How do we measure quality care? One patient at a time.

How do we measure
quality care?
One patient at a time.
We Believe in
the Constant Pursuit
of Quality.
Robert A. Fale
President & Chief Executive Officer
We hear a lot these days about the need for
Beyond the hard measures of cost and
“transparency” in healthcare. Transparency is
outcomes, we serve our communities by
needed for consumers and businesses to find
publishing important information through a
quality, affordable care. Good health, in turn, is
variety of media, including Agnesian HealthCare’s
essential to productivity and quality of life. This
web site, In coming months, our
is why Agnesian HealthCare believes it’s vital to
site will include more interactive content for our
provide our community the information needed
patients and families, providing more healthcare
to make better, more informed decisions.
and community information and other tools
At Agnesian HealthCare, we continually raise
the bar on quality throughout our system in
to provide for a better experience and more
informed decisions.
pursuit of the most advanced technologies, top
professionals and best facilities. Our dedicated
providers, nurses, leaders and associates have
helped Agnesian HealthCare achieve status as
one of Wisconsin’s leading healthcare systems.
Just as quality decisions can only be made
with transparency, improvement can only
happen with measurement.
Among the countless areas of focused expertise
at Agnesian HealthCare are cardiology, cancer
Every day, the Agnesian HealthCare team
care and orthopedics. For all, our mission is to
works diligently to provide compassionate care
provide the best. Just as quality decisions can
that brings hope, health and wholeness to the
only be made with transparency, improvement
community we serve by honoring the sacredness
can only happen with measurement.
and dignity of all persons at every stage of
In this spirit we share the quality and price
measures included in this document. In addition,
Agnesian HealthCare continues to post quality
life. Strong quality measures prove that our
commitment is making a positive impact on the
lives of our communities.
information about our care on a number of public
web sites including,
and the Medicare site,
Our quality numbers reported on these sites
are a clear indication of our strengths and
our commitment.
Exceeding the National Average by
The benchmark for door-to-balloon time is set at 90 minutes. At Agnesian
HealthCare, we consistently surpass that benchmark. Door-to-balloon is a
time measurement in emergency cardiac care. The time clock begins when the
patient arrives in the emergency room, and ends in the cardiac catheterization
lab, when an interventional cardiologist inserts a catheter to open the blockage.
Door-to-Balloon Time
Minutes to Intervention
Agnesian HealthCare
National Benchmark
Dale Michels Center for Heart Care
The Dale Michels Center for Heart Care offers the most advanced, comprehensive cardiac procedures,
close to home. It offers access to more personalized treatment plans, a full continuum of care,
a state-of-the-art cardiac catheterization lab, and with a partnership with Froedtert & The Medical
College of Wisconsin, patients have access to even more of the best cardiac experts.
Agnesian HealthCare has shown significant decreases in 30-day readmission
rates for acute myocardial infarction (AMI) and heart failure (HF) patients from
CY 2009 to CY 2010 (see chart below). 30-day readmissions are those patients
readmitted within 30 days of discharge for any cause from an inpatient admission
with a principle diagnosis of AMI or HF.
Agnesian HealthCare heart failure “Perfect Patient” scores indicate whether
patients receive all standards of practice applicable to them. It has consistently
been above the state average, which is 85%, for “Perfect Patient” scores.
Patients in the St. Agnes Hospital Emergency Department (ED) are now benefiting
from cardiac testing performed by Consultants Laboratory staff within the ED itself.
This Point-of-Care testing improves the turnaround time for cardiac tests helping
physicians provide excellent care and rapid door-to-procedure time.
The Dale Michels Center for Heart Care also covers a wide area of heart care specialties including
preventive medicine, medical imaging/diagnostic procedures, EKG services, acute care services,
cardiac catheterization/vascular laboratory, cardiac rehabilitation, open-heart surgery and a
pacemaker clinic.
Readmissions are those patients readmitted within
30 days of discharge from an inpatient admission with
a principle diagnosis of acute myocardial infarction (AMI)
or heart failure (HF).
Average cost comparison between St. Agnes Hospital
and all hospitals with a similar volume.
Central Wisconsin Cancer Program
The Central Wisconsin Cancer Program (CWCP) brings cancer care closer to cancer patients. With
offices in Fond du Lac, Berlin and Waupun, patients can get the most advanced technology and
treatment close to home. The CWCP’s cancer specialists offer expert medical diagnosis combined
with compassionate care.
Colon Cancer – 100% performance rate* on adjuvant chemotherapy is considered
or administered within four months.
Breast Cancer – 100% performance rate* on combination chemotherapy.
