sustainability

Article
Making Hospitals Sustainable: Towards Greener, Fairer and
More Prosperous Services
Karine Borges de Oliveira and Otávio José de Oliveira *

Production Department, Guaratinguetá Engineering School, São Paulo State University-UNESP,

São Paulo 01049-010, Brazil
* Correspondence: otaviodeoliveira@uol.com.br; Tel.: +55-12-3123-2231

Abstract: The growing demand for hospital services and the pressure to incorporate sustainable
strategies into hospital management have led hospitals to rethink their business model and seek new
ways to manage their operations. Corporate sustainability is an important way to make hospitals
more sustainable and competitive. Therefore, this paper proposes a framework that contains the
drivers for the management of sustainability in hospitals (SH), developed through the content
analysis method. As a result, this study proposes five drivers: toward the circular economy; making
sustainable buildings; adopting knowledge management and organizational culture; employing
management systems, tools, and methods; and applying technological innovations. This framework
contributes in a managerial way to helping managers of hospitals in managing sustainability; making
their businesses fairer, greener, and more prosperous; and fulfilling their commitments to the well-
being of their employees and society, providing a basis for moving toward the premises of the United
Nation’s 2030 Agenda. This study also scientifically contributes to the academic maturation of the
topic by systematizing elements and adding insights to the state of the art on SH. It is recommended
that future studies add new elements to the drivers or even propose new drivers for the continuous
scientific advancement of this topic.
Citation: Borges de Oliveira, K.; de
Oliveira, O.J. Making Hospitals
Sustainable: Towards Greener, Fairer
Keywords: sustainability in hospitals; sustainable services; sustainable development; hospital
and More Prosperous Services. management
Sustainability 2022, 14, 9730.
https://doi.org/10.3390/su14159730

Academic Editors: Teen-Hang Meen,

1. Introduction
Chun-Yen Chang, Charles Tijus and
Po-Lei Lee Intense population growth has contributed to the increase in the consumption of
goods and services, which, added to inefficient public policies, are negatively transforming
Received: 2 July 2022 the living conditions on the planet, causing impacts on the environmental, economic, and
Accepted: 19 July 2022
social spheres and on the balance between them [1]. The high demand implies an increase
Published: 8 August 2022
in production activity, which increases the emission of greenhouse gases and culminates
Publisher’s Note: MDPI stays neutral in the warming of the planet, causing severe environmental consequences. This warming
with regard to jurisdictional claims in generates climate changes that threaten to reverse the advancements in health achieved by
published maps and institutional affil- society. Heatwaves are increasing in intensity and number, aggravating chronic diseases,
iations. and leading to the deaths of thousands of people. Storms, floods, tornadoes, and droughts
are occurring with increasing intensity, compromising water supplies in many parts of the
world, triggering mass migrations and public health crises [2]. If commitments are not
made by governments and organizations and effective actions against global warming are
Copyright: © 2022 by the authors.
not taken, these effects will become irreversible [3]. Regarding the economic sphere, the
Licensee MDPI, Basel, Switzerland.
intense production of goods and services to meet the growing demands of consumption
This article is an open access article
has generated an exponential and unsustainable increase in the exploitation of resources,
distributed under the terms and
which is leading to their scarcity and/or depletion, causing economic stagnation and crisis
conditions of the Creative Commons
Attribution (CC BY) license (https://
in many countries [4]. Consequently, the social sphere is also directly affected by these
creativecommons.org/licenses/by/
issues, since they imply an increase in inequality and the difficulty of access to education,
4.0/).
security, housing, health, and basic sanitation [5].

Sustainability 2022, 14, 9730. https://doi.org/10.3390/su14159730 https://www.mdpi.com/journal/sustainability

