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, agnesian.com. 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 checkpoint.com, leapfrog.com and the Medicare site, hospitalcompare.gov. Our quality numbers reported on these sites are a clear indication of our strengths and our commitment. 3 27 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 90 60 30 4 90 62.2 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. 5 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. 6 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. 100 % 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. 7 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 100 100 Percent 97 99 100 100 100 90 Start ABX Appropriate ABX 100 99 94 80 8 98 100 93 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. 9 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 10 Based on patient surveys returned. 100 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. 11 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. 12 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. 13 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 14 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. 15 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 agnesian.com
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