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: Sunday, April 14, 2024
Measure Hospital Result State Average State Benchmark National Average Report Period
Cesarean Birth 26.471 21.77 11.65 --- 10/1/2022-9/30/2023
Early Elective Delivery 1.786 3.31 0 --- 10/1/2022-9/30/2023
Exclusive Breast Milk Feeding 72.388 62.92 77.55 --- 10/1/2022-9/30/2023
Newborn Screening Card Transit Time 99.743 98.71 100 --- 10/1/2022-9/30/2023
Term Newborn Complications DNR 3.37 1.31 --- 10/1/2022-9/30/2023
Measure Hospital Result State Average State Benchmark National Average Report Period
Hip and Knee Surgery Complications 3.3 3.1 2.6 3.2 4/1/2019-3/31/2022
Measure Hospital Result State Average State Benchmark National Average Report Period
Catheter-Associated Urinary Tract Infections 0.371 0.61 0 1 10/1/2022-9/30/2023
Central Line Associated Blood Stream Infections 0.44 0.69 0 1 10/1/2022-9/30/2023
Clostridioides difficile Infections 0.333 0.67 0 1 10/1/2022-9/30/2023
Methicillin-Resistant Staph. aureus Infections 0 0.42 0 1 10/1/2022-9/30/2023
Surgical Site Infection - Abdominal Hysterectomy 1.15 0 1 10/1/2022-9/30/2023
Surgical Site Infection - Colon Surgery 0 0.88 0 1 10/1/2022-9/30/2023
Measure Hospital Result State Average State Benchmark National Average Report Period
Acute Stroke 2.894 6.431 0 6.86 10/1/2022-9/30/2023
Chronic Obstructive Pulmonary Disease 12.2 9.3 7.8 9.2 7/1/2019-6/30/2022
GastrointestinaI Hemorrhage 4.047 2.336 0 2.51 10/1/2022-9/30/2023
Heart Attack 10.6 12.2 10.6 12.6 7/1/2019-6/30/2022
Heart Failure 13.6 12.4 9.9 11.8 7/1/2019-6/30/2022
Hip Fracture 1.026 2.376 0 1.96 10/1/2022-9/30/2023
Pneumonia 19.5 18.1 15.8 18.2 7/1/2019-6/30/2022
Measure Hospital Result State Average State Benchmark National Average Report Period
Abdominal Aortic Aneurism Repair 1.854 0 3.61 10/1/2022-9/30/2023
Carotid Endarterectomy 0.082 0 0.43 10/1/2022-9/30/2023
Coronary Artery Bypass Graft 3.678 2.985 0 2.49 10/1/2022-9/30/2023
Percutaneous Coronary Intervention 2.745 2.262 0 3.26 10/1/2022-9/30/2023
Measure Hospital Result State Average State Benchmark National Average Report Period
Always Quiet at Night 67 66 76 62 4/1/2022-3/31/2023
Definitely Recommend Hospital 65 73 83 69 4/1/2022-3/31/2023
Doctors Always Communicated Well 78 81 88 79 4/1/2022-3/31/2023
Nurses Always Communicated Well 80 82 89 79 4/1/2022-3/31/2023
Patient Rated Hospital High 74 75 87 71 4/1/2022-3/31/2023
Patients Always Received Requested Help 61 70 81 66 4/1/2022-3/31/2023
Patients Understood Their Care When They Left 49 55 64 52 4/1/2022-3/31/2023
Room Always Clean 77 77 86 72 4/1/2022-3/31/2023
Staff Always Explained Medications 64 66 75 62 4/1/2022-3/31/2023
Staff Provided Discharge Instructions 90 89 93 86 4/1/2022-3/31/2023
Measure Hospital Result State Average State Benchmark National Average Report Period
Falls with Major Injury 0.027 0.035 0 --- 10/1/2022-9/30/2023
Healthcare Personnel Influenza Immunization 92.51 83.2 94.8 --- 10/1/2022-5/15/2023
Pneumothorax 0 0.01 0 0.02 10/1/2022-9/30/2023
Pressure Ulcers 0.348 0.064 0 0.07 10/1/2022-9/30/2023
Measure Hospital Result State Average State Benchmark National Average Report Period
Perioperative Blood Clot 0.09 0.235 0 0.35 10/1/2022-9/30/2023
Perioperative Hemorrhage 0.194 0.253 0 0.23 10/1/2022-9/30/2023
Postoperative Respiratory Failure 0.13 0.537 0 0.73 10/1/2022-9/30/2023
Postoperative Sepsis 0 0.257 0 0.43 10/1/2022-9/30/2023
Measure Hospital Result State Average State Benchmark National Average Report Period
All Cause Unplanned Readmissions 8.9 9.1 6.38 --- 7/1/2022-6/30/2023
Chronic Obstructive Pulmonary Disease 18.2 18.8 17.8 19.3 7/1/2019-6/30/2022
Coronary Artery Bypass Graft 11 9.9 11 7/1/2019-6/30/2022
Heart Attack 12.5 13.7 12.5 14 7/1/2019-6/30/2022
Heart Failure 20.8 19.9 18.3 20.2 7/1/2019-6/30/2022
Hip and Knee Surgery 4 4.2 3.5 4.3 7/1/2019-6/30/2022
Pneumonia 16.2 16.6 15.6 16.9 7/1/2019-6/30/2022