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: Thursday, July 18, 2024
Measure Hospital Result State Average State Benchmark National Average Report Period
Newborn Screening Card Transit Time 100 98.98 100 --- 1/1/2023-12/31/2023
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 0.384 0.63 0 1 1/1/2023-12/31/2023
Central Line Associated Blood Stream Infections 0 0.69 0 1 1/1/2023-12/31/2023
Clostridioides difficile Infections 0.236 0.54 0 1 1/1/2023-12/31/2023
Methicillin-Resistant Staph. aureus Infections 0.826 0.47 0 1 1/1/2023-12/31/2023
Surgical Site Infection - Abdominal Hysterectomy 1.11 0 1 1/1/2023-12/31/2023
Surgical Site Infection - Colon Surgery 0 0.85 0 1 1/1/2023-12/31/2023
Measure Hospital Result State Average State Benchmark National Average Report Period
Acute Stroke 5.579 4.924 0 6.86 1/1/2023-12/31/2023
Chronic Obstructive Pulmonary Disease 12.2 9.3 7.8 9.2 7/1/2019-6/30/2022
GastrointestinaI Hemorrhage 3.164 2.194 0 2.51 1/1/2023-12/31/2023
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 1.952 2.15 0 1.96 1/1/2023-12/31/2023
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 1.978 0 3.61 1/1/2023-12/31/2023
Carotid Endarterectomy 0.055 0 0.43 1/1/2023-12/31/2023
Coronary Artery Bypass Graft 1.923 2.589 0 2.49 1/1/2023-12/31/2023
Percutaneous Coronary Intervention 2.452 1.971 0 3.26 1/1/2023-12/31/2023
Measure Hospital Result State Average State Benchmark National Average Report Period
Always Quiet at Night 67 66 76 62 7/1/2022-6/30/2023
Definitely Recommend Hospital 63 73 84 69 7/1/2022-6/30/2023
Doctors Always Communicated Well 78 82 88 80 7/1/2022-6/30/2023
Nurses Always Communicated Well 80 83 89 79 7/1/2022-6/30/2023
Patient Rated Hospital High 71 75 85 71 7/1/2022-6/30/2023
Patients Always Received Requested Help 62 70 80 66 7/1/2022-6/30/2023
Patients Understood Their Care When They Left 48 55 65 52 7/1/2022-6/30/2023
Room Always Clean 76 77 86 73 7/1/2022-6/30/2023
Staff Always Explained Medications 63 66 75 62 7/1/2022-6/30/2023
Staff Provided Discharge Instructions 89 89 93 86 7/1/2022-6/30/2023
Measure Hospital Result State Average State Benchmark National Average Report Period
Falls with Major Injury 0.027 0.036 0 --- 1/1/2023-12/31/2023
Healthcare Personnel Influenza Immunization 92.51 83.2 94.8 --- 10/1/2022-5/15/2023
Pneumothorax 0 0.008 0 0.02 1/1/2023-12/31/2023
Pressure Ulcers 0.236 0.063 0 0.07 1/1/2023-12/31/2023
Sepsis-1 61 66 67.5 60 4/1/2022-3/31/2023
Measure Hospital Result State Average State Benchmark National Average Report Period
Perioperative Blood Clot 0.174 0.215 0 0.35 1/1/2023-12/31/2023
Perioperative Hemorrhage 0.194 0.27 0 0.23 1/1/2023-12/31/2023
Postoperative Respiratory Failure 0.133 0.554 0 0.73 1/1/2023-12/31/2023
Postoperative Sepsis 0.213 0.247 0 0.43 1/1/2023-12/31/2023
Measure Hospital Result State Average State Benchmark National Average Report Period
All Cause Unplanned Readmissions 9.3 9.13 6.56 --- 10/1/2022-9/30/2023
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