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Health care technology management (HCTM) : an assessment of its application in Canadian teaching hospitals Eisler, George 2002

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HEALTH CARE TECHNOLOGY MANAGEMENT (HCTM): AN ASSESSMENT OF ITS APPLICATION IN CANADIAN TEACHING HOSPITALS by George Eisler Diploma BASc. MA.Sc. M.BA  Polymer Engineering Mechanical Engineering Mechanical Engineering Commerce  Vienna Technical Institute University of Waterloo University of Waterloo Simon Fraser University  1968 1974 1976 1985  A THESIS SUBMITTED IN PARTIAL FULFILMENT O F THE REQUIREMENTS FOR THE D E G R E E OF D O C T O R O F PHILOSOPHY in T H E F A C U L T Y O F G R A D U A T E STUDIES Department of Health Care and Epidemiology, Faculty of Medicine  W e accept this thesis as conforming to the required standard  T H E UNIVERSITY O F BRITISH COLUMBIA April 17, 2002 © George Eisler, 2002  In presenting degree  this  at the  thesis  in partial fulfilment  University of  freely available for reference copying  of  department publication  this or of  British Columbia, and study.  thesis for scholarly by  this  his  or  of  her  the  requirements  I agree  that the  I further agree  purposes  representatives.  may be It  thesis for financial gain shall not  is  granted  Date  DE-6 (2/88)  2r  /(PL  by the that  allowed without  C&k, iZc«L £^tjLe*><<^V)  The University of British Columbia Vancouver, Canada  advanced  that permission for extensive  permission.  Department of  an  Library shall make it  understood be  for  head  of  my  copying  or  my written  Abstract  T h e rate of technological c h a n g e is often referred to a s o n e of the drivers of c h a n g e in C a n a d a ' s health care s y s t e m . H o w e v e r , the c h a l l e n g e of m a n a g i n g technology h a s not received extensive attention in the health c a r e m a n a g e m e n t literature. T h i s study w a s c o n d u c t e d to provide a model for technology m a n a g e m e n t a n d a n a s s e s s m e n t of the level of technology m a n a g e m e n t practices in C a n a d a ' s t e a c h i n g hospitals.  T h e r e s e a r c h strategy involved a n a n a l y s i s of d e v e b p m e n t s to date in the a c a d e m i c disciplines of  Management  of T e c h n o l o g y  (MOT)  and  Management  Medical  of  T e c h n o l o g y ( M M T ) . A n e x t e n s i v e literature content a n a l y s i s g e n e r a t e d a set definitions  and  attributes of  the  conceptual  construct  'technology  of  management'.  T h r o u g h a formal s u r v e y d e s i g n p r o c e s s involving expert input, pilot testing, a n d field testing a m e a s u r e m e n t  instrument  w a s d e v e l o p e d . T h e A s s o c i a t i o n of C a n a d i a n  A c a d e m i c Health Organizations ( A C A H O ) enthusiastically supported a w e b - b a s e d survey of senior administrators, representing m a n y of C a n a d a ' s technology intensive teaching  hospitals. 324  CEOs,  V P s , and  managers  reporting  to the  Executive  r e s p o n d e d . T h e y e a c h rated the importance a n d the extent of implementation of 26 indicators, which had been derived via the content analysis from the list of attributes. F r o m e a c h set of importance a n d implementation ratings, a g a p s c o r e m e a s u r e w a s calculated.  T h r o u g h a variety of statistical methods including factor a n a l y s i s a n d cluster a n a l y s i s of the g a p s c o r e s , it w a s determined that there w e r e significant differences between organizations relative to the g a p between a b e n c h m a r k level a n d their actual level of technology m a n a g e m e n t practice. T w o major clusters of hospitals e m e r g e d . O n e of the  clusters  performed  significantly  better  than  the  other  for  each  of  the  26  m e a s u r e m e n t indicators.  ii  Comparison with an efficiency  pointed  to  independent a  clear  assessment of their  correlation  with  their  clinical and technology  operational management  performance. Executive-level leadership for technology strategy is critical.  The outcomes of this study are a comprehensive definition and model for the construct 'technology management', a measurement instrument validated for hospitals, a webbased  survey  mechanism, and  specific recommendations.  This project  should  contribute to the ability of organizations to manage technology as a strategic resource in recognition that technology both shapes and supports business strategy to meet customer needs.  iii  TABLE OF CONTENTS Abstract Table of Contents Table of Tables Table of Figures Acknowledgements  ii iv vi viii ix  CHAPTER 1  INTRODUCTION 1.1 Background 1.2 The MOT Research Perspective 1.3 The Research Problem 1.4 Thesis Structure  1 1 3 6 9  CHAPTER 2  LITERATURE REVIEW 2.1 The Changing Technology Environment 2.1.1 The increasing Rate of Technological Change 2.1.2 Technology as a Strategic Resource 2.2 The Challenges Are Common Across Industries 2.2.1 Manufacturing/Production/Process Technologies 2.2.2 Information Technologies 2.2.3 Educational Technologies 2.2.4 The Technology Strategy 2.3 Technology Management in Health Care 2.3.1 Not-For-Profit Health Care in Canada 2.3.2 Not-For-Profit and For-Profit Health Care in US 2.3.3 Technology and Innovation in Health Care in Canada 2.4 The Health Care Technology Management Domain 2.4.1 The MOT Discipline 2.4.2 The MMT Discipline 2.4.3 Definition of Technology' 2.4.4 Definition of 'Technology Management* 2.4.5 Attributes of 'Technology Management'  11 11 11 14 17 17 19 22 25 27 30 32 33 36 37 45 50 52 53  CHAPTER 3  RESEARCH METHODOLOGY AND DEVELOPMENT OF THE MEASUREMENT INSTRUMENT 3.1 The Research Strategy 3.2 Phase I - Content Analysis 3.2.1 Content Analysis Methodology 3.2.2 The Sample Literature 3.2.3 Definition of the Construct Technology Management' 3.2.4 The Model of the Construct Technology Management'  56 56 60 60 61 64 68  iv  3.3 Phase II - Development of the Measurement Instrument 3.3.1 The Measurement Instrument 3.3.2 The Web-Survey Procedure 3.3.3 The Pilot Test 3.3.4 The Field Test 3.4 Phase III - Administration of the National Survey 3.4.1 The Sample 3.4.2 Survey Administration 3.4.3 Statistical Methodology  73 73 76 78 83 90 91 92 94  CHAPTER 4  RESEARCH RESULTS 4.1 Survey Responses 4.2 Testing the Model Using Factor Analysis 4.3 Testing for Differences between Categories of Respondents 4.4 Testing for Differences between Organizations 4.5 Reliability Analysis 4.6 The Hay Group Study 4.7 Comments from Respondents  103 103 112 117 118 125 125 128  CHAPTER 5  CONCLUSIONS AND RECOMMENDATIONS 5.1 Contribution of this Study 5.2 Discussion 5.2.1 Conceptual Construct Technology Management' 5.2.2 Technology Management in Canada's Teaching Hospitals 5.2.3 Technology Management and Organizational Performance 5.2.4 Future Research 5.2.5 Limitations of this Study 5.3 Recommendations 5.3.1 The MOT Discipline 5.3.2 The Health Care Industry 5.4 Summary and Conclusions  132 132 134 136 140  Bibliography Appendix 1 Appendix 2 Appendix 3 Appendix 4 Appendix 5 Appendix 6 Appendix 7  142 143 144 144 144 146 147 150 159 163 165 174 181 184 187  T A B L E OF TABLES Table 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41  Title  Matrix of Research Questions in Recent MMT Literature Four MOT Perspectives A Matrix Linking Business and Technology Strategies A Matrix Linking Medical Technology and MMT Functions Perspectives of Technology Comparison of Attributes of Technology Management Construct Measurement Structures in Technology Management Research Metrics Construction Research Questions Research Strategy 17 Journals Rated by IAMOT and Anbar Definitions and their Sources Thesis Definitions of Technology Management Attributes from the Content Analysis Structure of Measurement Instrument Excerpt from Technology Management Survey Survey Instrument after Pilot Test Evidence for Implementation of Indicators Field Test Participation Importance of Technology Management Distribution of Indicators by Gap Score Range Respondents' Comments Fifty Technology Intensive Health Care Organizations Structure of the Survey Instrument Response Variables Organizations Invited to Participate Response Analysis Descriptive Statistics for all Indicators Indicators Requiring Least and Most Attention Summary of the Model Factor Analysis Individual Factor Analysis Revised Model of Indicators Descriptive Statistics for the three Dimensions Breakdown of Responses T-Test for Significant Differences between Managers T-Test for Significant Differences between Organizations T-Test for Significant Differences between Clusters 1 and 2 Gap Score Differences between Clusters 1 and 2 Indicator Distribution Ranked Indicators and Dimensions  Page 8 38 43 46 52 54 57 58 58 59 62 65 66 69 74 75 81 82 83 84 86 88 93 95 96 104 105 111 112 113 114 115 116 116 117 117 118 119 120 121 123  vi  42 43 44 45 46  Comparison of Average Rankings within Clusters Cronbach Alpha Reliability Coefficient Hay Study Comparison Data The Metrics of Technology Management The Technology Management Model  124 125 127 137 139  vii  TABLE OF FIGURES Figure 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16  Title The Research Perspective Thesis Structure Growth in Number of Articles on Technology Management Literature Search Process Technology Management Framework Field Test Gap Scores Topic Importance Rating Response Pattern for Question 1 Gap Score Distribution for Question 1 Mean Benefit Rating for each Indicator Mean Implementation Rating for each Indicator Mean Gap Score for each Indicator Mean Gap Scores Cluster 1 - Cluster 2 Hospital Comparison Hay Study Comparison Meeting Customer Needs  Page 5 9 63 64 67 87 106 106 107 107 109 109 110 122 127 135  viii  ACKNOWLEGEMENTS This thesis could be the last major stop in my life-long learning journey. Half of my 25 year long working life I have spent evenings and weekends studying in addition to my work responsibilities. Now I have 'really' graduated. All the doors are open to any exciting work and position I might aspire. Just in time to think of retirement.  I can honestly say, this journey would never have been completed without the encouragement and guidance of Dr. Joseph Tan, the good-will and assistance of Dr. Sam Sheps, and the love and support from my wife Janice. Every member of the Faculties of Graduate Studies and Health Care and Epidemiology has shown flexibility and patience to give me a chance to complete. Dr. Dean Uyeno and Dr. Gary Poole provided specific guidance and set a very positive tone.  Three other individuals need to be mentioned for their  invaluable support and  cooperation. Mr. Jim Flett is one of Canada's most senior hospital administrators. A s Executive Director of the Association of Canadian Academic Health Organisations (ACAHO) at the time of this study, he was instrumental in gaining support of teaching hospital C E O s across the country for this project. Mr. Murray Martin, C E O of the Hamilton Health Sciences Corporation orchestrated the first audience to the Board of A C A H O , which led to their enthusiastic support. Mr. Shan Satoglu, Program Head for Health Technology Management at BCIT, provided assistance and objective analysis during the critical literature content analysis phase of the project. I also have to acknowledge the support in time and money from my employer, the British Columbia Institute of Technology.  For my children, Lily and Simon, I hope that by setting an example I will in the end have compensated them for the time we didn't spend together because I was busy studying.  ix  CHAPTER 1 INTRODUCTION 1.1  BACKGROUND  The task of managing health care organizations and systems is a complex challenge. Specifically, managing teaching hospitals requires executives to master many different management skills, among them, government relations, community liaison, human resources, finances, patient care, research, and teaching.  Communication  skills,  culture  management,  creativity,  shared  leadership, and alliance building rank at the top as identified by Canadian health care C E O s (Armstrong et al, 2001). Health Care Technology Management (HCTM) adds one more dimension to these challenges. A H C T M system suitable for teaching hospitals may also be able to serve the needs of other health care organizations.  H C T M has been receiving increasing attention professionally and academically. The World Health Organization (WHO), for example, had proclaimed that there were serious shortcomings in the performance of health systems in virtually all countries (World Health  Organization,  2000).  So far,  WHO's attempts  at  introducing components of a technology management system into countries and regions around the world  have not been very successful. The lack of a  technology management framework and of technology management skills and knowledge in those countries were identified as serious limitations. Without an HCTM  system,  assessment,  component  functions  life-cycle management,  and  activities,  such  as  technology planning, and  technology performance  assurance had no long-term support and could not be sustained. (World Health Organization, 1986).  Nationally, the 1999/2000  Health  Systems  Update  published by the Canadian  College of Health Service Executives cited typical examples of technology related challenges in health care delivery. For example: the shortage of Nuclear  l  Magnetic Resonance Imaging facilities may perpetuate  illegal  out-of-pocket  payments in order to jump the queue; some diagnostic tests in hospitals involve a slow process and turnaround time; equipment may be unreliable and/or almost obsolete; developments in technology are outpacing the creation of attendant regulations, policy, legislation, and capital investments. The Health Systems Update  presents the view  that health  care technology has the  ability  to  revolutionize the practice of medicine. The developments in biotechnology are compared to those of the Industrial Revolution. Modern health infrastructure  information  is expected to present significant benefits for providers and  patients, leading to increased empowerment of consumers, improved and timely clinical treatment, and advances in health research. However, the publications points to significant legal, financial and technical barriers to enhancement of existing infrastructure ( C C H S E , 2001).  In British Columbia, in a submission to the provincial government in the fall of 1999, the Health Association of British Columbia (HABC) recommended that "the Ministry of Health, in conjunction with health authorities, consider the need for restructuring capital and equipment planning and funding for regionalized health services" (Health Association of B C , 1999). Among other comments, H A B C member organizations cite equipment on the verge of collapse and equipment needs at ten times the availability of capital funding. The H A B C expressed concern over the impact of inadequate technology infrastructure on the ability of complex  health  care organizations to deliver safe, efficient,  and  effective  services. The report emphasized the need to link technology planning to health service planning.  The C E O of one of the H A B C member regions in British Columbia (BC) proposed in the fall of 2001 the establishment of a sub-committee to look at the issue of technology management, stating that: "It would not be a stretch to argue that health care management has not only failed to manage its technology properly, it has also failed to recognize the importance of managing technology.  We may  2  have tried to manage individual parts of the technology puzzle i.e. ICT systems here, telehealth projects there, P A C S over there, etc. But this only amounts to a piecemeal approach at best"(Brown, 2001).  One of BC's major teaching hospitals attempted in 1999 to recruit an individual into a senior technology management  position. Not only were there initial  difficulties in defining the role and its positioning within the  organizational  structure, but no individuals with experience in the Canadian health care system met the candidate profile. Those candidates with senior technology management expertise from other industry sectors expected salaries at the C E O level, well beyond the hospital's salary range for the position. The search was unsuccessful. This experience points to a lack of understanding of H C T M and a shortage of experienced practitioners . 1  The above examples point to deficiencies in the health care system with respect to management of technology. Empirical and scientific evidence increasingly point to the crucial need to align technology strategy and business strategy in organizations across many industry sectors, including health care (Kaounides, 1999). Health care organizations, in particular, could do better in this respect (Neumann & et al , 1999). The strengthening, linking, and aligning of technology planning and business planning is the essential purpose of H C T M .  1.2  THE MOT RESEARCH PERSPECTIVE  The field of Management  of Technology (MOT)  is an emerging academic  discipline based on an evolving concept about the role of technology in organizations. Technology and its management are now seen as critical factors in  an  organization's  success  and  survival,  particularly  in  competitive  environments (Scott Morton, 1991; Badawy, 1996; Perrino & Tipping, 1989; van Wyk, 1988). In public sector environments MOT concepts are relevant because  1  The author was a member of the selection committee;  3  they help organizations to provide better service within available resources, they optimize seamless access and quality, and/or they address special needs, societal problems, or political goals.  The concept of strategic MOT is the most contemporary evolutionary stage of the MOT. It imputes on technology the power to alter markets, business strategy, and industry characteristics. This impact is attributed to the rapid pace of change in technologies such  as  computers  and  telecommunications,  as  well  as  biotechnology and genomics. This represents a qualitative shift from previous MOT principles which were intended to optimize the success of a business  strategy  (Drejer,  1996)  rather  than  the  optimization  of  specific business  flexibility to improve potential outcomes for customers.  In many industries, computer and telecommunications technologies, for example, were formerly considered overhead costs i.e., not central to corporate objectives. However, these technologies are now recognized as significant enabling assets with major strategic importance. The power of these particular converging technologies  is  blurring  the  boundaries  between  administrative  and  core  business technology tools. If managed appropriately, such enabling technologies can contribute greatly to the achievement of organizational objectives. At the same time, they may change the fundamental way an organization functions and the way it relates to its industry sector, its sponsors, suppliers, and, perhaps most importantly, its customers and clients.  Unpredictable and rapid technological development creates a volatile technology push on tie input side of organizations. On the output side, customers expect reliable, consistent, safe, effective, and efficient service. To them, the technology and its applications should be seamless. The challenge is for executives to employ management  strategies to enable the organization to continuously  transform the turbulent technology input into a customer-focused and appropriate output, in the face of increasingly difficult internal and external constraints  4  (Tapscott & Caston, 1993; Tapscott, 1996). The input/output analogy also has been identified in the health care setting:  •  • •  technology exercises a more powerful and pervasive impact on hospital organizations, the manner and the types of services provided, and the competencies required to provide and manage the services (Geisler & Heller, 1996; Geisler & Heller, 1998b); and the public's expectations are based on its perceptions and understanding of technological capabilities (Evans, 1984). Access to diagnostic testing is causing turbulence in the system ( C C H S E , 2001)  Over the past few years, there have been attempts to position Management of Medical Technology (MMT) as a new multidisciplinary academic field. MOT and MMT build on basic and applied sciences as depicted in Figure 1. Social and physical sciences inform the applied science disciplines of engineering and business/management.  MOT  draws  from  these  disciplines and addresses  technology management issues. MMT adds knowledge and methods from the life sciences and the applied health sciences to the MOT inventory of tools. The H C T M research agenda applies them in an integrated and holistic way to the health care sector. This perspective is shown in Figure 1.  Figure 1 Social And Physical Sciences  The Research Perspective  Engineering And Business MOT MMT  Life Sciences  HCTM Research Agenda  Health Sciences  MOT and MMT are becoming topics of serious study in the health  care  management field (Geisler & Heller, 1996). The terminology and the constructs are still poorly understood in business generally; understanding is even poorer in  5  the health care sector. The problem lies in the many interpretations of the individual components of these constructs and in the lack of commonly accepted definitions of the constructs, even in the dedicated literature on technology management (Anderson, 1993). Before measures for the constructs can be established, clear definitions and indicators have to be determined. They are not currently agreed upon in a satisfactory manner (Geisler, 2000; Anderson, 1993).  Further, although MOT is the focus of several programs in Canadian postsecondary educational institutions, the emerging academic focus areas of MOT and MMT have not received significant attention in the Canadian health care management arena. Moreover, no measurement instrument has been reported for assessing an organization's strengths and weaknesses in this area or for analyzing the relationship between MOT implementation  and  organizational  performance.  1.3  THE RESEARCH PROBLEM  This thesis was motivated by the author's personal experience in the Canadian health care system. This experience ranged from artificial organ research, to biomedical engineering for a region of hospitals, to the strategic technology decisions and discussions at the Board of one of Canada's largest teaching hospitals. After 30 years of technology focus, it seemed that a more systematic approach to technology management was called for.  The results of this work are intended to strengthen the ability of the Canadian health care system to meet the goals and objectives set forth in the Canada Health Act. This is to be achieved by improved alignment  of technology  strategies with those goals and objectives at every level in the system, nationally, provincially, and organizationally.  6  This  research attempts to  identify  the  status  of technology  management  approaches in Canadian teaching hospitals. Due to the very limited number of Canadian publications about technology management, this thesis builds on the largely American literature in the established field of MOT and the emerging field of MMT. It examines the stage of development of MOT and MMT and applies these findings to the Canadian health care field in general, and to Canadian teaching hospitals in particular.  This thesis aims to identify the key factors to be addressed by executive teams in order to manage technology successfully. The author believes that the attributes that constitute successful technology management in other industries could also be applied in Canadian teaching hospitals to support the principles of the Canada Health Act and to address the current attempts to decrease costs or to improve services without increasing costs The problems addressed by this thesis build on the research agenda proposed in the literature on the topic of MMT and are informed by recommendations for quality  MOT  research.  It  involves the  identification  of a  critical  body of  management capabilities and attributes. Examples of research questions asked in recent MMT literature are categorized in Table 1. The research problem described in this thesis falls into category ' C in the table, as it deals with the total technology management construct.  The intent of this study was to establish general targets and measures for critical technology management functions and activities, to identify which targets and measures should be addressed by a technology management system within the Canadian health care system, and to identify technology management system priorities to Canadian health care managers.  7  Table 1  Matrix of R e s e a r c h Q u e s t i o n s in Recent MMT Literature  Specific technologies or technology lifecycle issues  Organizational, cultural, administrative, and management issues  Technology in general or the total construct 'technology management'  B  C  Application of specific methods from business, engineering or A health sciences Q U E S T I O N S ( G e i s l e r & Heller, 1998b), (Rubinstein, )  MATRIX FIELD C C  What functions and activities are properly included in M M T ? How does the emerging literature describe the field? What are the various definitions floating around and how do they differ? Do practitioners recognize it as a legitimate, important field of study? How is medical technology managed in hospitals? Is there a general model of managing medical technology? How does MMT influence effectiveness and quality of patient care?  c c c c c  How do communications and information technology affect health care technology management?  A  How does the management of information systems and technology influence the effectiveness of medical delivery?  A  How does MMT influence the choice of IS and IT, their usage, and implementation?  A  What are the effects of technology on human resource growth, mobility and performance?  B  What are the effects of technology on human resource selection, training, and development?  B  The specific research questions addressed by this study are:  • How can the conceptual construct Technology Management' be defined? • What are the dimensions, indicators, and measures of the conceptual construct 'Technology Management'? • How can the Management of Technology capacity of Canadian teaching hospitals be measured? • What is the level of 'Technology Management' teaching hospitals?  capacity in Canadian  • Where are the weaknesses?  8  1.4  THESIS STRUCTURE  The following figure outlines the overall approach adopted for this thesis.  Figure 2  Thesis Structure  MOT IN CANADIAN TEACHING HOSPITALS  I CHAPTER 1 INTRODUCTION  - Background - Research Problem,  CHAPTER 2 LITERATURE REVIEW  CHAPTER 3 RESEARCH METHODOLOGY and MEASUREMENT INSTRUMENT  • T h e New Technological  Three of the Four Research  Environment  Phases  Research Question, and  - Technology Management in Health Care  Thesis Structure  • The Technology Management  CHAPTER 4 RESEARCH RESULTS for the NATIONAL SURVEY  Construct  - Statisical Analysis - The Fourth Research Phase  CHAPTERS CONCLUSIONS AND RECOMMENDATIONS BIBLIOGRAPHY APPENDICES  Chapter 1 (Introductions) has touched on M O T and MMT, on the significance of the research to be carried out, the overall research approach, and the research problem. The intent here is to clarify that the issue of M O T in Canadian teaching hospitals is a real world problem to be solved and that the solutions to this problem are not readily apparent. These solutions require original contributions, a gap that this thesis aims to close. This chapter also provides a perspective on related academic endeavors and the relationship of this thesis to the current state of understanding.  Chapter 2 (Literature Review) provides an in-depth summary of the relevant key literature published in the past 15 years. The chapter is organized into several sections. The first section establishes that the basis for the research problem is well understood and that the problem is not unique to the health care environment. The next section provides the rationale for the adoption of M O T as an enabling process for innovation and application of appropriate technology in health care. This section reviews the more recent academic focus on M O T in health care. It also discusses the academic discipline of MMT. Lastly, the chapter  9  provides an overview of the historical development and the current state of the art of MOT.  Chapter 3 (Research Methodology) describes the methodological challenges encountered and the approaches used to address the research questions. The suggested methods flow from several key academic sources. The research strategy is presented as a four-phase process to address the research questions. Chapter 3 also covers the development of the measurement instrument.  Chapter 4 (Research Results) presents the results of the national Canadian survey of senior managers in teaching hospitals. It leads the reader through the sequence of statistical analysis steps and provides an associated rationale. Results are correlated with another independent performance survey.  Chapter 5 (Conclusions and Recommendations)  discusses conclusions and  recommendations, and provides an overall summary.  10  CHAPTER 2 LITERATURE REVIEW The literature review is organized into several distinct sections. The environment that has given rise to the emerging focus on the topic of technology management is  explored  in  section  2.1.  Section  2.2  demonstrates  that  technology  management activities are widely promoted, and that there are similarities across industry sectors with respect to technology management challenges, concerns, and approaches. The section highlights manufacturing, production, and process technology, information  technology, and education technology. Section  2.3  provides a perspective on the challenge of technology management in health care, with reference to considerations in for-profit and not-for-profit health care environments.  Section 2.4 of the literature review is devoted to the academic discipline of MOT. The stages of development are discussed, including the more recent emergence of academic focus on MMT.  Included in section 2.4 are also introductory comments about the concepts 'technology' and 'technology management' and an introduction to the discussion of their attributes. A more exhaustive literature review of definitions and attributes is the focus of a formal research method referred to as 'content analysis', which is presented in Chapter 3. Chapter 2 addresses the need for technology management, and the components of successful technology management are addressed through the content analysis. Specific recommendations by authors cited in Chapter 2 have been incorporated into the literature content analysis.  2.1  THE CHANGING TECHNOLOGICAL ENVIRONMENT  2.1.1 The Increasing Rate of Technological Change  Human history and development have always been linked dynamically to the technology inherent in tools and means of production. Survival of individuals,  n  clans, tribes, societies, and empires depended on the power of their technology relative to that of others and relative to nature. How people lived, how they organized their society, and how they saw the universe were shaped by their ability to innovate, create, adopt, implement and change with technology. Their minds, their political economy, and their spirituality were affected  by their  technological environment (Ulhoi, 1996; Geisler, 2000).  The evolution of human civilization from the hunter and gatherer stage to the industrial stage took approximately two million years. The approach to exploit science and technology for commerce and wars by governments became more organized over the past few centuries. Examples of state interventions are such measures as institutes of higher learning (e.g., Napoleon's Ecole polytechnique), patent acts (e.g., as found in Venice), incentives for research and development, innovation and  its commercialization,  and trade policies. The  process of  technological development accelerated with the Industrial Revolution, the two World Wars, the Cold War and the related race to the moon. It is now spiraling due to instant global access to information, global competition, and the pervasive power of converging computer-, communications-, and bio-technologies (Geisler, 2000; Ulhoi, 1996; Ramanathan, 1990).  "Where change used to occur periodically, it's a way of Ife now," said Charles Webb Edwards, Executive Vice President, Technology & Operations Group, Wells Fargo, formerly Executive Vice President and Chief Technology Officer at Norwest Corporation, prior to its merger with Wells Fargo. "There is real value in being able to manage that (..change)". A s a result, strategic planning horizons for most companies are shortening from 10 or 20 years to five, and more recently to three years. "The new approach to strategic planning recognizes that the New World  is not  predictable,  linear,  or deterministic.  On  the  contrary,  it is  unpredictable, nonlinear, and full of surprises." Rapid technological change is partly responsible for this non-linearity. (Scott Morton, 1991)  12  This situation is captured in business articles with titles like "Changing at Warp Speed: Managing Technology" (McCallum, 1996). Successful firms are found increasingly among the newer entrants, since established firms frequently face difficulties in managing technological discontinuity (Ehrnberg & Jacobsson, 1996; Kenney-Wallace, 1994). In A Strategic  Approach  to Technology,  the author  discusses the "unprecedented levels of change in advanced technological capabilities and virtual unlimited access to information" in the banking and financial services industry (Neckopulas, 1993).  As examples of the impact of the current technology environment, the literature lists shorter product lifetimes,  manufacturing systems changes, increasing  productivity, and new products and markets in the service sector. "Newer technologies are rapidly becoming pervasive, redefining competitive value-added across a broad range of traditional markets and spawning major emerging growth markets" (Perrino & Tipping 1989).  Andersen confirms that the issues are similar in the public service sector. (Andersen, Belardo, & Dawes, 1994). Referring to the situation in the US, he states: "Public expectations for the level and quality of government services were formed  in better  economic times. Those expectations  have  grown  while  satisfaction with their fulfillment has steadily declined. In the past few years, it has become evident that cutting fat, eliminating waste, and preventing abuse is not nearly enough. Government needs to rethink its methods and restructure its approach  to  public  services."  New  combinations  of  computer  and  communications technology allow for strategic information management as a powerful tool for service integration, vertically and horizontally.  Public sector organizations now compete for government funds, for customers or for private-sector business. Interagency competition may lead to inefficient turfprotecting behavior, rather than to better and more cost-effective services. Internal competition within such organizations does not necessarily lead to more  13  streamlined and improved organizational operations (Andersen et al., 1994). Strategic technology however, can enhance or transform significantly the nature of services provided to the public.  The increases in the rate of technological change are expected to continue according to the literature referred to below. This accelerating trend coupled with the ability to distribute associated knowledge instantly and globally seems to have triggered a qualitative change in the role of technology in organizations. Technology has evolved quickly into a key strategic resource for organisations and countries. This phenomenon is an underlying theme of MOT literature. The resulting turbulent technological environment impacts private and public sector organizations, including hospitals.  2.1.2 Technology as a Strategic Resource  Rapidly changing technology is altering the rules of business. Technology has become a major change agent for markets and industries around the world. Technology  strategy  must  be  an  integral  strand  in the  woven  strategic  management fabric of an organization. (Mitchell, 1988; Mierzwa, 1995; McGee & Thomas, 1989; Campbell, 1997; Badawy, 1998; Husain & Sushil, 1997).  