of 5 stars
Ssm Health St Agnes Hospital-Fond Du Lac
- Location
- Fond Du Lac, WI 54935
- Ownership
- Voluntary non-profit - Private
- CMS Facility ID
- 520088
- Phone
- (920) 929-2300
The CMS overall star (1 = lowest, 5 = highest) summarizes up to 5 quality groups — see what drives it below.
What's behind this 4-star rating
CMS builds the overall star from up to five measure groups, weighted as shown. This is how Ssm Health St Agnes Hospital-Fond Du Lac compares to national on the measures in each group — it explains the rating without reproducing CMS's exact internal model. More on the data →
Patient experience
From the CMS HCAHPS patient survey (Medicare). Star ratings are 1–5; higher is better. Reporting period: Jul 2024 – Jun 2025
Mortality & safety
Reporting period: Jul 2021 – Jun 2024
| Measure | This hospital | National | vs. national |
|---|---|---|---|
| Death rate — CABG surgery (30-day) | 2.7% | 2.6% | No different |
| Death rate — COPD (30-day) | 11.2% | 8.8% | No different |
| Death rate — heart attack (30-day) | 11.6% | 12.2% | No different |
| Death rate — heart failure (30-day) | 13.6% | 11.6% | No different |
| Death rate — pneumonia (30-day) | 17.8% | 16.2% | No different |
| Death rate — stroke (30-day) | 13.7% | 13.3% | No different |
| Serious complications (PSI-90 composite) | 1.06 | 1.00 | No different |
Readmissions
Reporting period: Jul 2021 – Jun 2024
| Measure | This hospital | National | vs. national |
|---|---|---|---|
| Hospital-wide readmission (30-day) | 15.0% | 15.0% | No different |
| Readmission — COPD | 18.9% | 18.2% | No different |
| Readmission — heart attack | 12.9% | 13.6% | No different |
| Readmission — heart failure | 18.3% | 19.7% | No different |
| Readmission — pneumonia | 16.2% | 16.0% | No different |
Infections
Reporting period: Jul 2024 – Jun 2025
| Measure | This hospital | National | vs. national |
|---|---|---|---|
| C. difficile (C. diff) infection | 0.24 | 1.00 | Better than avg |
| Catheter urinary-tract infection (CAUTI) | 0.00 | 1.00 | No different |
| Central-line bloodstream infection (CLABSI) | 0.49 | 1.00 | No different |
| MRSA bloodstream infection | 0.00 | 1.00 | No different |
| Surgical-site infection — colon surgery | 0.00 | 1.00 | No different |
Timely & effective care
Reporting period: Jan 2024 – Jun 2025
| Measure | This hospital | National | vs. national |
|---|---|---|---|
| Healthcare workers vaccinated for flu | 84.0% | 78.0% | |
| Left ED before being seen | 1.0% | 2.0% | |
| Median ED time before leaving | 157 min | 161 min | |
| Sepsis bundle compliance | 69.0% | 64.0% | |
| Severe hypoglycemia (hospital harm) | 1.00 | — |
CMS Care Compare measures (largely a Medicare population). Rates are this hospital's reported value vs the national figure for the same measure; “better / worse than average” is CMS's own statistical comparison. Mortality, readmission, and infection measures are risk-adjusted; lower is better for those, higher is better for screening, sepsis care, and patient experience. How to read these →
Ratings like this move when care gaps close at the population level. Quaility's AI-native population health platform unifies every data source into one record and runs the outreach that turns measures into results — without replacing your EHR.
See the population health data platform →