It would be good idea to collect data on processes also from other hospitals than yours which would give the exact status where u stand and then fix up the CTQ targets. Agencies like IMRB carry out inter unit research/survey(VOC collection) designed on clients requirement which can give u the insight into processes to be improved upon. Alternatively large hospital chains can benchmark their process CTQ's across different location and take up six sigma projects with Current CTQ's as existing performance & the Best CTQ performance as CTQ targets Regards abnish