The literature refers to economists such as Schumpeter and Porter, who point to technology as an important change agent in the structure of industries and competition. However, the traditional  management/strategy  literature view of  technology as an implementation issue, or just another operational department vying for resources, may be one of the reasons for the poor coupling of technology and business strategy. This view sees technology simply as one of the vehicles to implement business strategy. It assesses technology in terms of return on investment (ROI) or in terms of satisfying the current market need. The key point to consider is the power of technology to change business strategy, not just to support it. As technology emerges that better meets customer's needs, the  14  business may have to change (Mitchell, 1988; Mierzwa, 1995; McGee & Thomas, 1989). This is not to diminish the importance of tactical technology plans. Some organizations still have to master this more traditional technology management challenge,  covering such  aspects as  identification,  selection, acquisition,  exploitation, and protection of product and/or process technologies (Gregory, Probert, & Cowell, 1996).  Technological innovation can shift the competitive balance within an industry and can create opportunities for growth. A technology management problem arises when business strategy development does not fully incorporate technologybased threats and opportunities, or if these are assessed mainly by short-term indicators. McGee and Thomas (1989) provide a review of the literature in strategic management research about the li nk between technology and strategic management. The review covers a range of economic, production management, decision process, entrepreneurship, and strategic perspectives. They conclude that firms can be differentiated by their position on a research-to-development continuum, in terms of risk, commitment, structure, organizational processes, skill and asset base, and time frame of opportunities.  The commitment to knowledge acquisition rather than product development varies under different  combinations of these conditions, involving different  people, using different information, and emphasizing different linkages, features, and control systems. Decisions and attitudes would be based on analysis of competitive position, market intelligence, and internal capabilities; it would involve vision, foresight, and entrepreneurial spirit. For example, coordination across functional boundaries is found to be more important than efficiency-driven divisions  within functions. Moreover,  cross-functional approaches  convergence of divergent views between technical- and  facilitate  marketing-oriented  individuals (Chappuis & Reimers, 1994; McGee and Thomas, 1989).  15  Around the world, countries recognize that the competitiveness of their industries in the global arena  depends on their focus on technology  management.  Technology has become a competitive tool in national and corporate survival (van Wyk, 1988), especially in an environment of more intensive and global competition (Perrino & Tipping, 1989; Sharif, 1994a). In a world of global competition and instant access to information, competitive survival a paradigm shift to a new management order: Management technologies and methods are largely knowledge-oriented. Knowledge is the major form of capital. Managing labor, land, money, or machines is fundamentally different from managing human knowledge. Managerial decisions and allocation of resources must be market driven. Full and meaningful worker and customer participation in the production process must be assured. Emphasis must shift from the economies of scale of the assembly line to the economies of scope of the flexible production or service delivery system. Process management must replace product management. The name of the game is flexibility, adaptability, and effectiveness rather than efficiency; and responsiveness rather than costs. As turbulence, unpredictability, and change become the only constants of the new business environment, an institution's capacity for survival depends on its ability to change, to adapt, and to avail itself of new opportunities. Competitive advantage, for the most part, must now come from technology and strategy, not from savings in labor costs. Management systems must focus on an integrated enterprise. Time-based management focusing on the customer must replace organization-centered approaches. (Badawy & Badawy, 1993)  In the fields of management of technology and industrial economics, what has been missing "is a comprehensive view of how technological change can affect the rules of competition, and the ways in which technology can be the foundation of  creating  defensible  strategies  for  firms"  (McGee  &  Thomas,  1989).  Restructuring programs, takeover campaigns, and the unprecedented trend toward joint ventures are indications of the new way of doing business, "driven by the need to compete more aggressively and efficiently in world scale markets" (Perrino & Tipping, 1989; Sharif, 1994a). A key aspect of managing technology strategically is the ability to keep up with innovative products and processes and  16  their  underlying technologies. Studies show that the levels of companies'  investments in technology explain international differences in productivity and in shares of world markets.  In order to achieve "institutional continuity in the face of technical discontinuity," the responsibility for technology policy in Japan and Europe often rests with C E O s and Board members (Pavitt, 1990). Such executive level attention is presented  as one of the  contributors to successful innovation  particularly with respect to related integration external  and  linkages  sources  of  decisions about vertical and  involving departments,  technical  expertise.  responsibility for technology strategy  The  strategies, horizontal  suppliers, customers, and theme  of  executive-level  appears in literature across industry  sectors.  2.2  THE CHALLENGES ARE COMMON ACROSS INDUSTRIES  This section of the literature review focuses on industries that rely on enabling process technologies to meet their objectives. The industries are both serviceand product-oriented.  While the emphasis on certain factors may vary, the  overall principles that relate to enabling technologies appear to be consistent. Cited authors in the following sections on manufacturing, information, and education environments suggest successful management suggestions are  captured  systematically  in the  strategies. These  literature content  analysis  discussed in Chapter 3. This section indicates that the expressed concerns and the strategies discussed in industry-specific literature are common when it comes to responding to the new technological environment. Particularly consistent is the call for a top-level coordinator of technology strategy in organisations.  2.2.1  Manufacturing/Production/Process Technologies  Models for strategic technology management decisions in manufacturing are  17  presented  in  technological  the  literature.  change  has  These become  models one  of  suggest the  that  management  of  critical  determinants  of  organizational performance, if not survival. For example, in one study three interconnected dimensions are identified as basis for technology strategy: the competitive environment, the organization, and the technology (Albayrakoglu, 1996). Case studies of the technology adoption decisions in fourteen Canadian enterprises group decision factors along four dimensions: strategic advantage, technological  expertise,  the  decision making  process,  and  organizational  capabilities (Raymond, Julien, Carriere, & Lachance, 1996). Another model captures the effect of flexibility, life-cycle cost, and technological improvement rate into a single measure to support strategic decision making for technology adoption (Abdel & Wolf, 1994). Strategic technology acquisition decisions for production technologies need to consider firm-specific factors, environmental factors, and customer preference, which change over the product life cycle (Ahmed, 1995; Sohn, 1994).  Attention to changing factors ranging from design to total cost over the life-cycle of a process and its product is a common theme. Life-cycle cost includes measurements of all phases of the entire useful life span, from R&D, installation, and operation, to decommissioning. Life-cycle costing skills are an important management attribute; setting related policies about the critical success factors (CSF) is a top management responsibility.  Understanding  the  technical  preferences  of  customers  is  an  important  component of technology management. For example, the strategic architecture at Kodak emphasizes market pull rather than technology push. "Directly or indirectly, customers will determine the technologies we pursue by choosing the products that best meet their needs. In turn, the company will have to be prepared with the appropriate technologies to best serve such product needs. Kodak leverages its technical core platforms, competencies, and competitive  18  skills  by  a  series  of  technology  management  performance  capabilities"  (Przbylowicz & Faulkner, 1993).  Traditional cost accounting methods do not capture strategic implications of technology management decisions. Management must know what it wants, given the difficult-to-quantify costs and benefits of new technologies and attributes like flexibility. Setting the goals, understanding the product/market interactions, being clearly aware of resources, constraints, and risks are components of strategic technology management. "Implementation  of new manufacturing technology  typically requires comprehensive rethinking and readjustment of job descriptions, information systems, organizational structure, incentives, and decision making processes. To the extent that  status quo represents a barrier to such changes,  the role of top management is critical to successful implementation" (Grant, Krishnan, Shani, & Baer, 1991). Top management must have commitment, but it also must have technical competence. It must be capable of managing in an environment of decentralized decision making with a high level of inter-functional coordination.  2.2.2  Information Technologies (IT)  The theme of executive-level leadership for technology strategy is particularly pronounced in IT literature. The Management in the 1990s Research Program at MIT's Sloan School of Management was created to "examine the profound impact that information technology (has) on organizations of all kind" (MIT Sloan School of Mgmt., 1996). A decade ago, Scott Morton reviewed the role of project leadership in the implementation  process, a role captured in the titles of  champion, change agent, coach, coordinator, and mediator. Scott Morton states: "Most often  they  are  a triple  threat,  being conversant in business and  organizational matters, as well as with technical information" (Morton, 1991). According to Scott Morton, in order to grant project leaders in line organizations the necessary authority, they are in some cases positioned quite high in the  19  organization,  such as at  the  vice  presidential  level,  especially for  large,  complicated transition projects.  In Paradigm  Shift - The New Promise  of Information  Technology,  the authors  devote a chapter to the role of the CIO (Tapscott & Caston, 1993). The broad range of skills (political, technical, organizational change, etc.) required by this position make it a difficult one to fill and to retain. Tapscott reflects on the ClO's potentially dangerous transitional role of leading adoption and implementation of fundamental organizational change enabled by new information technology. He ponders the challenge of changing the perception of the acronym for CIO from 'Career is Over' to 'Career Is Opening'.  This is the topic of Tapscott's later analysis, The Digital Economy Peril  in the Age  of Networked  Intelligence  (Tapscott,  - Promise  and  1996). Here Tapscott  describes the C E O of the successful organization as the steward of internetworked leadership. Tapscott cites David Cox, V P of Information Systems and CIO at Northern Telecom in 1990 to emphasize the challenge of the CIO: "ClOs are expected to give visionary leadership, yet at the same time are being asked to get back to basics and deliver the goods. We're told we have to be close to the business front line, yet build an invisible enabling infrastructure." Successful Chief Information Officers (ClOs) "understand the importance of systems that provide a competitive edge and the need for systems that support the goals of their organization." C l O s must also understand "that they are responsible for seeing that the promises made on behalf of technology are kept - that they are building a viable, productive, and flexible technology asset base" (Atkins, 1993).  Executives in charge of information technology need to be champions for technology-enabled change, because information technology moves the centers of knowledge and power in the organization, changes time dimensions of processes and decisions, and enables new organizational structures. Benjamin highlights several key management challenges and concludes: "Largely missing  20  in organizations today is a person to take responsibility for managing technologydriven organizational change, for learning what can be done and how to apply it, and for acting as a change champion" (Benjamin & Blunt, 1992). The track record for information technology implementation is not optimal, because "investment is heavily biased toward technology and not toward managing changes in process and organizational structure and culture" (Benjamin & Levinson, 1993). Different change strategies are appropriate for different organizations, depending on their rate of technical implementation. In addition to flexible organizational structures, management needs to emphasize information flow, incentives and different performance assessment schemes. It also needs policies to hold together a decentralized, virtual work place with instant access to global information (Thach & Woodman, 1994).  In a study of best practices in information technology management across nineteen government and private organizations, the author concludes that these practices have a direct, positive effect on the quality, quantity, timeliness, and costs of organizational products and services (Caudle, 1994). Organizations were  judged  successful  based  on  their  strategic  information  resource  management capability in senior management. Most of the literature on strategic information  management  reflects  corporate  experience.  But the  goals of  generating revenue and strategic competitive advantage increasingly also apply to some publicly funded services, such as education and health care.  Information Resource Management (IRM) is a concept frequently mentioned in the literature. Lewis (1993) provides an exhaustive review and concept definition, based on a rigorous literature review  and an equally rigorous research  methodology applied to validating the factors that define IRM.  Lewis also  developed a measurement tool to assess an organization's state of development in IRM, which includes a number of factors relating to the role of Chief Information Officer.  21  "The rapid advances of information technology in the past two decades have been staggering, but a look into future applications is like reading a science fiction thriller." Experts predict that the following four categories of information technology will have profound impacts on organizations in the next decade (Thach & Woodman, 1994):  •  individual work support (PCs and telecommunications to make workers completely mobile and 'knowbots' serving as personal secretaries to sort e-mail, read journals and highlight important areas, and communicate in any language or form);  •  group work support (groupware to help team-decision making, computer simulations and virtual reality for teamwork, cyberspace); advanced organizational automation (electronic data interchange, automated customer response systems); and global communications (e-mail and voice-mail, group and desktop videoconferencing, videophone, holographic telepresence).  • •  2.2.3 Education Technologies  Information technology has entered the pedagogical main stream. Green points to statistics indicating that the industrial revolution has ended and that the much discussed Information Age has really arrived (Green, 1996).  Ownership of  computers in North American affluent and middle-income households seems to be rising rapidly, information  having reached 40%  technology  has  in the  surpassed  US. Corporate spending on  expenditures  on  manufacturing  technology. The ubiquitous access to technology, combined with the demand for increased capacity in post-secondary education, has given rise b expectations for cost-effective alternatives to the construction of new campuses.  The short life span of information technology hardware and software and the attendant  recurring  acquisition  costs  present  an  enormous  economic  management challenge, especially at this time of fiscal restraint. Green (1996) posits that technology could become part of the cure, by increasing productivity or decreasing  unit-cost.  Burke  (1994) speaks of the  serious  competitive  22  challenge to the monopoly in granting degrees posed by the educational potential of the information superhighway. This is reinforced by academic resistance to incorporate new technologies into teaching, the consumerism of many students and entrance into the market by communication companies with extensive electronic networks.  Mathieson  suggests  that  the  management  of  information  technology  in  educational institutions needs attention (Mathieson, 1995). He recommends new organizational educational changes,  structures to deal with challenges, such as changes in the environment,  improved  substitutability,  expectations.  and  administrative  changes  This leads to the  in  systems,  customer  technological  sophistication  concept of a Vice President,  and  Information  Resources (VPIR), a position already in place at institutions such as Stanford, Maryland, and Syracuse, among others (Green, 1996). The VPIR is responsible for the integration of computing, telecommunications, library, office automation, and physical plant. The University of Wisconsin-Eau Claire was, according to Hogue's case study, an early adopter of an organizational innovation to respond to concerns about  the  strategic  directions of information  technologies  in  universities (Hogue, 1995) . At Eau Claire, an Assistant Chancellor (akin to a Vice President) leads the Office of Information and Technology Management. The Office encompasses the library, academic and administrative computing, data and video networking, telephone and other voice services, and a unit responsible for instructional materials development, distance education, and classroom support services.  In addition to the alignment with strategic planning and integration of related functions, the need for cross-functional teams and for user development has been  recognized. Among many  other factors,  structure as one of the most important information centralization  technology versus  (Person,  organizational  issues in the evolution of campus  1994). Further,  decentralization  Person sees  as  he sees the  "perhaps  the  question  single  of  biggest  23  organizational issue." He states that effectiveness has to be considered with efficiency, and that leadership is the most critical aspect of the debate. The lack of an established career path may make it difficult to find individuals for such a CIO role among the functional areas that may be integrated under a ClO's responsibilities.  The education system is being swept toward backdrop of fundamental  dramatic change against a  restructuring of the corporate sector (Heterick &  Sanders, 1993). The wrenching changes in the economy are more than simply the latest iteration in the boom/bust cycle of free enterprise. In the information age of global competition, education, like business, has to embrace information technologies to create new educational opportunities. "We must carefully analyze the world around us and our own institutions, extrapolating a vision to guide the formulation  of an information systems strategy for education" (Heterick &  Sanders, 1993). Such a strategy leads to many more instructional modes and educational  outreach,  enhanced  research  capabilities,  and  flattened  organizational structures.  Heterick classifies the necessary strategic responses in education to the trends toward globalization, networking, information access, and digital media. He identifies several critical categories: leadership, organization, responsibility, and funding.  He strongly supports the role of the Chief Information Officer (CIO) for  the creation of the vision, alignment with objectives, and bridging between and among  operational  units.  Planning,  resource  allocation,  development  of  standards, and rapid reorganization, when necessary, are also listed as essential functions to be facilitated by the CIO. Even if not the champion of change directly, part of the ClO's success depends on having skills to effect and manage change (Salisbury & Conner, 1994). Reflecting on the similarities in the adoption and implementation  difficulties  associated with educational technology and information technology, Jost argues  24  that the lessons learned from information technology can usefully be applied to education and educational technology (Jost & Schneberger, 1994).  The role of management exhaustively  explored  and  in the planned change process in education is tested  against  a  case  study  (Nuske,  1993).  Recognizing that managing change is only one component of managing educational technology and information technology, Nuske's assimilation of change models as they relate to the crucial role of project leader provides additional insight into the role of a CIO.  2.2.4 The Technology Strategy  Summarizing section 2.2, yields the following conclusions about the basis for a technology strategy, for the characteristics of a technology focused organization, and for the responsibilities and capabilities of the chief technology officer (CTO).  a) The technology strategy is based on: •  the competitive environment, the organization, and technology ; consideration of firm-specific factors, environmental factors, and customer preferences; creation of strategic advantage, technological expertise, the decision making process, and organizational capabilities; comprehensive rethinking and readjustment of job descriptions, information systems, organizational structure, incentives, and decision making processes  •  organizational structure is one of the most important issues; policies hold together a decentralized, virtual work place with instant access to global information; in addition to flexible organizational structures, management emphasizes information flow, incentives, and different performance assessment schemes; centralization versus decentralization is one of the single biggest organizational issue.  b) Technology strategy is characterized by: •  top management vision, foresight, and entrepreneurial spirit; leadership is the most critical aspect; commitment to knowledge acquisition rather than product development; alignment with strategic planning and integration of related functions; management must know what it wants, given the difficult-to-quantify costs and benefits of new technologies and attributes  25  like flexibility; set the goals, understand the product/market interactions, being clearly aware of resources, constraints, and risks; •  decisions and attitudes are based on analysis of competitive position, market intelligence, technical preferences of customers and internal capabilities; focus on the customer replaced organization-centered approaches; emphasis is on market pull rather than technology push;  •  management systems focus on an integrated enterprise; coordination across functional boundaries has priority over efficiency-driven divisions within functions; cross-functional approaches facilitate convergence of divergent views between technical- and marketing-oriented individuals; full and meaningful worker and customer participation in the production process is assured;  •  process management has replaced product management; focus is on flexibility, adaptability, responsiveness, and effectiveness rather than efficiency and costs; competitive advantage comes from technology and strategy, not from savings in labor costs; able to change, to adapt, and to avail itself of new opportunities; effectiveness is considered with efficiency;  c) Characteristics of the C T O •  responsible for visionary leadership, organization, funding, alignment with objectives, bridging between and among operational units, planning, resource allocation, development of standards, rapid reorganization when necessary, leading adoption and implementation of fundamental organizational change; must also be steward of inter-networked leadership, be close to the business front line, and build an invisible enabling infrastructure  •  assures that promises made on behalf of technology are kept; builds a viable, productive, and flexible technology asset base; gets back to basics and delivers the goods; takes responsibility for managing technologydriven organizational change, for learning what can be done and how to apply it, and for acting as a change champion  •  capabilities include managing in an environment of decentralized decision making with a high level of inter-functional coordination; must have commitment, technical competence, capable of skills to effect and manage change; conversant in business and organizational matters, as well as with technical information; understands the importance of systems that provide a competitive edge and the need for systems that support the goals of the organization  26  2.3 TECHNOLOGY MANAGEMENT IN HEALTH CARE  This section of the literature review addresses the legitimacy of transferring technology management lessons from other industry sectors to health care and hospital management.  It focuses on the  concept of strategic technology  management and the importance of innovation, It also discusses the challenges of sustainability, cost, and quality of health care and incentives for technological innovation in health care. This section points to the complexity of the health care environment and the multitude of forces that shape technology decisions. The uniqueness of the health care environment is part of the justification for the promotion of the academic discipline of MMT as separate and unique from MOT. Compared to other industry sectors, such as banking and transportation, the health care environment is seen not only as more complex but also as more emotionally charged (Geisler & Heller, 1996). The environment is characterized not only by the complexities inherent in the development and maintenance of a seamless system spanning the continuum of health care delivery, but also by the complexity of relationships between provider organizations, service and product vendors,  payers/funders/insurers, patients,  the  general  public,  regulators,  researchers, and educators.  The health care industry is an industry in transition, driven by such factors as changing economic conditions, changing technology, and changing population demographics (Claire, 1993; Decter, 1996). These pressures have resulted in changes to structure, process, financing, and human resource management. The challenges can be summarized as attempts to ensure timely access to highquality and cost-effective health care services. Health care systems in Canada, the US, and other O E C D countries are expected to continue on this road of cost reduction and quality improvement, as reflected in the titles of government publications: "A New Era for Patient-Centred Health Care; Building a Sustainable, Accountable Structure for Delivery of High-Quality  27  Patient Services" (BC Ministry of Health, 2002). However, the severe budgetary situation of Canadian governments in the early 1990s (and again in 2002) characterized by debt situations and slow economic growth, led to stringent cost control measures at the federal and provincial levels. The measures were introduced through reduced federal transfer payments to the provinces (which have in part been reinstated since 2001) and through major provincial health care reform initiatives. These reforms were intended to increase efficiency, flexibility, and integration, improve health outcomes, community participation, and cost control. Judging from the continuing restructuring of the health care system and the  continuing  provincial  and  national  studies  (Romanov,  Kirby,  Fike,  Mazankowski, Fraser Institue, Tommy Douglas Institute), the reforms have so far not achieved the desired and hoped for results.  Among O E C D members, many countries regard cost control rather than any kind of health objective as the paramount policy aim (Gray, 1992). B C and Canada are responding to such data as that provided by the Conference Board of Canada (2000) . The Board projects that the proportion of Canada's population 2  over the age of 55 will increase 10% per year for the next 20 years, rising from 22% to 32% of the population. Public health expenditures are projected to rise from 31 % in 2001 to 42% in 2020 as a share of provincial government revenue, representing an annual growth in health care costs of 5.2% over that period, of which 1.7%  are attributed to demographic changes (aging and population  growth). Adjusted for inflation, per capita spending on health care is projected to increase by 58% while per capita spending on all other government services is projected to increase by 17% over the next 20 years.  Given these economic pressures, a debate about the role of technology as 'the villain' or as an important part of the solution is taking place against the backdrop of the incentive structures in publicly funded, not-for-profit, for-profit, and mixed health care environments. The B C Medical Association (BCMA) is not alone in  28  sighting 'rapidly expanding high-cost technologies' as one of the key drivers contributing to the 'unsustainability' of Canada's current health care delivery system. (BCMA, 2001). In defense of technological innovation and investments in research, some authors caution that often the deployment of technology, not the technology itself, is responsible for cost increases.  The proliferation of MRI units in the US compared to Canada is used as example where incentives encourage overuse because too many owners need to recoup their investment. Still, this does not deny that patients should be able to benefit from such state-of-the-art technology (Udvarhelyi et al., 1994), assuming that there is evidence to support the claims of benefit compared to less costly strategies. Technology can play a vital strategic role in health care, as it does in other knowledge-based professional  service industries  and  technical  fields.  like This  banking, entertainment, is  particularly  communications technology, which can contribute management,  cost  effectiveness,  customer  true  and for  significantly to  service  and  other  IT  and  improved  support.  These  applications have strategic implications, creating opportunities for new services or for delivering existing services in new ways. It is for these reasons that the B C Government has maintained information technology and telehealth applications on its list of priorities at a time of severe cost reduction responses to the economic situation (BC Ministry of Health, 2002). Only thorough economic evaluation could answer questions about comparative costs and benefits of various technologies, including the status quo.  The Conference Board of Canada is an independent, not-for-profit research organization with a mission to help it members to "anticipate and respond to the increasingly changing global economy".  29  2.3.1  Not-For-Profit Health Care in Canada  Health care in Canada is a social service, not a business (Decter,  1996).  Canadians value their world-class universal health care system and the system's hospitals. Both are treated as social welfare, for which no costs are to be spared (Chan & Lynn, 1998). However, in its 1997 final report, the National Forum on Health (NFH), a group appointed to advise the Prime Minister on health issues, concluded that Canadians are concerned about deterioration in access to and quality of health care services. There is currently a raging public and political debate if Canada's health care system is in crisis and in need of fundamental change (i.e.: introduction of privately provided services) or in need of 'revitalizing' through innovative new delivery models within the current system (Rachlis, Evans, Lewis, & Barer, 2001).  Canada currently operates a national, publicly administered health insurance system, loosely formed by an amalgamation of separate provincial and territorial programs. Although health insurance and health financing is governed and regulated at the provincial level, the federal government is able to broadly influence policy through financial transfers linked to the five national standards articulated by the Canada Health Act (CHA) of 1984. (Health Canada, 1998). The Act, a cornerstone of the Canadian health system, affirms the federal government's commitment to a health insurance system identified through five underlying  principles:  of  universality;  accessibility;  comprehensiveness;  portability; and public administration. The C H A aims to ensure that all residents of Canada have access to necessary health care on a prepaid basis by establishing criteria and conditions for the provinces and territories to satisfy in order to qualify for their full share of federal transfer funds for health care services. The C H A criteria underlying the five principles are:  •  Universality requires all residents be entitled to public health insurance coverage;  30  •  • • •  Accessibility requires reasonable access unimpeded by financial or other barriers to medically necessary hospital and physician services, and reasonable compensation for physicians and hospitals; Comprehensiveness requires all medically necessary services provided by hospitals and doctors be insured; Portability requires coverage be maintained when a resident moves or travels within Canada or travels outside the country; and Public Administration requires the administration of the insurance plan be carried out on a non-profit basis by a public authority.  Some authors comment on recommendations that see privatization and extrabilling as a way to compensate for under-funding in the system. These scenarios require patients to pay doctors a supplement to the fee paid them by the provincial plan and to pay a user fee at hospitals and clinics. Federal policy dictates against user fees by hospitals and extra-billing by doctors. The federal government  sees user fees as a financial  barrier  to access  and as an  unacceptable subsidization of two-tier health care. Other concerns are the potential erosion of citizen support for the publicly administered system and the undermining of government's capacity to control costs. The federal government fears that private facilities might concentrate on easy procedures, leaving the public system to handle more compfcated and costly cases. Financial incentives might draw trained personnel away from the public system. Resources might be used to attract consumers, without contributing to quality of care (Marleau) (Evans, Barer, & Marmor, 1994).  Various  interest  privatization  groups,  including  Canada's  Fraser  Institute,  advocate  as a means to address issues of waiting times for specialist  services. Some surveys about waiting times have been judged as flawed (Roos & Brownell, 1998) and efforts to get more accurate data are under way in various provinces (Rachlis, Evans, Lewis, Barer, 2001). According to a 1995 study of patients' perspectives on access to health care, more Canadians than Americans complain about the choice of doctors and the waiting times for obtaining specialist services, which average weeks in Canada, compared to days in the US (Donelan & Blendon, 1996). It is the lack of reliable information about actual  31  waiting times that allows quite contradictory conclusions and characterizations, maybe even 'misinformation' and 'deliberate disinformation' (Rachlis, Evans, Lewis, Barer, 2001).  