The CWCP also offers the latest radiation technology including the Protura Robotic Patient Positioning
System (a new robotic table that helps radiation oncologists deliver highly-targeted doses of radiation
at cancerous tumors), 3D treatment planning computers, simulators, linear accelerators, 3D tissue
compensators and radiation implants. The CWCP at Agnesian HealthCare gives patients all the tools
they need to effectively treat cancer.
Overall quality of care for cancer care patients.
Data is based on 2009 pricing out of Craneware.
* The 100% performance rate represents compliance with national standard of care as determined by the American Society for Clinical
Oncology (ASCO) and the National Comprehensive Cancer Network (NCCN). The achieved 100% performance rate indicates each and
every patient is being treated according to the ASCO and NCCN guidelines 100% of the time for sites listed.
performance rate
on combination
chemotherapy and
adjuvant chemotherapy
year after year.
The numbers represent the national standard of care.
A 100% performance rate indicates each and every patient
is being treated/or considered for treatment according to
the National Comprehensive Cancer Network (NCCN)
guidelines 100% of the time for sites listed. All Commission
on Cancer accredited cancer programs, such as ourselves,
are required to submit this data and monitor our quality of
care. The four-month time frame is a NCCN standard of care
and the time frame starts from the time of diagnosis.
Agnesian HealthCare matches the state benchmark
for appropriate ABX administration at 100%
Prophylaxis antibiotics for surgery patients help to decrease
surgical infection rates. The goal is to use an antibiotic that
is safe, cost effective and has a spectrum of action that
covers most of the probable intraoperative contaminants
for the surgery.
Hip Surgery Antibiotic Measures
National Average
State Benchmark
St. Agnes Hospital
Waupun Memorial Hospital
Start ABX
Appropriate ABX
Stop ABX
Agnesian Center for Bone & Joint Health
The Agnesian Center for Bone & Joint Health is the region’s destination of choice for sports medicine
and sports-related injuries. It offers a full continuum of care: joint care, spine care, hand and upper
extremity and rehabilitation, as well as a multi-disciplinary approach to better serve the community.
Managing patient expectations from the beginning results in patient satisfication
levels near 100% for Agnesian HealthCare’s joint replacement program.
Continuously improving coordination means length of stay has been reduced from
4.3 to 3.5 days, resulting in fewer staffing and expenses and easier planning.
Consultants Laboratory now offers a Nasal Complete test, which screens patients
for Methicillin-resistant Staphylococcus Aureus (MRSA) who are having joint
replacement surgery. This testing is completed when the patient visits the PASS
Clinic for pre-op testing and training. Knowing if a patient is Staph positive prior to
the procedure allows for better patient outcomes.
Patients have access to board-certified orthopedic surgeons, highly-trained physical therapists,
a modern rehab facility, state-of-the-art equipment and a full staff of licensed athletic trainers
including comprehensive programs at area high schools. Everything a patient needs to help
them have a quick recovery.
Cost comparison between Agnesian HealthCare and all hospitals
with a similar volume.
Primary Stroke Center
Agnesian HealthCare is proud to be a designated Primary Stroke Center. The Primary Stroke Center
provides symptom recognition, prevention, activation of 9-1-1, rapid acute evaluation/diagnosis/treatment
and rehabilitation to better serve the community.
Agnesian HealthCare was the first Primary Stroke Center in Fond du Lac and five
surrounding counties.
Gold Seal of Approval with TJC* Primary Stroke Center Certification.
Sustaining Our High Performance:
• 2009 Bronze Plus GWTG** Award
• 2010 Silver Plus GWTG Award
• 2011 Gold Plus GWTG Award
April 2011 – St. Agnes Hospital was re-accredited as a Primary Stroke Center,
having earned high marks for its quality efforts. The re-accreditation came after
an on-site review by The Joint Commission, which confirmed St. Agnes Hospital
follows national standards set by the American Stroke Association and continues
to achieve superior patient outcomes in the area of stroke treatment.
With all these services, combined with a well-prepared team of healthcare professionals,
the Primary Stroke Center is able to provide expert care and more positive outcomes.
Based on patient surveys returned.
* The Joint Commission
** Get With The Guidelines® – American Heart Association
Based on patient surveys returned.
For two consecutive years, Agnesian HealthCare achieved
of positive outcomes
of tPA given within 180
minutes of the first signs
of a stroke.
tPA treatment (tissue plasminogen activator) is a clot-busting
drug that can reduce the amount of damage to the heart
muscle and save lives. To be effective, it must be given
within a few hours after symptoms begin.
Patient & Associate Experience
A strong commitment to healthcare that’s responsive and delivered with kindness is the
foundation that Agnesian HealthCare is built upon. This mission is seen everyday within
the walls of Agnesian HealthCare and on the faces of the many patients, residents and
their families who have been touched by this compassion.
