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SSM Health St. Agnes Hospital - Fond du Lac

430 E Division St
Fond du Lac, WI 54935-0385
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This Hospital's Grade
Grade c
Fall 2023

Outcomes measures include errors, accidents, and injuries that this hospital has publicly reported.

Measure The Hospital's Score Worst Performing Hospital Avg. Performing Hospital Best Performing Hospital Data Source Time Period Covered
Dangerous object left in patient’s body What's This? 0.000 0.340 0.014 0.000 CMS 07/01/2020 - 06/30/2022
Air or gas bubble in the blood What's This? 0.000 0.308 0.001 0.000 CMS 07/01/2020 - 06/30/2022
Patient falls and injuries What's This? 0.700 2.006 0.429 0.000 CMS 07/01/2020 - 06/30/2022
Infection in the blood What's This? 1.969 3.512 0.888 0.000 CMS 10/01/2021 - 09/30/2022
Infection in the urinary tract What's This? 1.600 3.026 0.735 0.000 CMS 10/01/2021 - 09/30/2022
Surgical site infection after colon surgery What's This? 1.788 2.868 0.832 0.000 CMS 10/01/2021 - 09/30/2022
MRSA Infection What's This? 0.712 3.653 0.927 0.000 CMS 10/01/2021 - 09/30/2022
C. diff. Infection What's This? 0.847 1.876 0.488 0.000 CMS 10/01/2021 - 09/30/2022
Death from treatable serious complications What's This? 148.91 186.71 143.25 73.88 CMS 07/01/2019 - 12/31/2019 and 07/01/2020 - 6/30/2021
Harmful Events What's This? 0.94 2.70 0.98 0.50 CMS 07/01/2019 - 12/31/2019 and 07/01/2020 - 6/30/2021
      Dangerous bed sores What's This? * 0.11 9.62 0.59 0.01 CMS 07/01/2019 - 12/31/2019 and 07/01/2020 - 6/30/2021
      Collapsed lung What's This? * 0.20 0.39 0.19 0.08 CMS 07/01/2019 - 12/31/2019 and 07/01/2020 - 6/30/2021
      Falls causing broken hips What's This? * 0.15 0.33 0.08 0.01 CMS 07/01/2019 - 12/31/2019 and 07/01/2020 - 6/30/2021
      Blood Leakage What's This? * 2.99 4.73 2.38 1.29 CMS 07/01/2019 - 12/31/2019 and 07/01/2020 - 6/30/2021
      Kidney injury after surgery What's This? * 0.76 3.06 0.92 0.27 CMS 07/01/2019 - 12/31/2019 and 07/01/2020 - 6/30/2021
      Serious breathing problem What's This? * 7.54 46.91 6.75 1.15 CMS 07/01/2019 - 12/31/2019 and 07/01/2020 - 6/30/2021
      Dangerous blood clot What's This? * 3.17 7.74 3.41 1.11 CMS 07/01/2019 - 12/31/2019 and 07/01/2020 - 6/30/2021
      Sepsis infection after surgery What's This? * 4.02 8.70 4.15 1.53 CMS 07/01/2019 - 12/31/2019 and 07/01/2020 - 6/30/2021
      Surgical wound splits open What's This? * 1.06 1.98 0.81 0.30 CMS 07/01/2019 - 12/31/2019 and 07/01/2020 - 6/30/2021
      Accidental cuts and tears What's This? * 1.32 3.13 1.04 0.32 CMS 07/01/2019 - 12/31/2019 and 07/01/2020 - 6/30/2021
* This measure is a part of the Harmful Events Composite and is not used for scoring.

Process measures include the management structures and procedures a hospital has in place to protect patients from errors, accidents, and injuries.

Measure The Hospital's Score Worst Performing Hospital Avg. Performing Hospital Best Performing Hospital Data Source Time Period Covered
Doctors order medications through a computer What's This? 86 15 90.58 100 Imputation Model Applied Not Applicable
Safe medication administration What's This? 84 25 92.67 100 Imputation Model Applied Not Applicable
Specially trained doctors care for ICU patients What's This? 5 5 62.31 100 CMS Cost Report Not Applicable
Effective leadership to prevent errors What's This? Declined to Report 64.62 117.49 120.00 2023 Leapfrog Hospital Survey 2023
Staff work together to prevent errors What's This? Declined to Report 0.00 116.99 120.00 2023 Leapfrog Hospital Survey 2023
Nursing and Bedside Care for Patients What's This? Declined to Report 15.00 71.00 100.00 2023 Leapfrog Hospital Survey 2023
Handwashing What's This? 59 15 77.32 100 Imputation Model Applied Not Applicable
Communication with nurses What's This? 92 75 89.55 97 CMS 10/01/2021 - 09/30/2022
Communication with doctors What's This? 90 76 89.45 98 CMS 10/01/2021 - 09/30/2022
Responsiveness of hospital staff What's This? 84 60 80.97 95 CMS 10/01/2021 - 09/30/2022
Communication about medicines What's This? 81 57 73.85 88 CMS 10/01/2021 - 09/30/2022
Communication about discharge What's This? 90 62 84.80 95 CMS 10/01/2021 - 09/30/2022