Sustainability 2022, 14, 9730 2 of 21

Due to this scenario, organizations are being pressured by society, governments,

environmental agencies, competitors, customers, and even their own employees to incor-
porate sustainable strategies into the management of their companies [6]. Sustainability
has become an important part of business success because it helps businesses improve
their operational, environmental, and social performance and, thus, their competitiveness.
Therefore, sustainability makes it possible to balance organizational objectives with the
preservation of human beings and the planet [7].
In 2015 the United Nations proposed the 2030 Agenda, which is a document that
guides nations toward sustainable development and presents a shared plan for peace
and prosperity for people and the planet. This agenda is based on the premise that
ending poverty and other deprivations must be addressed in strategies that improve
health and education, reduce inequality, and stimulate economic growth while combating
climate change [8]. It sets out 17 Sustainable Development Goals (SDGs), which are an
urgent call and commitment to action from member countries in a global partnership to
establish and fulfill strategies, processes, and practices to achieve and enhance sustainable
development [9]. According to the Brundtland Report, sustainable development is a set
of actions that meets the needs of current generations without putting the ability to meet
those needs of future generations at risk [10].
In the business context, sustainable development starts with corporate sustainability
(CS), which is applied to the business field through management and organizational
processes [11]. CS is an operationalized approach based on the triple bottom line (TBL);
that is, it considers the three dimensions of sustainability (environmental, economic, and
social) [12]. It has emerged as an alternative to traditional short-term, for-profit approaches.
In this sense, organizations must develop their operational thinking while also thinking
about the environmental and social dimensions that will contribute to their longevity and
the well-being of human beings and the planet [13].
The movement towards sustainability has also been intense in the service sector [4],
among them the hospital sector [14]. Hospitals are increasingly adding the precepts of CS
and sustainable development to their business strategies and operational processes [15].
Because their operations occur, in general, 24 h a day uninterruptedly, they are among
the organizations that consume the most natural resources, produce waste, emit polluting
gases, and need an intense workforce to provide their services [16], which is aggravated
by having to deal with unforeseen events, such as the demand arising from the COVID-19
pandemic [17]. Therefore, many hospitals have started to consider CS as an important
approach to providing their services not only according to economic and health promotion
criteria but also to environmental efficiency and social responsibility, which contribute to
sustainable development [18]. Furthermore, hospitals are the central link in the healthcare
service delivery chain [19], and by conducting studies to improve their management,
positive impacts are generated on the other links of this chain.
Corporate sustainability in the health context has been discussed in the academic
community, and some works dealing with its development and management are important
inputs for this article. For example, [20] analyzed the role of human capital in sustainability
management in hospitals and found that departmental approaches, in which each sector
develops projects in isolation, hinder human capital development and negatively impact CS.
Ref. [21] analyzed CS in the healthcare supply chain in emerging countries and proposed
a framework for its management. Ref. [17] identified in the literature propositions and
dimensions for service delivery only in public hospitals and, from them, proposed a
framework for hospital managers to identify opportunities and improve service delivery to
make it more sustainable. Ref. [22] conducted a bibliometric analysis on sustainable health
management and found that the economic dimension receives greater importance than
the environmental and social dimensions in the analyzed articles, which also indicates an
imbalance among the pillars of sustainability in the area of health and must be combated.
These studies present relevant contributions to sustainability management in hospi-
tals, but do not present recommendations that are structured, feasible, and adapted to
Sustainability 2022, 14, 9730 3 of 21

their reality. This scientific opportunity is corroborated by the research gap pointed out
by [23], who indicated the need to develop new research that identifies good practices
and proposes new approaches to support the development of sustainability in healthcare
settings. Because of this, this paper fills this gap and expands and deepens the studies that
came before it by making propositions that help hospitals become more sustainable.
Thus, the following research question guided this work: how is it possible to develop
and manage sustainability in hospitals? To answer this question, the goal of this study
is to propose a framework that includes drivers for the development and management
of sustainability in hospitals. This will help hospitals become more committed to the
well-being of society, the preservation of the planet, and their ability to compete against
other health service providers.
After this introduction, Section 2 presents a synthesis of the theoretical framework
for corporate sustainability; Section 3 details the research method; Section 4 presents the
boosting elements of sustainability; and Section 5 proposes and discusses the drivers for
developing and managing sustainability in hospitals. Finally, the conclusion, references,
and appendix are presented.

2. Theoretical Framework
Hospital services are central to the well-being of society because the physical, mental,
and economic health of a community or country is directly linked to the effectiveness and
efficiency of this type of service [24]. However, hospitals are among the most complex
organizations to be managed, with several peculiarities in their operational processes that
are required for the functioning of their facilities and direct patient care. The instability of
demand and the complexity of measuring the results of their intangible activities are great
difficulties to be overcome. For example, it is possible to measure how many surgeries
and consultations were performed, but it is not possible to measure how much health is
being obtained [25]. The demand for hospital services has intensified considerably due to
population growth, chronic diseases, and emergencies caused by unexpected conditions,
such as COVID-19 [26,27]. Parallel to this, hospitals need to make the most of their natural
and financial resources and improve their labor productivity without sacrificing the quality
of the services they provide [28].
The hospital setting is dynamic, with activities that require quick decision-making
that are subject to constant changes; many distinct but intensely interconnected tasks; and
often involves simultaneous care performed by the same team. In this setting, time is a
crucial factor for patient survival, which requires that resources be used optimally [14]. It
is also characterized by a high turnover of clinical staff (technical/medical area) and the
reasonable stability of administrative staff [29]. Besides these, one of the main challenges
for hospital managers is to reconcile business interests with ethical and legal principles,
because decisions based solely on administrative criteria are not always consistent with
technical health criteria. They need to define and achieve organizational goals considering
the triad “organization, professionals, and patients”; however, in hospitals, it is common
for leadership positions to be held by doctors and nurses who are not prepared to perform
management activities [26]. Therefore, these managers need to be trained to be able to
balance administrative and health care activities without hampering the economic viability
of the hospital [30].
Despite the peculiarities of hospitals, there are many similarities between them and
other types of organizations. Private hospitals make financial investments with their own
resources or from shareholders, and their main objective is to generate profits. Public
hospitals, on the other hand, are financed by resources from taxes and donations, which
must be effectively managed to keep within the parameters set by the responsible public
agency. Therefore, both private and public hospitals must manage their revenues in a way
that ensures their financial and operational soundness and efficiency. Thus, the financial
management expected from a hospital is similar to that of a company, since they must
seek maximum efficiency and effectiveness of processes to fulfill their role in health care
Sustainability 2022, 14, 9730 4 of 21

