Rebuilding KPI governance
Every operational target now traces to one of two sanctioned derivation methods and to source-level data integrity — measurement that holds up in an audit, not a reporting artifact.
- Problem
- Important measures were not consistently defined or defensible. Schedule attainment was an aggregate ratio that could exceed 100%; two paired targets were structurally impossible to hit together; source data was being transcribed by hand.
- Decision
- Exactly two sanctioned ways to derive a target, applied everywhere, with the method written down beside the number.
- Mechanism
- Trailing-twelve-month baselines with a delta projection bridging missing history; a calibration scatter that exposed the impossible pair as complementary tails of one distribution; schedule attainment rebuilt as a per-interval pass rate; utilization redefined to in-office shrinkage; a twenty-item discrepancy checklist with exact artifact, page, and cell; data integrity corrected at the query source.
- Adoption
- Facilitation guides with run-of-show timing and domain-split question banks carried the changes through operations, workforce management, quality, and training.
- Outcome
- Auditable measurement tied to sanctioned methods and source-level integrity — part of the evidence behind the site’s May 2026 COPC recertification.