Hospital Report
SSM Health St. Agnes Hospital
430 E. Division, PO Box 385
Fond du Lac, Wisconsin, 54935
920-929-2300
http://www.ssmhealth.com/wisconsin
Generated: Monday, June 15, 2026
Birth
| Measure | Hospital Result | State Average | State Benchmark | National Baseline | Report Period |
|---|---|---|---|---|---|
| Newborn Screening Card Transit Time | 98.57 | 98.11 | 100 | --- | 1/1/2025-12/31/2025 |
Hip and Knee Surgical Complications
| Measure | Hospital Result | State Average | State Benchmark | National Baseline | Report Period |
|---|---|---|---|---|---|
| Hip and Knee Surgery Complications | 3.294 | 2.66 | 3.6 | 7/1/2021-6/30/2024 |
Infections
| Measure | Hospital Result | State Average | State Benchmark | National Baseline | Report Period |
|---|---|---|---|---|---|
| Catheter-Associated Urinary Tract Infections | 0 | 0.46 | 0 | 1 | 1/1/2025-12/31/2025 |
| Central Line Associated Blood Stream Infections | 1.433 | 0.53 | 0 | 1 | 1/1/2025-12/31/2025 |
| Clostridioides difficile Infections | 0.115 | 0.57 | 0 | 1 | 1/1/2025-12/31/2025 |
| Methicillin-Resistant Staph. aureus Infections | 0 | 0.44 | 0 | 1 | 1/1/2025-12/31/2025 |
| Surgical Site Infection - Abdominal Hysterectomy | 1.21 | 0 | 1 | 1/1/2025-12/31/2025 | |
| Surgical Site Infection - Colon Surgery | 0.681 | 1.12 | 0 | 1 | 1/1/2025-12/31/2025 |
Mortality - Conditions
| Measure | Hospital Result | State Average | State Benchmark | National Baseline | Report Period |
|---|---|---|---|---|---|
| Acute Stroke | 2.56 | 5.199 | 0 | 6.95 | 1/1/2025-12/31/2025 |
| Chronic Obstructive Pulmonary Disease | 11.2 | 8.882 | 7.3 | 8.8 | 7/1/2021-6/30/2024 |
| GastrointestinaI Hemorrhage | 2.011 | 1.394 | 0 | 2.72 | 1/1/2025-12/31/2025 |
| Heart Attack | 11.6 | 11.898 | 10.64 | 12.2 | 7/1/2021-6/30/2024 |
| Heart Failure | 13.6 | 12.329 | 9.7 | 11.6 | 7/1/2021-6/30/2024 |
| Hip Fracture | 0 | 1.338 | 0 | 2 | 1/1/2025-12/31/2025 |
| Pneumonia | 17.8 | 15.989 | 13.03 | 16.2 | 7/1/2021-6/30/2024 |
Mortality - Procedures
| Measure | Hospital Result | State Average | State Benchmark | National Baseline | Report Period |
|---|---|---|---|---|---|
| Abdominal Aortic Aneurism Repair | 2.081 | 0 | 3.69 | 1/1/2025-12/31/2025 | |
| Carotid Endarterectomy | 0.12 | 0 | 0.47 | 1/1/2025-12/31/2025 | |
| Coronary Artery Bypass Graft | 1.591 | 2.136 | 0 | 2.54 | 1/1/2025-12/31/2025 |
| Percutaneous Coronary Intervention | 3.071 | 2.295 | 0 | 3.46 | 1/1/2025-12/31/2025 |
Patient Experience
| Measure | Hospital Result | State Average | State Benchmark | National Baseline | Report Period |
|---|---|---|---|---|---|
| Always Quiet at Night | 66 | 65 | 77 | 60 | 7/1/2024-6/30/2025 |
| Definitely Recommend Hospital | 66 | 74 | 85 | 71 | 7/1/2024-6/30/2025 |
| Doctors Always Communicated Well | 79 | 82 | 88 | 80 | 7/1/2024-6/30/2025 |
| Nurses Always Communicated Well | 81 | 83 | 89 | 80 | 7/1/2024-6/30/2025 |
| Patient Rated Hospital High | 70 | 77 | 88 | 72 | 7/1/2024-6/30/2025 |
| Room Always Clean | 75 | 78 | 90 | 74 | 7/1/2024-6/30/2025 |
| Staff Always Explained Medications | 61 | 66 | 76 | 62 | 7/1/2024-6/30/2025 |
| Staff Provided Discharge Instructions | 90 | 89 | 93 | 87 | 7/1/2024-6/30/2025 |
Patient Safety - All Patients
| Measure | Hospital Result | State Average | State Benchmark | National Baseline | Report Period |
|---|---|---|---|---|---|
| Healthcare Personnel Influenza Immunization | 83.541 | 79.62 | 94.09 | --- | 10/1/2024-5/15/2025 |
| In Hospital Fall Associated Fracture Rate | 0 | 0.027 | 0 | 0.03 | 1/1/2025-12/31/2025 |
| Pneumothorax | 0.017 | 0.007 | 0 | 0.02 | 1/1/2025-12/31/2025 |
| Pressure Ulcers | 0.168 | 0.044 | 0 | 0.08 | 1/1/2025-12/31/2025 |
| Sepsis-1 | 69 | 71 | 72 | 64 | 7/1/2024-6/30/2025 |
Patient Safety - Patients with Surgery
| Measure | Hospital Result | State Average | State Benchmark | National Baseline | Report Period |
|---|---|---|---|---|---|
| Perioperative Blood Clot | 0.083 | 0.308 | 0 | 0.33 | 1/1/2025-12/31/2025 |
| Perioperative Hemorrhage | 0 | 0.129 | 0 | 0.23 | 1/1/2025-12/31/2025 |
| Postoperative Respiratory Failure | 0.418 | 0.507 | 0 | 0.72 | 1/1/2025-12/31/2025 |
| Postoperative Sepsis | 0.191 | 0.306 | 0 | 0.45 | 1/1/2025-12/31/2025 |
Perinatal
Readmissions
| Measure | Hospital Result | State Average | State Benchmark | National Baseline | Report Period |
|---|---|---|---|---|---|
| All Cause Unplanned Readmissions | 11.3 | 9.85 | 6.96 | --- | 10/1/2024-9/30/2025 |
| Chronic Obstructive Pulmonary Disease | 18.9 | 17.911 | 17.3 | 18.2 | 7/1/2021-6/30/2024 |
| Coronary Artery Bypass Graft | 11.2 | 10.483 | 9.22 | 10.6 | 7/1/2021-6/30/2024 |
| Heart Attack | 12.9 | 13.484 | 12.52 | 13.6 | 7/1/2021-6/30/2024 |
| Heart Failure | 18.3 | 19.339 | 18.01 | 19.7 | 7/1/2021-6/30/2024 |
| Hip and Knee Surgery | 4.722 | 3.9 | 4.8 | 7/1/2021-6/30/2024 | |
| Pneumonia | 16.2 | 15.778 | 14.62 | 16 | 7/1/2021-6/30/2024 |