Quality Report


Quality Report

ST. AGNES HOSPITAL
HCO ID: 7635
430 E. DIVISION ST.
Fond Du Lac, WI, 54935
(920) 929-2300
www.agnesian.com
Summary of Quality Information

Accreditation Programs

Gold Seal
Behavioral Health Care and Human Services
Accreditation Decision
Effective Date
9/25/2019
Last Full Survey Date
9/24/2019
Last On-Site Survey Date
9/24/2019
Gold Seal
Home Care
Accreditation Decision
Effective Date
9/27/2019
Last Full Survey Date
9/26/2019
Last On-Site Survey Date
9/26/2019
Gold Seal
Hospital
Accreditation Decision
Effective Date
9/28/2019
Last Full Survey Date
9/27/2019
Last On-Site Survey Date
11/8/2019

Advanced Certification Programs

Gold Seal
Certification Decision
Effective Date
10/6/2021
Last Full Survey Date
10/5/2021
Last On-Site Survey Date
10/5/2021

Sites

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 )

Agnesian Cancer Center
480 East Division Street
Fond Du Lac, WI, 54935

Available Services

  • Administration of High Risk Medications (Outpatient )
  • Single Specialty Practitioner (Outpatient )

Agnesian Healthcare dba Doll & Associates
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 )
  • 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

Bereavement Services
1161 W. Johnson Street
Fond Du Lac, WI, 54937

Available Services

  • Single Specialty Practitioner (Outpatient )

Department of Pain Management
421 Camelot Drive
Fond Du Lac, WI, 54935

Available Services

  • Anesthesia (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 )

Hospice Home of Hope
400 County K
Fond Du Lac, WI, 54935

Available Services

  • Hospice Care

Sport, Spine & Work Center
421 Camelot Drive
Fond Du Lac, WI, 54935

Available Services

  • Single Specialty Practitioner (Outpatient )

Sports, Spine & Work Center
360 S. Mountin Drive
Mayville, WI, 53050

Available Services

  • Single Specialty Practitioner (Outpatient )

ST. AGNES HOSPITAL
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 )
  • EEG/EKG/EMG Lab (Imaging/Diagnostic Services )
  • Gastroenterology (Surgical Services )
  • GI or Endoscopy Lab (Imaging/Diagnostic 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 )
  • Nuclear Pharmacy (Inpatient )
  • Ophthalmology (Surgical Services )
  • Orthopedic Surgery (Surgical Services )
  • Plastic Surgery (Surgical Services )
  • Positron Emission Tomography (PET) (Imaging/Diagnostic Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Radiation Oncology (Imaging/Diagnostic Services )
  • 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 )
  • Teleradiology (Imaging/Diagnostic Services )
  • Thoracic Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Primary Stroke Center

St. Agnes Hospital Home Care/St. Agnes Hospital Hospice Hope
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

St. Agnes Hospital Hospice Hope
745 South Street, Suite 4
Green Lake, WI, 54941

Available Services

  • Hospice Care

The Fond du Lac Surgery Center
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 )

National Patient Safety Goals and National Quality Improvement Goals

Symbol Key

  • starThis organization achieved the best possible results
  • plusThis organization's performance is above the target range/value
  • checkThis organization's performance is similar to the target range/value
  • minusThis organization's performance is below the target range/value
  • naThis measure is not applicable for this organization
  • ndNot displayed

Measures Footnote Key

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

Symbol Key

  • starThis organization achieved the best possible results
  • plusThis organization's performance is above the target range/value
  • checkThis organization's performance is similar to the target range/value
  • minusThis organization's performance is below the target range/value
  • naThis measure is not applicable for this organization
  • ndNot displayed

Measures Footnote Key

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

The Joint Commission only reports measures endorsed by the National Quality Forum.
* 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 2019 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Behavioral Health Care and Human Services 2019 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Home Care 2019 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Reporting Period: January 2020 - December 2020
Emergency Department National Comparison: nd 2 Statewide Comparison: nd 2
Perinatal Care National Comparison: nd 2 Statewide Comparison: nd 2

New Changes to Quarterly Measure

Download Quarterly Measure Results

The Joint Commission only reports measures endorsed by the National Quality Forum.
* State results are not calculated for the National Patient Safety Goals.