2.3.2 Not-For-Profit and For-Profit Health Care in the United States  Current incentives in the US are said to favor innovations that raise costs or that increase quality regardless of costs. Incentives are also said to skew the normal rules of competition, implying that competition is the only or the best way to compel organizations to deliver increasing value to customers (Teisberg, Porter, & Brown, 1994). This view is not shared by those who see the patient-physician relationship, as opposed to the economic interests of for-profit investor owned companies, as the primary driver of resource allocation in health care. While not agreeing on the solution, there is agreement on the problem of inefficiencies and skewed incentives (Udvarhelyi etal., 1994). Competition advocates argue that reform in the US should attempt to cure competition in health care by incorporating four basic elements: corrected incentives  to  spur productive  competition;  universal  insurance to  secure  economic efficiency; relevant information to ensure meaningful choice; and vigorous innovation to guarantee dynamic improvement. This view holds that technology is not the enemy, but that, as in other industries, innovation is the only true, long-term solution for high quality, affordable health care (Teisberg et al., 1994).  This view is also supported by drug manufacturers who point to treatments and cures that were achieved by entrepreneurial  companies willing to assume  enormous risks to conduct research, with the expectation of economic rewards (Udvarhelyi et al., 1994). However, the payment regulations and practices for prescription drugs are among the most debated incentives relative to their impact on quality, cost-avoidance, cost of health care, and treatment options (Udvarhelyi etal., 1994).  32  Fostering the right kind of managed competition appears to be the goal of the US Health Security Act (Udvarhelyi et al., 1994). Accepting that all incentives have unintended side effects, the goal is to create workable markets involving accountable health plans (AHP) (Claire, 1993). These A H P s would compete on the basis of quality and cost of care for a full array of service attributes. This model assumes that current medical standards and performance data do not permit competition on individual types of services involving informed choices by individual consumers (Udvarhelyi et al., 1994). If the goal of the fee-for-service system was 'to manage sick people... the goal of managed care is to keep patients healthy within a certain budget.' This represents a move away from 'competing for patients, performing tests of perhaps unknown effectiveness, or having uncertain and unfair guidelines for compensation' [Holmes].  2.3.3 Technology and Innovation in Health Care in Canada  In its 1997 report, the National Forum on Health (NFH), suggested that the system keep up with technology and different ways of delivering service: 'the system needs to continually adapt and transform itself.  The N F H stressed the  need for high-quality information for all stakeholders, including patients and providers. The Forum also highlighted the need to create a culture of evidencebased decision making supported by a comprehensive health research agenda.  Some authors characterize the current risk-averse nature of health care delivery as creating a barrier to implementing change. They advocate taking more risk by changing the provider mix, reviewing scopes of practice, adopting non-traditional modes of care, and looking for less costly sites for service delivery (Udvarhelyi et al., 1994).  The necessary drive for innovation in health care must be balanced by concerns that technological extension (technical advances, innovation, etc.) not contribute further to 'free-market failure' due to information asymmetry in health care.  33  Extension of technology accentuates the asymmetry of information about the consequences of use between health care providers and users of services. The information gap increases with the expansion of range and complexity of medical interventions. Actual health care needs may be determined in large part by perceptions about prevailing technology (Evans, 1984). Therefore, diffusion of technologies  into  widespread  practice  should  occur  only  after  adequate  assessment of risks and benefits, based on information about improved health outcomes or equal health outcomes at a lower cost. Increasing accountability for the application of technology in its broadest sense is expected from initiatives in evidence-based practice, outcome evaluation, and technology assessment.  Skills and knowledge as forms of the technology domain play an important role in characterizing the health care industry. 'Indeed, the greater the knowledge and skill intensity of the service, the less likely are supervisors - or customers - to be in a position to adequately evaluate its qualitative characteristics. Thus society relies on boards of experts and courts of law to pass judgement on the possible errors  of airline  pilots  and  heart  surgeons" (Alic,  1997).  These  'market  imperfections' in health care are 'failures of competition' that need to be compensated for by public policy and regulations. Market failures, therefore, justify government intervention in the form of macro-technology management at the national level (Huijiong, 1993).  Technology that increases the earning potential of for-profit providers may be promoted more vigorously than technology that reduces the cost of production. Spending on drug advertising in the US has now reached twice the level spent on research. Not always are the results better than the ones provided by older and cheaper drugs (Evans, 2002). Effectiveness may be difficult to assess and may not be the primary outcome of profit-driven innovation. In Canada, rationing and limiting capacity to extend technology are examples of government interventions to address market imperfections inherent in health care. The goal is to balance the benefits of rapid innovation and per-unit cost control on the one hand, with  34  the risks of inefficacious utilization and high promotional c o s t s o n the other hand ( E v a n s , 1984).  A l l s t a k e h o l d e r s in the C a n a d i a n health c a r e s y s t e m f a c e c o m p l e x c h o i c e s a n d decisions.  T h e s e options  require  improved  outcome  measures and  better  information not only for individual c o n s u m e r s or providers, but a l s o for t e a m s of stakeholders involved in the coordination and selection of treatment options. C o s t containment, quality of c a r e , a n d o u t c o m e s are c l o s e l y linked a n d s h o u l d not be a d d r e s s e d in isolation from e a c h other. Innovation, therefore, n e e d s to include 'the tools that allow physicians, payers, a n d patients to m a k e better d e c i s i o n s ' (Udvarhelyi et a l . , 1994).  O u t c o m e m e a s u r e s are being d e v e l o p e d for clinical health (biomedical a n d physiological status), functional health (quality of life a n d well being), satisfaction (consumer attitudes about s e e k i n g a n d receiving care), a n d cost of care (to a c h i e v e the desired level of health outcome). Availability, reliability, validity, a n d utility of t h e s e m e a s u r e s are critically d e p e n d e n t on innovation in information s y s t e m s . O u t c o m e m e a s u r e s m a y be the most critical innovation toward further improvement  of  population  health  within  limited  budgets,  by  rewarding  innovations that m a k e s e n s e with respect to high quality a n d affordable health care. T h e debate about the value of innovation in health care, in turn, c a n , be resolved  only  through  innovations  in  evaluation  and  information  systems  (Udvarhelyi e t a l . , 1994).  Innovation is s e e n a s vehicle to maintain the reputation of C a n d a ' s health c a r e s y s t e m internationally a n d in the minds of the C a n a d i a n public. High on the list of requests  is a substantial  i n c r e a s e in  r e s o u r c e s committed  to  information  m a n a g e m e n t infrastructure to support electronic health records a s prerequisit to integrated  c a r e delivery. A  evidence-based  practice,  host of innovations  introduction  of  new  are  p r o p o s e d to  treatment  enhance  modalities,  wealth  creation fom biomedical r e s e a r c h , capitalization of the s y s t e m , a n d i n c r e a s e d  35  production of health professionals (Guerriere, 1999).  The above review of the literature points to the many stresses and strains that influence technology decisions in health care. Not surprisingly, calls are mounting for a more systematized and planned approach to managing technology (World Health Organization, 1986; CCHSE, 2001); Health Association of BC, 1999; Brown, 2001; Neumann & et a l , 1999). This study was intended to develop a framework for technology management in health care, where the many issues addressed above could be brought to bear in a coordinated and planned manner. In the process, it became apparent that two new academic disciplines, referred to in the literature as Management of Technology (MOT) and Management of Medical Technology (MMT), had already evolved around similar issues in a variety of other industry settings (MOT) as well as with respect to medical care (MMT). 2.4 THE HEALTH CARE TECHNOLOGY MANAGEMENT DOMAIN The World Health Organization (WHO) defines health as a state of total physical, mental, and social well being and not merely as the absence of disease and infirmity. It is now recognized that population and individual health has many determinants not traditionally associated directly with the health care system. Accordingly, the concept of health care technology includes applications of technology that influence the environment, information dissemination, health protection and disease prevention. It goes beyond applications of technology found in modern acute care systems or for direct medical care. In this context, the term 'health care technology' applies to facilities, information, devices, processes, and drugs in the broadest sense, from the simplest to the most complex, along the total continuum of health care. As presented earlier in Chapter 2, technologies that may contribute to quality or sustainability of health care systems could be associated with direct patient care, infrastructure, or  36  business processes. It seems, therefore, appropriate to refer to the management of these technologies as Health Care Technology Management (HCTM).  2.4.1 The MOT Discipline The  academic and  professional literature in the  field  of Management  of  Technology (MOT) consistently links strategic management of an organizational entity with technology management for that organization. This linkage applies equally to a firm (micro-technology management) or a country (macro-technology management). (Mitchell, 1988; Sharif, 1994a; Huijiong, 1993; Drejer, 1996; Ulhoi, 1996;  National  emergence  Research Council,  of technology  as  the  1987;  Mitchell,  primary  lever  & of  Morgan, 1993). competitive  The  economic  advantage has created a demand for personnel who can help enterprises take advantage of technological innovation. That demand more than anything else (i.e., rather than scholarly breakthrough)  is responsible for the growth  of  technology management as an academic specialty (Shorten, Gillies, Andersen, 1993).  As evidence of the newness of the field, van Wyk (1996) sights the examples that: the Technology and Innovation Management Division of the Academy of Management was formed only in the late 1980s; the European Technology Management Initiative was launched soon after; and the International Association for the Management of Technology was established only in 1992.  In 1987, a  special task force of the US National Research Council (NRC) on MOT found the field to be poorly understood. Although the field was not formally codified, the following industry needs were identified (National Research Council, 1987):  •  •  the exponential growth in generation of new product and process technologies around the world requires companies to stay abreast of internal innovation and to assimilate external developments; new developments in science and engineering as well as increasingly sophisticated consumers combine to shorten product lifecycles; successful companies need to respond rapidly and flexibly and to shorten product development times;  37  •  •  The  the nature of international competition and the many sources of technology lead to the need for integrating technology strategies into the firm's strategic objectives; and different cost structures, investment justifications, and strategic priorities can only be adopted by an integrated system and appropriate new tools of management, which were still in their infancy in the late 1980s. concepts  R&D  management,  innovation  management,  engineering  management and strategic management could be considered precursors to MOT, which emerges in the literature in the 1980s (Ulhoi, 1996). Some authors advocate  the importance  of technology  management  because they see  technology as one of the most important resources of an organization. Others write from the perspective of invention/innovation management and technology planning; still others view M O T as an explicit part of strategic management. Environmental conditions associated with these M O T perspectives vary as summarized in Table 2 below (Drejer, 1996): Table 2  Four MOT Perspectives  Innovation Management  R&D  Management  Technology Planning  Strategic MOT Changing, discontinuous, and unpredictable business environment Began mid 1980s  Stable, simple, expanding business environment  Changing but predictable business environment  Changing and discontinuous business environment  Began mid-1960s  Began early 1970s  Began late 1970s  Evolved methods to manage R&D  First methods to cope with the entire innovation process  Refinement of methods and models for risk uncertainty  Strategic  MOT  addresses  the  low  relative  rate  Strategic integration including organizational change management  of  technological  innovation/absorption, high rate of implementation failures, poor handling of social issues, and failures associated with earlier stages of development. Integrated  strategic  MOT  represents  simultaneous  consideration  of  organizational/business issues and technological issues. Drejer sees a direction for future  research and development  of M O T that shifts from  individual  38  technologies  to  relationships  between  organizations  and  technologies,  particularly the integration of business strategy with M O T (Drejer, 1996).  MOT is still an emerging discipline described as cross-disciplinary, problem driven, and integrative (Badawy & Badawy, 1993). They encourage a scientific problem solving approach applied to such questions as: • •  What are the core concepts, domains, and boundaries of the field of MOT? and What are the major elements constituting the foundations of MOT as a discipline?  To advance this field, (Shorten et al., 1993) suggests that scholars should agree on definitions and measures that demonstrate more reliability and validity within a paradigm characterizing the management of technology. Such a paradigm should deal with (Betz, Keys, Khalil, & Smith, 1995): •  Value creation for customers and society;  • • • • • •  Quality and cost-leadership; Responsiveness by managing for change; Agility to enable quick response to opportunities; Innovation via a professionalized work place; Teaming; and Fairness in the type or distribution of the wealth generated.  Van Wyk (1996) reflects on the need for new developments in product, process and information technologies to be monitored, evaluated, and utilized. This, he feels requires an understanding of the interplay between technology, economics, environment, and the impact on corporate functions. According to 1500 C E O s polled in the late 1980s, the major limitation inappropriate  management  of technology  to US competitiveness was  by executives.  Executives were  challenged by the revolutionary speed of technological change and by the assessment of the impacts of the technology on organizations and on society (Ramanathan, 1990). The study indicated that executives failed because of: • • •  inadequate understanding of the process of technological change; inadequate involvement of top management with technology; inadequate appreciation of the importance of innovation; and  39  •  society's conflicting views of technology in general (i.e. Is technology part of the problem or part of the solution to particular societal challenges?)  Improved technology management involves a variety of functions and activities, such as assessing/evaluating technology more effectively, improving technology transfer  capability,  managing  large,  complex,  interdisciplinary,  and  inter-  organizational projects, managing the internal use of technology, and leveraging the effectiveness of technical professionals. The development of an academic discipline, including training and research, has been encouraged (van Wyk, 1988; Drejer, 1996).  In the early 1980s, US business schools were criticized for their lack of focus on science and technology. The feeling was that the nation's ability to manage its technology needed to be improved. Professional and postgraduate programs addressing technology management have emerged all over the world; examples include Sussex and Stirling in the UK, and Berkeley and MIT in the US (Jones, Green, & Coombs, 1994). Over the past 10 years, technology management increasingly has become part of graduate studies in management and business administration, evolving from such areas as science policy, corporate strategy, manufacturing processes, and management of innovation. Stated reasons for this emerging academic discipline are concerns about competitiveness, shifting from short-term to long-term perspectives, bringing advances in technology to the market place, changes to business, social, and political environment, restructuring  of organizations,  and the  worldwide  demand  the  for technology  managers at senior management levels (Jones et al., 1994).  The same concerns existed in Europe, as expressed by the JUPITER (Joint Universities, Polytechnics and Industry, Technology Education and Research) Consortium (Heaton, 1993). The work of Heaton et al is a major initiative in Europe on the topic of Technology Management. A s in the US, it was sparked by the realization that European industry was facing increasing competition from  40  other countries and needed to improve expbitation of technology. Because of global competition and rapid technological change, driven by shorter time-tomarket and shorter technology lifecycles, organizations need to acquire the abilities to generate and assimilate innovation through greater emphasis on Management of Technology.  Technology management was defined as the design needed  within organizations  technological  innovation.'  to achieve  economic  and use of the  and social objectives  means through  Senior managers and technical personnel were felt to  lack the necessary skills in this area. The JUPITER Consortium reports on research on the technology management training needs of various organizations. Twenty-six senior executives of UK companies participated in semi-structured interviews. They were asked about their perceptions about future technologies, how they would manage their adoption, and what training needs would arise. In addition to specific individual core-technologies, they identified IT, materials, and opto-electronic devices as technologies with more general impact. Investment in technology management staff training was not seen as adequate. Management training of technical staff was seen as the preferred approach, as opposed to technical training for administrative and commercial staff. It is one of several such initiatives in Europe.  Aligning the management of technology with business strategy at the corporate level is a common theme in the literature about successful organizations across many  industries.  Much of the  literature deals with this topic in a  fragmented way because there is no common definition or framework  rather  (Badawy,  1996). MOT advocates a view of technology as a critical resource, requiring investment in time and other resources. This approach supports forecasting of technology needs to understand the technology and where to access it. In addition to technical business investment,  investment  in knowledge building  through exploratory research is advocated as a means to develop strategic technical areas (Mitchell, 1988) or core technologies (Mierzwa, 1995), which in  41  turn influence the business strategy. This process shifts business strategy to being more customer- and innovation-driven, requiring the dedicated leadership of a VP-level executive (Mierzwa, 1995).  The VP's responsibility is to ensure that the organization has the competencies to deal with core technologies (Mitchell, 1988; Mierzwa, 1995). This includes resource allocation for knowledge building, facilitating appropriate organizational cooperation, and acknowledging that technology is one of the drivers of business strategy. Chief Technology Officers (CTOs) are being asked "to assume major responsibilities for decisions about R&D deployment, worldwide  technology  sourcing, the value of technology related to costs, and the market potential of key technologies as they relate to corporate timing" (Perrino & Tipping, 1989).  Sharif presents a matrix linking business strategies with technology strategies (Sharif,  1994a).  He  applies  technology  management  concepts  at  the  organizational level of a developing country, as shown in Table 3.  Using the firm as the unit of analysis and accepting the impact of technology on competition provides firms with the choices of being first movers/innovators, or followers/imitators  (McGee & Thomas, 1989). Other terminology for distinct  competitive stances are early or first-to-market, fast-follower, cost-minimizer and late-to-market, and market segmentation specialist.  It follows that R&D and innovation processes are critical to the above choices. They range, respectively, from leading edge and basic research commitment to R&D, to flexible product and process development and engineering ability.  42  Table 3  A Matrix Linking Business and Technology Strategies  Business Strategies  Technology Strategies  Technology Leader  Production of state of the art technologies  Technology Follower  Adaptation of advance technologies Utilization of standardized technologies Salvation of obsolete technologies  Technology Exploiter Technology Extender  Price Leadership Cost Minimization Compulsive strategy for profit and survival  Quality leadership Value Maximization Proactive strategy for customer satisfaction  Niche leadership Feature Specialization Reactive strategy for segment superiority  Green leadership Environment conservation Proactive strategy for image building Very high value market  Low value market  The complexity of the interfaces and relationships between rapidly changing markets and advancing science and technologies leads to the conclusion that successful innovation is the result of both plain chance and a range of purposeful efforts (McGee & Thomas, 1989). The capacity to link technical and market possibilities by managing the information flow within the firm is seen as a test of successful entrepreneurship and management. Technology enables the firm's response to market opportunities, but in turn pervasively changes the nature of the market and the character of competition.  Increasingly, the linkages, downstream coupling, and causalities that connect the market structure, corporate strategies, and technological change, are becoming the focus of related studies (McGee & Thomas, 1989; van de Meer & Calori, 1989). These studies attempt to test various hypotheses about the relationships between the scale and focus of technological change, and the size and sources of competitive advantage. They give rise to important  questions about the  43  compatibility of an innovation with the firm's existing skills, technology, and product range, as well as the firm's characteristics in terms of being innovationdominated, product-intensive, and science-based. Although small and medium sized companies may have incomplete knowledge of available technology, e.g., they may not have the absorptive capacity to access and apply knowledge, (Dankbaar,  1998)  current  argues that all organizations should increase  technology surveillance efforts The strategies for accessing relevant knowledge range from dedicating an executive member to this task to intensifying training and hiring practices. Top management's involvement in systematic monitoring and evaluation of relevant technology fields is a constant requirement across all organizations, as is the need for a long-term strategic view of the business (Dankbaar, 1998; Chappuis & Reimers, 1994). For example, a study of twelve semiconductor, photovoltaic, robotics,  and  pharmaceutical  technology-intensive  companies differentiating  industries from  marketing-,  labor-,  high-technology or or  capital-intensive  industries, identifies high-technology characteristics (van de Meer & Calori, 1989): •  generic technologies are at the forefront of science, inducing instability and unpredictability, and imposing a strong reliance on fundamental research;  •  many often interchangeable technologies compete for applications, and product and process life-cycles may be short;  •  high R&D expenditures dictate that critical mass in R&D is an important entry barrier; and  •  need for a comparatively high proportion of specialists exceeds the availability of such personnel.  Definitional dissensus and a lack of demonstrated reliability and validity are raised as potential barriers to the growth of related research. In time it is hoped that evolving theories 'will favor one set of definitions over others.' Lack of a paradigm is 'a sign of an immature discipline' and may be a barrier to the theoretical advancement of MOT. Establishing a paradigm too soon, however, may also serve as barrier to the maturation of the discipline (Andersen, 1994).  44  2.4.2 The MMT Discipline Geisler and Heller (1996,1998b) pioneered the application of the technology management construct to the health care field in a two-book series. Their goal was to develop a new intellectual space, which they termed Management of Medical Technology (MMT). Their premise was that, due to economic pressures, health care might be in crisis (at least in the US); concurrently, technology was playing an ever greater management  role. Their  proposal was that proper and better  of medical technology presented  some hope for facing  the  forthcoming challenges.  The efforts of Geisler and Heller also led to a special series of the Journal  of  (International  Technology Journal  Management,  of Health Care  two  volumes  Technology  have  Management,  been  International published  Volume 1, Nos  1/2, 1999; Volume 2, Nos 1/2/3/4, 2000). A review of these four publications is used below for the analysis of the current thinking on MMT and its relationship to MOT and health care management.  The first book presents MMT as the interface between MOT and the discipline of health care management. MMT is characterized as "expanding the theoretical and methodological tools used by MOT to the specific domain of medicine and health care." The domain of MMT is described in a matrix with five major categories of medical technology on one axis and the first 11 of the major MMT functions on the other, as shown in Table 4.  The areas of intersection, A1 to E11, characterize the important areas of practice and research in the academic discipline of MMT. Based on a review of the different concepts of technology in the second book, Geisler expands on the definition of medical technology by adding an additional three categories ( 1 2 - 1 4 above)  to include technology strategies  and policies; administrative  rules,  procedures, and work flow; and technology training and education:  45  "Medical Technology encompasses  the knowledge, systems,  information, materials, goods, services, things that enable, professional accomplish  and  rites, procedures,  facilitate, or make it possible the  health  care  organization  the goals of the profession and the  Table 4  approaches,  and any other  for the health care to  function  and  to  organization"  A Matrix Linking Medical Technology and MMT Functions  MMT Functions  Medical Technology Categories A B C D E  = = = = = A  medical devices drugs and pharmaceuticals disposables medical/surgical procedures information technology B C D E  1. Technology Implementation 2. Technology Planning and Integration 3. Technology Monitoring, Surveillance and Intelligence 4. Technology Commercialization 5. Technology Evaluation and Assessment 6. Technology Marketing 7. Evaluation of the MMT program . 8. Technology Utilization Review 9. Management of Technological Resources 10. Technology Commercialization and Marketing 11. Integration of Technology Management 12. Technology Strategies and Policies 13. Administrative Rules, Procedures, and Work Flow 14. Technology Training and Education  In Volume 2 of the Journal, Geisler mentions other key managing technology functions: technology needs assessment, technology in clinical decision-making, technology and health outcomes, technology and medical practice, technology and  patient value,  technology  for  integration  and  networking  of  different  functions, and technology for the advancement of medical care. These relate more to the roles of technology than to managing technology functions. This observation leads to the conclusion that there has not been a rigorous attempt at identifying the matrix of essential functions and capabilities for an organization's M O T system. This thesis attempts to contribute such a matrix.  46  In the second book, MMT is presented as an emerging discipline at the intersection or fusion of business/management disciplines (e.g., management,  marketing,  human  resource management,  etc.)  operations  and  medical  sciences (nursing, pharmacy, etc.) The status of new academic or intellectual space is justified by the uniqueness of the health care system, the sporadic application of management  science and managing technology to  medical  technology, the lack of focus in health care management on technology, and the central importance technology plays in health care.  There is a shift from presenting MMT as an interface between MOT and health care management (HCM)  in the first book to presenting it as an interface  between business disciplines and medical sciences in the second book. This shift seems to be linked to Geisler's attempt to establish a unique intellectual space for MMT. MOT and H C M have become two of the business disciplines.  In a further shift, Geisler [Journal Volume 1, page 2] describes MMT as a new intellectual  space that integrates  engineering.  The  health  care  knowledge from medicine, business, and environment  covers  all  the  stakeholder  organizations involved, including providers, vendors, regulators, payers, and innovators, among others, in the public and private sector. MMT is seen as a driver and facilitator of the current massive transformation in the health care industry. A s an example, Geisler refers to an article in the New England of Medicine  Journal  by Jerome Kassirer, where the changes predicted due to the  application of the Internet are described as "more radical than the restructuring of the health care industry."  The  breadth  of  MMT  advocated  by  Geisler  encompasses clinical  and  administrative technologies and functions of the health care system. Yet a curious contradiction lies in the recurring reference to medical technology as "all that which enables medical professionals to discharge their duties and to accomplish the goals of their profession" [Journal Volume 2, page 3]. This  47  definition is provider-focused rather than customer-focused. A more appropriate definition would define health care technology as all that enables the health care system to accomplish its goals.  This thesis does not attempt to add to or inform the discussion about the legitimacy of claiming MMT as a unique academic discipline. The research questions do, however, flow from the research agenda suggested for the MMT area,  particularly  the  questions: How  is medical  technology  managed  in  hospitals, and is there a general model of managing medical technology?  In light of the implied all-inclusive definitions of technology and management in the MMT construct, it appears that a broadening of the acronym MMT to H C T M (Health Care Technology Management) is appropriate. This is reflected in the title of  the  Technology  dedicated  new  and Management.  journal:  International  Journal  of  Health  Care  This thesis adopts the view of technology and  health care technology as it has evolved to date. A focus on health and health care also respects the evolution of these concepts beyond the traditional focus on medicine. Kumar & Motwani's Review A milestone review of H C T M literature is Kumar & Motwani's Health Care Technology  Literature.  Management  of  The authors look at the period from 1979 to  1997 and argue that the past 20 years of increasing stress in the health care industry have been caused by "immense pressure from the general public (and payers) to provide customized, high-quality care that renders salutary results virtually instantly and at the lowest possible cost" (Kumar & Motwani, 1999). The difficulty of achieving all these objectives simultaneously has led to tough choices.  The U S Joint Commission on Accreditation of Health (JCAHO), therefore  Care  Organizations  is requiring organizations to focus more on technology  48  management  techniques to obtain accreditation  status. Changing  payment  methods initiated in the early 1980s are also acknowledged as a further impetus for innovation and as the beginning of growing attention in the literature to issues of health care technology management in the U.S. The Prospective Payment System (PPS) and the 468 associated Diagnosis Related Groups (DRGs) had revenue  implications  for  providers  and  required  significantly  greater  accountability. Kumar & Motwani also found that the next impetus for attention to technological solutions and related research came from the national discussion around the Clinton health plan  (1993-94), involving a sharp increase in scrutiny  and accountability.  Kumar & Motwani report a several fold increase in the rate of H C T M literature, with 56% of the total 20-year output occurring in the period of 1994 to 1997, much of it relating to IT, tele-medicine, and the Internet (28.5%), administration (21.3%), and clinical/medical records (35%). Almost one-third  of the total  publications occurred in the last two years of the study (1996 and 1997). Nearly 60%  of all articles came from two journals,  Technology  (40%) and Health Care Financial  namely  Management  Health  Management  (19%). The authors  noted that the top technology and innovation management journals "were conspicuous by their absence."  333 articles in 47 journals qualified for the Kumar & Motwani review. The articles were categorized according to six well-researched and validated schemas: research strategy, application/theory content, technology application setting, objectives pursued, operations strategy, and type of hospital decision systems. The most common research strategies employed by authors were: • •  incremental extension of previous theoretical or applied type of research in a given discipline or sub-discipline (ripple strategy); direct application of a known methodology to a problem or a research question that was not previously so addressed (creative application strategy);  49  • •  the use of knowledge from one discipline to model problem domains falling in some other discipline (technology transfer strategy); and the bridging of known models or known theories resulting in the growth of the contributing and/or some initially unrelated field of knowledge (bridging strategy).  