and ensure economic performance coupled with sustainable social and environmental
performance [31]. These challenges indicate the need and opportunity for the development
of scientific papers that discuss and present solutions for hospitals to remain resilient and
sustainable, corroborating the research gap presented in the introduction of this article.
Many hospitals have invested in projects with sustainable initiatives without creating
a system that provides continuous improvement and perpetuity. These watertight projects,
in general, are of short duration and do not generate medium- and long-term benefits,
increasing the chances of failure of actions aimed at sustainability, which generates a waste
of resources (human, financial, infrastructure, time, etc.) [32]. It is important to create
mechanisms to maintain the engagement of hospitals and their employees during the
development period of programs and actions related to sustainability. Despite research
with considerable evidence on the positive outcomes of sustainable initiatives in healthcare
delivery, there is still a lack of studies with approaches that keep hospitals engaged [6]. It
is also important that sustainability is seen as a process of development and adaptation
in response to organizational and patient needs [33]. This view is supported by [14], who
point out that hospitals’ perspectives on sustainability must shift from a short-term to a
long-term view in order to ensure organizational survival and viability. CS is represented
by the economic, environmental, and social pillars, and its management is an important
way for hospitals to be resilient and fulfill their mission of treating and saving lives [34].
Hospital processes and services are intensive in material, energy, and water consump-
tion; they generate significant amounts of waste, especially toxic waste; and they have high
carbon emissions [35]. Environmental management in hospitals to mitigate these impacts
can be done by operationalizing the environmental pillar of CS, which involves the use of
renewable natural resources, the mitigation of toxic gas emissions, and the implementation
of environmental strategies, such as cleaner production, ISO 14001, green design [36],
studies on energy efficiency [37], and the analysis of life-cycle impact assessment (LCA) in
hospitals [38], etc.
Hospitals are under great pressure to reduce costs, improve operational efficiency, and
maintain service capacity [32]. The management of hospitals can be achieved through the
operationalization of the economic pillar of CS, which encompasses the development of
policies and actions to generate added value for goods and services, and initiatives that
help improve and optimize processes, conquer new markets, and responsibly increase the
financial return on investments [6].
Social problems in hospitals are mainly related to employees who work long hours
in a work environment of high variability and complexity, with a high burden of physical
and psychological stress. These characteristics negatively impact the health and safety
of employees and the quality of patient care [35]. The solution to these issues can be
found in the operationalization of the social pillar of CS, which includes the training and
development of human capital, promoting satisfaction, health, safety, and quality in the
working conditions of its employees, which will be reflected in better patient care [39].

3. Research Method
This section details the methodological elements for the development of this work.
This includes the methodological flow (Figure 1) and the description of its phases.
Sustainability 2022,
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Figure 1.
Figure 1. Methodological
Methodological flow.
flow.

3.1.
3.1. Preparation
Preparation Phase
Phase
3.1.1.
3.1.1. Definition of
Definition of the
the Structural
Structural Bases
Bases of
of the
the Work
Work
The
The first
first step
step of
of the
thework
workwaswastotoestablish
establishthe
thestructural
structuralbasis
basisnecessary
necessaryforforitsitselabora-
elabo-
tion:
ration:definition,
definition, research
researchgap,gap,question,
question,objective,
objective,and
andresearch
researchmethod.
method.TheThe potential
potential of of
the topic was selected through a search carried out in the Scopus database, which is one
the topic was selected through a search carried out in the Scopus database, which is one
of the largest and most relevant interdisciplinary bases of peer-reviewed documents in
of the largest and most relevant interdisciplinary bases of peer-reviewed documents in
the area of management and corporate sustainability in hospitals. From this search, it was
the area of management and corporate sustainability in hospitals. From this search, it was
identified the opportunity to propose drivers for the development and management of sus-
identified the opportunity to propose drivers for the development and management of
tainability in hospitals. These drivers were proposed in order to incorporate all dimensions
sustainability in hospitals. These drivers were proposed in order to incorporate all dimen-
of sustainability into hospital practices and thus contribute more robustly to the current
sions of sustainability into hospital practices and thus contribute more robustly to the cur-
requirements of healthcare services. This was corroborated by the gap presented by [23],
rent requirements of healthcare services. This was corroborated by the gap presented by
who stated that solutions need to be developed to improve sustainability in hospitals. From
[23], who stated that solutions need to be developed to improve sustainability in hospitals.
this, the authors defined the research question, the objective of the paper, and the research
From this, the authors defined the research question, the objective of the paper, and the
method. In this sense, this work was carried out through a qualitative approach based on
research method. In this sense, this work was carried out through a qualitative approach
the content analysis method.
based on the analysis
Content content analysis method.
is a scientific method of analyzing textual data through a systematic
process of identifying and coding method
Content analysis is a scientific units of of analyzing
analysis usedtextual data through
to interpret a systematic
documents whose
process of identifying and coding units of analysis used to interpret
results are concepts and categories that describe and allow the analysis of a given documents whose
phe-
results are[40].
nomenon concepts
Contentandanalysis
categories
canthat describe and
be performed allow inductive
through the analysis of a given
and/or deductive phe-
nomenon
analysis [40].
[41]. In Content
this study,analysis can be
the authors performed
performed boththrough
analyses, inductive
and theyand/or
will be deductive
explained
analysis [41]. In this
in the organization phase. study, the authors performed both analyses, and they will be ex-
plained
Next,in the
the unit
organization
of analysis phase.
was defined, which can be a letter, word, sentence, or excerpt
Next, the unit of analysis
about the object under investigation was defined, which
[42]. In this canthe
study, be unit
a letter, word, sentence,
of analysis selected was or ex-
all
cerpt
the about the
excerpts thatobject
pointedunder investigation
to actions [42]. In this study,
for the development the unit of analysis
and management selected
of sustainability
was
in all the excerpts that pointed to actions for the development and management of sus-
hospitals.
tainability in hospitals.
3.1.2. Document Selection Criteria
English language articles and review-type documents published between 2016 and
2021 were selected from the search query TITLE ((sustainability) OR (sustainable) OR (“cor-
Sustainability 2022, 14, 9730 6 of 21

