure
HH_ORAE 0.0 Electronic Clinical Quality Measure
IMM_3 82.0 Healthcare Personnel Vaccination
OP_18a Emergency Department
OP_18b Emergency Department
OP_18c Emergency Department
OP_18d Emergency Department
OP_22 Emergency Department
OP_23 Emergency Department
OP_29 Colonoscopy care
OP_31 Cataract surgery outcome
SAFE_USE_OF_OPIOIDS 21.0 Electronic Clinical Quality Measure
SEP_1 61.0 Sepsis Care
SEP_SH_3HR 78.0 Sepsis Care
SEP_SH_6HR 93.0 Sepsis Care
SEV_SEP_3HR 84.0 Sepsis Care
SEV_SEP_6HR 77.0 Sepsis Care
STK_02 Electronic Clinical Quality Measure
STK_03 Electronic Clinical Quality Measure
STK_05 Electronic Clinical Quality Measure
VTE_1 55.0 Electronic Clinical Quality Measure
VTE_2 Electronic Clinical Quality Measure

Unplanned Hospital Visits

Readmission and ED return rates within 30 days of discharge.

Measure Score vs. National
EDAC_30_AMI
EDAC_30_HF 13.70 Average Days per 100 Discharges
EDAC_30_PN -23.70 Fewer Days Than Average per 100 Discharges
Hybrid_HWR 14.80 No Different Than the National Rate
OP_32
OP_35_ADM
OP_35_ED
OP_36
READM_30_AMI
READM_30_CABG
READM_30_COPD Number of Cases Too Small
READM_30_HF 20.30 No Different Than the National Rate
READM_30_HIP_KNEE
READM_30_PN 15.80 No Different Than the National Rate

Medicare Spending Per Beneficiary

MSPB ratio: values > 1.0 mean this hospital's episode spending is higher than the national median hospital.

Value
0.80

Financial Health (Cost Report — FY 2023)

All Data

Every labeled metric surfaced for this hospital, with national medians and percentiles where a benchmark is available.

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Show 63 rows
Source Metric Value National Median Pctl. Raw key
Cost Report Employees per Bed 16.35 metrics.employees_per_bed
Cost Report fiscal_year 2,023 fiscal_year
Cost Report Net Income ($) $-271,680,094 metrics.net_income
Cost Report Total Costs ($) $161,930,244 metrics.total_costs
General Information Address 516 E NIZHONI BLVD Address
General Information City/Town GALLUP City/Town
General Information Count of Facility MORT Measures 2 Count of Facility MORT Measures
General Information Count of Facility Pt Exp Measures 8 Count of Facility Pt Exp Measures
General Information Count of Facility READM Measures 3 Count of Facility READM Measures
General Information Count of Facility Safety Measures 3 Count of Facility Safety Measures
General Information Count of Facility TE Measures 5 Count of Facility TE Measures
General Information Count of MORT Measures Better 0 Count of MORT Measures Better
General Information Count of MORT Measures No Different 2 Count of MORT Measures No Different
General Information Count of MORT Measures Worse 0 Count of MORT Measures Worse
General Information Count of READM Measures Better 0 Count of READM Measures Better
General Information Count of READM Measures No Different 3 Count of READM Measures No Different
General Information Count of READM Measures Worse 0 Count of READM Measures Worse
General Information Count of Safety Measures Better 0 Count of Safety Measures Better
General Information Count of Safety Measures No Different 3 Count of Safety Measures No Different
General Information Count of Safety Measures Worse 0 Count of Safety Measures Worse
General Information County/Parish MCKINLEY County/Parish
General Information Emergency Services Yes Emergency Services
General Information Facility ID 320061 Facility ID
General Information Facility Name GALLUP INDIAN MEDICAL CENTER Facility Name
General Information Hospital overall rating 2 Hospital overall rating
General Information Hospital overall rating footnote 17 Hospital overall rating footnote
General Information Hospital Ownership Government - Federal Hospital Ownership
General Information Hospital Type Acute Care Hospitals Hospital Type
General Information Meets criteria for birthing friendly designation Y Meets criteria for birthing friendly designation
General Information MORT Group Footnote MORT Group Footnote
General Information MORT Group Measure Count 7 MORT Group Measure Count
General Information Pt Exp Group Footnote Pt Exp Group Footnote
General Information Pt Exp Group Measure Count 8 Pt Exp Group Measure Count
General Information READM Group Footnote READM Group Footnote
General Information READM Group Measure Count 11 READM Group Measure Count
General Information Safety Group Footnote Safety Group Footnote
General Information Safety Group Measure Count 8 Safety Group Measure Count
General Information State NM State
General Information TE Group Footnote TE Group Footnote
General Information TE Group Measure Count 12 TE Group Measure Count
General Information Telephone Number (505) 722-1000 Telephone Number
General Information ZIP Code 87301 ZIP Code
HAC Reduction Program fiscal_year 2,026 fiscal_year
HAC Reduction Program measures — cauti — sir 0 measures.cauti.sir
HAC Reduction Program measures — cdi — sir 1.58 measures.cdi.sir
HAC Reduction Program payment_reduction No payment_reduction
HAC Reduction Program total_hac_score 0.23 total_hac_score
Medicare Spending per Beneficiary End Date 12/31/2024 End Date
Medicare Spending per Beneficiary Measure ID MSPB-1 Measure ID
Medicare Spending per Beneficiary Start Date 01/01/2024 Start Date
Medicare Spending per Beneficiary Value 0.80 Value
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of discharges 0 READM-30-AMI-HRRP.num_discharges
Readmissions (HRRP) Heart Failure — Excess readmission ratio 1.03 0.9983 p69 READM-30-HF-HRRP.excess_readmission_ratio
Readmissions (HRRP) Heart Failure — Expected readmission rate 17.2% READM-30-HF-HRRP.expected_readmission_rate
Readmissions (HRRP) Heart Failure — Predicted readmission rate 17.8% READM-30-HF-HRRP.predicted_readmission_rate
Readmissions (HRRP) Pneumonia — Excess readmission ratio 0.96 0.9955 p25 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 12.1% READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Predicted readmission rate 11.7% READM-30-PN-HRRP.predicted_readmission_rate
Value-Based Purchasing Clinical Outcomes 6.25 5.00 p58 clinical_outcomes_score
Value-Based Purchasing Efficiency & Cost Reduction 25.00 2.50 p96 efficiency_score
Value-Based Purchasing Person & Community Engagement 1.25 8.75 p0 person_community_score
Value-Based Purchasing Safety 10.83 10.00 p53 safety_score
Value-Based Purchasing Total Performance Score 43.33 29.50 p86 total_performance_score
Methodology

Full methodology →