Quality Report

ST. AGNES HOSPITAL

DBA: SSM HEALTH ST. AGNES HOSPITAL FOND DU LAC
HCO ID: 7635
430 E. DIVISION ST.
Fond Du Lac, WI, 54935
(920) 929-2300
www.ssmhealth.com

Summary of Quality Information

Accreditation Programs

View Accreditation History

Behavioral Health Care and Human Services	Accreditation Decision Accredited	Effective Date 2/15/2023	Last Full Survey Date 2/14/2023	Last On-Site Survey Date 2/14/2023
Home Care	Accreditation Decision Accredited	Effective Date 2/18/2023	Last Full Survey Date 2/17/2023	Last On-Site Survey Date 2/17/2023
Hospital	Accreditation Decision Accredited	Effective Date 2/18/2023	Last Full Survey Date 2/17/2023	Last On-Site Survey Date 4/5/2024

Advanced Certification Programs

View Certification History

Primary Stroke Center

Certification Decision

Certification

Effective Date

9/30/2023

Last Full Survey Date

9/29/2023

Last On-Site Survey Date

9/29/2023

Sites

Agnesian Healthcare
DBA: SSM Health FDLRC
420 E. Division Street
Fond Du Lac, WI, 54935

Available Services

Administration of High Risk Medications (Outpatient )
Outpatient Clinics (Outpatient )
Perform Invasive Procedure (Outpatient )

Other Clinics/Practices Located at This Site:

FDLRC Cardiology
FDLRC Internal Medicine
FDLRC Nephrology
FDLRC Neurology
FDLRC Rheumatology
FDLRC Urology

Agnesian Healthcare
DBA: SSM Health FDLRC
480 E. Division St
Fond Du Lac, WI, 54935

Available Services

Outpatient Clinics (Outpatient )

Other Clinics/Practices Located at This Site:

Medical Oncology

Agnesian Healthcare Inc
DBA: SSM Health Therapy Services
130 Corporate Drive
Beaver Dam, WI, 53916

Available Services

Outpatient Clinics (Outpatient )

Agnesian HealthCare, Inc
DBA: SSM Health at Home Hospice-Green Lake
745 South Street, Suite 4
Green Lake, WI, 54941

Available Services

Hospice Care

Agnesian HealthCare, Inc
DBA: SSM Health Therapy Services
421 Camelot Drive
Fond Du Lac, WI, 54935

Available Services

Single Specialty Practitioner (Outpatient )

Agnesian HealthCare, Inc
DBA: SSM Health Therapy Services
360 S. Mountin Drive
Mayville, WI, 53050

Available Services

Single Specialty Practitioner (Outpatient )

Agnesian HealthCare, Inc
DBA: SSM Health Pain Care
421 Camelot Drive
Fond Du Lac, WI, 54935

Available Services

Anesthesia (Outpatient )
Perform Invasive Procedure (Outpatient )
Single Specialty Practitioner (Outpatient )

Agnesian HealthCare, Inc
DBA: SSM Health St. Agnes Hospital Outpatient Surgery
421 Camelot Drive
Fond Du Lac, WI, 54935

Available Services

Ambulatory Surgery Center (Outpatient )
Anesthesia (Outpatient )
Pediatric Dentistry (Outpatient - Child/Youth )
Perform Invasive Procedure (Outpatient )

Agnesian HealthCare, Inc
DBA: SSM Health Cancer Care
480 East Division Street
Fond Du Lac, WI, 54935

Available Services

Single Specialty Practitioner (Outpatient )

Agnesian HealthCare, Inc
DBA: SSM Health Hospice Home of Hope
400 County K
Fond Du Lac, WI, 54935

Available Services

Hospice Care

Agnesian HealthCare, Inc
DBA: SSM Health at Home Home Health/Hospice Fond du Lac
239 Trowbridge Drive
Fond Du Lac, WI, 54937

Available Services

Home Health Aides
Home Health, Non-Hospice Services
Hospice Care
Medical Social Services
Occupational Therapy
Physical Therapy
Skilled Nursing Services
Speech Language Pathology

Agnesian Healthcare, Inc
DBA: SSM Health Behavioral Health
40 Camelot Drive
Fond Du Lac, WI, 54935

Available Services

Behavioral Health (Non 24 Hour Care - Adult )
Behavioral Health (Non 24 Hour Care - Child/Youth )
Behavioral Health (In-Home Behavioral Health Care Services - Child/Youth )
Developmental Disabilities - Programs / Services (Non 24 Hour Care - Adult )
Developmental Disabilities - Programs / Services (Non 24 Hour Care - Child/Youth )

Other Clinics/Practices Located at This Site:

Agnesian Beyond Boundaries of Autism
Treffert Center

Agnesian Healthcare, Inc
DBA: SSM Health Adult Day Services
420 East Merrill Avenue
Fond Du Lac, WI, 54935

Available Services

Administration of High Risk Medications (Outpatient )
Perform Invasive Procedure (Outpatient )
Single Specialty Practitioner (Outpatient )

Domestic Violence

Fond Du Lac, WI, 54935

Available Services

Behavioral Health (Non 24 Hour Care - Adult )
Behavioral Health (Non 24 Hour Care - Child/Youth )
Community Integration (Non 24 Hour Care )
Family Support (Non 24 Hour Care )
Peer Support (Non 24 Hour Care )

St. Agnes Hospital
DBA: SSM Health St. Agnes Hospital -Fond du Lac
430 East Division Street
Fond Du Lac, WI, 54935