porate social responsibility”) OR (“CSR”) OR (“sustainable development”) OR (“global

report initiative”) OR (“GRI”) OR (“triple bottom line”)) AND TITLE ((hospital) OR (health-
care) OR (“health care”)). After applying these filters, the search resulted in 449 documents.
To select the 30 most influential articles (see Table A1 in Appendix A), that is, the most
cited articles on sustainability in hospitals in the analyzed period, the titles, keywords, and
abstracts of the documents obtained from the Scopus database were read. Thus, those in
which sustainability in hospitals was addressed as a secondary aspect or those that referred
to the sustainability of the governmental health structure and not sustainability in health
organizations were excluded.
The restriction to papers in the period between 2016 and 2021 was because the most
recently published papers present the innovations in sustainability in hospitals (SH) and
incorporate the consolidated knowledge already developed. These 30 documents totaled
778 citations in all, which means that they served as a basis for several other studies and
contributed significantly to the advancement of the state of the art in this topic. Once the
documents were selected, they subsidized the construction of the theoretical framework
and were subjected to content analysis.

3.1.3. Theoretical Framework

The theoretical reference about sustainability in hospitals was prepared based on
the 30 most cited papers and, when necessary, other papers were added to support the
fundamental concepts and characteristics that based the development of this work.

3.2. Organization Phase

3.2.1. Identifying Boosting Elements of Sustainability in Hospitals
Inductive analysis was carried out to identify the boosting elements of SH. Considering
that the theme of sustainability in hospitals is still very dispersed and this type of analysis
is used when knowledge about a certain theme is pulverized, the inductive analysis was
adopted to contribute to the consolidation of this theme. There is no standardized way
to perform inductive content analysis. Due to this, ref. [42] recommends that reliability
should be evidenced from the quality of the description and execution of how the analysis
was performed. Thus, this is explained as follows: after defining the unit of analysis of this
study in the preparation phase, a thorough reading of the textual data began. As these units
of analysis were identified, they were given alphanumeric codes to represent them, and the
elements were constructed. Next, all units of analysis and their codes were reviewed, and
codes related to content that had similar meanings were recoded and merged to become a
single element. The coding was used to reference the elements in all subsequent analyses of
the study. Finally, 30 boosting elements of SH were obtained from the identification of the
units of analysis that were repeated and present contributions to this theme. They received
identifiers from E1 to E30 and were arranged in decreasing frequency of occurrence in the
articles, as shown in Table 1.

3.2.2. Classification and Discussion of the Elements according to the TBL Dimensions
As already mentioned, deductive analysis was also performed. This type of analysis
is based on pre-existing structures, concepts, or theories for analysis and, as the theory
about the environmental, social, and economic dimensions of the TBL is already well
structured in the scientific literature, the process of classifying the elements within these
dimensions meets the requirements of deductive content analysis [41]. Therefore, in this
work, the elements previously identified during the inductive analysis were classified
according to these dimensions through deductive content analysis to facilitate the reader’s
understanding of these elements in their respective TBL dimensions.
Sustainability 2022, 14, 9730 7 of 21

Table 1. Boosting elements of sustainability.

