Ascension All Saints Hospital
Racine, Wisconsin 53405-1690
Patient Rights and Ethics
| Measure name | Leapfrog’s Standard | Hospital’s Progress |
|---|---|---|
| Billing Ethics |
Hospitals should provide patients with complete billing information and access to a representative that can quickly resolve billing issues. In addition, hospitals should not sue patients over late or unpaid bills. |
 SOME ACHIEVEMENT |
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This hospital provides a detailed bill within 30 days of receiving insurance payments: No This hospital provides access to a representative who can quickly investigate billing errors and establish payment plans: Yes This hospital sues patients: No |
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| Health Care Equity |
Hospitals should examine their own data to identify any differences in processes or outcomes for patients of different races and ethnicities, and patients who speak different languages. Hospitals should also put action plans in place if differences are identified. |
 ACHIEVED THE STANDARD |
| Informed Consent |
Hospitals should ensure that all patients are fully aware of risks and alternatives prior to procedures. |
ACHIEVED THE STANDARD |
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All staff involved in the informed consent process achieve the appropriate training: Yes Doctors explain expected difficulties and recovery time and allow patients to ask questions: Yes Doctors involved in the procedure are listed on the consent form, and patients are notified if the doctor will be absent and if trainees will be involved: Yes Consent forms are written at a 6th grade reading level: Yes Staff ask patients about their preferred language for decision-making and make a trained medical interpreter available if appropriate: Yes Doctors use the "teach back method" to ensure patients understand what will be performed and what are the risks: Yes |
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| Responding to Never Events |
Hospitals should have a never events policy that includes all nine (9) actions that should occur following a “never event,” which includes apologizing to the patient and not charging for costs associated with the never event. |
ACHIEVED THE STANDARD |
More Information
| Patient and Family Caregiver Initiated Rapid Response Team |
This hospital does not have a patient and family caregiver initiated rapid response team.
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| Protocol to collect and respond to patient-reported concerns about care |
This hospital does have a protocol to collect and respond to patient-reported concerns about care.
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Preventing Patient Harm
| Measure name | Leapfrog’s Standard | Hospital’s Progress | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Nursing and Bedside Care for Patients |
Hospitals should have nurse staffing plans in place that ensure there are enough nurses of all types (i.e., registered nurses, licensed practical nurses, or unlicensed assistive personnel) to provide direct care to patients in medical, surgical, or med-surg units each day. |
 LIMITED ACHIEVEMENT |
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| Nursing Care for Patients |
Hospitals should have nurse staffing plans in place that ensure there are enough registered nurses (RNs) to provide direct care to patients in medical, surgical, or med-surg units each day. |
LIMITED ACHIEVEMENT |
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| Percentage of Nursing Staff who are Registered Nurses (RNs) |
Hospitals should have nurse staffing plans in place that ensure the proportion of nursing hours performed by registered nurses (RNs) is adequate. |
LIMITED ACHIEVEMENT |
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| Percentage of Registered Nurses (RNs) who have a Bachelor’s Degree in Nursing |
Hospitals should have a high proportion of highly trained and skilled registered nurses (RNs) who have an advanced nursing degree. |
LIMITED ACHIEVEMENT |
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| Effective Leadership to Prevent Errors |
Hospitals should take meaningful steps to raise awareness about patient safety, hold leadership accountable for reducing unsafe practices, provide resources to implement a patient safety program, and develop systems and structures to support action to improve patient safety. |
ACHIEVED THE STANDARD |
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This hospital scored 120.00 out of 120.00 possible points. |
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| Staff Work Together to Prevent Errors |
Hospitals should assess their culture of safety and hold leadership accountable for implementing policies, procedures, and staff education to improve the culture of safety. |
ACHIEVED THE STANDARD |
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This hospital scored 120.00 out of 120.00 possible points. |
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| Handwashing |
Hospitals should regularly monitor hand hygiene practices for everyone interacting with patients, and give feedback to ensure compliance. Hospitals should foster a culture of good hand hygiene, offer training and education, and provide equipment, such as paper towels, soap dispensers, and hand sanitizer. |
ACHIEVED THE STANDARD |
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Medication Safety
| Measure name | Leapfrog’s Standard | Hospital’s Progress | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Safe Medication Ordering |
Hospitals should enter at least 85% of inpatient medication orders through the CPOE system, and should fully demonstrate their CPOE system meets the national safety standard for decision support. |
ACHIEVED THE STANDARD |
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This hospital's percentage of inpatient medication orders entered electronically: 85% or greater This hospital's score on the CPOE Evaluation Tool: Full Demonstration of National Safety Standard for Decision Support |
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| Medication Reconciliation |
Hospitals should have a rate of unintentional medication discrepancies per medication that is lower than or equal to the 50th percentile (where lower performance is better) nationally. |
ACHIEVED THE STANDARD |
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This hospital's rate of unintentional discrepancies per medication is: 0.050 |
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| Safe Medication Administration |
Hospitals should have nurses and other clinicians use BCMA in all medical/surgical units, intensive care units, labor and delivery units, pre-operative and post-anesthesia care units to scan the patient and medication prior to administration at least 95% of the time. The BCMA system includes decision support to prevent errors and the hospital has processes to prevent workarounds. |