Available Services

Addiction Services
Addiction Services (Detox/Non-detox - Adult )
Behavioral Health (Day Programs - Adult )
Behavioral Health (Non 24 Hour Care - Adult )
Behavioral Health (Non 24 Hour Care - Child/Youth )
Behavioral Health (24-hour Acute Care/Crisis Stabilization - Adult )
Behavioral Health (Partial Hospitalization - Adult )
Cardiac Catheterization Lab (Surgical Services )
Cardiac Surgery (Surgical Services )
Cardiothoracic Surgery (Surgical Services )
Cardiovascular Unit (Inpatient )
Chemical Dependency (Day Programs - Adult )
Chemical Dependency (Non 24 Hour Care - Adult )
Chemical Dependency (Non 24 Hour Care - Child/Youth )
Chemical Dependency (24-hour Acute Care/Crisis Stabilization - Adult )
Chemical Dependency (Partial Hospitalization - Adult )
Chemical Dependency (Detox - Adult )
Chemical Dependency (Non-detox - Adult )
Chemical Dependency (Detox/Non-detox - Adult )
Community Integration (Non 24 Hour Care )
Coronary Care Unit (Inpatient )
CT Scanner (Imaging/Diagnostic Services )
Ear/Nose/Throat Surgery (Surgical Services )
Eating Disorders
Eating Disorders
Eating Disorders
Eating Disorders (Outpatient - Adult )
Eating Disorders (Outpatient - Child/Youth )
Eating Disorders (Non 24 Hour Care - Adult )
Eating Disorders (Non 24 Hour Care - Child/Youth )
Gastroenterology (Surgical Services )
Gynecological Surgery (Surgical Services )
Gynecology (Inpatient )
Hazardous Medication Compounding (Inpatient )
Inpatient Unit (Inpatient )
Interventional Radiology (Imaging/Diagnostic Services )
Labor & Delivery (Inpatient )
Magnetic Resonance Imaging (Imaging/Diagnostic Services )
Medical /Surgical Unit (Inpatient )
Medical ICU (Intensive Care Unit )
Neurosurgery (Surgical Services )
Non-Sterile Medication Compounding (Inpatient )
Normal Newborn Nursery (Inpatient )
Nuclear Medicine (Imaging/Diagnostic Services )
Ophthalmology (Surgical Services )
Orthopedic Surgery (Surgical Services )
Plastic Surgery (Surgical Services )
Positron Emission Tomography (PET) (Imaging/Diagnostic Services )
Post Anesthesia Care Unit (PACU) (Inpatient )
Rehabilitation Unit (Inpatient )
Rehabilitation Unit (24-hour Acute Care/Crisis Stabilization )
Sleep Laboratory
Sleep Laboratory (Sleep Laboratory )
Sterile Medication Compounding (Inpatient )
Surgical ICU (Intensive Care Unit )
Surgical Unit (Inpatient )
Technology-Based Addiction Services (Non 24 Hour Care - Adult )
Technology-Based Addiction Services (Non 24 Hour Care - Child/Youth )
Technology-Based Addiction Services (Detox/Non-detox - Adult )
Technology-Based Behavioral Health Srvs (Non 24 Hour Care - Adult )
Technology-Based Behavioral Health Srvs (Non 24 Hour Care - Child/Youth )
Teleradiology (Imaging/Diagnostic Services )
Thoracic Surgery (Surgical Services )
Ultrasound (Imaging/Diagnostic Services )
Urology (Surgical Services )
Vascular Surgery (Surgical Services )

Certification Programs

Primary Stroke Center

National Patient Safety Goals and National Quality Improvement Goals

Symbol Key

This organization achieved the best possible results
This organization's performance is better than the target range/value
This organization's performance is similar to the target range/value
This organization's performance is worse than the target range /value
This measure is not applicable for this organization
Not displayed

Measures Footnote Key

The measure or measure set was not reported.
The measure set does not have an overall result.
The number is not enough for comparison purposes.
The measure meets the Privacy Disclosure Threshold rule.
The organization scored above 90% but was below most other organizations.
The measure results are not statistically valid.
The measure results are based on a sample of patients.
The number of months with measure data is below the reporting requirement.
The measure results are temporarily suppressed pending resubmission of updated data.
Test Measure: a measure being evaluated for reliability of the individual data elements or awaiting National Quality Forum Endorsement.
There were no eligible patients that met the denominator criteria.
The measure rate is within optimal range.

Symbol Key

This organization achieved the best possible results
This organization's performance is better than the target range/value
This organization's performance is similar to the target range/value
This organization's performance is worse than the target range/value
This measure is not applicable for this organization
Not displayed

Measures Footnote Key

The measure or measure set was not reported.
The measure set does not have an overall result.
The number is not enough for comparison purposes.
The measure meets the Privacy Disclosure Threshold rule.
The organization scored above 90% but was below most other organizations.
The measure results are not statistically valid.
The measure results are based on a sample of patients.
The number of months with measure data is below the reporting requirement.
The measure results are temporarily suppressed pending resubmission of updated data.
Test Measure: a measure being evaluated for reliability of the individual data elements or awaiting National Quality Forum Endorsement.
There were no eligible patients that met the denominator criteria.
The measure rate is within optimal range.

* This information can also be viewed at Hospital Compare.

** Indicates per 1000 hours of patient care.
*** The measure was not in effect for this quarter.
---- Null value or data not displayed.

Hospital	2023 National Patient Safety Goals	Nationwide Comparison:	Statewide Comparison:
Behavioral Health Care and Human Services	2023 National Patient Safety Goals	Nationwide Comparison:	Statewide Comparison:
Home Care	2023 National Patient Safety Goals	Nationwide Comparison:	Statewide Comparison:
	Reporting Period: January 2022 - December 2022 National Quality Improvement Goals:
	Perinatal Care	National Comparison: 2	Statewide Comparison: 2

New Changes to Quarterly Measure

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* State results are not calculated for the National Patient Safety Goals.