Most Cited Articles

# Elements TBL Freq.
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
E1 Perform hospital waste management EN x x x x x x x x x 9
Consider environmental sustainability requirements in the design, construction, and operation of hospital
E2 EN x x x x x x x x 8
facilities
E3 Consider stakeholders’ opinions and needs during the decision-making processes EN/SO/EC x x x x x x x x 8
E4 Train employees and sensitize stakeholders and suppliers EN/SO/EC x x x x x x x 7
E5 Develop a culture of corporate social responsibility in hospitals SO x x x x x x x 7
E6 Make sustainable decisions shared with the other members of the hospital supply chain EC/EN x x x x x x x 7
E7 Use Health Technology Assessment (HTA) as a decision support tool EC x x x x x x 6
E8 Create work teams for implementation and operationalization of sustainability EN/SO x x x x x 5
E9 Use management systems in hospitals EN x x x x x 5
Adopt technological innovations to aid economic sustainability in hospitals and in the links of their
E10 EC x x x x x 5
supply chain
E11 Define objectives, targets, and key performance indicators (KPIs) in hospitals EN/SO/EC x x x x x 5
E12 Engage employees in sustainable hospital projects EN/SO x x x x 4
E13 Foster the creation and implementation of sustainable ideas EN x x x x 4
E14 Develop the ability to be open to change EN x x x x 4
E15 Insert sustainability criteria for supplier selection in hospitals EN/SO/EC x x x x 4
E16 Establish partnerships with material recycling companies EN x x x x 4
E17 Adopt technological innovations to aid environmental sustainability EN x x x x 4
Consider social sustainability requirements in the design, construction, and operation of hospital
E18 SO x x x 3
building facilities
E19 Reuse materials and instruments whenever possible EN x x x 3
E20 Adopt technological innovations to aid social sustainability SO x x x 3
E21 Employ corporate governance in the management of sustainable systems and processes EC x x x 3
E22 Develop public-private partnerships (PPP) in public hospitals EC/SO x x x 3
E23 Develop and/or improve the sustainable procurement process EC/EN x x x 3
E24 Act as agents of pressure for the insertion of sustainability issues in the curricula of health courses SO x x x 3
E25 Encourage the active participation of human resources for the sustainable performance of hospitals SO x x 2
E26 Integrate sustainability into the mission, vision and policies of hospitals EC x x 2
E27 Develop partnerships for reverse logistics of hospital products EN x x 2
Manage in a structured way the intellectual capital in all its dimensions (human, structural, and relational
E28 SO x x 2
capital) in order to contribute to sustainability management.
Implement Lean Six Sigma methodology in hospitals to improve economic, social and
E29 EC x x 2
environmental performance
Analyze the economic feasibility of using the technologies in the design, construction, operation of your
E30 EC x x 2
buildings while considering environmental sustainability requirements

Notes: EC = economic sustainability; EN = environmental sustainability; SO = social sustainability.

Sustainability 2022, 14, 9730 8 of 21

3.2.3. Categorizing the Elements into Drivers

The elements were grouped by similarity into five drivers, i.e., each driver with its own
set of boosting elements for the development and management of sustainability in hospitals.
This data grouping process, called categorization or category creation, is recommended
by [42] in studies that use content analysis to summarize and make sure that all the elements
are understood and included.

3.3. Reporting Phase

Presentation and Discussion of Sustainability Drivers in Hospitals
Regarding the creation of categories, in this study called “drivers”, they were presented
and discussed in light of the literature and the authors’ interpretation in order to report the
results generated from this grouping.
Assessing the reliability of qualitative research is a process with a high burden of
subjectivity [41]. It is worth noting that content analysis in its qualitative aspect relies
on several assumptions that serve as support for extracting insights that are not always
explicit. Moreover, a text can contain many meanings and be interpreted from different
perspectives. Thus, the analysis of the textual data in this paper went through the judgment
and interpretation of the authors, as is common in qualitative research. Therefore, the
way the process was conducted can be repeated in the future and the results obtained are
considered reliable.

4. Identifying the Boosting Elements of SH

This section presents the 30 boosting elements of corporate sustainability in the hospi-
tal setting. These elements were identified in the most influential literature on the topic,
which provided the analysis of a wide range of knowledge produced and disseminated in
the period between 2016 and 2021. Table 1 shows the 30 elements in order of how often
they appear in the articles. They are arranged from most common to least common.
These elements contemplate several actions for the development and management of
sustainability in hospitals and were analyzed under the prism of the three dimensions of
TBL. To make it easier for the reader to understand, there is a column in Table 1 that lists
these elements by their environmental (EN), social (SO), and economic (EC) dimensions.
The elements classified as environmental (30%) contemplate actions that aim to mit-
igate negative environmental impacts to the planet from hospital buildings and their
operational processes. Thus, the elements contemplate the implementation of environ-
mental management systems and tools [15]; the elaboration of eco-efficiency performance
strategies and indicators [43]; the acquisition of environmentally friendly products, materi-
als, and equipment [44]; and the provision of health services based on more sustainable
operations and practices without reducing the quality of care [32].
The elements classified as social (20%) contemplate actions that aim at social benefits
to patients, employees, and the surrounding community for valuing the people who are
part of this ecosystem of health services provision. Thus, the elements contemplate, for
example, the development of corporate social responsibility to embrace the surrounding
community [6]; the valorization of human capital as an important resource for the organi-
zation [20]; improving technological resources for the well-being of patients [45]; working
conditions, health, and safety for employees [15]; and the thermal, acoustic and visual
comfort of the building facilities, benefiting both employees and patients [39] among others.
The elements classified as economic (20%) contemplate actions that contribute to
reducing operational costs, increasing the efficiency and effectiveness of processes, and the
financial development of hospitals, based on the establishment of strategies committed
to sustainability. Actions such as investments in technologies [46]; the adoption of more
sustainable business models [47]; the execution of public–private partnerships [48]; and
the analysis of the economic viability of investments in an integrated manner with social
and environmental concerns [36] stimulate the development and management of economic
sustainability in hospitals.
Sustainability 2022, 14, 9730 9 of 21

The elements classified as environmental/social; economic/environmental; economic/

social; and environmental/social/economic (30%) cover more than one TBL dimension
or all three dimensions concurrently. Actions such as considering stakeholders’ opinions
and needs [7]; making sustainable decisions shared with the other members of the hospital
supply chain [21]; and acting as agents of pressure for the insertion of sustainability issues
Sustainability 2022, 14, x FOR PEER REVIEW 10 of 22
into the curricula of health courses [49] are examples of actions that stimulate SH in a more
systemic, integrated, and effective way from the perspective of sustainability dimensions.