More than 60% of the papers were rated as primarily theory papers; 86% of these fell into the pure theory category. This rating implies that they essentially failed to demonstrate specific real world applications. 26% of all papers were "grounded in the real world, demonstrated applications that made a difference, or additionally used synthetic data to test sensitivity, conducted an error analysis, and/or explored behavior boundaries" (Kumar & Motwani, 1999). This compares well with other Operations Research/Management Science studies.  40% of all articles had cost issues as a primary or secondary goal and 60% of those were published in the last four years of the study (1994 to 1997). A s well, more than half of all articles with quality improvement as primary or secondary objective (24% of total) were published in those same four years. Similar trends were apparent for strategic planning (26%) and MIS development (16%).  34% of the studies deal with process, technology and equipment issues, while 22% deal with information. 14% deal with adaptive mechanisms, defined as "the interest among the providers to install modified or improved mechanisms of administration or technology" (Kumar & Motwani, 1999). 13% deal with internal (within the hospital) and external (beyond the hospital) integration issues. The authors interpret this to be in agreement with the notion that '"an adroit use of technology  can  best  allow  these  conflicting  objectives  to  be  obtained  simultaneously"  2.4.3 Key  Definition of 'Technology' elements  of  an  organization's  technology  construct  are  technology  5 0  availability and technology capabilities (utilization, compilation, acquisition, and generation)  (Sharif,  1994b).  Sharif  introduces  the  terms  'technoware',  'humanware', 'inforware', and 'orgaware':  •  •  •  •  Technoware includes object-embodied physical facilities, such as tools, devices, equipment, etc. Technoware also determines the complexity of the physical transformation operations; Humanware refers to person-embodied human abilities, such as skills, expertise, creativity, etc. Humanware also indicates the level of competence; Inforware covers record-embodied documented facts, such as design parameters, specifications, manuals, etc. Infoware also represents utility of available facts; and Orgaware describes institution-embodied organizational frameworks, such as methods, linkages, practices, etc. Orgaware also results in improved overall performance in the marketplace.  Alternatively, other authors define an organization's technology construct based on interdependent  and co-determinant  hardware,  software,  and  brainware  technology components (Husain & Sushil, 1997).  Critics of technology and technology management focus on the technoware aspect of technology. They raise concerns about the role of technoware or technological rationality as a vehicle of repression, de-skilling the work force, polluting and despoiling the environment. Linking technology strategy (in terms of technoware)  with business strategy could also be viewed as a move by  engineers and scientists to displace accountants in the central role of strategic decision making and organizational power (Jones et al., 1994). While a broader view of technology counteracts some of these criticisms, it is also acknowledged that technology management has to incorporate assessment and evaluation of technology in terms  of broader societal, cultural, and workforce impacts,  particularly in areas of market failure.  In attempting to present a unifying construct of technology in organizations, Geisler conducted an extensive review of the literature to identify six  51  perspectives by which the technology imperative can be realized, as summarized in Table 5 (Geisler & Heller, 1998a):  Table 5  Perspectives of Technology  Physical Perspective  Organizational Perspective  Information Perspective  Implements, tools, devices, techniques, systems  Relation to structure and processes  Knowledge, information, approaches  Process Perspective  TECHNOLOGY EXTENDS HUMAN AND ORGANIZATIONAL ABILITIES Change Perspective  Stages of activities in the innovation continuum, outcomes and outputs  Effects on structure, processes, work, and culture  Enabling Resource Perspective Internal management, interaction with environment, task performance  As discussed earlier, the authors further apply this technology construct to medical technology, by which they mean anything that enables the health care professional and the health care organization to function, such as: • • • • • •  2.4.4  physical perspective (devices, drugs, etc.); knowledge perspective (clinical and administrative procedures); information perspective (information and it storage, analysis, retrieval, etc.); process perspective (health care delivery process, quality/utilization measures, outcomes, etc.); change perspective (effects on structure, processes, outcomes, culture, etc.); and enabling resource perspective (clinical, administrative, managerial, etc.).  Definition of 'Technology Management'  Content analysis of M O T literature leads to the conclusion that there is currently no commonly accepted definition of this construct. There is recognition that the lack of agreement on a definition may be a barrier to the growth of the technology management concept. There is expressed hope that a set of favored definitions will evolve over time (Anderson, 1993). A synthesis of the definitions for the  52  technology management construct into a new and all-encompassing version is presented in Chapter 3.  A large component of the MOT literature focuses on the application of specific management science methods to technology management challenges. Another prevailing  interest  are the  stages of the technological life-cycle, such as  Koelling's review of the human resource issues in R&D (Koelling, 1994) or Scott's review of perceived management problems in New Product (Scott,  Development  1999). The number of sources which focus on the total conceptual  construct of MOT is limited.  There is some agreement that MOT is a multi-disciplinary endeavor, linking engineering, science and management disciplines in a holistic, systematic, and integrative  approach. There is also agreement  that MOT both shapes and  supports strategic goals and objectives. In line with the previous definition for the construct 'technology', MOT is viewed as managing the process of extending human and organizational ability to achieve strategic objectives. (Kanz & Lam, 1996; Price, 1996; Collins, Gardiner, Heaton, Macrosson, & Tait, 1991; National Research Council, 1987). While the strategic objective of gaining competitive advantage is the most common implicit or explicit interpretation  of the term  'strategic objective' (Betz et al., 1995), the objectives could be social or economic objectives  (Jones et  al.,  technology management  1994). A further  refinement  includes the management  is the  of every  concept that phase of the  technology life-cycle (Cory, 1988).  2.4.5 Attributes of the Technology Management'  MOT still lacks a disciplinary matrix and widely accepted problem solutions (Anderson, attributes,  1993). There have been attempts to identify or critical  success  factors,  such as  Berman's  important  issues,  executive-levers  (Berman, Vasconcellos, & Werther, 1994), Scott's critical issues (Scott, 1999),  53  Geisler's MMT functions (Geisler & Heller, 1998b), the JUPITER Consortium report (Jupiter), and Lewis' IRM study (Lewis, 1993),as summarized in Table 6.  Geisler  Jupiter  Lewis  Attributes  Scott  Comparison of Attributes of the Technology Management Construct by Author Berman  Table 6  Integrate technological planning into strategic planning Training and education; hard skills and soft skills Creating a conducive innovation culture Administrative rules, procedures, and work flow Integration of technology management Technology commercialization and marketing Lifecycle management of technological resources Technology utilization review, evaluation and assessment Evaluation of the MMT program Technology monitoring; surveillance, and intelligence Technology implementation Organisational Context of Technology Management Implement milestones and accountability framework Managing complex products, processes, and systems Develop an appropriate reward system Maintain continuity through constancy of business focus, communication, and managerial integrity Create multi-functional teams, matrix structures involving customers, marketing, etc.  lllS  Bring research units closer to production units Appoint C T O Organizational Change Technology Project Management Involve senior managers from throughout the organization Assure effective use of external resources (academia, other labs, etc) Alliances/partnerships between technology companies Security Compare technology plan with that of competitors Establishing a 'technology vision'  These attempts approach the technology management construct from different angles and, therefore, include some attributes and not others. They do not claim to present a holistic model of the construct, but attempt to present examples of attributes with provisos that there may be others. All issues in Table 6 have been considered for inclusion in the proposed model.  54  The literature suggests that the alignment between technology and business strategy is crucial for organizations. This alignment is achieved through a formal technology management Canadian health  system. The  investigator's  care system lacks the  hypothesis is that the  knowledge  and the skills for the  application of best practices in technology management. Whereas competitive survival  necessitates  motivation  technology  management  in  the  private  sector,  the  in the public sector comes from the desire to satisfy customer  expectations, the need to deal with resource challenges, and the desire to sustain the principles of the Canadian health care system.  In summary, Chapter 2 relates the widespread view that the global technological environment  has become considerably more turbulent  and unpredictable.  In  response, successful firms manage technology from the executive level as a strategic resource that can influence business strategy as well as support it. To support competitiveness of their industries in a global marketplace, academic attention to the discipline of Management  of Technology (MOT)  has been  increasing in the US and in Europe. However, as yet no well accepted and broadly  applied  definition  and  framework  for  the  construct  'technology  management' has evolved. The lessons from MOT are increasingly also studied with respect to health care, where technology management practices have not received the same level of attention compared to other industries.  Chapter 3 describes and applies a formalized literature content analysis. The objective is to synthesize currently referred to definitions and attributes of the 'technology management' construct based on the literature reviewed in Chapter 2 and from selected additional academic work.  55  CHAPTER 3 RESEARCH METHODOLOGY AND DEVELOPMENT OF THE MEASUREMENT INSTRUMENT  Chapter 3 covers three of the four major phases of the research strategy applied in this thesis. The fourth phase, the description and analysis of research results, is presented in Chapter 4.  Following an elaboration of the overall research strategy in section 3.1, phase 1 of the research strategy (the literature content analysis) is provided in section 3.2. It leads to the development of a new model for the technology management construct. In phase 2 of the research strategy, as described in section 3.3, a measurement instrument is developed from the model. The resulting web-based survey instrument is refined through pilot and field-testing. Section 3.3 also presents a particular 'gap score' measure derived from the survey results. Phase 3 of the research strategy involves the administration of the survey instrument to senior managers in Canadian teaching hospitals, and is described in section 3.4. The statistical analysis methodology applied to the results of the national survey is discussed in section 3.5.  3.1  THE RESEARCH STRATEGY  This study can be categorized as a cross-sectional survey utilizintg  cluster  sampling. The executive team members of the forty largest Canadian teaching hospitals constituted a target sample representative of the senior administrators in the Canadian health care system. Selected individuals from this group responded to a newly developed measurement instrument. Factor analysis and cluster analyses were the two key statistical inference methods applied to the resulting data set. In the absence of a generally accepted paradigm in MOT (Anderson, 1993), the research methodology also involved development of a new measurement  structure  or abstraction  ladder  (Geisler,  2000). To  address  56  criticisms of technology  management  research  (Lewis) (Anderson)  special  attention was paid to the establishment of reliability and validity.  A theoretical framework  had to be created for the ideas and concepts that  evolved over the past 15 years. The three measurement structures in Table 7, following, had previously been applied in technology management research. The framework adopted by Geisler seemed the most developed, and included the most comprehensive conceptualization of an "abstraction ladder' as shown in Table 7. Table 7  Measurement Structures in Technology Management Research Author Geisler  Lewis Abstraction Ladder  Premise Domain Characteristic  Phenomenon Conceptual construct Dimensions, Variables Indicators, Measures  Anderson Thematic Paradigm Exemplars  Using the Geisler terminology, the methodological objectives of this thesis can be summarized as:  • •  To define the phenomena To define the conceptual construct,  • • • •  To To To To  •  To address reliability and validity  define the dimensions, indicators, and measures develop a measurement instrument apply the instrument analyze the results  The measurement system defined 'what is being measured, how it is measured, and why it is measured. (Geisler, 2000), as summarized in Table 8, below.  57  Table 8 What we wanted to measure What we wanted to achieve with the measurement New measures and combinations Selection criteria for measures  Metrics Construction  The degree of technology management implementation in health care Identification of weaknesses, gaps, and barriers  To be developed through this project  Methodology • Base instrument development on good data that allow for meaningful analysis and interpretation • Develop a generic instrument that could be standardized across disciplines • Ensure comprehensiveness of the instrument set to measure a substantial portion of phenomena (content validity) • Enable relatively easy data collection, manipulation, and interpretation Ontology • • •  Attempt to integrate and converge with other related measures Explore validity Encourage measures for different aspects of the phenomena to be developed as follow-up to this thesis Organization and Management • Ensure outcomes are relevant to organizational and managerial objectives • Anticipate recommendations for potential action by managers/decision makers • Establish credibility of the measure • Encourage capability of evaluation and analysis • Consider cost-effectiveness • Review relation and relevance to other metrics used in different evaluations The specific research questions to be addressed by this thesis flow from the current state of evolution of the academic focus areas of Management of Medical Technology and Management of Technology . They are shown in Table  Table 9 Addressed in Chapter 3  1. 2. 3.  Addressed in Chapter 4  4. 5. 6.  9,  Research Questions  How can the conceptual construct of Technology Management be defined? What are the dimensions, indicators, and measures of the conceptual construct of Technology Management? How can the Technology Management capacity of Canadian teaching hospitals be measured? What is the level of Technology Management capacity in Canadian teaching hospitals? Is there a gap between desired and actual practice? Where are the weaknesses?  58  The specific assumption to be tested by this survey are that the success factors across a variety of industries also apply in the health care industry, and that there is currently a gap between environment  actual and desired implementation.  to be addressed is that of Canadian teaching  Since the  hospitals, the  conceptual construct and its indicators have to be validated for this environment. Once validation is established, a measurement instrument can be designed. Application of the measurement provides a  national  perspective  instruments to Canadian teaching hospitals on the  state of technology  management  capacity.The research strategy for this thesis is divided into several phases, as indicated in Table 10, below. Table 10 Research Phases Phase I (see Chapter 3; section 3.2)  Phase II (see Chapter 3; section 3.3)  Phase III (see Chapter 3, section 3.4 for methodology) Phase IV (see Chapter 4 for results)  R e s e a r c h Strategy  Research Questions How can the conceptual construct of technology management be defined? What are the dimensions, variables, and indicators of the conceptual construct of technology management? How can the technology management capacity of Canadian teaching hospitals be measured?  Design, application, and administration of the measurement instrument.  What is the level of technology management capacity in Canadian teaching hospitals? Where are the weaknesses in the capacity of Canadian teaching hospitals relative to technology management?  R e s e a r c h Strategy Rigorous content analysis  Combination of content analysis and triangulation with some key sources of information A survey instrument can be developed based on the indicators resulting from the content analysis; the survey instrument will be subjected to a pilot test involving senior health care consultants and administrators not currently employed as hospital executives; they were asked to critique the survey instrument and to recommend auditable evidence for each of the categories in the three M O T domains; validation of the applicability of the survey components to the teaching hospital environment through field testing in four regional referral hospitals in B C Application of the survey instrument to the executives of Canadian teaching hospitals  Gap analysis of survey results and feedback  The  research  strategy  roughly  parallels  one  employed  by  development of the Information Resource Management (IRM)  Lewis  in  the  concept (Lewis,  1993). This is justified on the basis that Lewis had similar research objectives, that IRM can be considered a specific technology management problem, and the rigor and quality of Lewis' research methodology. Lewis' model is generated by a rigorous process and statistical analysis, but focuses on 'information' as a strategic resource (IRM) and the attributes necessary to manage it as such.  The IRM concept originated in the 1970s. Similar to the current situation with the concept of Technology Management, Lewis still identified considerable confusion about the IRM concept, in spite of its wide exposure across many industry settings. Available definitions for  IRM  were contextual  and dependent  on  people's perspective. Lewis identified a need for an assessment tool to identify the extent to which IRM was implemented in an organizational setting. His "systematic and thorough approach was an attempt to overcome the criticisms leveled at MIS research for lack of rigor and continuity." (Lewis 1996)  Through an extensive content analysis of the literature, Lewis established an IRM domain in terms of its underlying premise, its definition, and its characteristics. From the characteristics, a validated measurement instrument was developed. Lewis applied a process involving an initial questionnaire, a pre-test, a pilot test, an item screening process, the administration of the questionnaire, and an evaluation of the measurement instrument. From the survey responses, a statistical profile of IRM implementation was created.  3.2  PHASE I - CONTENT ANALYSIS  3.2.1  Content Analysis Methodology  This thesis applies a  rigorous content  analysis to the  development  and  contribution of a definition of technology management and to the identification of  60  related critical MOT capabilities. Content analysis as research methodology also formed the basis of Lewis' effort to establish a premise and definition of the Information Resource Management concept, including a list of characteristics. Lewis refers to this methodology as a "common technique employed in the social sciences to draw  inference  from text; it is executed  by objectively  and  systematically extracting attributes from written communication and by analyzing those extracted parts" (Lewis, 1996).  Content analysis had its roots in trend analysis of mass communication media, such  as  newspapers,  radio,  and  television.  Unlike  direct  observation,  interviewing, or the use of questionnaires, content analysis is an interpretive, indirect and unobtrusive approach, meaning that it can utilize a document produced for a purpose other than the inquiry. Procedurally, a sampling strategy has to be identified, to identify a manageable population of source documents. In addition, a recording unit has to be selected. Depending on the research question, this could be an individual word, a semantic unit, or a theme (Robson, 1993).  In this thesis, the recording unit for the content analysis emphasized management  of  enabling  process technologies,  as  opposed  to  the  product  technologies. As discussed earlier, health technology is primarily a means to an end for teaching hospitals, enabling the achievement of diagnostic, treatment, clinical, and management objectives.  3.2.2 The Sample Literature The identification of the sample literature to arrive at a composite definition and premise of the construct of technology management was designed to yield a balanced approach between top-ranked journals and a wider set of related literature. This was done to avoid biasing the result to the perspectives of a few journals and to capture the most advanced thinking on the subject.  61  The wider set of literature was searched using ProQuest Direct by University Microfilms International (UMI), one of the largest academic article indexing services in North America. Ulrich's International Periodicals (UIP) was used to identify  top-ranked  academic journals  related  to technology  management.  Dissertations on technology management were identified through a search of UMI's Dissertation Abstracts database. Ten years of published literature were considered.  The UIP database of periodicals yielded 77 journals that pertained somewhat to technology  management.  They  listed  "technolog*" and "manag*"  in their  abstracts, tiles, or subject descriptor fields. Periodicals that were not specifically identified as academic or refereed journals, such as newsletters, bulletins, and trade publications, or those not written in English or not sufficiently related, were excluded. 17 of the 77 journals were considered appropriate. They were ranked based on l A M O T ' s Anbar  400 : 3  Intelligence,  2  Globally  web-site list of top-journals (IAMOT.1999) and the 1997 Accredited  Management  Journals  1997). These are shown in Table  list (Anbar Electronic  11. IAMOT  is the major  association to sponsor conferences, publications, research, and education related to technology management. Anbar creates an annual list of the world's most important journals. Table 11  Journal listed in Anbar Journal not listed in Anbar  17 Journals Rated by IAMOT and Anbar Journal listed on IAMOT website  Journal not listed on IAMOT website  2 journals 3 journals  5 journals 7 journals  The top ten journals were: R&D Management, Technological Forecasting and Social Change, Journal of Product Innovation Management, Technology Management: Strategies and Applications for Practitioners, Technology Studies, Technology Analysis and Strategic Management, Information Resource Management Journal, Research Technology Management, International Journal of technology Management, and the Journal of Global Information Management. 2  3  Web site: Web site:  62  Those not listed in Anbar and not listed by IAMOT were: Journal of High Technology Management, Journal of Information Technology Management, International Journal of Continuing Engineering Education and Life-Long Learning, Failure and Lessons Learned in Information Technology Management Journal of Technology Transfer, Journal of Engineering Technology Management, and Health Technology Management.  Of these 17 journals, eight were referenced in ProQuest Direct. The remaining nine journals  were searched through  other  indices such  as  Sociofile, El  Compendex, Ebsco, and indices provided at the journal publisher's website. The search of ProQuest and the other indices for the large set of articles yielded 219 articles with technology management or Management of Technology in the title field. The growth in annual frequency of articles per year, shown in Figure 2 indicates the increasing attention this topic has received over the past few years. Figure 3  Growth in Number of Articles on Technology Management, 1989-1998  I #of articles  1989-94  1995-96  1997  1998  The search of UMI's Dissertation Abstracts, the largest publisher of doctoral dissertations worldwide,  yielded 36 dissertations published after 1988.  They  represent the bulk of doctoral research on technology management. Only 13 dissertations on this topic appeared in the database between 1971 and 1988. They were not included in the process.  63  To identify the large set of articles, ProQuest was given a query for articles with the  following  criteria:  "Management  of  Technology",  or  "Technology  Management" in the title field; "technolog*" in the subject field, was a periodical, and was written between  1989  and 1998.  219  articles were selected and  collected using the ProQuest e-mail function. The literature search of journals, articles, and dissertations for the content analysis of the technology management concept is summarized in Figure 4.  Figure 4  Literature Search P r o c e s s  Sample Literature for Content Analysis  Top Ranked Journals  Other Journals  Dissertations  Ulrich Periodical Directory (77 journals identified, 17 selected and ranked from IAM0T and Anbar)  ProQuest Direct article index and full text database (219 articles found, 1989-98)  UMI's Dissertation Abstracts (36 revealed, 1988-97)  In this search for ten years of MOT literature, steps were taken to ensure that the range of literature selected tdescribed the field accurately. Top journals for this literature search were selected and ranked using authoritative sources. Also, business, applied science, and technology journal articles were searched to select additional literature on MOT. Citations, abstracts, and if available, full texts of the papers were imported into an Access database to view the results.  3.2.3  Definition of the Construct 'Technology Management'  The database of 255 articles and dissertations was searched for the sampling unit "defin*" (for definition) in its abstract or full text, to locate discussions of the definition of technology management. 30 such articles were found. The articles were scanned to eliminate those that did not in fact discuss or contain a  64  definition, leaving seven articles. Although only one dissertation contained the root word 'defin*' in its abstract, eight more dissertations with discussions about the definition were located by reading 47 dissertation abstracts in detail. Of the seven articles, four were about the field of management of technology as a whole, one was about a sub-field, and two were book reviews of textbooks on the subject. T a b l e 12  Definitions and their S o u r c e s  Definition Management of technology links engineering, science, and management disciplines to plan, develop, and implement technological capabilities to shape and accomplish the strategic and operational objectives of an organization. Technology management is about getting people and technologies working together to do what you want. Technology management is a collection of systematic methods for managing the process of applying knowledge to extend the range of human activity and produce defined products (goods or services). It is not about managing only technical specialists in technologybased businesses, but includes that conventional, but very limited definition in a holistic and integrative approach. Effective technology management synthesizes the best ideas from all sides: academic, practitioner, generalist, or technologist. Management of Technology links engineering, science, marketing, operations, human resources, and other management disciplines to formulate strategy, develop technological capabilities, and use them to achieve strategic objectives.  Author/Reference (National Research Council (U.S.) Task Force on MOT, 1987) (Kanz & Lam, 1996, p. p.27)  (Price, 1996)  Technology management is concerned with the identification, acquisition, (Jones et al., 1994, p. 157) development, and application of relevant technological knowledge and expertise to assist in achieving the organization's goals and objectives. This includes activities carried out by the R&D department, but extends into areas of specific technologies (particularly when those technologies have strategic implications for the organization). Technology management is defined as the means by which organizations use technological innovation to achieve both social and economic objectives.  (Jones et al., 1994, p. 165)  It is a human skill, combining elements of engineering, science and management techniques, which is needed by the organization in order that they may fulfill their technological capabilities and thus maximize their strategic and competitive advantage in the market-place.  (Collins et al.,  Technology management is rapidly emerging as a discipline combining the elements of business management and engineering. One description views this discipline as the research and education on how to manage the technology component of individual product lifecycles, capitalize on process technology to gain a competitive advantage, relate and integrate product and process technologies.  (Cory, 1996, p. 2.1)  Technology management means to use new technology to create competitive advantages.  (Betz,  Management of Technology is that part of management concerned with exploring the potential of new technologies and developing the technological base of the corporation to utilize this potential.  (van Wyk, 1996, p. 5.3)  1991, p. 571)  1987)  Each Technology Management definition (as stated in Table 12) captured one or more of the following concepts about Technology Management: what it is; what it does; why it is done; and what its end-objective would be. From the decomposed definitions,  a  new  synthesized  version  was  developed  for  this  thesis,  incorporating the key ideas from each of the earlier definitions. The original and the synthesized versions are highlighted in Table 13.  Table 13  Thesis Definition of Technology Management  Original Definition What it is •  A collection of systematic methods  •  The means and human skills  •  A discipline  What it does •  Links engineering, science, and management  •  Gets people and technologies working together in a holistic an integrative approach  •  Manages the process of applying knowledge  •  Synthesizes the best ideas of academics, practitioners, generalists, or technologists  •  Links engineering, science, marketing, operations, human resources, etc. activities in R&D and other areas of specific and strategic technologies  •  Combines elements of business management and engineering  •  Conducts research and education  •  Synthesized Definition A discipline and collection of systematic methods, skills, and means. Aligning human and technical resources to apply engineering, science, and management knowledge in a holistic and integrative process.  Combines elements of engineering, science, and management techniques  Why it is done •  To plan, develop, and implement technological capabilities  •  To extend the range of human activity  •  To produce goods and services  •  To formulate strategy, develop technological capabilities  •  To extend human capacity and activity through strategic lifecycle management of new and relevant product and process technologies.  To identify, acquire, develop, and apply relevant technological knowledge and expertise  •  To fulfill technological capabilities  •  To manage the technology component of product  •  To capitalize on process technology, relate and integrate  lifecycles product and process technologies •  To use new technology  •  To explore the potential of new technologies and to develop the technological base to utilize this potential  66  What is the end objective? • •  To shape and accomplish the strategic and operational objectives of an organization To do what you want  •  To achieve strategic objectives  • •  To achieve the organization's goals and objectives To achieve the organization's social and economic objectives To maximize strategic and competitive advantage in the marketplace To gain a competitive advantage To create competitive advantage  • • •  To shape and accomplish the strategic goals and operational, social, and economic objectives of an organization, to achieve sustainability and competitive advantage.  A new and comprehensive general definition of the conceptual construct of technology management emerged from this exercise:  Technology management can be defined as a holistic and integrated application  of engineering, science, and management  capabilities to  strategic lifecycle management of new and relevant product and process technologies in order to shape, as well as accomplish the goals and objectives necessary for organizational success.  From this definition, a schematic diagram for the Technology  Management  Framework emerges, as shown in Figure 5, following. Organizational success in health care could, for example, be expressed as improved patient care within given resources or as protection of the principles of the Canada Health Act. Figure 5  Engineering, Science and Management Methods  Technology Management Framework  Holistic and Integrated Technology Lifecycle Management  Shape and Accomplish Strategic Goals and Objectives  Organizational Success  67  3.2.4 The Model of the Construct Technology Management' The content analysis of the previously selected journals and articles also yielded attributes of successful technology management programs and systems. As stated earlier, Technology Management is a construct composed of several subfields from engineering, business, and health science. The attempt of this content analysis was to distinguish articles that discussed a sub-field from those whose scope covered tie holistic MOT concept. Based on the previously developed definition of the construct, the rational was that executive-level practice of MOT should be at a more holistic level and that relevant attributes were more likely to be found in articles dealing with MOT as a whole. Attributes related to sub-fields were considered more the responsibility of functional middle managers (e.g.: quality assurance, preventive maintenance, MIS, R&D Management, etc.).  The definition guided the identification of appropriate articles from which to extract the necessary attributes for successful technology management. Selected attributes described executive-level or corporate-level actions and satisfied at least one component of the objective of the definition, as captured in the 4  th  row  of Table 13 (To shape and accomplish the strategic goals and operational, social, and economic objectives of an organization, to achieve sustainability and competitive advantage).  Several iterations of ordering and synthesizing of related statements led to the list in Table 14.  After the content analysis, the list was cross referenced with  specific published lists of attributes, such as Berman's executive levers (Berman, 1994), the report from the Jupiter consortium in Europe (Heaton, 1993), and Geisler's MMT list (Geisler, 1998 a). The resulting list of attributes forms the conceptual construct of technology management as a whole and represents a comprehensive array of attributes from which a measurement instrument can be developed.  