Waupun Memorial Hospital, as part of Agnesian HealthCare, received a 2011
PRC 4-Star Award for scoring in the top that score between the 75th and 89th
percentiles. Our focus on excellence is making it a better place to work, a better
place to practice medicine and a better place for its patients to be treated.
Agnesian HealthCare was recently named as one of the top 100 Best Places to Work
in Healthcare as part of the 2011 Becker’s Hospital Review/Becker’s ASC Review.
The top 100 list is developed through nominations and research, and organizations
are selected for their demonstrated excellence in providing a work environment that
promotes teamwork, professional development and quality patient care.
Customer loyalty scores with Consultants Laboratory services continues to build
as an independent study of clients and physicians rose by up to two points in the
last year. 100% of participants indicate they would recommend the Consultants
Laboratory to others.
Percentages as of March 2011.
Fiscal year 2010.
Retail Services
Agnesian HealthCare reaches patients through the retail branch called Agnesian HealthCare
Enterprises. It’s another way to help meet customers’ ever-changing healthcare needs. It includes eight
retail pharmacies, and a home medical and respiratory equipment business – Agnesian Health Shoppe.
Medications are an important part of patient care so it’s important to have a safe,
effective medication management system. To help in this effort, the Agnesian
Pharmacy uses a multi-disciplinary team approach to enhance patient safety and
clinical outcomes through effective medication management.
Medication Filling Rate. Overall efforts to reduce error rates in filling prescriptions
at the Agnesian Pharmacy have been consistently meeting quality benchmarks of
under .025%. The pharmacy’s goal is to continually improve systems to prevent
harm to patients due to medication errors.
Agnesian HealthCare is helping its customers effectively manage costs relating
to their prescribed medications, especially when they don’t have prescription
coverage. The Agnesian Pharmacy Prescription Club is a great way to assist
uninsured customers to access more affordable medications so they can more
easily take their medications as prescribed. For a low annual fee of $10 for an
individual or family, members can save on more than 5,000 brand name and
generic prescriptions; and they can access more than 300 generic medications
at a competitive flat price.
in patient satisfaction level
for education of home oxygen
products used at home.
One dedicated associate. One happy patient.
Agnesian HealthCare provides compassionate care that brings hope, health and wholeness to those we
serve by honoring the sacredness and dignity of all persons at every stage of life. Providing simply the
best does not take days off. It is an ongoing call to provide simply the best.
As part of her continual efforts to provide simply the best care, Lanette Bruflat, a registered nurse, was
looking for an easier, less painful way for dialysis patients to receive their life-saving treatments.
Adequate vascular access is an essential factor in successful hemodialysis, and it has a major
effect on the quality of life. Bruflat, like her colleagues, wanted to avoid multiple needle access
points and worked to implement the buttonhole techique, or constant-site cannulation.
So, Bruflat started her mornings early with patients so they had the consistency of receiving
this level of care from one nurse. She has worked individually with each patient to establish one
common access point.
“This new process allows our patients the ability to utilize ‘blunt needles’ where they are guided into
the track that has been developed – similar to an earring being pushed through the track or hole in
the ear lobe,” says Bruflat. “Patients experience less pain, as well as less bleeding post treatment.”
For Don Kindschuh, of Fond du Lac, the new technique
has been a welcome addition, as well as the personalized
care he receives from the dialysis center.
“Having treatments three times a week, Lanette takes
such great care to make sure my treatments are as
pain free as possible,” says Kindschuh. “This procedure
seems less complicated after she helped to streamline
the procedure and provide me with a clear understanding
of what to expect.”
Kindschuh’s story is one example. But there are
thousands of stories of the Agnesian HealthCare family
teaming up to serve our patients, our community and
our mission.
Don Kindschuh
Patient, Friend, Neighbor
Fond du Lac, WI
The exceptional care you expect from
friends and neighbors.
Today’s healthcare consumer is a sophisticated comparison
shopper. They look for value, a proven safety record and
top-notch care marked by professionalism and compassion.
At Agnesian HealthCare, we’re committed to creating
the kind of healthcare experience patients and residents
expect and deserve. We encourage and invite all of your
conversations and comments along the way.
Agnesian HealthCare
430 East Division Street
Fond du Lac, WI 54936-0385
(800) 922-4300
(920) 929-2300
Consultants Laboratory | Fond du Lac Regional Clinic | St. Agnes Hospital | St. Francis Home | Waupun Memorial Hospital
Agnesian HealthCare Enterprises | Agnesian HealthCare is Sponsored by the Congregation of Sisters of St. Agnes