ACHIEVED THE STANDARD |
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| Medication Documentation for Elective Outpatient Surgery Patients |
Hospitals should document 90% or more of home medications, visit medications, and allergies/adverse reaction(s) in the patients’ clinical record. |
 DECLINED TO RESPOND |
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Healthcare-Associated Infections
| Measure name | Leapfrog’s Standard | Hospital’s Progress |
|---|---|---|
| C. difficile Infection |
Hospitals should have fewer than expected colon infections from C. diff bacteria. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC’s National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given various factors. A number lower than one means fewer infections than expected; a number more than one means more infections than expected. |
ACHIEVED THE STANDARD |
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This hospital’s standardized infection ratio (SIR) is: 0.395 |
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| Infection in the Blood |
Hospitals should have fewer than expected central-line associated blood stream infections. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC’s National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given various factors. A number lower than one means fewer infections than expected; a number more than one means more infections than expected. |
 CONSIDERABLE ACHIEVEMENT |
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This hospital’s standardized infection ratio (SIR) is: 0.712 |
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| Infection in the Urinary Tract |
Hospitals should have fewer than expected catheter-associated urinary tract infections. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC’s National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given various factors. A number lower than one means fewer infections than expected; a number more than one means more infections than expected. |
ACHIEVED THE STANDARD |
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This hospital’s standardized infection ratio (SIR) is: 0.233 |
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| MRSA Infection |
Hospitals should have fewer than expected antibiotic resistant bacterial infections. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC’s National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given various factors. A number lower than one means fewer infections than expected; a number more than one means more infections than expected. |
ACHIEVED THE STANDARD |
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This hospital’s standardized infection ratio (SIR) is: 0.000 |
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| Surgical Site Infection After Colon Surgery |
Hospitals should have fewer than expected surgical site infections after major colon surgery. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC’s National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given various factors. A number lower than one means fewer infections than expected; a number more than one means more infections than expected. |
LIMITED ACHIEVEMENT |
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This hospital’s standardized infection ratio (SIR) is: 1.334 |
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Critical Care
| Measure name | Leapfrog’s Standard | Hospital’s Progress |
|---|---|---|
| Specially Trained Doctors Care for Critical Care Patients |
Hospitals should have intensivists present on-site at least eight hours a day, seven days per week or have intensivists present via 24/7 telemedicine with some on-site intensivist presence. When not in the ICU, the intensivist immediately responds to calls and has another physician or trained clinician who can immediately reach the patient. |
ACHIEVED THE STANDARD |
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This hospital achieved the standard using on-site intensivist coverage. |
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Pediatric Care
| Measure name | Leapfrog’s Standard | Hospital’s Progress |
|---|---|---|
| Experience of Children and Their Parents |
Hospitals should perform better than most hospitals in five (5) areas:
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DECLINED TO RESPOND |
| Radiation Dose for Pediatric Abdomen/Pelvis Scans |
Hospitals should have an average radiation dose for routine pediatric CT scans of the abdomen and pelvis that falls within national benchmarks. |
DECLINED TO RESPOND |
| Radiation Dose for Pediatric Head Scans |
Hospitals should have an average radiation dose for routine pediatric CT scans of the head that falls within national benchmarks. |
DECLINED TO RESPOND |
| Congenital Heart Surgery for Infants (Norwood Procedure) |
Hospitals should perform at least 8 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 5 procedures annually. |
DECLINED TO RESPOND |
Maternity Care
| Measure name | Leapfrog’s Standard | Hospital’s Progress |
|---|---|---|
| High-Risk Deliveries |
Hospitals should deliver at least 50 very-low birth weight babies per year OR the hospital must maintain a lower-than-average morbidity/mortality rate for very-low birth weight babies. |
CONSIDERABLE ACHIEVEMENT |
| Cesarean Sections |
This is defined as first-time mothers giving birth to a single baby, at full-term, in the head-down position who deliver their babies through a C-section. Hospitals should have a rate of C-sections of 23.6% or less. |
SOME ACHIEVEMENT |
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This hospital's rate of Cesarean sections is 26.9% |
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| Episiotomies |
This is defined as mothers having an incision made in the perineum (the birth canal) during childbirth. Hospitals should have a rate of episiotomies of 5% or less. |
ACHIEVED THE STANDARD |
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This hospital's rate of episiotomies is 2.2% |
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| Screening Newborns for Jaundice Before Discharge |
Hospitals should screen at least 90% of babies for jaundice. |
ACHIEVED THE STANDARD |
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This hospital's rate of screening newborns for jaundice before discharge is 100.0% |
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| Preventing Blood Clots in Women Undergoing Cesarean Section |
At least 90% of women undergoing a cesarean section receive treatment to prevent blood clots. |
ACHIEVED THE STANDARD |
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This hospital's rate of preventing blood clots in women undergoing cesarean section is 93.3% |
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More Information
| Number of Live Births |
The hospital had 1,174 live births (i.e., liveborn infants) at this hospital location for the reporting time period.