68  CD £ <2 o> QJ  CD CO c o  CL  ~  — >i  ap  TJ I  to CJ)  o>  O3  ure astri  E  $  co  ds  — CO c V. CD CO CL (0 C O CO c  o"  °3 uen  CO  CO £ CO xter  CO  a. 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CO rp  8= g°  f t 3 £co to  .0  CD  ro 5  T3 CO  CD CO  CD  8"2  |3  O  fc c o  2  t= CO  Q. CO 76 - g o o 2 CD  CD  f|  ™ ca E P I 5 o CO ' = « & —  CD j r  2  »- 5 fc  0 ®.|  2 CL " TD CO — CD  8  75 * £E c  •§ s  r S co  a>E ° o  75 S § ® 75 -J CO c CO - <o SJ ro "g i CD .2 — J c" CO ^ s  1 8-i 2*1  — T3 ca lz cz  8  t |  8  "1 0  co S  2i|Ito 3 > jz ® E g o  O «0 j ,  T3 £ ^  g « "  j§  m  a) o Cf) » C CO CD C CD N O E ^ ® m ill E N ' g r -O co a £ 6 co CO * - N 02  It  s  "8 S  CO COfc3> To  i s *~  co N £ c c > < E ® E .§80 E?g>c? . g>a jco - vfc 2>a>  g  r  O -° Ul Si t— ® O «  ® 5rCD to i2 fc g  3.3 PHASE II - DEVELOPMENT OF THE MEASUREMENT INSTRUMENT 3.3.1  The Measurement Instrument  Technology  management  is a complex, multifaceted  process with  interlinked  activities, clearly containing more than one indicator. The measurement instrument then evolved from iterations of logical assembly of attributes into specific indicators, variables, and dimensions.  The 35 composite themes listed in Table 14 represent a thematic ordering of reported attributes for presentation purposes. Guided by the previously described abstraction ladder approach to metric development, the goal was to create a hierarchy of major dimensions, of variables that described the dimensions, and of indicators that gave shape to the variables. The measurement instrument itself was constructed from an exhaustive list of individual attributes. They were grouped and regrouped until an intuitively sensible and comprehensible list of indicators emerged. The list of indicators was far more detailed than similar reported attempts in the literature, although, it became apparent, that the indicators could be grouped into variables comparable in name to ones referred to in the literature.  The variables, in  turn, also fell readily into three groups, which are referred to as the three dimensions of the measurement instrument, as indicated in Table 15. Where it seemed that there were options, an attempt was made to create a model with some structural balance between  dimensions, variables, and indicators in order to  enhance  presentation and comprehensibility.  The complete measurement instrument (as shown in Appendix 3) was based on discussion with experienced surveyors and on principles of survey design reported in the following web-sites: •  •  Guidance Notes for Placement Students, School of Computing and Mathematics, University of Huddersfield ( A Framework for Questionnaire Design: Labaw Revisited  73  ( Creative Research Systems; Survey Design (  Table 15  3 Dimensions 5 Variables in Each Dimension  Structure of Measurement Instrument  Strategic Technology Management • • • • •  2 or 3 Indicators for Each Variable  Technology strategy Chief Technology Officer  Management of Change and Innovation •  Change management process  •  Organizational effectiveness and flexibility  •  Executive leadership and communication Integration of the innovation chain  •  Core technologies  •  •  Project/process management Lifecycle management Technology assessment and evaluation  Strategic intelligence Customer focus  •  Performance evaluation  •  Human resource management  •  Knowledge management Statements 15 to 28  Statements 1 to 14  Lifecycle and Organizational Management  •  Statements 29 to 42  The resulting survey design was further influenced by the choice of a web-based delivery system and by the fact that the target audience was a busy group of individuals with considerable knowledge about the survey statements they were asked to assess. The survey was presented in a logical sequence according to the overall model laid out for participants in the covering letter. Given that the target audience for the survey were senior and knowledgable individuals, itwas deemed unnecessary and probably not helpful in this case to scramble the sequence of the statements. The use of a Likert scale to rate the respondent's perception about the importance of the topic and the extent of its implementation in the respondent's organization was adopted from Lewis' study about the  Information Resource  Management construct (Lewis, 1993).  Certain similarities  in objectives between the  IRM  study and this technology  management study underlie the complimentarity in approach. As was the case with reviewers of past technology management research, IRM studies had been criticized  74  for a lack of attention to validity and reliability. Lewis attempted explicitly to correct that situation with a well-referenced research and statistical analysis methodology. Furthermore, 'information' is a particular form of technology and certainly has evolved into a recognized strategic resource. The focus on technology in general in this study expands the scope of the IRM study, but there are clearly similarities in management challenges. The IRM study is one of many that have focused on management  of a specific technology as opposed to the overall conceptual  construct. The excerpt frame in Table 16, below, covers the first two variables in the strategic technology management domain. In line with the above metrics discussion, strategic technology management represents one of the three domains; technology strategy and Chief Technology Officer represent two of the 15 variables; and items one to five, represent five of the 42 indicators. The measurement units are the rating scale scores, ranging from 1(not at all), 2(very little), 3(little), 4(some), 5(great), to 6(very great). Table 16  Excerpt from Technology Management Survey  Executive Activity/Function  Importance of implementation  Current level of implementation  Technology Strategy 2 3 4 5  6  1  2 3 4 5 6 1 2 3 4 5  6  1  2 3 4 5 6 1 2 3 4 5  6  1.  Technology strategy is aligned with the business strategy, the strategic goals and the strategic objectives of the organization.  1 2 3 4 5 6 1  2.  A strategic intent focus drives the technology vision, strategy, plan, and policies, which are clearly stated.  3.  Core and peripheral competence/technologies are defined; the intellectual and technical infrastructure around core technologies relates and contributes to all internal and external key/competitive business aspects, such as price, quality, flexibility, rapid response, customer service, and reputation.  Chief Technology Officer 4.  C T O or equivalent senior technological leadership with clearly identified responsibilities at the executive level appointed and reporting to the C E O .  1 2 3 4 5 6 1  5.  Technical, strategic, and project management competency expectations and measures include demonstrated personal commitment, staying abreast of present and potential future technologies, knowing when to abandon, support existing, or adopt new technology  1 2 3 4 5 6 1 2 3 4 5 6  2 3 4 5  6  75  3.3.2  The Web-Survey Procedure  While Internet surveys obviously can only be employed if the intended audience can be assumed to have access to appropriate technology, this method was chosen for a variety of reasons:  •  Senior hospital administrators are expected to have access to the technology. The spirit of the technology management topic encouraged an application that would better serve the customers (speed, convenience for the recipients, ease of data handling for the principal investigator).  The most time consuming portion of the process was the determination and iterative correction of hundreds of e-mail addresses. This was accomplished with repeated exchanges of notes and information to and from representatives of the C E O offices of participating organizations.  The process of developing and posting the survey on the web involved a number of additional steps. The survey content was developed as a Microsoft Word document, including all associated notes, rating scales, etc. Dreamweaver 4.0 web design software was used to design the web pages with forms to accept data input. Several edit and reformatting steps were involved to assure that the survey was pleasant to the  eye, easy to follow,  professional looking, and inviting to complete.  The  'instruction to participant' section was considerably shortened from the field test stage to the national survey stage. This was based on advice that respondents would be deterred by a long introduction and that once they decided to go into the survey, they needed to be captured immediately and asked for information, rather than be led into another reading exercise.  The covering letter introducing the survey and leading people to the survey URL was also rewritten several times; there was an attempt to strengthen the message that respondents would gain something by completing the survey. The survey instrument  76  represented a menu of activities which they could use as a guide for their own organizational development.  Another design decision was to require completion of all specified fields before submission back to the web server was allowed. While this frustrated some respondents because they did not feel really comfortable with their knowledge about certain aspects, it was the view of the principal investigator that as senior managers they should have a reasonable capacity to respond to each indicator in the survey. It was also felt that analysis of the results would be enhanced by the elimination of missing data, even if it reduced response rate. The above was added to the web pages via Javascript by the BCIT web-management team.  The decision to design the web-survey tool rather than to use purchased web-survey software was based on the ability to design a more professional look and on the ability to create data files of submitted responses that could easily be exported directly into an Excel database/spreadsheet program. A thank-you page was created and sent automatically upon receipt of a survey response to the web server. The survey was tested internally and externally before it was posted live on the BCIT server on the School of Health Sciences website. It was sent electronically with the cover letter including the survey U R L to the hundreds of senior managers for whom e-mail addresses had been provided by their C E O ' s office.  Organizations and individuals were assured that only the principal investigator would know the identity of respondents and that future reports would not identify and link organizations,  individuals, or  responses. Still, the  process allowed  targeted  reminders and requests for responses to individuals from whom none had been received within the specified time period. Overall, the speed of distribution, receipt of responses, and creation of the data set for statistical analysis was of great benefit, as it was accomplished in a six-week time frame; the up front collection and correction of e-mail addresses took approximately eight weeks.  77  3.3.3 The Pilot Test Using the Delphi approach, senior health care administrators and health care management consultants were asked to rank and validate the attributes of the construct of technology management from the perspective of Canadian teaching hospitals, with a focus on the responsibilities at the corporate or executive level. This pilot process constituted a more specific content validity assessment.  Additional content validity was achieved through consensus-building about the attributes  of the conceptual construct. A  Delphi technique was adapted for  consensus-building among experts in this case. It requires judgment on a collective basis. Each expert had the opportunity to present and react to feedback in anonymity.  Group responses were  redistributed to the  participants and  new  feedback was encouraged (Chocholik 1997).  The web-based survey was piloted through the Delphi process. Health care managers in British Columbia were contacted and asked if they would agree to serve as expert participants in the Delphi study. In order to qualify as expert, an individual had to have been involved in health care management at senior levels for more than ten years. Their collective professional backgrounds were to cover technical, administrative, and patient care arenas. They were provided with a draft survey  and were  asked to  understandability. The  critique  pilot test  it from  the  perspectives of clarity  and  participants were also asked to recommend  unambiguous descriptors for the state of implementation of each statement category in the survey. The positions held by the pilot test participants at some point in their career were:  Assistant Deputy Minister, B.C. Ministry of Health C E O , B.C. Cancer Agency C E O , B.C. 's Women's and Children's Hospital C E O , Canadian Cancer Society, B.C. and Yukon Division CIO, [B.C.] Okanagan Health Region Deputy Minister, B.C. Ministry of Health  78  Director, Alberta Heritage Foundation for Medical Research Executive Director, B.C. Health Industry Development Office Executive Director, [B.C.] Council of University Teaching Hospitals Executive Director, Health Association of B.C. Health Care Management Consultant Program Head, Health Care Management UBC/BCIT V P , [B.C.] Capital Health Region V P , Surrey [B.C.] Hospital V P , Vancouver Hospital and Health Sciences Centre A cover letter explained that the outcomes of this study would lead to a new research agenda for technology management in B C , that they would influence curriculum development for training in this area, and that they would provide useful guidance for health care managers. The letter also quoted a statement published by the Canadian College for Health Service Executives, based on their own survey about desirable attributes of future health service leaders:  "Health care leaders carefully and successfully adapt some features of the private sector model for use within the public sector infrastructure. Technology conscious, leaders are increasingly able to guide its infusion to their best advantage" ( C C H S E , 2000)  This statement succinctly captures the essence of this research project, which takes lessons from various industry sectors and assesses their applicability in health care.  Pilot study participants were informed about the national character and the expected target audience of the study. They were presented with the prototype questionnaire including all 42 indicators, and were asked to:  • •  Complete the survey keeping any familiar large health care organization in mind. Identify if and how specific statements should be altered.  • •  Add statements that they thought were important but not included. Express concerns they may have about the appropriateness of the three main domains and the categories within each domain of the survey. Identify examples of additional real and practical evidence or indicators that could be used to support statements about the extent of implementation in the various categories (strategic plans, job descriptions, budgets, etc.).  •  79  The objective at this stage was to test the comprehensiveness and comprehensibility of the measurement instrument. This was also an early attempt (through the last bullet, above) to collect objective indicators for the extent of implementation of each of the indicators and variables for a particular organization. This evidence could form the basis of an audit process.  Appendix 3 contains the survey as presented to pilot study participants. Their comments and suggestions through two rounds of Delphi response and subsequent consultation with faculty, led to changes in presentation, wording, simplification, and shortening of the instrument. The number of indicators was reduced to 26 by combining indicators that were identified as being too similar and by eliminating some  that  participants  disagreed  with.  For  example,  a  suggestion  for  an  organizational matrix structure was identified by a couple of respondents as being too specific.  Based on feedback from pilot participants, the variables and indicators grouped as performance evaluation and core technologies were embedded and realigned with other variables. The revised model is presented in Table 17. Through this process, descriptions for individual indicators became longer. In order to reduce variability in interpretation of the indicator statements by the respondents, the format for each statement  consisted of a major theme  (capitalized  and bolded) and a  more  descriptive elaboration (in small print) as shown in Appendix 4.  The survey language was not specifically adapted or related to hospitals, since the intention was to validate that the model, derived from reported experience in a variety of industries, could also be applied  in health care. The instrument was  designed to identify the gap between the extent of implementation of the indicators and full implementation of the model, incorporating the importance attached to each indicator by the respondents.  80  Table 17  Strategic Technology Management  3  Dimensions 11 Variables and 26 Indicators  Survey Instrument After Pilot Test  Technology Strategy 1  2  Technology and business strategies aligned Key technology supported by infrastructure  Chief Technology Officer 3  4  Executive member formulates technology strategy Executive member administration/ management technology strategy  Management of Change and Innovation Change Management Process 10  11  6  7  9  Organizational strategies to respond to change 20 Organizational design  12  13  Senior management promotes organizational vision/direction Performance management based on customer satisfaction Communication system promotes technology  21  22  Organization uses sound project/process management 23 Technology lifecycle systematically managed  14  Environmental factors re technology strategy identified Organization protects intellectual property  Integration of the Innovation Chain  24  15  25  Technology linked to customer needs Line managers responsible for customer service.  Innovation system  integrates R&D/operations 16 Technology diffusion/transfer encouraged  Human Resource Management 17  uses multi-functional teams Skilled employees seek innovative opportunities  Project/Process Management  Vision re technology through routine scanning  Customer Focus 8  19  culture prevails  Executive Leadership and Communication  Strategic Knowledge Management 5  Senior management participates in change management Corporate learning  Lifecycle and Organizational Management Organizational Effectiveness and Flexibility  Assessment and Evaluation  26  Technology-related risks evaluated Technology assessment informs technology decisions Performance due to technology management evaluated  HR development/ planning key to  technology capability 18 Accomplishments formally recognized  As mentioned earlier, pilot study participants were asked to comment on the structure and wording of the instrument. In addition, pilot participants were asked to suggest specific types of observable evidence that could support the individual rating of the extent of implementation of these indicators, such as the existence of a written technology strategy document, or the position description of the Chief Technology Officer. This information would be of assistance in future audit or evaluation  81  processes about an organization's technology management  practices. Table 18  provides examples cited by pilot-study participants. Table 18  Variable Technology Strategy  Descriptors • • • •  technology strategy referenced in the business plan checklist of issues to address in considering the introduction of new technology formal process exists for examining the costs/benefits of a new technology cross-reference between organizational mission/vision and technology vision/mission  • • •  priority statement for the technology strategy relative to other priorities quality indicators that relate to technology and technology management wording in documents to suggest that the organization understands the difference between technology as a strategic and a tactical resource specific statement on how technology can influence business practices in a positive way  •  CTO  Customer Focus  Evidence for Implementation of Indicators As Suggested by Pilot Study Participants  •  C E O or someone else in senior executive management comfortably, coherently and succinctly vocalizes the technology strategy  • •  position description position is filled  •  C T O has resources identified, budgeted and supported to adequately fulfill the responsibilities  •  C T O reports to the C E O  • •  C T O understands the strategic business issues of the organization C T O knows who his/her customers are?  • •  documented customer surveys have been done in the last year documented evidence that customer needs have been met  • •  job descriptions of line managers include responsibility for customer service Information about patient and staff (customer) needs and evidence that these factors drive change in the organization. line managers can identify their customers  • •  every level of the organization not only identifies its customers but also identifies what its customers need to improve and augment services to their customers  •  mechanisms in place whereby the organization, as a whole, identifies all of its customers  Performance • Evaluation • •  organization's business strategies undergo an external review mechanisms are in place to support the notion that technology and business strategies are evaluated  •  the performance management system reflects internal and external customer satisfaction accreditation reports  •  evidence how technology assessment has influenced technology decisions  Change • Management • Process • •  evidence of the organization's change process. Is there is a documented a communication plan in the organization that provides for 2-way communication? examples of awards hiring and retention mechanisms in place to ensure that the necessary human resources are in place to grow and maintain the technology dimension  82  3.3.4  The Field Test  For further refinement of the questionnaire a field test was undertaken. It was targeted at institutions that would not be included in a survey of teaching hospitals. Senior managers of four regional referral organizations participated in the field test of the survey instrument that was significantly reshaped after the  pilot test.  Participants represented a variety of administrative responsibilities as indicated in Table 19.  The C E O s of four medium-size B C health service organizations provided the e-mail addresses of their Executive Teams and the individuals reporting to the Executive Team members (VPs, C E O s ) . These 64 senior managers received the cover letter and the survey instrument. They represented eight different areas of responsibility..  The responses from the field test participants were analyzed as planned for the national survey, even though the sample size was not sufficient for statistically valid conclusions. Two emerging trends shaped the design of the survey instrument and the statistical analysis for the national survey. The pattern of responses suggested that patient care managers and non-patient care managers might have different interpretations of the indicator descriptions or of the reality in their organizations. Similarly, the possibility of similar systemic differences in ratings appeared between executive team members, and those managers reporting to the executive.  Table 19  Field Test Participation  Area of Responsibility CEO, COO Research/Education/Library Nursing/Medicine/Clinical Programs Diagnosis/Therapy/Allied Health Facilities/Biomedical Engineering/Environmental Services/Food Planning/Evaluation/Quality/lnformation Systems/Records HR/OD/Finance/Business Development/Materials Management PR/Communications/Patient Relations. Total  Response Rate 3/4 1/1 8/19 7/12 2/7 5/9 4/9 3/3 33/64 = 52%  83  With 33 responses from 64 individuals on the email list, overall response rate was 52% and varied between 43% and 64% for the four participating institutions  as  indicated below. A s in the pilot test, respondents were asked to comment on content, wording, and structure of the instrument. No changes to the instrument were suggested. The importance of the 'technology management' topic itself was confirmed by a consistently high average rating from each organization, as shown in Table 20. On the six point Likert scale, average ratings for each organization ranged from 5.6 to 5.9, where 5 means 'great importance' and 6 means 'very great' importance.  Table 20  Organization  Organization Organization Organization Organization Total  1 2 3 4  Importance of Technology Management  Response Rate  Importance of Topic (Rated 1 - 6)  9/14 = 64%  5.8  9/20 = 45% 9/16 = 56% 6/14 = 43% 33/64  5.9 5.6 5.8  The Gap Score  In addition to the Likert ratings for each indicator, a single measure was established to capture each respondent's perception of the gap between  ideal extent of  implementation (reflected in a rating of 6 on the Likert scale) and perceived extent of implementation (1-6 rating) for each of the 26 indicators. Gap scores were weighted using the respondent's assessment of the importance of the respective indicator. This resulted in a new variable (Gap Score) calculated by the formula G S = (6-E) x B, where G S = gap between ideal and perceived implementation 6 = ideal implementation rating E = rating for perceived extent of implementation B = rating for the perceived benefit/importance of implementation  84  A Gap Score (GS) was calculated for each respondent, where: GS =  (6-E)xB  The term (6 - E) can be interpreted as an indication for 'room for improvement', as an E score of '6' would indicate full implementation. The factor B becomes a weighting factor relative to the perceived importance of the item. For example, perceived full implementation of an indicator would yield a gap score of zero: GS=(6-6)xB = 0  G S = ( 6 - 1 ) x 6 = 30  A rating of '1' (meaning: not at all) for implementation would yield the highest gap score if the indicator was also rated as '6' for importance (meaning: very great):  The possible range, therefore, for gap scores is zero to thirty. An average gap score (average of responses from a particular organization) of less than eight for an indicator can be interpreted to mean that this indicator has been implemented to a high level and would not require additional attention for improvement. This could be either because the indicator has been well implemented (rating of 5 or 6) or because the importance was rated lower than other indicators (4 or less). Field test results indicated that the measurement instrument and the gap score measure seemed to capture  differences  in  perception  between  senior  managers  from  different  organizations with some consistency.  Interpretation of the Gap Score  As summarized below in Table 21, responses from organizations 1 and 2 did not result in an average gap score of less than 10 for any of the 26 indicators in the survey. The numbers in each block represent the individual indicators (numbered 1 to 26). Respondents from Organization 3 achieved average gap scores of 6-10 for eleven indicators, and Organization 4 achieved average gap scores of 6-10 for eight of the indicators. On the other hand, Organizations 1,2,and 4 received average gap scores of 15-19 for eight, ten, and six indicators respectively, while none were received at the higher gap score for Organization 3. One could interpret this as an  85  indication that Organizations 1 and 2 are not performing well in the eyes of their senior managers, especially compared to Organization 3, while senior managers in Organization 4 have a less consistent view of their organization's performance. Organization 3 seems to have reached a high level of technology management performance. Coincidentally, Organization 3 is nationally recognized for its Quality Management System.  Table 21  Distribution of Indicators by Gap Score Range  Average Gap Score Range (high, low)  Indicators Organization 1  Organization 2  none  none  6-10  15-19  4,8,15,19,20,21, 26  Organization 3  1,3,10,11,12,13, 14,20,21,22,24  3,4,11,13,17,18, 21,23,25,26  Organization 4  2,3,4,6,10,14,16, 25  9,13,18,19,23,26 none  Figure 5 shows the 26 mean gap scores for Organization 3 consistently below the mean  gap scores for the  four organizations.  Organization  2  ends  up  fairly  consistently above the others, and Organization 4 displays a broader range of mean gap scores.  86  Figure 6  Field Test G a p S c o r e s  Field Test Gap S c o r e s 25.0  • 20.0  ,  4  f *  i>  AVG  •  t I Ji •V  15.0 i• r.1 c  ORG 2  •a • O R G 3 — O R G 4  4•  i r. V. 11  i L  J  i  > l  .,<  •  rt  c]..  u  ¥•  "r  p"  •  i j  i  £  p^ —  >—  3  I] 5.0  0.0  26 18 19  8  15  11 13 17 23 21  4  14  9  2  25  1  3  5  24 16 22 20  6  7 12 10  Four respondents each from Organizations 2 and 4 provided some comments about their situation, which are summarized in Table 22, following. The individuals who provided the comments were senior managers (CEO, VPs, and Directors) in charge of Public Relations, Pharmacy, Clinical Services, Medicine, and Administration. The comments can be related to the gap score results. Organization 4 responses reflect concerns about communication and about not knowing the plan, which could lead to the variance in ratings reflected in the gap scores. Improved communication would seem to be in order. In Organization 2 respondents seem to share the opinion that there are problems, which are reflected in the consistently high gap scores, reflecting room for improvement in management activity. These opinions are  87  reinforced by further analysis of the gap score results for particular indicators as displayed in Table 21.  Table 22  Respondents' Comments  Organization 1  Organization 2 Strategic Management  -  -  -  -  -  W e are a government agency, but a technology strategy is very important. W e do not have a CIO; the lack of leadership has allowed a schism to develop between record/information technologists and the rest of the staff. The C T O has the roles described above, and is well respected by all at the senior management level; C T O is not a member of the executive team, which is a weakness in my view; also does not have appropriate support, though staffing levels are increasing. C T O reports up through a C O O and is NOT present at the executive level and this is vital. C T O has to cope with a small IT unit, demands from multiple sources, fiscal restraints and lack of an Information management strategy. End user involvement is minimal in new developments; communication about developments is inadequate. Little evidence available to suggest that e-business applications are being considered to improve operations within and without the organization.  -  -  -  -  updates on planning and strategies have not be publicized to the general staff or managers; progress has been gradual. Rumors of inadequate computer resources to handle new initiatives (i.e., S A P ) without impacting functions at general user level i.e., more down time incidents. Not clear who is responsible for technology strategy; V P ? Director? Manager? Not well defined here; formulator may differ from administrator/manager - further discussion would be helpful. C T O is a member of the senior management team but does not report to the C E O directly. Need for someone to keep on the leading edge of the wave to keep us moving ahead; identification is not bad, but follow-up is important haven't seen significant commitment here. Customer survey done but follow-up slow or lacking; need to publicize and share results, strategy and follow-up; line managers need to be invited and to actively participate to insure compatibility, focus and obtaining desirable outcomes.  Change Management  88  -  -  -  -  This is an area of weakness for our organization, part of an overall lack of understanding about (a) customer service and (b) our basic "product." Turf and budget wars generally inhibit collaboration between programs; standardization has become the catchword; this will only breed mediocrity. Innovation is suppressed because it may endanger standards, or it is not openly communicated for critical and constructive criticism; organization's "thinking" is insular and incestuous; centralized "command and control" thinking persists. Unionized environment and issues during technological change need to be covered. Union thinking exemplifies the IT group; technical support personnel are not supposed to do any "programming" even with .asp development; people who are creative have left to work elsewhere.  -  The change process has been extremely challenging; trust and risk taking is limited; demands for more education and educational support is high and is receiving significant attention and resources. An element of the medical and nursing staff are undermining the hospital leadership at the moment. Participation by general staff remains of utmost importance; how to obtain this support for change is also key. External funding must be considered in this economic climate; info sharing and marketing of new programs developed on site is an innovative approach to keep funding flowing in. Recruitment and retention required to keep ahead with good people; training must occur at all levels to maintain and improve skills; formal recognition would be added incentive to do well.  -  -  -  -  Organizational Management  -  Projects not monitored to ensure objectives are met before resources are reassigned to other projects (staff pulled in all directions by multiple changing priorities). Poor understanding of leadership in the area of systems lifecycles; multi-functional teams are left to work off the corners of the desktops.  — Advanced planning for evaluation is poor; systems are implemented for specific programs without assessment of impact on others.  Organization  -  Multifunctional teams provide more insight into different services. This is key to obtaining high quality results. Continual support and monitoring necessary to insure staff remain committed; planning for updates and testing must be integrated into timelines. Actions planned or undertaken not well publicized to general staff; need to have this stated and clear.  -  -  4 ratings indicate that an executive  team member  is in c h a r g e  of  technology strategy (indicators 3 a n d 4 h a v e very low g a p s c o r e s a s s i g n e d to them). Key  technologies  are  well s u p p o r t e d  by  necessary  infrastructure (indicator  2).  E n v i r o n m e n t a l factors that could impact on t e c h n o l o g y strategy h a v e b e e n identified (indicator 6) a n d technology  assessment  is part of t e c h n o l o g y  m a k i n g (indicator 25). T h e s e n i o r m a n a g e m e n t  related  t e a m s e e m s to be actively  decisioninvolved  89  in change and innovation (indicator 10), and the communication system promotes technology as part of the organization's thinking at all levels (indicator 14). However, a customer service attitude seems to be questionable for Organization 4 (indicator 9), as is the recognition system for individual and team accomplishments (indicator 18).  On the other hand, Organization 2 did not fair well on any of the indicators. Nobody on the executive team seems to be associated with responsibility for technology strategy, and the corporate learning culture received a poor rating (indicator 11), as did human resource management (indicator 17).  These  examples indicated that the  instrument  could capture the technology  management characteristics of differing organizations. The detailed analysis of the strength and weaknesses of specific institutions was not part of the research objective for this thesis, but could be entertained in future by employing this measurement instrument if proven effective by statistical analysis of the national survey. The  indicator statements  were comprehensible and were  interpreted  consistently based on the patterns shown in Table 21. No changes to the instrument were suggested that were deemed worthwhile or sufficiently significant to alter the survey instrument.  3.4  PHASE III - ADMINISTRATION OF THE NATIONAL SURVEY  This section covers the identification of the target sample for the national survey and the administration of the measurement instrument developed in Phase II of the project. The web based approach paralleled the pilot and field test strategies and has been covered in the previous sections of this chapter. The measurement instrument and the gap score analysis follow the field-test approach described in section 3.3.  