5.
5. Presentation
Presentation and
and Discussion
Discussion ofof Sustainability
Sustainability Drivers
Drivers in
in Hospitals
Hospitals
The
The elements
elements identified
identified in
in the
the literature
literature from
from the
the 30
30 most
most cited
cited articles
articles in
in the
the period
period
from
from2016
2016to
to2021
2021were
weregrouped
groupedintointofive
fivedrivers
driversfor
fordeveloping
developing and managing
and managing sustainabil-
sustaina-
ity in hospitals,
bility as shown
in hospitals, as shownin Figure 2. 2.
in Figure

Hospitals contributing to sustainable development

Figure 2.
Figure 2. Drivers
Drivers for
for developing
developingand
andmanaging
managingsustainability
sustainabilityin
inhospitals
hospitalstotoachieve
achievethe
theSDG
SDGgoals.
goals.
It is worth noting that the set of elements of each driver was grouped according to
the similarity
It is worthof noting
the themes
that addressed and discussed
the set of elements of eachin driver
the light
wasof grouped
the literature and the
according to
expertise of theofauthors
the similarity to enhance
the themes the results
addressed of their joint
and discussed in theaction.
light of the literature and the
expertise of the authors to enhance the results of their joint action.
5.1. Toward the Circular Economy
5.1. Toward
Circularthe CircularisEconomy
economy a new business model approach that encompasses the redesign of
processes from the production
Circular economy is a new of business
productsmodel
and services
approachto the disposal
that of waste.
encompasses theItredesign
focuses
on circularity rather than linearity and aims to minimize resource extraction and
of processes from the production of products and services to the disposal of waste. It fo-optimize
resource
cuses onuse. As such,rather
circularity circular economy
than can
linearity andbe aims
seen as
to aminimize
promisingresource
approach to help meet
extraction and
global sustainability demands [50].
optimize resource use. As such, circular economy can be seen as a promising approach to
helpThe
meetdevelopment and management
global sustainability demandsof[50].
SH is a challenging issue, and the supply chain
in which hospitals are involved
The development plays a dynamic
and management of SH is aand active role
challenging in this
issue, andprocess [44].chain
the supply For
the development and management of SH, hospitals need to be inserted into a supply
in which hospitals are involved plays a dynamic and active role in this process [44]. For
the development and management of SH, hospitals need to be inserted into a supply chain
that shares the same culture committed to the development of a circular economy. Other-
wise, SH development and management become less effective since the services provided
by hospitals and the fulfillment of all sustainability-related goals are hindered by the in-
compatibilities of the different visions and engagement of the organizations that make up
Sustainability 2022, 14, 9730 10 of 21

chain that shares the same culture committed to the development of a circular economy.
Otherwise, SH development and management become less effective since the services
provided by hospitals and the fulfillment of all sustainability-related goals are hindered
by the incompatibilities of the different visions and engagement of the organizations
that make up the chain [17]. This synergy between the hospital and the other members
of the supply chain to which it belongs strongly influences the practices and decision
processes, positively impacting sustainability [21]. Thus, hospitals must “make decisions
that impact sustainability in a shared manner with the other members of their supply
chain (E6)” as a sustainable management strategy. This synergy is enhanced through
long-term business relationships focused on sustainability, which demand the commitment
of the entire chain. Furthermore, hospitals are institutions that should act as leaders
that encourage sustainability within this complex chain, which includes several types of
manufacturers, distributors, and suppliers.
In this context, although sustainable procurement is a common practice among hos-
pitals that aim to develop sustainability, they face difficulties in finding information that
can guide this process [51]. To help overcome this difficulty, the ISO 20,400 standard pro-
poses guidelines for the sustainable procurement process that cover political and strategic
aspects, aiming at the alignment of contracts with the hospital’s sustainability objectives
and goals [52]. It is important that hospitals “develop and/or improve the sustainable
procurement process (E23)” to make good financial deals and bring benefits to society and
the environment.
Another difficulty faced by hospitals is selecting sustainable suppliers because several
criteria are used in decision making and often these criteria are conflicting [51]. In a tra-
ditional supply chain, the most important criteria for supplier selection are price, quality,
and delivery, whereas in a sustainable supply chain, supplier selection also includes envi-
ronmental (based on environmental impacts) and social (occupational, health, and safety
issues) criteria [15]. The “insertion of sustainability criteria for hospitals’ supplier selection
(E15)” plays a key role in applying circular economy to the performance of sustainability
of hospitals and their supply chains. Thus, it is recommended that hospitals consider
this element during sustainability management to ensure that the working conditions of
employees and their suppliers are appropriate, that the products or services purchased are
sustainable, and that socioeconomic issues, such as inequality and poverty, are considered
during their supplier selection.
In addition to the selection of sustainable suppliers, it is important to develop partner-
ships with suppliers to promote circular economy, focusing on practices to reduce, recycle,
and reuse materials and reverse logistics is one of these practices that integrate SSC [21].
Several items can be destined for reverse logistics, from product packaging to expired
medicines [53]. Hospitals should “develop partnerships for reverse logistics of hospital
products (E27)” enabling recyclable products to be able to continue in the cycle and return
safely to society, fulfilling their SSC path.
Similarly, hospitals are advised to “establish partnerships with material recycling
companies (E16)” to promote circular economy. Ref. [54] cites examples of materials, such
as paper and cardboard, plastic, glass, aluminum, electronics, batteries, light bulbs, TNT—
Trinitrotoluene blankets, alcohol gel bags, syringes, cooking oil, thinner, and organic waste,
which after being duly selected in the selective waste collection, can be sent for recycling
instead of going to landfills. This element also promotes corporate social responsibility
(CSR) with the local communities because the collaboration with recycling companies can
be expanded to local seamstress cooperatives, craft fairs, and vocation schools, among
others. These partnerships strengthen CSR, paving the way for the generation of value for
the hospital and stimulating other similar initiatives [21].
The reuse of materials and instruments is a practice that has been advocated by circular
economy and contributes to sustainability, as it provides for optimizing the use of reusable
instruments and supplies and maximizing the reprocessing of single-use devices [55].
The “reuse of materials and instruments (E19)”, always complying with the disinfection
Sustainability 2022, 14, 9730 11 of 21