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| Midwives |
This hospital does not have certified nurse-midwives and/or certified midwives deliver newborns.
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| Doulas |
This hospital allows patients to bring their own doulas.
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| Lactation Services |
This hospital offers lactation services in the hospital and outpatient setting.
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| Vaginal Delivery After Cesarean Section (VBAC) |
This hospital does offer vaginal delivery after cesarean section (VBAC).
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| Tubal Ligation |
This hospital does not offer tubal ligation during the labor and delivery admission.
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| Policy to Prevent Early Elective Deliveries |
This hospital does have a policy to prevent early elective deliveries. |
Complex Adult Surgery
| Measure name | Leapfrog’s Standard | Hospital’s Progress |
|---|---|---|
| Carotid Endarterectomy |
Hospitals should perform at least 20 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 10 procedures annually. |
DECLINED TO RESPOND |
| Mitral Valve Repair and Replacement |
Hospitals should perform at least 40 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 20 procedures annually. In addition, hospitals should participate in a national clinical registry and achieve the same or better outcomes when compared to others who also perform this procedure. |
DECLINED TO RESPOND |
| Open Aortic Procedures |
Hospitals should perform at least 10 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 7 procedures annually. |
DECLINED TO RESPOND |
| Bariatric Surgery for Weight Loss |
Hospitals should perform at least 50 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 20 procedures annually. |
DECLINED TO RESPOND |
| Esophageal Resection for Cancer |
Hospitals should perform at least 20 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 7 procedures annually. |
DECLINED TO RESPOND |
| Lung Resection for Cancer |
Hospitals should perform at least 40 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 15 procedures annually. |
DECLINED TO RESPOND |
| Pancreatic Resection for Cancer |
The hospital performs at least 20 procedures annually, and as part of their process for privileging surgeons, ensures that each surgeon performs at least 10 procedures annually. |
DECLINED TO RESPOND |
| Rectal Cancer Surgery |
Hospitals should perform at least 16 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 6 procedures annually. |
DECLINED TO RESPOND |
| Total Knee Replacement Surgery |
Hospitals should perform at least 50 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 25 procedures annually. |
DECLINED TO RESPOND |
| Total Hip Replacement Surgery |
Hospitals should perform at least 50 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 25 procedures annually. |
DECLINED TO RESPOND |
| Safe Surgery Checklist - Complex Surgery |
Hospitals should go through all the elements of a complete safe surgery checklist on all patients every time a surgery is performed. |
DECLINED TO RESPOND |
Care for Elective Outpatient Surgery Patients
| Measure name | Leapfrog’s Standard | Hospital’s Progress |
|---|---|---|
| Elective Outpatient Surgery Recovery Staffing - Adult |
Hospitals should ensure that a specially certified clinician is present and immediately available while an adult patient is present until discharge. |
DECLINED TO RESPOND |
| Elective Outpatient Surgery Recovery Staffing - Pediatric |
Hospitals should ensure that a specially certified clinician is present and immediately available while pediatric patient is present until discharge. |
DECLINED TO RESPOND |
| Safe Surgery Checklist - Elective Outpatient Surgery |
Hospitals should go through all the elements of a complete safe surgery checklist on all patients every time a procedure is performed. |
DECLINED TO RESPOND |
| Experience of Patients Undergoing Elective Outpatient Surgery |
Hospitals should perform better than most on four (4) areas including regarding the experience of adult patients: (a) facilities and staff (b) communication about the procedure, (c) patients’ overall rating of the facility, and (d) patients' willingness to recommend the facility. |
DECLINED TO RESPOND |
| Unplanned Hospital Visits after Colonoscopy |
Unplanned hospital visits can occur when patients experience complications after a colonoscopy procedure. Facilities should have a rate of unplanned hospital visits that is lower than most hospitals and surgery centers. |
DECLINED TO RESPOND |
Ascension All Saints Hospital
3801 Spring Street
Racine, Wisconsin 53405-1690
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