90  Phase IV of the research strategy is comprised of the statistical analysis and discussion of the responses to the national survey. The statistical methodology applied to the survey results is described in section 3.4.4. The actual analysis is presented in Chapter 4.  3.4.1 The Sample  A number of sources were used to establish the list of teaching hospitals in a constantly changing Canadian scenario. The former Medical Research Council of Canada (MRC, now the Canadian Institute for Health Research, CIHR), a federal health research funding organization, informs researchers in teaching hospitals across Canada about funding opportunities. An updated list of teaching hospitals was obtained from M R C in January of 1998 and included 29 teaching hospitals (Medical Research Council of Canada (MRC), 1998). The Association of Canadian Teaching Hospitals (ACTH) provided a list including 65 hospitals (Office of the Secretariat,  1998). The 1997-98 edition of the Guide to Canadian  Healthcare  Facilities, which is published by the Canadian Healthcare Association (CHA) lists health authorities and hospitals across Canada (CHA, 1998). The C H A guide provided the most comprehensive listing of facility information, both in detail and volume, including type of service provided, number and type of beds, statistics, names and titles of professional staff, ownership/operation (federal, provincial, municipal, regional board, religious, lay, or private), and licensing.  For the purpose of this study, technology intensive institutions were to be targeted and needed to be identified. It was assumed that these institutions would best represent organizations that needed to deal with technology management challenges. In order to capture  and  rank the  organizations  by technology  intensity,  the  number  of  'technology intensive beds' was used as a proxy indicator. Specialty care and surgical care beds were designated as 'technology intensive beds'. This included the numbers recorded in the C H A guide under critical care, intensive care, neonatal intensive care, obstetric intensive care, pediatric intensive care, surgical care, and  91  other special care units. Ninety-six institutions with at least 10 'technology intensive beds' were selected.  In February of 2001, the Executive Committee of the Association of Canadian Academic Health Organisations (ACAHO) enthusiastically endorsed this research and its importance. Executive members, the C E O s of some of Canada's largest teaching hopitals, shared the view that technology management approaches in the Canadian health care system could and needed to be strengthened. Their support and active promotion of this project presented an  invaluable opportunity to attract  participation from senior managers in Canada's teaching hopitals.  The  list  of A C A H O  member  organisations was  compared  with the  list  of  organisations ranked by number of 'technology intensive beds' from the C H A guide. This list indicated that A C A H O member organisations provided a national target audience of most of the major and most technology intensive organisations. It was felt that the senior managers of these organisations were best positioned to assess the technology management  practices in Canadian health care agencies. The  shaded and bolded lines in Table 23 indicate organisations in the C H A list which were also A C A H O members in the spring of 2001. Due to the active restructuring of health care in Canada over the past few years, the actual names of organisations identified in this list have a relatively short life time.  3.4.2 Survey Administration  Following the decision of the A C A H O ' s Executive Committee, which included the C E O s of six of Canada's largest health care organizations and A C A H O ' s Executive Director, to sponsor the technology management survey, letters were sent to the C E O s of member organizations asking for their organization's participation. A C A H O and the investigator issued requests to the C E O s for the e-mail addresses of their executive teams and their senior management.  92  Table 23  Fifty Technology Intensive Health Care Organisations  Organizations 1 Capital Health Authority (Edmonton) 2 Centre Hospitalier de l'Universite de Montreal 3 Vancouver Hospital and Health Sciences Centre 4 Toronto Hospital 5 Centre Hospitalier Universite de Quebec 6 Capital Health Region (Victoria)  7 Ottawa Civic and General Hospitals 8 Regina Health District 9 Hamilton Health Sciences Corporation 10 Montreal General Hospital 11 Centre Hospitalier Universite de Sherbrooke  Specialty Surgical Technology Intensive Beds Beds Beds 184 439 623 573 38 , 522 560 87 397 484 55 428 483 63  275  338  73 262 103 227 72 ^ 244 35 , 253 iv^2:;S 237  335 330 316 288 269  12 Jewish General Hospital (Montreal)  63  176  239  13 Queen Elizabeth II Health Sciences Centre (Halifax)  22  207  229  14 Centre Univiversitairede Sante de I'Estrie (Sherbrooke)  70  153  223  15 Health Sciences Centre (Winnipeg) ..In .  26  178  204  16 Centre hospitalier Angrignon (Verdun)  16  184  200  17 Providence/St. Paul's Hospital (Vancouver)  40  160  200  18 Simon Fraser Health Region (BC)  52  139  191  19 Kingston General Hospital  53  138  191  20 Royal Victoria Hospital (Montreal)  61  130  191  147 168 117 124 159  187 186 177 174 173  21 St. Michael's Hospital (Toronto) 22 St. Boniface General Hospital (Winnipeg) 23 St. Joseph's Health Centre (London) " 24 Atlantic Health Sciences Corporation (Saint John, NB) 25 The Wellesley Central Hospital (Toronto)  * *-40*fVK? 18 60 50 14  26 Centre Hospitalier affilie Universite de Quebec  24  148  172  27 London Health Sciences Centre (London) 28 St. Joseph's Hospital (Hamilton)  12 43  159 128  171 171  29 Hopital Sainte-Justine (Montreal)  81  90  171  30 Scarborough General Hospital  18  151  169  31 Hopital Charles Le Moyne  16  152  168  32 Hopital de Sacre-Coeur de Montreal  34  131  165  33 Hotel-Dieu Grace Hospital (Windsor) 134, Mount Sinai Hospital (Toronto) 35 South-East Health Care Corporation (Moncton) 36 St. Mary's Hospital Centre (Montreal)  38  122  160  45  115  160  0  149  149  11  137  148  37 Cite de la sante de Laval  12  135  147  38 Sunnybrook Health Sciences Centre (Toronto)  12  130  142  39 Toronto East General and Orthopaedic Hospital Inc.  28  111  139  40 BC's Children's Hospital (Vancouver)  70  66  136  41 Hopital de la Saguenay (Chicoutimi)  24  107  131  42 North York General Hospital Toronto)  27  101  128  43 St. Paul's Hospital of Saskatoon  12  115  127  93  St. Joseph's Health Centre (Toronto) mm 45 Hopital Regional Dr G.L.Dumont (Moncton)  15  99  114  16  98  114  46 Hotel-Dieu de Levis  0  105  105  47 Sudbury General Hospital  12  92  104  48 Centre hospitalier Sainte-Marie  9  92  101  Saskatoon District Health  32  64  96  50 Centre hospitalier de Gatineau  12  80  92  n?  The collection, validation, and correction of e-mail addresses was a considerable undertaking  involving two rounds of messages before the actual survey was  transmitted to all the individuals whose e-mail addresses proofed correct. The webbased survey delivery process was discussed earlier as part of the measurement instrument in section 3.3.2.  Appendix 6 contains the pre-survey announcement to all target individuals as well as the survey cover letters to the Executive Team members (CEOs and VPs) and to senior managers (individuals reporting to VPs). Weekly reminders were e-mailed to participants for four weeks before the survey was closed off.  3.4.3  Statistical Methodology  The Questions To Be Answered  This thesis deals with the phenomenon that organizations should strive for alignment between business strategy and technology strategy. This goal is supported by the academic literature on 'technology management'  and by reports about lessons  learned across a variety of industry sectors and organizations, from nations to departments, as outlined and discussed in the literature review in Chapter 2. Our study  focuses specifically  on  the  state  of  affairs  in  Canadian  health  care  organizations.  94  Conceptually, the way to achieve this alignment is through employment of the construct 'technology management'. But, what does that mean? What does it look like? How do we know when we've got it?  We have already defined the construct by synthesizing previous reported attempts:  'Technology Management' can be defined as holistic and integrated application of engineering, science, and management capabilities to strategic lifecycle management of new and relevant  product and  process technologies in order to shape as well as accomplish the goals and objectives necessary for organizational success.  We have also developed, via literature content analysis, its metric, by identifying its dimensions, its variables, and its indicators, as previously illustrated and restated in Table 24.  Table 24 3 Dimensions 11 Management Variables and 26 indicators  Structure of the Survey Instrument  Strategic Management  1. 2. 3. 4.  Technology Strategy Chief Technology Officer Strategic Knowledge Management Customer Focus  Management of Change and Innovation 5. 6. 7. 8.  Change Management Process Executive Leadership and Communication Integration of the Innovation Chain Human Resource Management  Organizational Management 9.  Organizational Effectiveness and Flexibility 10. Project/Process Management 11. Assessment and Evaluation  The national survey presented this metric for consideration by hundreds of senior managers in the largest Canadian health care organizations and asked them to tell us how important they think each of the indicators are for their organization's success and to what extent their organization has implemented them. Their responses were analyzed to answer the following questions:  95  Is the topic of technology management also important in health care? Do the metrics describing the conceptual construct also apply in health care? Does the metric have to be modified further? To what extent has the construct, its dimensions, variables, and indicators been implemented within and across Canadian health care organizations? Does the metric work as a measurement instrument and can it detect differences within and across organizations? If so, what are those differences and what conclusions can be drawn to improve performance within and across the organizations?  •  •  The Data Set  The data set for statistical analysis was generated by the responses to the webbased survey of senior hospital administrators. Each response consisted of the components listed in Table 25. The statistical analysis was performed on the basis of the gap score variable, resulting in the data set for N=324 responses.  Table 25  Response Variables  Item  Variable Label (value range)  Respondent's area of responsibility: 'patient care' or 'non-patient care'  RC (1 or 2)  Respondent's position: 'executive' or 'non-executive' Respondent's organization: code for each A C A H O member organizations Respondent's rating of the importance of technology management in health care  PC (1 or 2) OC (1 to 40) IMP (1 to 6)  Respondent's rating of the importance (benefit) of each of 26 indicators Respondent's rating of the extent of implementation of the same 26 indicators  B1 - B26 (1 to 6) E1 - E26 (1 to 6)  Investigator's calculation of a 'gap score' based on the difference in respondent's rating of importance and extent of implementation for each indicator  G1 - G26 (0 to 30)  ID 1 2 3 ... 324  RC  PC  OC  IMP  B1-B26  E1-E26  G1-G26  96  Validity  Getting at the question 'Are we measuring what we think we are measuring?', three categories of validity are commonly discussed. These can be based, for example, on a classification prepared by a joint committee of the American Psychological Association, the American Educational Research Association, and the National Council on Measurement Used in Education (Kerlinger 1986). Of the various categories, a)face,  b)content, c)criterion, d)concurrent, and e)construct validity,  construct validity has been identified as probably the most important form of validity from the scientific research point of view (Kerlinger 1986) (Robson 1993). It may also be the most frequently applied validity measure (Streiner, Norman, Blum 1989),  The literature seems to support Lewis' interpretation  of an approach to the  evaluation of validity. The approach has also been employed in this case. Content validity was optimized through the iterative process in which the instrument was developed. Content analysis informed the measurement instrument and expert opinions in pilot and field test stages refined the instrument  Construct validity addresses the issue whether the measure reflects true dimension of the concept or if it is influenced simply by, say, the methodology. Construct validity was tackled through factorial validity assessment. Based on numerous references, Lewis points out that 'the appearance of logical factors is one indication of construct validity for a measure' and that 'examining the components that make up the overall measure is a legitimate method for assessing one aspect of construct validity'. (Lewis 1996). Exploratory factor analysis is discussed in more detail in section Several studies in the management information systems area have utilized factor analysis to examine scale validation (Lewis 1996).  Concurrent validity was assessed informally through a comparison of related results from an independent, completely separate analysis of organizational performance (Hay Group study described in section 4.6).  Several of the A C A H O  member  97  organizations had previously commissioned a benchmark study of clinical and operational performance. The confidential results were made available for the purpose of a comparison with results from this national survey.  In summary, validity was established by  •  The instrument development (face/content validity)  process was  supported by the  literature  •  Refinements were made based on initial faculty suggestions and on comments and suggestions received in the two-stage pilot-test (content validity)  •  The field-test stage tackled content as well as comprehensibility, understandability, clarity, and structure of the survey instrument.  • •  Construct validity was addressed through a factor analysis of all responses. A comparison was undertaken with a performance review of the same institutions using a completely different metric and conducted completely independently.(concurrent validity)  Reliability  A variety of methods are reported for arriving at reasonable judgement about reliability, such as test-retest reliability, cross-test reliability, intra-item or intra-test reliability, and inter-rater reliability. A common definition of reliability incorporates the terms of stability, repeatability, accuracy, dependability, and predictability. (Ellis, 1994; Kerlinger, 1986).  It can also be defined as the relative absence of errors of measurement in a measuring instrument, particularly in the items on a scale. (Kerlinger 1986). Such internal consistency is commonly measured by coefficient alpha. A large alpha indicates a close relationship between the instrument scale and the true score (Lewis  1996). Internal consistency of a test  means that the test  items  are  homogeneous. The common idea underlying both, the test-retest interpretation of reliability and the internal consistency interpretation, is accuracy (Kerlinger 1986).  98  The internal consistency coefficient, Cronbach's alpha coefficient, was computed via S P S S . It was applied to each of the dimensions resulting from the factor analysis. An alpha of .8 is desirable (Lewis, 1993)  According to S P S S F A Q (  on the  Internet, the coefficient of reliability (consistency) 'Cronbach's alpha measures how well a set of items (or variables) measures a single unidimensional latent construct'. Cronbach's alpha can be written as a function of the number of test items AND the average inter-correlation among the items:  a = (N.r)/(1 + ( N - 1 ) » r  where N is equal to the number of items and r is the average inter-item correlation among the items. If N increases, Cronbach's alpha increases. If the average interitem correlation is low, alpha will be low. High inter-item  correlation provides  evidence 'that the items are measuring the same underlying construct'.  Factor Analysis  The first major analytical method applied to the data was factor analysis, a type of multivariate statistic. 'Factor Analysis refers to a set of procedures that can be applied to a set of data for the purpose of identifying variables that reflect some common underlying factor or dimension. It is able to detect common patterns in the way subjects respond to questions' (Ellis 1994). In addition to exploring the data for patterns, it can be used to confirm hypotheses, or reduce the number of variables to be more manageable (Norman & Streiner, 1986)  Factor Analysis is essentially a mathematical process that requires knowledgeable interpretation of the character of resulting factors on which the variables 'load', meaning that the variable correlates with all other variables connected with the factor in question. Results are displayed in a factor matrix, 'a table of coefficients that  99  expresses the relations between the variables and the underlying factors' (Kerlinger 1986). The analysis applied in this thesis is referred to as Principle Factors Method plus Varimax rotation. The process involves iterative positioning of multi-dimensional set of co-ordinates, rotated to account for as much of the variance of the variables as possible. Each axis relates to a factor. The number of factors depends on the coordinates of the test results. Those that are 'bunched' around the axis are said to be loaded on the corresponding factor and are thus correlated with each other.  In this study, factor analysis is used to assess construct validity as well as to refine the technology management model.  Testing for Differences between Clusters of Respondents  The key clusters of respondents were those associated with individual organizations. Their responses were analyzed to identify systemic differences in the technology management practices of different organizations. Analysis of Variance (ANOVA) was applied for this purpose. It assumed that respondents from within each organization could be treated as one cluster. However, field test analysis was inconclusive on this question due to limited sample size. It suggested the need to investigate  the  possibility that senior managers with direct patient care responsibilities responded significantly  differently  from  those  that  did  not  have  direct  patient  care  responsibilities. As well, it seemed prudent to explore if executive team members (VPs, C E O s ) would respond differently from those senior managers reporting to VPs.  As noted in Table 28, two separate t-tests for equality of means were used to test for these possibilities. Respondents were asked to identify themselves as having directpatient care responsibility or not, as well as if they were members of the executive team or not. The tests were performed on the total population of respondents.  100  Differences between organizations were examined through A N O V A , a multivariate tool to test for comparing means that permits comparison of several means simultaneously  (Ellis, 1994). It is a method of 'identifying, breaking down, and  testing for statistical significance variances that come from different sources of variation', such as variance due to experimental treatment, error, or other causes (Kerlinger, 1986). Essentially, A N O V A calculates the ratio of between-group variance (experimental variance) over the within-group variances (chance variance).  Cluster Analysis of Organizations Another multivariate analysis employed in this thesis was cluster analysis. This technique 'seeks to organize information about variable responses such that relatively homogeneous groups, or "clusters" of respondents, can be formed'. There are similarities between  members within clusters (internally  homogenous), but  members are not like members of other cluster (externally heterogeneous). The following web-site speaks to 'cluster analysis':  trochim.human.Cornell, edu/tutorial/flynn/cluster.htm.  The site recommends the following basic steps:  •  data collection and selection of the variables for analysis  •  generation of a similarity matrix  •  decision about number of clusters and interpretation  •  validation of cluster solution.  According  to  SPSS  (  Cluster  Analysis, also called segmentation analysis or taxonomy analysis, is similar in purpose to Q-mode factor analysis ~ both seek to identify homogenous subgroups of cases in a population. That is, cluster analysis seeks to identify a set of groups which both minimize within-group variation and maximize between-group variation'.  101  The similarity or distance matrix is a table 'in which both the rows and columns are the units of analysis and the cell entries are a measure of similarity or distance for any pair of cases' (SPSS). The process involves a variety of similarity measures, including Euclidian distance, K-means cluster analysis, correlation between cases, binary matching, and others.  In this thesis, cluster analysis was used to group 'like' hospital organizations ('like' based on indicator gap scores) to optimize the comparison and identification of differing technology management practices and capabilities.  Summary of Chapter 3  The research methodology and strategy  described in Chapter 3 employs an  established metrics development approach and is modeled roughly on a similar study about the 'Information Resource Management' construct. A definition and a model of the 'Technology Management'  construct are established via literature  content analysis. The model consists of dimensions, variables, and indicators, from which a measurement instrument is designed. The instrument is administered as web-based survey and is refined via a two-stage Delphi approach at a pilot stage. The refined instrument and a gap score analysis are subjected to field-testing. Chapter 3 describes the target audience selection and the survey administration of the national survey. Chapter 3 ends with a discussion of the statistical methodology applied to the national survey results. The results of the national survey of senior administrators of Canadian teaching hospitals and the analysis of the survey results are covered in Chapter 4.  102  CHAPTER 4 RESEARCH RESULTS  So far in this thesis it has been established that private sector organizations in various industries need to manage technology as a strategic resource. It has been shown that there seems to be growing awareness that technology management is also important in health care and in the public sector in general.  A general model of the technology management construct has been developed, including definition and attributes. In order to establish if the model could also apply in health care, a survey instrument was developed and a sample population of technology intensive organizations has been identified. The administration of the instrument to the sample population has been discussed and described. The statistical analysis methods employed in Chapter 4 have been discussed in the previous chapter.  Chapter 4 represents Phase IV of the overall research strategy of this thesis. It describes the results of the national survey and presents their statistical analysis, as well as the results of validity and reliability examination. Chapter 4,  therefore  addresses the primary questions of this thesis: Does the general technology management model apply to Canadian teaching hospitals, and to what extent has it been implemented?  4.1  SURVEY RESPONSES  The 33 A C A H O member organizations listed in Table 26 were invited to participate in this project. The offices of the C E O s of the 33 A C A H O member organizations invested considerable energy in putting these lists together and still it required several iterations to establish accurate information. In the end, approximately 850 individuals in 28 organizations received the survey and 324 responded, representing an average response rate of approximately 38% per participating institution with a  103  range of 24% to 58%. In his IRM study of Fortune 1000 companies, Lewis (1993) achieved a 32% response rate through two mailings of the survey.  Table 26  Organizations Invited to Participate  Baycrest Centre for Geriatric Care, Toronto  Calgary Health Authority  Capital Health Authority, Victoria  Centre Hospitalier Universite de Sherbrooke  Centre Hospitalier Universite de Quebec  B C ' s Children's and Women's Health Centre  Hamilton Health Sciences Corporation  Healthcare Corporation of St. John's  Hotel Dieu Hospital, Kingston  Institut de cardiologie. de l'Universite Laval  Institut universitaire de geriatrie de Montreal  Kingston General Hospital  London Health Sciences Centre  McGill University Health Centre, Montreal  Mount Sinai Hospital, Toronto  Ottawa Hospital  Providence/St.Paul's Hospitals, Vancouver  Queen Elizabeth II Hospital, Toronto  Saskatoon District Health Board  Regina Health District  Sherbrooke Geriatric University Institute  St. Boniface General Hospital, Winnipeg  St. John - Region 2 Hospital Corporation  St. Joseph's Hospital and Health Centre, Toronto  St. Joseph's Hospital, Hamilton  St. Michael's Hospital, Toronto  Sunnybrook Health Sciences Corporation  The Grace-1 WK Hospital, Halifax  The Hospital for Sick Children, Toronto  Toronto Rehab Institute  University Health Network, Toronto  Vancouver Regional Health Board/Vancouver Hospital and Health Sciences Centre  Winnipeg Health Sciences Centre  To protect their confidentiality, the organizations were assigned an organization code between 1 and 33, by which they will be identified for the remainder of the discussion. Table 27 presents an overview of responses and response rates.  For example, organization 1 submitted 37 responses, reflecting a 33% response rate relative to the number of senior managers who received the survey. Of the 37 respondents, six executive members had patient care responsibilities (VP Nursing, V P Medicine, etc.) and seven did not (VP Finance, V P Support Services, etc.). Of  104  the responding managers reporting to V P s , eight had patient care responsibilities and fifteen did not. Table 27  Response Analysis  Organization Code  Number of Responses  Response Rate %  1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24-33  37 25 24 19 18 18 18 17 15 15 14 13 15 11 10 9 9 8 7 5 4 3 3 8 324  33 53 41 34 42 30 55 30 56 45 58 30 45 28 26 41 41 27 24 25 27 38 25 30  Total  Twenty  organizations  submitted  Executives Patient Not Patient Care Care 7 4 3 6 2 3 2 1 3 2 6 3 2 4 3 3 3 2 1 2 3 3 2 5 74  6 3 3 4 6 2 2 2 1 1 0 4 1 0 2 1 0 0 0 2 0 0 1 2 43  more  than  five  Managers Patient Not Patient Care Care 8 7 10 3 3 5 6 13 9 7 2 4 8 4 4 4 4 4 4 0 1 0 0 0 110  responses. The  15 11 8 6 7 8 8 1 2 5 5 2 4 3 1 1 2 2 2 1 0 0 0 1 97  number  of  responses was a composite result of the fact that some organizations chose not to participate (i.e. no e-mail addresses were provided by the C E O ) , the number of emails provided was limited in some cases (e.g. it included only executive team members), or that staff chose not to respond as in the case of Quebec institutions (comments indicating that language was an issue).  The respondents were first asked to rate the importance of the topic of the survey ( 1 - 'not at all', 2 - 'very little', 3 - 'little', 4 - 'some', 5 -'great', and 6 - 'very great'). A s  105  indicated in Figure 6, 317/324 = 98%  rated the topic's importance as great or very  great. No respondent rated the importance at less than 4 (some) on the 1-6 rating scale.  Figure 7  T o p i c Importance Rating  topic importance rating  250  -220~ 97  0 1  0 2  0  7  3  4  5  6  rating Bimportance rating  Figure 8  R e s p o n s e Pattern for Q u e s t i o n 1  t y p i c a l r e s p o n s e pattern ( q u e s t i o n 1)  250 200  o  c  150  CO 3 CT O  100 50 0 Ibenefit  _  -D-D  rating  implementation  rating  48  12 73 134 rating  115 53  1 94 14  A typical response pattern (question 1 asks for indicator 1 rating) is shown in Figure 7 with the frequency distribution for the associated gap scores shown in Figure 8 indicating approximately  normal distribution of the  gap scores.  Readers  are  106  reminded that respondents were asked to rate the benefit (B) and the extend of implementation (E) of each of the 26 indicators in the survey, and that gap scores (GS) were calculated as G S = (6 - E) x B. Figure 9  typical 140  G a p S c o r e distribution for Q u e s t i o n 1  gap s c o r e  distribution  (question  i  1)  — —  120  • i i  1 00  H  0-5  5.1-10  10.1-15  15.1-20  20.1-25  25.1-30  gap scores  Senior managers in the system on average rated the benefit for each indicator between 5 and 6 as shown in Figure 9. Figure 10  1  2  3  4  5  6  7  Mean Benefit Rating for E a c h Indicator  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  indicators  • avg. benefit rating  • std. deviation  107  These results can be interpreted as a validation of the attributes extracted from the literature. It validates them generally, but more importantly it indicates that these attributes are perceived to apply similarly in health care. On a relative basis and with good agreement, indicators 1, 2, 10, 11, 12, and 17 received the highest average benefit ratings on the survey, corresponding to:  1 the technology strategy is aligned with the business strategy. (s.d.= .65) Clearly documented technology vision, strategy, plans, and policies are both shaping and supporting the strategic goals and objectives of the organization. Technology plans and business plans are cross-referenced and identify technology as a strategic resource.  2 key technologies are supported by necessary infrastructure. (s.d.= .77) These are clearly identified core technologies that impact on such critical business factors as costs, quality, outcomes, flexibility, timely response, customer service, and reputation. They are receiving strong technical and intellectual support.  10 the organization's senior management team actively participates in change and innovation. (s.d.= .69) Their role in managing, leading, supporting, and monitoring change and innovation is incorporated in an explicit and defined change process covering incremental change (cqi or other), as well as more radical change (introduction of new technology).  11 a corporate learning culture supports a diverse technological knowledge base and long-term experimentation. (s.d.= .61) The learning culture is characterized by mutual trust, sharing of ideas, personal commitment, team and entrepreneurial spirit, a willingness to take risks, education and training, synergy, and the prevalence of systematic/critical thinking over fragmented/sporadic thinking.  12 senior management frequently promotes the vision and strategic direction of the organization. (s.d.= .68) This communication occurs throughout all stages of organizational change according to the communication plan, such as during exploration, strategic planning, initiation, and implementation.  17 human resource development and planning are identified as key to technological capability building. (s.d.= .72) A human resource strategy covers recruitment and retention of people with the necessary skills, the identification and tracking of leading edge talent with high expertise and technical excellence, as well as provision of access to appropriate professional development, training, and education.  Recognizing that there may be significant differences between organizations, it is interesting to note in Figure 11 that implementation ratings are lower than benefit ratings, as expected, and variances are higher. Significantly, across system variation (standard deviation) in responses was greatest for indicators 3 and 4, both dealing with the need for executive level Chief Technology Officer (CTO) responsibilities. This signifies considerable implementation differences between organizations.  108  Figure 11  Mean Implementation Rating for E a c h Indicator  Figure 12  1  2  3  4  5  6  7  8  I  9  Mean G a p Score for E a c h Indicator  10  11  12  13  l£fvq.gapsocres  14  15  16  17  18  19  20  21  22  23  24  25  26  • standard deviafori  According to Figures 11 and 12 above, while not providing information about the differences between better or worse performing organizations, the three key areas for improvement on a national scale are indicators 8, 26, and 19. They received the lowest implementation ratings, resulting in the highest gap scores. It is again apparent that variations in gap scores for the C T O indicators, 3 and 4, are clearly greater than for other indicators. This is driven largely by the variations in perceived  109  extent of implementation. Following are the descriptions for the above mentioned indicators, 8, 26, and 19 in decreasing order of their gap scores.  19 the organization has strategies to respond flexibly and rapidly to technological change. Development times, innovation cycles, and overall cycle times to put ideas and innovations into practice are short in relation to industry norms.  26 the organization's performance as a function of technology management activities is routinely evaluated and benchmarked. All aspects of the technology management system covered by this survey are subject to systematic performance reviews against targets and in terms of their impact on overall organizational goals, objectives, and customer service. This includes annual performance evaluations of the executive member fulfilling the eto role.  8 technology is linked to clearly identified customer needs and priorities. There is ongoing access to information from timely customer and staff surveys about current and future needs and priorities of customers. The organization responds quickly and emphasizes 'market pull' rather than 'technology push' strategies as part of a customer relation policy.  