criteria, is another important element that hospitals should develop to promote increased
efficiency of available resources and avoid the emissions of pollutant gases generated in
the manufacturing processes of new materials.
In the context of circular economy, waste is considered as input for the production
of new products [47]. For this, it is necessary that hospitals manage this waste efficiently
and safely, from its generation to its final disposal, including the selection of a supplier
that meets the legal environmental requirements regarding the collection, transportation
and allocation of waste in landfills, and partnerships with suppliers in the case of reverse
logistics or with cooperatives to send the waste for reuse, recovery, recycling of materials,
etc. [21]. The World Health Organization (WHO) has indicated that waste management
should be more robust in view of the lack of strict legislation, inefficient management, and
the growing increase in hospital waste generation, which has been causing severe impacts
on public health and the environment [56]. It is essential that hospitals develop the element
of “hospital waste management (E1)” to mitigate these impacts. To accomplish this, hospi-
tals must comply with their country’s legislation and adopt environmental management
systems, such as ISO 14001. According to [57], an environmental management system
based on ISO 14,001 contains requirements for the development and implementation of
environmental policies to manage the environmental aspects of an organization’s products
or services.

5.2. Making Buildings Sustainable

Design, construction, operation, maintenance, and demolition are all stages of a
building’s life cycle that offer opportunities for the insertion of sustainability requirements.
Sustainable buildings are buildings designed, constructed, and operated according to these
requirements to increase their efficiency and decrease their impact on the environment and
public health [58]. To this end, sustainable buildings adopt solutions and technologies for
environmental preservation, saving natural resources, meeting the needs of the occupants,
and reducing operating costs. Sustainability requirements are relevant elements that must
be considered in the context of sustainable buildings and are usually studied according to
the environmental, economic, and social pillars reflecting positively on the environment,
on the satisfaction and comfort of its occupants, and on the hospital’s business [43].
Environmental sustainability requirements are related to the rational and sustainable
use of energy and water, the use of more sustainable materials during construction or
maintenance, the sustainable use of land, the efficiency of the air conditioning and lighting
system, and the environmental management of waste, among others [36,59]. Compliance
with environmental requirements allows hospitals to use natural resources more efficiently
in their operational processes [34]. As such, hospitals should “consider environmental
sustainability requirements in the design, construction, and operation of hospital building
facilities (E2)” to help balance resource consumption with the economic development of
the institution.
When designing sustainable hospital buildings, technologies that enable results, such
as lower waste generation, higher resistance to building deterioration, higher energy and
water efficiency, environments with more comfort and healthiness to the occupants, and
market valuation for the property, should be used [60]. All these results have an impact on
the reduction of operational costs and return on the capital invested in the construction,
maintenance, or renovation of the buildings, i.e., they reflect economic sustainability [43].
For example, the use of technologies aimed at reducing the energy consumption and emis-
sions of pollutant gases enables economic benefits proportional to the financial investments
made. Thus, it is recommended that hospitals “analyze the economic feasibility of using
technologies in the design, construction, and operation of their buildings (E30)”. The
feasibility of each technology employed for more sustainable buildings needs to be studied
in relation to its cost–benefit.
Social sustainability requirements, such as accessibility to social areas and the avail-
ability of public transportation, impact the perception of safety and physical and mental
Sustainability 2022, 14, 9730 12 of 21

well-being of building occupants (patients, visitors, and employees). Other social sustain-
ability requirements are not always so obvious to understand, such as indoor air quality,
thermal, acoustic, and visual comfort, but are equally relevant in this context. Incorporating
these requirements into the design, construction, and operation of buildings plays a key
role in hospital social sustainability management, benefiting patients and employees [36].
Increasing the level of patient satisfaction can speed up the recovery process and decrease
the length of hospital stay, which is directly related to the decrease in hospital costs [61].
Regarding the benefits provided to employees, working in an environment with these
characteristics is reflected in the reduction of medical errors, absenteeism, staff turnover,
and productivity gains [39]. Regarding this aspect, hospitals should “consider social sus-
tainability requirements in the design, construction, and operation of hospital building
facilities (E18)” so that they can fulfill their people-centered social role and thus boost social
sustainability.

