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 20, 2025
Birth
| Measure | Hospital Result | State Average | State Benchmark | National Average | Report Period |
|---|---|---|---|---|---|
| Newborn Screening Card Transit Time | 96.974 | 97.95 | 100 | --- | 10/1/2023-9/30/2024 |
Hip and Knee Surgical Complications
| Measure | Hospital Result | State Average | State Benchmark | National Average | Report Period |
|---|---|---|---|---|---|
| Hip and Knee Surgery Complications | 3.285 | 2.76 | 3.5 | 7/1/2020-6/30/2023 |
Infections
| Measure | Hospital Result | State Average | State Benchmark | National Average | Report Period |
|---|---|---|---|---|---|
| Catheter-Associated Urinary Tract Infections | 0 | 0.62 | 0 | 1 | 10/1/2023-9/30/2024 |
| Central Line Associated Blood Stream Infections | 0 | 0.53 | 0 | 1 | 10/1/2023-9/30/2024 |
| Clostridioides difficile Infections | 0.056 | 0.63 | 0 | 1 | 10/1/2023-9/30/2024 |
| Methicillin-Resistant Staph. aureus Infections | 0 | 0.4 | 0 | 1 | 10/1/2023-9/30/2024 |
| Surgical Site Infection - Abdominal Hysterectomy | 1.62 | 0 | 1 | 10/1/2023-9/30/2024 | |
| Surgical Site Infection - Colon Surgery | 0 | 1.07 | 0 | 1 | 10/1/2023-9/30/2024 |
Mortality - Conditions
| Measure | Hospital Result | State Average | State Benchmark | National Average | Report Period |
|---|---|---|---|---|---|
| Acute Stroke | 8.218 | 5.938 | 0 | 6.83 | 10/1/2023-9/30/2024 |
| Chronic Obstructive Pulmonary Disease | 12.5 | 9.518 | 7.97 | 9.4 | 7/1/2020-6/30/2023 |
| GastrointestinaI Hemorrhage | 1.476 | 1.633 | 0 | 2.54 | 10/1/2023-9/30/2024 |
| Heart Attack | 11.6 | 12.112 | 10.86 | 12.6 | 7/1/2020-6/30/2023 |
| Heart Failure | 13.5 | 12.496 | 10.2 | 11.9 | 7/1/2020-6/30/2023 |
| Hip Fracture | 1.871 | 1.022 | 0 | 1.95 | 10/1/2023-9/30/2024 |
| Pneumonia | 21.1 | 17.418 | 14.58 | 17.9 | 7/1/2020-6/30/2023 |
Mortality - Procedures
| Measure | Hospital Result | State Average | State Benchmark | National Average | Report Period |
|---|---|---|---|---|---|
| Abdominal Aortic Aneurism Repair | 1.408 | 0 | 3.64 | 10/1/2023-9/30/2024 | |
| Carotid Endarterectomy | 0.214 | 0 | 0.43 | 10/1/2023-9/30/2024 | |
| Coronary Artery Bypass Graft | 2.321 | 2.613 | 0 | 2.48 | 10/1/2023-9/30/2024 |
| Percutaneous Coronary Intervention | 2.707 | 2.184 | 0 | 3.31 | 10/1/2023-9/30/2024 |
Patient Experience
| Measure | Hospital Result | State Average | State Benchmark | National Average | Report Period |
|---|---|---|---|---|---|
| Always Quiet at Night | 65 | 67 | 80 | 62 | 4/1/2023-3/31/2024 |
| Definitely Recommend Hospital | 64 | 74 | 85 | 70 | 4/1/2023-3/31/2024 |
| Doctors Always Communicated Well | 80 | 82 | 89 | 80 | 4/1/2023-3/31/2024 |
| Nurses Always Communicated Well | 83 | 83 | 90 | 80 | 4/1/2023-3/31/2024 |
| Patient Rated Hospital High | 70 | 76 | 86 | 72 | 4/1/2023-3/31/2024 |
| Patients Always Received Requested Help | 66 | 71 | 83 | 67 | 4/1/2023-3/31/2024 |
| Patients Understood Their Care When They Left | 51 | 56 | 64 | 52 | 4/1/2023-3/31/2024 |
| Room Always Clean | 76 | 77 | 88 | 74 | 4/1/2023-3/31/2024 |
| Staff Always Explained Medications | 63 | 66 | 76 | 62 | 4/1/2023-3/31/2024 |
| Staff Provided Discharge Instructions | 89 | 90 | 93 | 86 | 4/1/2023-3/31/2024 |
Patient Safety - All Patients
| Measure | Hospital Result | State Average | State Benchmark | National Average | Report Period |
|---|---|---|---|---|---|
| Healthcare Personnel Influenza Immunization | 91.8 | 83.41 | 94.79 | --- | 10/1/2023-5/15/2024 |
| In Hospital Fall Associated Fracture Rate | 0 | 0.015 | 0 | 0.03 | 10/1/2023-9/30/2024 |
| Pneumothorax | 0.035 | 0.009 | 0 | 0.02 | 10/1/2023-9/30/2024 |
| Pressure Ulcers | 0.178 | 0.029 | 0 | 0.07 | 10/1/2023-9/30/2024 |
| Sepsis-1 | 63 | 69 | 70 | 62 | 4/1/2023-3/31/2024 |
Patient Safety - Patients with Surgery
| Measure | Hospital Result | State Average | State Benchmark | National Average | Report Period |
|---|---|---|---|---|---|
| Perioperative Blood Clot | 0.084 | 0.148 | 0 | 0.31 | 10/1/2023-9/30/2024 |
| Perioperative Hemorrhage | 0.099 | 0.233 | 0 | 0.23 | 10/1/2023-9/30/2024 |
| Postoperative Respiratory Failure | 0.119 | 0.259 | 0 | 0.73 | 10/1/2023-9/30/2024 |
| Postoperative Sepsis | 0.168 | 0.324 | 0 | 0.42 | 10/1/2023-9/30/2024 |
Perinatal
Readmissions
| Measure | Hospital Result | State Average | State Benchmark | National Average | Report Period |
|---|---|---|---|---|---|
| All Cause Unplanned Readmissions | 10.6 | 9.57 | 6.76 | --- | 7/1/2023-6/30/2024 |
| Chronic Obstructive Pulmonary Disease | 18.2 | 18.139 | 17.3 | 18.5 | 7/1/2020-6/30/2023 |
| Coronary Artery Bypass Graft | 11.3 | 10.679 | 9.8 | 10.7 | 7/1/2020-6/30/2023 |
| Heart Attack | 11.9 | 13.55 | 12.6 | 13.7 | 7/1/2020-6/30/2023 |
| Heart Failure | 19.3 | 19.4 | 17.91 | 19.8 | 7/1/2020-6/30/2023 |
| Hip and Knee Surgery | 4.33 | 3.76 | 4.5 | 7/1/2020-6/30/2023 | |
| Pneumonia | 16.3 | 16.134 | 15.2 | 16.4 | 7/1/2020-6/30/2023 |