Table 28 lists all 26 indicators rank ordered by mean national gap score and provides descriptive statistics for their benefit and implementation ratings as well as for their resulting gap score. The mean gap scores (over N=324) for the 26 indicators range from a low of 8.4 to a high of 14.66 as depicted in Figure 13. Figure 13  Mean G a p S c o r e s  G A P SCORE FOR 26 INDICATORS (averaged over 324 reposnses) 16 14 12 10 -  cs  8 • 6 42012  10  7  22  9  4  11  14  16  24  3  6  5  17  20  1  13  2  21  25  15  18  23  8  26  19  ™ " mean gap score  110  Table 28  Descriptive Statistics for all Indicators  12 Senior m a n a g e m e n t  promotes  E (Implementation) ci  c 2  co  Mean  c  s  G (Gap Score) Max  b co  Mean  Max  c 2  Mean  B (Benefit)  Max  Abbreviated Indicators  ri co  1  6  5.56  0.68  1  6  4.46  1.04  0  30  8.40  5.68  2  6  5.52  0.69  1  6  4.28  1.04  0  30  9.40  5.73  1  6  5.09  1.03  1  6  4.04  1.30  0  30  9.48  6.55  1  6  5.40  0.72  1  6  4.01  1.05  0  30  10.64  5.83  Line m a n a g e r s r e s p o n s i b l e for customer service  1  6  5.37  0.82  1  6  3.94  1.12  0  30  10.94  6.24  Executive m e m b e r  1  6  5.28  0.93  1  6  3.82  1.54  0  30  11.06  8.03  2  6  5.63  0.61  1  6  4.02  1.07  0  30  11.08  6.08  14 C o m m u n i c a t i o n s y s t e m promotes technology  2  6  5.37  0.69  1  6  3.92  1.15  0  30  11.08  6.23  16 T e c h n o l o g y diffusion/transfer encouraged  2  6  5.23  0.73  1  6  3.85  1.08  0  30  11.12  5.78  24 E v a l u a t e s / a s s e s s e s technology-  1  6  5.30  0.81  1  6  3.85  1.03  0  30  11.22  5.45  organizational vision/direction 10 S e n i o r m a n a g e m e n t participates in c h a n g e 7  management  Organization protects intellectual property  22 Organization u s e s s o u n d project/process m a n a g e m e n t 9 4  a d m i n i s t e r s / m a n a g e s technology strategy 11 Corporate learning culture prevails  related risks 3  Executive m e m b e r formulates technology strategy  1  6  5.25  0.92  1  6  3.73  1.62  0  30  11.39  8.27  6  Environmental factors re technology strategy identified  2  6  5.01  0.86  1  6  3.58  1.13  0  30  11.89  5.77  5  Vision re technology through routine s c a n n i n g  1  6  5.29  0.78  1  6  3.70  1.08  0  30  12.17  6.17  17 H R development/planning key to technology capability  2  6  5.57  0.72  1  6  3.79  1.07  0  30  12.27  6.11  20 Organizational design u s e s multi-  1  6  5.14  0.89  1  6  3.52  1.18  0  30  12.56  6.35  2  6  5.54  0.65  1  6  3.71  1.06  0  30  12.63  5.99  13 Performance m a n a g e m e n t b a s e d o n customer satisfaction  1  6  5.32  0.83  1  6  3.56  1.22  0  30  12.76  6.65  21 Skilled e m p l o y e e s , s e e k  1  6  5.30  0.76  1  6  3.56  1.15  0  30  12.77  6.30  K e y technology supported by infrastructure  1  6  5.50  0.77  1  6  3.66  1.01  0  30  12.77  5.82  25 T e c h n o l o g y a s s e s s m e n t informs  1  6  5.16  0.82  1  6  3.44  1.03  0  30  13.07  5.49  1  6  5.30  0.78  1  6  3.52  1.05  0  30  13.09  5.82  1  6  5.37  0.83  1  6  3.52  1.21  0  30  13.22  6.77  2  6  5.21  0.85  1  6  3.41  1.06  0  30  13.33  5.88  1  6  5.26  0.83  1  6  3.33  1.09  0  30  13.94  6.06  1  6  5.15  0.90  1  6  3.15  1.22  0  30  14.44  6.53  1  6  5.17  0.86  1  6  3.16  1.15  0  30  14.66  6.45  functional teams 1  Technology and business strategies aligned  innovative opportunities 2  technology decisions 15 Innovation s y s t e m integrates R&D/operations 18 A c c o m p l i s h m e n t s formally recognized 23 T e c h n o l o g y lifecycle 8  systematically m a n a g e d T e c h n o l o g y linked to customer needs  26 Performance d u e to technology m a n a g e m e n t evaluated 19 Organizational strategies to r e s p o n d to c h a n g e  Considering all 324 responses from senior managers, the data in Table 29 indicates the five technology management variables requiring the least and most attention  in  across the system. Table 29  Indicators Requiring Least and Most Attention  Indicators Requiring Least Attention  Gap Score  Senior management promotes organizational vision/direction  8.4  Senior management participates in change management  9.4  Organization protects intellectual property  9.48  Organization uses sound project/process management  10.64  Line managers responsible for customer service  10.94  Indicators Requiring Most Attention Accomplishments formally recognized  13.22  Technical lifecycle systematically managed  13.33  Technology linked to customer needs  13.94  Performance due to technology management evaluated  14.44  Organization has strategies to respond to change  14.66  It is interesting to note that the top and bottom three indicators (bold, italic) are the same as in the field test, confirming the robustness of the results and the instrument. Of course, as demonstrated in the field test, individual organizations may perform quite differently within the overall range.  4.2  TESTING THE MODEL USING FACTOR ANALYSIS  Table 30 restates the model presented to the respondents. It consisted of three dimensions, 11 variables, and 26 indicators. Would factor analysis of the actual responses support a three dimension model and what would be its structure? Two rounds of factor analysis were performed. The first round identified the number of underlying factors (or 'latent variables') on which the 26 indicators 'loaded'. The second round was performed seperately on each factor to assess if there were additional factors to be considered. There did not seem to be a strong reason to change the titles of the three factors from the dimension titles in the model.  112  Table 30  Summary of the Model  A) Strategic Management  B) Management of Change and Innovation  C) Organizational Management  Technology Strategy  Change Management Process  Organizational Effectiveness and Flexibility  10.  19.  1.  Technology and business strategies aligned  2.  K e y technology supported by infrastructure  Chief Technology Officer 3.  Executive m e m b e r fornulates technology strategy  4.  Executive m e m b e r a d m i n i s t e r s / m a n a g e s technology  11.  5. 6.  Vision re technology through routine s c a n n i n g Environmental factors re  technology strategy identified 7. Organization protects intellectual property  Corporate learning culture  Executive Leadership and Communication 12.  Senior m a n a g e m e n t promotes organizational vision/direction  13.  Performance m a n a g e m e n t C o m m u n i c a t i o n system  Integration of the Innovation Chain Innovation s y s t e m integrates R&D/operations  Customer Focus  16.  8.  T e c h n o l o g y diffusion/transfer encouraged  Human Resource Management  needs 9.  Line m a n a g e r s responsible for customer service  17.  Organizational d e s i g n u s e s multi-functional teams  21.  Skilled e m p l o y e e s s e e k innovative opportunities  Project/Process Management 22.  Organization u s e s sound project/process m a n a g e m e n t  23.  promotes technology  15.  T e c h n o l o g y linked to customer  20.  b a s e d o n customer satisfaction 14.  Organizational strategies to r e s p o n d to c h a n g e  prevails  strategy  Strategic Knowledge Management  Senior m a n a g e m e n t participates in c h a n g e management  T e c h n o l o g y lifecycle systematically m a n a g e d  Assessment and Evaluation 24.  T e c h n o l o g y related risks evaluated  25.  T e c h n o l o g y a s s e s s m e n t informs technology decisions  26.  P e r f o r m a n c e d u e to technology management  evaluated  H R dev./planning key to tech capability  18.  A c c o m p l i s h m e n t s formally recognized  As displayed in Table 31, below, factor analysis of the 324 responses largely confirmed the model but suggested some modifications in the  distribution of  indicators. The analysis demonstrated that the 26 indicators loaded on three factors, such that: Indicators 9,10,11,12,13,14,15, 17,18,19,20,21 loaded on one factor (management of change and innovation), indicators 2,16,22,23,24,25,26 loaded on another, (organizational management) indicators 1,3,4,5,6,8 loaded on a third factor. (strategic management)  The indicators 20, 19. 14, 16, 6, 1, 5, and 8 did not load clearly on any of the factors. Indicator 7 did not load strongly on any of the three factors and was dropped from  113  the model. When correlation factors are about the same for different factors, a logical choice can be made. There did not to be a sufficient reason to change the name of the three dimensions, which closely resembled the three factors indicated by the analysis. Indicators 1,6, and 8 were attached to the Strategic Management dimension,  while  indicators  16  was  added  to  Organizational  Management  dimension. Table 31  Factor Analysis  Rotated Component Matrix 12 11  Senior management promotes organizational vision/dir. Corporate learning culture prevails  10  Senior management participates in change management  18  Accomplishments formally recognized  21  Skilled employees seek innovative opportunities  9  Line managers responsible for customer service  15  Innovation system integrates R&D/operations  13  Performance management based on customer satisfaction  17  HR development/planning key to technology capability  20  Organizational design uses multi-functional teams  19  Organizational strategies to respond to change  Item Factors Loading 1 0.71 0.70 0.69 0.64 0.60 0.60 0.59 0.58 0.56 0.54 0.50 0.49  14  Communication system promotes technology  23  Technology lifecycle systematically managed  24  Evaluates/assesses tech-related risks  25  Technology assessment informs technology decisions  0.33  22  Organization uses sound project/process management  2  0.36  Key technology supported by infrastructure  26  Performance due to technology management evaluated  0.34  16  Technology diffusion/transfer encouraged  0.46  2  0.41 0.45 0.30 0.35 0.40 0.46 0.53  0.73 0.66 0.63 0.61 0.59 0.59 0.58  6  Environmental factors re technology strategy identified  1  0.54  Technology and business strategies aligned  0.52  5  Vision re technology through routine scanning  8  Technology linked to customer needs  3  Executive member formulates technology strategy  4  Exec, member administers/manages technology strategy  7  Organization protects intellectual property  0.52 0.32  3  0.40  0.38  0.49 0.42 0.54 0.39 0.87 0.89  0.32  Extraction Method: Principal Component Analysis. Rotation Method: Varimax with Kaiser Normalization. Rotation converged in 7 iterations.  This distribution was further confirmed by individual factor analysis of the above three groupings, in that all indicators in the group loaded strongly on one factor only.  114  The three factors corresponded to the three dimensions of the model, as indicated in Table 32, following. It shows fairly high correlation coefficient within each dimension. Table 32  Individual Factor Analysis  Component Matrix  Item Factor Loading  Grouping  Executive member administers/manages technology strategy Vision re technology through routine scanning Executive member formulates technology strategy  0.82  Strategic Management  0.76  1  Environmental factors re technology strategy identified Technology and business strategies aligned  8  Technology linked to customer needs  0.65  11 14  Corporate learning culture prevails Communication system promotes technology  0.75 0.74  15 21  Innovation system integrates R&D/operations Skilled employees seek innovative opportunities  0.74 0.73  17  HR development/planning key to technology capability  0.72  20 19  Organizational design uses multi-functional teams Organizational strategies to respond to change  0.70 0.70  12  Senior management promotes organizational vision/direction  0.70  18 10  Accomplishments formally recognized Senior management participates in change management Performance management based on customer satisfaction  0.69 0.68  Indie  o co  4 5 3 6  13 9  Line managers responsible for customer service  0.79 0.78  0.66  0.67 0.61  23  Technology lifecycle systematically managed  0.79  26  0.78  25  Performance due to technology management evaluated Technology assessment informs technology decisions  16  Technology diffusion/transfer encouraged  0.74  24 22  Evaluates/assesses technology-related risks Organization uses sound project/process management Key technology supported by infrastructure  0.74 0.71  2  Change Management  Organizational Management  0.77  0.61  The revised model is presented in Table 33. For comparison purposes with the model displayed in Table 30, the original numbering of variables has been maintained in the new model.  115  Table 33  Revised Model of Indicators  A) Strategic Management  B) Management of change and Innovation  Technology Strategy  Customer Focus  1. T e c h a n d b u s i n e s s strategies aligned  Effectiveness and Flexibility  9.  2.  9. T e c h n o l o g y linked to customer needs  13. P e r f o r m a n c e m a n a g e m e n t b a s e d  Chief Technology Officer  Change Management  3. Executive m e m b e r formulates technology strategy  Operations Management  10. S e n i o r m a n a g e m e n t participates in c h a n g e m a n a g e m e n t  22. Organization u s e s s o u n d  4. Executive m e m b e r a d m i n i s t e r s / m a n a g e s technology strategy  11. C o r p o r a t e learning culture prevails  23. T e c h n o l o g y lifecycle systematically m a n a g e d  Knowledge Management 5. V i s i o n re technology through routine s c a n n i n g 6. Environmental factors re technology strategy identified  Line m a n a g e r s responsible for customer service  C) Organizational Management K e y technology supported by infrastructure 16. T e c h n o l o g y diffusion/transfer  o n customer satisfaction  encouraged  12. Senior m a n a g e m e n t promotes organizational vision/direction 19. Organization h a s strategy to r e s p o n d to c h a n g e  Integration of Innovation Chain 14. C o m m u n i c a t i o n s y s t e m promotes  project/process m a n a g e m e n t  Assessment and Evaluation 24. T e c h n o l o g y related risks evaluated 25. T e c h n o l o g y a s s e s s m e n t informs technology decisions 26.  P e r f o r m a n c e d u e to technology m a n a g e m e n t evaluated  technology 15. Innovation s y s t e m integrates R&D/operations 20. Organizational design u s e s multifunctional teams  Human Resource Management 17. H R development/planning key to technology capability 18. A c c o m p l i s h m e n t s formally recognized 21. Skilled E m p l o y e e s s e e k innovative opportunities  With the finding that the indicators load clearly on the three dimensions, it was no longer necessary to treat the indicators individually for further analysis. The three dimensions became the new main variables. The descriptive statistics in Table 34 describe the three adjusted dimension variables according to the revised model. The mean gap score for each dimension is listed, as well as minimum, maximum, and standard deviation.  Table 34  Descriptive Statistics for the Three Dimensions N  Minimum  Maximum  Mean  SD  Strategic Management  324  0.67  28  12.18  5.04  Management of Change and Innovation  324  0.1  26.5  11.34  4.34  Organizational Management  324  0.33  27.56  12.83  4.31  Overall Score  324  0.32  24.72  12.08  4.04  116  4.3  TESTING FOR DIFFERENCES BETWEEN CATEGORIES OF RESPONDENTS  The new dimension variables were used to test for significant differences between the responses of the various categories of respondents. This was necessary in order to establish if all responses from individual organizations could be treated as coming from the same population for the purpose of organizational comparisons. Field-testing  raised  the  possibility  that  there  were  potentially  perceptional  differences between these subgroups. The t-tests for Table 36 were conducted in order to see if one could collapse over area of responsibility and position. The total population of 324 responses broke down as follows: Table 35  Breakdown of Responses  Non Patient Care  Patient Care  Total  74 97 171  43 110 153  117 207  Executive Non-executive Total  Using T-Test for testing for significant differences in responses yields the results shown in Table 36. The resulting p-values indicated no significant differences in gap scores between the categories of respondents. This meant that all responses from the same organization can be grouped for the purpose of testing for significant differences between organizations.  Table 36  T-Test for Significant Differences between Managers  Group Statistics Area of Responsibility Strategic Management Mgmt. of Change & Innovation Organizational Management Overall Score  N  Mean  S.D.  Non-patient care  171  11.74  5.22  Patient care  153 171  12.68  4.80  Non-patient care  11.13  4.08  Patient care  153  11.57  4.62  Non-patient care Patient care  171  12.68  4.47  153  13.00  4.13  Non-patient care  171  11.83  4.06  Patient care  153  12.35  4.02  P 0.09 0.37 0.50 0.25  117  Group Statistics Strategic Management  Position  N  Mean  S.D.  Executive  117  12.04  5.31  P 0.71  Non-executive  207  12.26  4.89  Mgmt. of Change & Innovation  Executive Non-executive  117 207  11.60 11.19  4.50 4.25  0.42  Organizational Management  Executive  117  13.20  4.65  0.25  207  12.62  Overall Score  Non-executive Executive  117  12.28  4.10 4.27  0.50  Non-executive  207  11.96  3.92  4.3  TESTING FOR DIFFERENCES BETWEEN ORGANISATIONS  One of the key questions to be answered by this research was the ability of the measurement instrument to differentiate  between organizations relative to their  technology management approach. The twenty organizations that supplied five or more responses were included in this part of the analysis, as shown in Table 37. Based on A N O V A and the resulting p-values, it can be shown that there are significant differences  in the  way  in which senior managers  across the  20  organizations perceive the state of technology management in their organization.  Table 37  ANOVA for Significant Differences between Organizations  Descriptive Statistics Mean  S.D.  P  Strategic Management  20  N  Minimum Maximum 7.13  20.57  12.34  3.03  .000  Mgmt. of Change & Innovation Organizational Management  20 20  7.84 9.93  16.64 19.38  11.69 13.23  2.19 2.34  .000 .000  Overall Score  20  9.35  18.57  12.40  2.32  .000  Cluster Analysis It remained to be determined, if the organizations clustered around similar mean gap scores for each of the three dimensions. Cluster analysis of the 20 organizations with more than five responses yielded a practical three-cluster solution:  • • •  Cluster 1: Organizations 1, 2, 3, 5, 6, 7, 9, 11, 13, 14, 17, 18, 19 Cluster 2: Organizations 4 , 8 , 1 0 , 1 2 , 1 6 Cluster 3: Organizations 15, 20  118  These results imply that minimum within-group variation is present among the organizations within each cluster, while between-group variation is maximized. It is, therefore, appropriate to group the responses received from the organizations in the same cluster for the purpose of determining mean cluster gap scores.  Testing for significant differences between these clusters indicates that there is a statistically significant difference between the mean gap scores of these clusters of hospitals for each of the three dimension variables. Since cluster 3 consists of only two institutions with comparatively fewer responses, further comparative analysis was focused particularly on the differences between clusters 1 and 2, as shown in Table 38, below. Table 38  T-Test for Significant Differences between Clusters 1 and 2  Group Statistics clusters  N  S.D.  P  1  13  12.90  1.11  .000  2  5  8.64  1.56  Strategic Management Mgmt. of Change & Innovation Organizational Management Overall Score  Mean  1  13  11.97  1.32  2  5  9.28  0.98  1  13  13.37  1.09  2  5  10.76  0.71  1  13  12.70  0.96  2  5  9.66  0.38  .001 .000 .000  Statistical analysis confirms (p=0) that significant differences exist with respect to mean gap scores between cluster 1 and cluster 2 hospitals. Furthermore, the average  gap  scores  for each and  every  indicator are  lower  for  cluster 2  organizations, as illustrated in Table 39, following.  119  Table 39 Indicator 7 22 10 9 25 17 8 2 14 21 20 23 15 24 6 19 11 18 16 1 13 12 5 26 4 3  Gap Score Differences between Clusters 1 and 2  % Difference Difference 6.54 0.61 7.50 0.80 13.15 1.24 13.53 1.53 14.26 1.89 15.85 2.00 16.03 2.34 16.17 2.15 17.58 2.83 17.72 2.33 18.50 2.36 18.57 2.58 18.82 2.59 19.00 2.20 20.66 2.49 21.48 3.27 21.77 2.54 24.38 3.34 25.28 2.94 28.98 3.93 28.98 4.02 29.89 2.69 31.37 3.98 4.86 31.52 48.15 5.71 56.42 7.29  Cluster 1 9.33 10.73 9.43 11.31 13.25 12.62 14.60 13 30 11.55 13.15 12.76 13.89 13.76 11.58 12.05 15.22 11 67 13.70 11.63 13.56 13.87 9.00 12.59 15.42 11.87 12.92  Cluster 2 8.73 9.93 8.19 9.77 11.36 10.62 12.26 11.15 8.72 10.81 10.39 11.31 11.16 9.38 9.56 11.95 9.13 10.36 8.69 9.63 9.85 6.31 8 61 10.55 6.15 5.62  The significant differences between the two clusters of organizations, as per the perception of their senior managers, are influenced more by some variables than others. Table 39 lists the 26 variables in the survey in the order of the percent difference between cluster 1 and 2 mean gap scores. Percent differences range from 6.54 to 56.62 %. The two indicators 3 and 4 with the highest percent difference were also the ones with the highest variability on a national basis.  So what constituted the major difference between the two clusters in the eyes of their senior managers? Cluster 2 managers rated their organization very highly (low gap score) in the following three areas: • • •  Indicator 3 - Executive member formulates technology strategy Indicator 4 - Executive member administers/manages technology strategy Indicator 12 - Senior management promotes organizational vision/direction.  120  Cluster 1 managers rated their organization particularly low (high gap scores) in the areas:  • • •  Indicator 8 - Technology linked to customer needs Indicator 19 - Organization has strategies to respond to change Indicator 26 - Performance due to technology management evaluated.  The distribution of indicators in the 4 quartiles of the gap score range is shown in Table 40, following. It is apparent that none of the indicators are rated in the lowest quartile of gap scores by cluster 1 managers, compared to 4 indicators for cluster 2. On the other end of the spectrum, seven indicators are rated in the highest quartile for cluster 1 as opposed to none by cluster 2 managers. It is interesting to note that indicators 8, 19, and 26 were also the ones that were deemed to need the most attention based on the overall national average.  They  also  top the  list of  indicators needing attention in cluster 1 organizations.  Table 40 Gap score quartiles 6.0 - 8.4 8.5-11.0 11.1 -13.5 13.6-16.0  Indicator Distribution Cluster 2 indicators  Cluster 1 indicators 3,4,12,10, 12,10,22 9,14,24,16,11,4,6,5,20,3,21,25,2,1  16,14,11,24,6,1,9,13,22,18,20,26,17,21 2,15,23,25,19,8  18,15,13,23,8,19,26  Figure 13 graphically displays the cluster gap scores and their comparisons in terms of absolute and percentage difference.  121  Figure 14  Cluster 1 - Cluster 2 Hospital Comparison  In addition to being more highly rated by their senior managers in all aspects of technology  management,  cluster  2  organizations  distinguished  themselves  particularly by having identified an executive team member as being responsible for technology strategy development and implementation. As is clearly apparent from the diagram above, the largest percentage differences between the gap scores of the two clusters relate to the C T O indicators 3 and 4. It would not be unreasonable to assume that the stronger functional role of C T O in cluster 2 organizations has a positive impact on all other indicators as well.  In Table 41 indicators are ranked by the size of the G S gap between clusters. It shows that the largest differences occur in the Strategic Management dimension, followed  by  the  Change  Management  dimension,  and  the  Organizational  Management dimension.  122  Variable  Table 41  3 4  26 5 12  13 1 16 18 11 19 6  24 15 23 20 21 14 2 8 17 25 9 10  22  Ranked Indicators and Dimensions  Indicator content  Executive member formulates technology strategy Executive member administers/manages technology strategy Performance due to technology management evaluated Vision re technology through routine scanning Senior management promotes organizational vision/direction Performance management based on customer satisfaction Technology and business strategies aligned Technology diffusion/transfer encouraged Accomplishments formally recognized Corporate learning culture prevails Organization has strategies to respond to change Environmental factors re technology strategy identified Evaluates/assesses technology-related risks Innovation system integrates R&D/operations Technology lifecycle systematically managed Organizational design uses multi-functional teams Skilled employees seek innovative opportunities Communication system promotes technology Key technology supported by infrastructure Technology linked to customer needs HR development/planning key to technology capability Technology assessment informs technology decisions Line managers responsible for customer service Senior management participates in change management Organization uses sound project/process management  Strategic Managament  ff  IIf  Management of Change  Organization Management  \  \ u KJ /llff  \  \XJ  /  Another reinforcement of these conclusions comes from comparing the  \\  internal  average rankings by G S within each cluster. Table 42 indicates that the average internal ranking for the dimension 'strategic management' is considerably higher for cluster 2(ranked 9) than for clusterl (ranked 14.17). While the relative ranking for the 'change management' dimension is similar, it is lower for cluster 2 (ranked 15.86) than cluster 1 (ranked 13.71) in the 'organizational management dimension. On a relative basis, therefore, the better performing organizations have placed relatively  123  higher emphasis on strategic management and organizational change, compared to organizational management.  Table 42  Comparison of Average Rankings within Clusters  Strategic Management Dimension  Cluster 1 Rank GS 1 3 4 5 6 8  Cluster 2 Rank GS  18 14 9 11 10 23  13.56 12.92 11.87 12.59 12.05 14.60  11 1 2 5 10 25  9.63 5.62 6.15 8.61 9.56 12.26  14.17  12.93  9.00  9 10 11 12 13 14 15 17 18 19 20 21  8.64  4 2 8 1 21 5 20 12 19 24 13 15  11.31 9.43 11.67 9.00 13.87 11.55 13.76 12.62 13.70 15.22 12.76 13.15  12 4 8 3 13 7 21 18 15 24 16 19  12.00  9.77 8.19 9.13 6.31 9.85 8.72 11.16 10.62 10.36 11.95 10.39 10.81  12.34  13.33  9.77  17 7 3 22 6 16 25  13.3 11.63 10.73 13.89 11.58 13.25 15.42  20 6 14 22 9 23 17  11.15 8.69 9.93 11.31 9.38 11.36 10.55  13.71  12.83  15.86  10.34  average  Change Management  average  Organizational Management  average  2 16 22 23 24 25 26  It can be concluded that the measurement instrument (the survey) is able to distinguish between  differences in perception by senior managers about their  organization's standard of technology management. Significant differences between clusters of organizations can be identified consistently across all three dimensions of the technology management construct. In particular, the perceived presence of 'Chief Technology Officer' roles in the organization seems to contribute strongly to the differences in mean Gap Scores between clusters. Other 'strategic management' and 'change management' variables seem to be perceived as being implemented to  124  a greater extent in cluster 2 institutions. Improvements seem to be possible along all three dimensions.  4.5  RELIABILITY ANALYSIS  The reliability of the instrument was assessed by calculating the Cronbach Alpha coefficient for each of the indicators according to the factors established by the factor analysis. As shown in Table 4 3 , following, reliability is high for all indicators with alpha ranging from . 7 9 to .94. Table 43  Cronbach Alpha Reliability Coefficient  DIMENSION 1 Reliability Coefficients  N of Cases =  Alpha =  DIMENSION 2 Reliability Coefficients  Alpha =  DIMENSION 3 Reliability Coefficients  Alpha =  OVERALL Reliability Coefficients  Alpha =  324.0  N of Items = 6  .8366  N of Cases =  324.0  N of Items = 9  .8794  N of Cases =  324.0  N of Items = 10  .8933  N of Cases =  324.0  N of Items = 25  .9419  Note: N of items = 25 because item 7 was eliminated by the factor analysis;  4.6  THE HAY GROUP STUDY  As pointed out earlier, the purpose of the whole technology management exercise is to improve 'organizational success' in terms of the strategic goals and objectives of the organization. For a private sector organization that may be expressed as competitive advantage, market share, profit, return on investment or other such measure.  What would be the performance measures that would indicate 'organizational success' for the hospitals that participated in this study? What difference does it  125  make that one cluster of hospitals seems to manage technology better than another cluster of hospitals?  For the answers to these questions, A C A H O provided independently generated information about operational efficiency and clinical efficiency on a confidential basis. The Hay Group in Toronto compiled the data in an annual report entitled Benchmarking  Comparison  of  Canadian  Hospitals.  The  Hay  study  was  commissioned by the hospitals in an effort 'to improve the efficiency, effectiveness and quality of their care processes'. The comparisons were based on CIHI hospital separation data, on accounts and statistics reported to Ministries of Health, and other data provided by the hospitals.  In order to determine  if there was any association between  the technology  management performance of the two clusters of hospitals identified in this thesis and other measures of performance, the Hay study outcomes for the same two clusters were analyzed. The following two summary measures, as defined in the report, were used: •  •  The measure for the overall clinical efficiency of a hospital is the percentage of inpatient days that can be reduced if a hospital were to achieve benchmark levels of performance. The smaller the percentage, the more efficient the hospital. The measure for the overall operational efficiency of a hospital is the potential reduction in operating cost to the 25 percentile performance, including direct care, administrative, and support functions. Subject to some caveats, the hospital with the smaller potential reduction can be considered more efficient with respect to the areas examined in these comparisons. th  If an average gap score of 6 (over all responses and all indicators for each organization) was considered as the benchmark target, the potential technology management improvement could be calculated and expressed in terms of potential percent reduction. This measure is used in the comparison.  126  Figure 15 Hay Study Comparison  60 cu  E  50  2  40  £ o  30  'vt  20  CD >  a  it)  o  Q.  1  10 0  IP days  Icluster 1  22.24 19.8  Icluster 2  Table 44 Organization  15.95 10.6  Hay Study Comparison Data  Clinical Efficiency (% of inpatient days saved)  4  8  12 16 Average (cluster 2) 1 2 3 6 9 11 13 14 15 19 20 Average (cluster 1) difference  16.4 23.2 20.6 19.0  19.8%  24.7 17.8 30.8 24.4 26.9 24.3 33.5 24.5 23.4 17 21.8 22.24% 10.97%  54.4 36.5  Operational Efficiency (% of reduction in operating costs)  15.7 4.2 16.2 6.3  Technology Management (% reduction in gap score to 6)  36.2 35.1 37.3 37.2  10.6%  36.5%  10.7 7 18.9 14.1 19.3 14.5 23.6 18.8 23 14 11.5  55.1 55.8 45.9 49.1 50.7 52.4 47.7 56.4 62.6 55.0 68.0  15.95% 33.54%  54.4% 32.9%  Twelve organizations were included in this analysis, since they were also included in both the Hay study and in the technology management Gap Score analysis. As shown in Figure 15 and Table 44 the results of this comparison indicated that the hospital cluster which  performed  approximately  33%  better in its technology  127  management practice (i.e.: 33% closer to the ideal average gap score, GS) also performed approximately 34% better in operational efficiency ($) and 11 % better in clinical efficiency (IP). In other words, cluster 2 organizations performed 34% and 11 % respectively closer to benchmark levels in operating costs and inpatient days.  4.7  COMMENTS FROM RESPONDENTS  The following section presents a summary of comments from respondents to the national survey. The unedited comments appear in Appendix 8. Comments are ordered by the three major dimensions of the model.  Strategic Management Comments  Respondents expressed concern about the difference between C l O s and C T O s and questioned whether the position, however named, should be part of the executive team.  Respondents also suggested that the  diversity of their  organizational  structures, from hierarchical to flat, and the range of decision-making approaches, from top-down to committee-based, made it difficult to determine where and how strategic technology decision-making might have the greatest influence. Some respondents suggested that creating a C T O position might be counter-productive, as each member of the management team ought to be technology-aware; others suggested that the C E O ' s interest and/or knowledge of technology management would be the driving force for strategic technology management, regardless of who, if anyone, held the portfolio.  Two further sets of comments suggested challenges to the implementation of strategic technology management. The first appeared to be a lack of a clear customer focus at all levels of the organizations. Respondents indicated that until this customer focus was foremost not just at the departmental level, but also at the senior executive level, melding customer service needs to strategic technology management would be difficult. In addition, respondents identified cost and funding  128  constraints as barriers to implementing the strategic technology management perspective. This cost issue went beyond the individual organization to the region and fie province. Respondents identified funding constraints primarily as limiting technology acquisitions; moreover, some respondents indicated that a lack of freedom  to  reallocate  even  non-capital  resources limited  the  possibility of  establishing an organizational strategic technology management function.  Change Management Comments  Generally, respondents did not perceive change management as strength either in their own organizations or in the health care field as a whole. Respondents who had gone through mergers or regionalization or other organizational structural changes were particularly critical of the lack of attention paid to the process of change, from both a human resource and a time perspective. Some of these respondents, and other respondents as well, commented on the importance of the visibility and interaction of the C E O as a supporter of change management.  On the whole, respondents commented that cost and funding constraints were major obstacles to better change management. They indicated that the human resource costs of change management were beyond the capability of most organizations in the current fiscal climate. Moreover, respondents commented that there were few examples of recognition and of encouraging a learning culture, which made change management even more difficult. For technology management in particular, these obstacles were seen as impeding the ability to attract and retain appropriately skilled technology managers.  Organizational Management Comments  Respondents were of two minds on the concept of process framework. Some suggested that the process, while important, could become more important than the desired outcome. Others suggested that often the process was too time-consuming  129  and that decisions were made in response to particular situations, e.g., specific funds available or required replacement of older technology.  Respondents commented that there was a lack of attention paid to assessment and evaluation of technology strategy decisions, except where evidence-based decisionmaking was in place. Not having an executive level C T O impeded the regular assessment and evaluation function. Further, respondents were concerned that there was a lack of strategic technology management to address the issue of outdated  technology and equipment.  Once again, respondents cited financial  constraints as the greatest challenge to organizational management of strategic technology. Even in those organizations that respondents identified as having advanced strategic  management  processes,  limited  resources were cited  as  constraining the implementation of the process.  Perspective on Technology Management  Without exception, every respondent cited fiscal constraints as a major, if not the outstanding  stumbling  block  to  the  implementation  of  strategic  technology  management. Some respondents acknowledged that the argument was circular, i.e., without the necessary funds to implement technology management, the cost-savings from appropriate technology management would not become available. Still, the initial outlay of costs for a technology management infrastructure [human resources and capital] were seen to be beyond the fiscal capability of most organizations and of provincial funding bodies.  Respondents also commented on a perceived dichotomy between  technology  related to patient care delivery and outcomes and technology related to information management. They stated that the existing technology in these two areas rarely is interconnected within one organization, let alone within newly amalgamated regions. Moreover, existing technology is often outmoded, so that establishing connectivity  130  and affecting patient care outcomes, i.e., affecting customers, is extremely difficult, if not impossible.  Comments about the Survey  Respondents commented that a "does not apply" or "do not know" option would have been helpful. They further suggested that a range of ratings between "great" and "some" would have been useful. Understandably, a French version of the survey would have helped francophone respondents to reply.  Several respondents commented that the survey was not geared sufficiently towards hospitals; they reflected that the survey's terminology appeared more oriented to industry. Some respondents also commented that the survey focused on technology management, which they saw as secondary to information management.  Other respondents were complimentary about the survey as a whole and expressed appreciation for the leadership taken in developing the survey. Some respondents indicated that they would use the survey as an in-house measurement tool. Others reflected on the range of questions and asked if they would see follow-up to the research.  131  CHAPTER 5 - CONCLUSIONS AND RECOMMENDATIONS 5.1 CONTRIBUTION OF THIS STUDY The outcome of this study is a new theoretical model for the conceptual construct 'technology management', consisting of a definition, of its attributes, and a metric. The  model  represents  a theoretical  contribution  to the  advancing  academic  disciplines of MOT and MMT. It also represents a real world contribution to applied health  care  management.  The  study  promotes  a  Health  Care  Technology  Management construct that recognizes and bridges a multi-disciplinary science base with the broad modern concepts of health care. It can serve as research agenda, as basis for a training curriculum, and as practical guide for the establishment of a technology management system in an organization, particularly in health care.  Foremost,  the  proposed  model  recognizes  the  critical  importance  of  the  customer/consumer/client in health care and of the need to understand in detail the various consumer groups and their needs, priorities, and values. The study also recognizes the increasing power of technology to meet those needs in revolutionary and unpredictable ways.  Although there is ample evidence of increasing academic attention to technology management issues, no widely held model has been accepted. The proposed model builds on previous published lists and curricula and can serve as a new unifying force. It should have credibility particularly in health care because of the combination of methodological steps that have been employed to address validity and reliability concerns. Like the management of other potentially strategic resources, such as health human resource and financial resource management, health care technology management should and could become a more commonly understood construct.  The role of technology in health care is now receiving much attention. It can be portrayed as a key contributor to escalating health care costs, as an essential clinical  132  tool, or as the foundation for the next version of Canada's health care system. If it really is to support the goals and objectives of the health care system, it has to be better managed. This thesis contributes to a more systematic approach to managing technology in health care. It has generated technology  management  practices  in  new knowledge about  health  care.  appropriate  Specifically, the  following  questions were addressed:  1. How can the conceptual construct Technology Management' be defined? 2. What are the dimensions, indicators, and measures of the conceptual construct Technology Management'? 3. How can the 'Technology Management' capacity of Canadian teaching hospitals be measured? 4. What is the level of 'Technology Management' capacity in Canadian teaching hospitals? 5. Where are the weaknesses? The primary focus of this thesis was the practice of technology management in health care. However, the lack of a commonly accepted theoretical framework for the conceptual construct 'technology management necessitated original contribution 1  to the generic academic field of Management of Technology, including synthesis of a comprehensive definition and development of a generic model for the conceptual construct.  Rigorous content analysis of the literature addressed questions one and two. The development of a measurement instrument to answer question three followed an academically well established abstraction ladder and metrics development process. After pilot- and field testing, a web-based survey instrument was administered to Canadian teaching hospitals. Statistical analysis of the survey responses yielded the answers to questions four and five. Validity and reliability were assessed, and results were compared to those from an independent benchmark study of operational and clinical performance involving the same institutions that participated in the survey.  133  5.2 DISCUSSION  The increasing economic pressures on health care coupled with an increasingly turbulent technological environment are responsible for a wave of attention, which has given rise to the emerging academic disciplines of MOT and MMT over the past few years. Technology has made the qualitative leap from being a tactical resource to also being a strategic resource for organizations. While a broad view of potentially strategic technology is suggested, the concept of a 'core technology' focuses the general definition on a specific technology that could be tactical or strategic in nature, but in either case represents a particular strength of the organization. For health care organizations, this could include direct patient care, infrastructure, and business process technologies that may eliminate the need to travel, reduce pain, shorten recovery time, or prevent disease and injury.  As such, executive level attention is strongly recommended to allow for alignment of an organization's business strategy and its technology strategy in order to achieve organizational success. Organizational success is defined differently for a health care system viewed as a social service (Canada Health Act) compared to one being viewed more as a business (Clinton Plan in US).  Both systems have efficiency  goals and consider innovation and technology as tactical tools to accomplish given services at lower cost or to produce more services at a given cost. The judgement of what constitutes strategic technology needs to be made with full knowledge and information about the organization's key customers. Strategic technology improves the manner in which customer needs are met. It is aimed at the highest order of customer needs achievable under prevailing circumstances.  Organizations should be guided by market pull as opposed to technology push considerations. The public's unlimited demand for customized, high-quality, instantly delivered, and low cost health care is well documented. Ready global access to information and the high rate of technological developments require both public and private sector organizations to manage technology and innovation  strategically,  134  albeit for different combinations of economic and altruistic motives. The perspective of technology as a strategic resource implies the willingness to change the business fundamentally if the needs of customers can be better met with different technology.  Figure 16 Meeting Customer Needs  CUSTOMER NEEDS HIERARCHY  BUSINESS STRATEGY  TECHNOLOGY  STRATEGY  One of the key research areas emerging from this study are issues related to the definition and identification of customers, customer groups, and customer needs in health  care.  Organizations  like  teaching  hospitals are  faced with competing  customer interests (provincial services, community services, research and education services). Resource planning of any kind, human, technology, or financial, is difficult under circumstances where the primary customers and their needs are not well defined.  Lately,  with the  customer/consumer  emergence  relationships  is  of e-health, unfolding  a  whole  with significant  new  scenario of  implications  for  providers and agencies of health care services (Berger, 1999: Eliasoph, 2001; Deloitte Research, 1999).  The author's hypothesis going into this study was that in Canada's health care organizations technology was not managed well enough, neither tactically nor strategically. The C E O s of some of Canada's largest teaching hospitals expressed support for this notion when they agreed to promote and support this study among their peers. Of the 324 surveyed senior managers, a vast majority of 317 confirmed the importance of technology management for Canadian health care managers by rating it as 'great' to very great (between 5 and 6 on a six point scale), the remaining managers rated it as being of 'some' importance (rating 4).  135  5.2.1 Conceptual Construct 'Technology Management'  This study did not develop a new definition for the construct 'technology'. Rather, the perspective of technology as extension  of human  and  ability was  organizational  adopted from the literature. Based on an extensive literature content analysis, the study does propose a new definition and a theoretical model for the conceptual construct 'technology management'. It thus contributes to the advancement of the academic exploration of this construct and provides a foundation for its practical application.  The proposed definition, restated below, acknowledges the multi-disciplinary and integrative nature of the construct. It captures the need to manage technology throughout its life cycle from conception to replacement. Inherent is the broadest view of technology as defined in the previous paragraph. The two most critical aspects of the proposed definition of technology management are the recognition that a) technology both shapes and supports business strategy, and b) that its objective is to contribute to organizational success, however 'success' is defined for a particular organization.  TECHNOLOGY application life-cycle  MANAGEMENT  of engineering, management  in order to shape, for organizational  can be defined as the holistic and  science,  and management  capabilities  of new and relevant product and process  as well as accomplish,  the goals and objectives  integrated to  strategic  technologies necessary  success.  Literature content analysis also yielded a list of critical attributes for successful management of technology in organizations. These attributes formed the basis of a metric and a model for the technology management construct. Their development was guided by Geisler's abstraction ladder and metrics development process (Geisler,  2000). Iterative expert input from senior managers in health care refined  the metric, the resulting measurement instrument and the model. Statistical analysis  136  of the input from 324 senior health care managers from some of the most technology intensive teaching hospitals in Canada led to minor adjustments of the model. The metric of 'technology management' as applied in this study, can be summarized as follows: Table 45 Phenomenon Conceptual Construct Measurement Instrument Measures  The Metrics of Technology Management  need for alignment of business and technology strategy technology management definition and model dimensions, variables, and rating scales for the indicators in the model ratings of benefit and extent of implementation of the indicators and the resulting gap scores  The technology management model summarized in Table 46 consists of three dimensions sub-divided into variables and indicators. It is the collective package that constitutes the new technology management model. The individual building blocks are not new to engineering, business, and social sciences. A body of literature, research, and empirical evidence informs each individual dimension, variable, and indicator.  Developing the technology strategy aligned with business strategy to meet the highest possible order of customer needs represents Dimension 1 of the model. The more sophisticated the organization's ability to become aware of relevant  new  technologies, the more timely its ability to adapt or adopt emerging technologies. If those emerging technologies can not be supported or sustained because of environmental factors, its usefulness is limited. Dimension 1, therefore, also includes technology and environmental scanning, and further suggests that the coordination of development, implementation, and administration of the technology strategy needs to be driven and managed from the Executive level.  The model further implies that in addition to the development of a technology strategy, the organization has to be nimble in order to accept changes in business  137  direction or adapt to new ways of meeting customer needs. Hence Dimension 2 focuses on change management. dimension  are  a  customer  Key elements  service  attitude  that  of the change permeates  management  throughout  the  organization, and a change management process driven by the Executive team. Celebrating technology as part of the solution, the future of the organization, and celebrating integrated  multi-functional  teams are the other components of this  dimension of the model. A human resource strategy that fosters innovation and creativity in line with strategic technologies is considered a further critical aspect.  Once strategic direction has been established and the organization  has been  prepared for change, the success of the implementation and operation depends on the organizational and operational management; Dimension 3 of the model. This continuous and iterative process should encompass every stage of the technology life cycle and should be well supported by ongoing evaluation and assessment of performance and risks at the technology and the organizational level.  The development of a new definition and model for the conceptual construct 'technology management' answered the first two of the five research questions to be addressed by this thesis. The third question concerning the need to measure the 'technology management' capacity of Canadian teaching hospitals, triggered the development of a measurement instrument. It was designed as a web-based survey instrument. The questionnaire and the questionnaire development process were modeled after one employed by Lewis in his study of the Information Resource Management (IRM) domain (Lewis 1993). The IRM survey method was expanded by the application of internet web-technology and by a 'gap score', a calculated measure based on survey responses.  The indicators of the model were presented as 26 statements in the survey. 324 senior managers from 28 teaching hospitals responded to the web-based survey. They ranked the 26 indicators in terms of their importance, and in terms of the extent of their implementation in the respondent's organization. From that, a gap score was  138  calculated for each indicator as a measure of the perceived need for improvement. Gap scores for individual indicators could range from zero to thirty. A gap score of eight or less was considered as indication that no improvement may be required for that aspect of the technology management model. Table 46 The Technology Management Model STRATEGIC MANAGEMENT Technology Strategy  MANAGEMENT OF CHANGE AND INNOVATION Customer Focus  • Technology and business strategies aligned • Technology linked to customer needs  • Line managers responsible for customer service.  Chief Technology Officer  • Senior management participates in change management • Corporate learning culture prevails  • Executive member formulates technology Strategy • Executive member administers technology strategy  Knowledge Management • Technology vision achieved through routine scanning • Environmental factors related to technology strategy identified  • Performance management based on customer satisfaction.  Change Management  • Senior management promotes organizational vision/direction •  Organization has strategies to respond to change  Integration of Innovation Chain • Communication system promotes technology. • Innovation system integrates R&D and operations • Organizational design uses multi-functional teams  Human Resource Management • HR development/planning key to technology capability • Accomplishments formally recognized •  ORGANIZATIONAL MANAGEMENT Effectiveness and Flexibility • Key technology supported by infrastructure • Technology diffusion/transfer encouraged  Operations Management • Organization uses sound project/process management • Technology life cycle systematically managed  Assessment and Evaluation • Technology related risks evaluated • Technology assessment informs technology decisions • Performance due to technology management evaluated  Skilled Employees seek innovative opportunities  A variety of methodological and statistical approaches contributed to validity and reliability of the measurement instrument and the gap score measure. These included content validity measures such as the literature content analysis, expert Delphi input, and pilot and field testing of the measurement instrument, and statistical analysis of the final survey responses. Internal construct validity was established via factor analysis. Concurrent validity was indicated by comparison with  139  an independent performance study of the same institutions, and high reliability was indicated by Cronbach alpha coefficients for each of the three dimensions of the model.  The timeliness of this study was confirmed by the enthusiastic support form the Executive  Committee  of  the  Association  of  Canadian  Academic  Health  Organizations, essentially the collection of Canada's teaching hospitals. Without that support it would have been nearly impossible to access the email addresses of their senior managers.  5.2.2 Technology Management in Canada's Teaching Hospitals  As a component of content validity assessment, the respondents were asked to rate the importance of the 26 indicators in the model. Every indicator received an average rating of greater or equal to 5 on the six point rating scale with a standard deviation range of .61 to 1.03. This implies that the 324 respondents agreed on average on the 'great' importance of each of the indicators. The results validate both the instrument itself, as well as the applicability of the model for a variety of industry settings.  As expected, implementation of the indicators was not rated as highly, with mean scores ranging from 3.15  to 4.46  and demonstrating greater variability with a  standard deviation range of 1.01 to 1.62.  The resulting mean gap scores ranged  from 8.4 to 14.66 with a standard deviation range of 5.45 to 8.27. These results are summarized in Table 28 on page 111.  This considerable variability raised questions about the factors contributing to these different perceptions. Statistical analysis showed that the key contributing factors were significant differences different organizations.  in responses from senior managers  representing  In fact, the participating organizations fell into two main  140  groups of perceived technology management performance, referred to as Cluster I and Cluster 2 hospitals.  Mean gap scores for Cluster 2 organizations were between 6.54%  and 56.42%  lower than the respective mean gap scores for Cluster 1 organizations. No single indicator in Cluster 2 showed a higher gap score than the corresponding indicator for Cluster 1. This represented strong indication that the five Cluster 2 hospitals were operating closer to the proposed technology management model than were the thirteen Cluster 1 hospitals.  By far the largest differences in reported perception based on implementation ratings and gap scores between Cluster 1 an 2 managers, related to indicators 3 and 4 of the technology management model. These are the two indicators that focus on the function of a Chief Technology Officer. This result strongly confirms the message from the literature about the necessity of executive attention and leadership for technology management. Indicator 3 states: A DESIGNATED MEMBER OF THE EXECUTIVE TEAM IS RESPONSIBILE FORMULATION OF THE ORGANIZATION'S TECHNOLOGY STRATEGY.  FOR  THE  Reporting drectly to the C E O , the individual is responsible for staying abreast of present and potential future technologies, and for leading the strategic decision making process about when to abandon, support, or adopt technologies. A job description identifies expected knowledge, skills, and qualifications. The C T O understands the strategic business issues, the customers, and the technology.  Indicator 4 states: A DESIGNATED MEMBER OF THE EXECUTIVE TEAM IS RESPONSIBLE FOR THE ADMINISTRATION AND MANAGEMENT OF THE ORGANIZATION'S TECHNOLOGY STRATEGY. Providing leadership, coordination, and facilitation, responsibilities also include such activities as gate keeping, advocacy, funding, sponsorship, policy and procedure development, promotion, capacity building; and includes responsibility for the overall technology management system. The C T O is an effective leader and commands the respect of his/her employees, managers and peers. The C T O demonstrates vital communication skills, which can translate technical issues into those that can be readily understood by non-technical individuals.  On the other end of the picture, Cluster 1 hospitals were shown to be the weakest in those indicators that also presented the highest need for improvement on a national, system-wide basis, namely indicators 8, 19, and 26.  141  Indicator 8 states: TECHNOLOGY IS LINKED TO CLEARLY IDENTIFIED CUSTOMER NEEDS AND PRIORITIES. There is ongoing access to information from timely customer and staff surveys about current and future needs and priorities of customers. The organization responds quickly and emphasizes 'market pull' rather than 'technology push' strategies as part of a customer relation policy.  Indicator 19 states: THE ORGANIZATION HAS STRATEGIES TECHNOLOGICAL CHANGE.  TO RESPOND FLEXIBLY AND RAPIDLY TO  Development times, innovation cycles, and overall cycle times to put ideas and innovations into practice are short in relation to industry norms.  Indicator 26 states: THE ORGANIZATION'S PERFORMANCE AS A FUNCTION OF TECHNOLOGY MANAGEMENT ACTIVITIES IS ROUTINELY EVALUATED AND BENCHMARKED. All aspects of the technology management system covered by this survey are subject to systematic performance reviews against targets and in terms of their impact on overall organizational goals, objectives, and customer service. This includes annual performance evaluations of the executive member fulfilling the C T O role.  The findings in relation to questions 4 and 5 concerning the level of 'technology management' capacity and the weaknesses within Canadian teaching hospitals were as follows. The results and statistical analysis indicate that there are significant differences in the technology management sophistication of Canadian teaching hospitals. The major differences occur in areas of strategic technology management, followed  by change management,  and to a  lesser extent, in organizational  management. The perceptions of senior managers are not significantly influenced by their area of responsibility relative to patient and non-patient care, or by their position in the reporting structure. Improvements are needed generally in all areas addressed by the indicators in the technology management model.  5.2.3 Technology Management and Organizational Performance  A further question relates to the impact of technology management sophistication on organizational performance and success. This study was able to explore to some extent the relationship between clinical and operational efficiency and technology management  performance.  technology management  It did not address the  more strategic  impact of  performance on customer satisfaction and customer  service levels relative to customer needs.  142  Four of the five Cluster 2 hospitals and eleven of the thirteen Cluster 1 hospitals participate  in  annual  benchmark  comparison studies.  Confidential  summary  statements provide participating organizations with feedback about the 'room for improvement' if they operated at benchmark levels on agreed upon performance indicators. Cluster 1 hospitals were left with considerably less room for improvement, suggesting a strong correlation between their technology management performance and their clinical and operational efficiency performance.  5.2.4 Future Research  This study built on earlier research in the areas of MOT and MMT. An outcome of this study are the enhancement and the expansion of the current research agenda for the MOT and MMT disciplines. Research in this area should be focused on a) the construct itself and b) its application. Since application of the model is thought to be context dependent, a stream of research should explore the model relative to issues at national, provincial, and institutional levels of management in various industry sectors. At issue are the priorities and shortcomings to be addressed in the particular environment, as well as the necessary adjustments to the model for specific environments.  There are a number of issues that arise relative to the application of the model in health care. The proposed model consists of a hierarchy of dimensions, variables, and indicators. A s mentioned earlier, there is a body of literature dealing with the basic and applied science fundamentals underlying each of the indicators. While knowledge could undoubtedly be expanded in each of these facets, some examples of priority research areas for technology management in the health care environment are listed below:  •  Who are the customers in health care, what are their needs, and what order of priority is attached to those needs (i.e. their needs hierarchy)?  •  There has been mixed success with the management of technology as a tactical resource, what particular challenges arise out of strategic technology  143  management (scope of professional practice, union jurisdiction, legal issues, etc.) in health care? •  •  While senior managers in teaching hospitals provided their perspective, what, concretely, differentiates hospital clusters with apparently quite different management /performance capabilities? How, concretely, can technology contribute to clinical and operational efficiencies, quality and levels of care, and customer satisfaction.  5.2.5 Limitations Of This Study  •  MOT and MMT are emerging academic disciplines. Expert opinion, particularly for the health care sector in Canada, is not readily accessible. The study had to rely on practitioners with experience rather than related academic preparation.  •  The study results are based on perceptions of senior managers. Follow-up case studies would be useful in order to compare perceptions with reality, based on the evidence suggestions made by pilot-study participants.  •  Case studies would also be useful with respect to the real, rather than perceived differences between some Cluster 1 and Cluster 2 hospitals. To what extent are C T O functions explicitly established, given the large difference in perception between the clusters on this point? The web-based survey approach was very successful. Language and design decisions, however, did impact on response rate. Participants had to complete all questions. They had to choose a rating between 1 and 6. Some would have preferred a 'N/A' or 'don't know' category. Translation into French might have generated more responses from Quebec. The measurement instrument could be used to probe into the strengths and weaknesses of an individual institution. A case study with full management and staff participation would allow further statistical validation of the instrument.  •  •  5.3 RECOMMENDATIONS 5.3.1 The MOT Discipline The model should be promoted and popularized. The goal of MOT researchers and practitioners has to be the promotion of the 'technology management'  construct. Senior managers  have to internalize  package of attributes and activities that represent effective  management  the of  technology as a strategic resource. The lack of a popular model has been a barrier  144  to fie acceptance of technology management as a distinct executive function and responsibility. The model proposed by this thesis could serve as the framework, to be refined and promoted over time.  The model should be implemented as a cohesive framework. While most organizations attempt to tackle various aspects of the technology management model, the lack of an integrated framework  limits and prevents  organizations and individuals from realizing the full benefit of those attempts. Without the framework and organizational focus there is no home for the ideas and a low capacity to respond to them. An example might be the often-lamented difficulty of bringing research results to bear on practice environments. A further example might be the limited success in changing environmental conditions in a fragmented approach, such as training of individuals; when they have to return to environments without a suitable support framework in place. A cohesive framework would optimize the benefit of individual actions.  The definitions of customers, stakeholders, and their 'hierarchy of needs' are paramount. Everyone in the organization has to be clear on whose needs are to be met and be prepared to adjust if there are better ways to meet those needs. Groups of customers or individual customers may prioritize their needs differently.  Most  expressed needs are simply means to another end, they are intermediate needs, which  could  possibly be  leap-frogged  by  technology.  Without  a  thorough  understanding and explicit statement of this 'hierarchy of customer needs', no effective technology strategy can be developed. Technology would remain a tactical resource.  Technology management is an executive responsibility. Recognizing the strategic importance of technology places the issue at the executive level  of organizations, next  to  human  resource management,  and financial  management. The empirical and academic message is clear on this point. To be  145  successful in the current turbulent  and unpredictable technology  environment,  organizations need to anchor technology management at the vice-presidential level.  Technology management training and research needs to be strengthened. The promotion of the technology management construct needs to be supported by appropriate framework  education  and  research.  The  proposed model  for research agendas and educational  endeavors need to consider situational  should serve  as  curriculum. Both academic  factors such as organizational  scope  (department, corporation, country, etc.) and industry sector (public or private, service or product, etc.)  5.3.2 The Health Care Industry The promotion and application of MOT principles to the health care industry needs to receive significant attention. The experience in other industry sectors suggests the appropriateness of M O T applied to health care. More significantly, senior managers in health care already recognize this need. Along the way, some mental stumbling blocks need to be overcome: a) the lack of an applied technology management framework has led to poor acquisition and/or implementation experiences, resulting in a cynical view of technology, b) the lack of resources for innovation and technology has led to a sense of frustration that even if appropriate technology was identified, it could not be acquired, c) technology is viewed too narrowly in terms of IT or medical technology, and d) there is a lack of understanding of the role of executive-level technology management.  The impact of situational and environmental factors of health care in Canada on the application of the proposed model needs further research and education. The principles of the model clearly apply in health care as in other industries. Application and implementation of every aspect of the model would benefit from  146  further research and education in terms of the specific conditions of the health care industry. High on the list of priorities is the analysis of customers, stakeholders, and their needs or expectations.  Health  care organizations  should not  hesitate  to  assign technology  management responsibility to a member of their executive team. Priority number one for improved technology management  in Canada is the  appointment and identification of an executive member with that responsibility. Ideally,  the  individual  understands  the  business of  understands science and technology broadly, and  health  care  possesses  in Canada,  other  required  management and leadership skills. The individual's task is to champion, coordinate, and manage the implementation of the proposed technology management model. There seems to be some opposition to the idea of a central executive coordinator of technology strategy and implementation. The main reason seems to be related to the breadth of technology in health care. It is important to remember that inherent in the model is the concept of multi-disciplinary and multi-functional teams with representation from research and operations departments.  5.4 SUMMARY AND CONCLUSIONS  This study advances the  emerging  academic disciplines of Management  of  Technology, Management of Medical Technology, and Management of Health Care Technology. They are deemed 'emerging' because of the lack of agreed upon theoretical frameworks, models, definitions, and paradigms.  Guided by research strategies, suggested by Lewis (1993) and Geisler (2000), the study contributes a definition and a model for the conceptual construct 'technology management . The model consists of a hierarchy of dimensions, variables, and 1  indicators, which like the definition, are a result of an extensive literature content analysis. A measurement instrument and a measure have been developed to assess organizational  technology  management  performance.  Definition,  model,  and  147  measurement instruments are not industry specific and could be generalizable, subject to further validation in different settings.  The measurement instrument has been applied to Canadian teaching hospitals. It was  able  to  demonstrate  significant  differences  in  perceived  technology  management performance between clusters of hospitals. Statistical analysis of a 'gap score' measure yielded a ranking of indicators relative to their need for improvement in order to achieve performance envisaged by the model, and in order to close the gaps between the 'good' and 'not so good' performing organizations. It was  also  possible  to  correlate  technology  management  performance  with  independently determined clinical and operational efficiency.  There is strong agreement both within and outside of the health care industry that technology management is an important management issue. There is also a strong feeling among senior managers that the frequent restructuring of the health care system, and the perceived shortage of funds for innovation, are barriers to sustained planning efforts including the development of technology strategies. The author would characterize these conditions as further incentives to assure that technology is seen as part of the solution to industry problems through executive attention to technology management.  The responses received from 324 senior managers in Canadian teaching hospitals largely confirmed the model that emerged from the literature. It would appear that the model could be generalized to any organization (department and country) and across all industry sectors. What would change, are the specifics on how particular attributes would have to be addressed and what situational priorities would arise. It would seem, that if an organization had a process to address the dimensions, variables, and indicators of the model, it could be reasonably confident that it had covered most of the relevant issues. It would be assured that customer needs were addressed most appropriately by its technology strategy, that technology contributed  148  optimally to organizational success, and that the organization was able to deal with technological change in a timely manner.  As a result, an image of the technology management construct could become common place, in a manner comparable to other management constructs for strategic  resources,  such  as  human  resource  management  and  financial  management. In that sense, the technology management model shares some of the components of other strategic resource constructs. The conceptual constructs 'human  resource management'  and 'financial management'  conjure  up fairly  consistent images in the minds of managers as to the features and attributes of these constructs. However, as yet no common image or shared understanding exists of the conceptual construct 'technology management'. The model above contributes this image. If adhered to, an organization will very likely be in a better position to meet the needs and expectations of its customers and major stakeholders.  149  BIBLIOGRAPHY  1. Abdel, M. L., & Wolf, C . (1994). Measuring the impact of lifecycle costs, technological obsolescence, and flexibility in the selection of F M S design. Journal of Manufacturing Systems, 13(1), 37-47. 2. Ahmed, N. U. (1995). A design and implementation model for life cycle cost management system. Information & Management: International Journal of Information Systems Applications, 28(4), 261-9. 3. Albayrakoglu, M. M. (1996). 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