5.3. Adopting Knowledge Management and Organizational Culture

What provides a sustainable competitive advantage to organizations is the knowledge
they hold, the efficiency with which they use information, and the speed with which they
make innovations from this knowledge. Tacit and explicit knowledge are converted into
organizational knowledge with the aim of improving communication and decision making,
bringing competitive advantages [62]. Knowledge management is the process of creating,
sharing, using, and coordinating knowledge by making it available to the organization’s
employees, improving the connectivity between knowledge sources and users [63].
For knowledge management, many organizations develop their intellectual capital.
Intellectual capital comprises human, structural, and relational capital. Human capital
represents the sum of the knowledge, skills, experiences, creativity, and capabilities of
an organization’s employees; structural capital represents the knowledge that remains
within the company such as organizational capabilities and commitments, knowledge
management systems, reward systems, information technology systems, databases, op-
erational processes, managerial philosophies, and organizational culture; and relational
capital is made up of the knowledge generated in the organization’s relationship with its
stakeholders [20]. Hospitals should “manage in a structured way the intellectual capital
in all its dimensions (human, structural, and relational capital) in order to contribute to
sustainability management (E28)”. By bringing all these dimensions of intellectual capital
together, hospitals will be able to strengthen their workforce and relationships with their
stakeholders and thus leverage social sustainability.
For the management of intellectual capital, the development of some elements consid-
ered essential is recommended: (1) “encourage the active participation of human resources
for the sustainable performance of hospitals (E25)”, because they play a key role in the
organization’s performance, which can lead to innovation and the efficient use of or-
ganizational resources to reduce threats and obstacles that hinder the achievement and
maintenance of sustainability [6]; (2) “empower employees and sensitize stakeholders and
suppliers (E4)” in order to enable the sharing of knowledge internally and in the supply
chain [21]; (3) “engage employees in the sustainable projects of hospitals (E12)”, where
this engagement should come from the leadership through the effective communication
of best practices, and by incentive systems that are able to recognize the effort and value
of employee initiatives [64]; (4) “foster the creation and implementation of sustainable
ideas (E13)”, because by encouraging suggestions, hospitals encourage their employees
to use and share their tacit knowledge to work together on solutions that contribute to
sustainability [62]; (5) “create work teams for implementation and operationalization of
sustainability (E8)”, because these teams promote collaboration between individuals and
facilitate the creation and implementation of new sustainable ideas. It is recommended
that these work teams be composed of inter- and multidisciplinary teams, as this will
bring together different expertise that will also help in problem-solving and improving
projects in general. These work teams can act to build an organizational culture focused
Sustainability 2022, 14, 9730 13 of 21

on sustainability [33]; and (6) “develop the ability to be open to change (E14)”, because
the implementation of new work routines and proposals related to sustainability requires
cultural and behavioral changes [47].
Another important element is related to the knowledge coming from stakeholders.
This element is essential for sustainability management in hospitals since stakeholders
(patients, community, employees, suppliers, R&D partners, shareholders, government, etc.)
are an important source of information that can increase the expertise of the hospitals’ hu-
man capital and thus boost the change towards sustainability [7,65]. For this, hospitals need
to “consider the views and needs of stakeholders during decision-making processes” (E3).
It is also important that health professionals acquire knowledge in undergraduate
and graduate courses about sustainability so that they understand both the impact of the
environment (temperature, air humidity, etc.) on health, and the impact of the health
system and its processes on preserving the environment [66]. Universities must insert in
their curricula subjects related to this topic so that students can acquire the knowledge that
adds to and strengthens a culture focused on sustainability and develop competencies in
the elaboration and conduction of environmentally sustainable projects [49]. Hospitals, on
the other hand, should “act as agents of demand for the insertion of sustainability issues in
the curricula of health courses (E24)” so that professionals arrive in the job market better
prepared for this new culture.
In addition, hospitals should align their culture with corporate social responsibility to
establish their commitment to society through social and educational projects, philanthropy,
ethics, and environmental preservation aimed at the public interest [6]. “Developing the
culture of corporate social responsibility (CSR) (E5)” can help hospitals with sustainability
as it provides a positive impact on society, the environment, and the satisfaction of their
employees and patients, improving their organizational image and the relationship with
their stakeholders.
Theoretical and empirical studies emphasize the importance of “integrating sustain-
ability into the mission, vision, and policies of hospitals (E26)” [33]. Defining these strategic
elements is important to direct the actions taken by hospital managers toward sustainabil-
ity and to make clear what goals are intended to be achieved and what strategies will be
adopted to do so.

5.4. Employing Management Systems, Tools, and Methods

Although sustainability principles have long been included in the business models
of many organizations, healthcare organizations have only recently begun the process of
implementing sustainability systems, methods, and tools. Like many other organizations,
sustainability in the healthcare sector can be considered a strategic issue with social, en-
vironmental, and financial results. As market competitiveness increases, organizations
need to innovate and adapt to new business models that incorporate sustainability in a
structured way [18].
Public–private partnerships (PPP) are considered a business model that can add value
to sustainability management in hospitals. In this model, public hospitals enter partnerships
with the private sector with benefits for both parties. Through PPP, it is possible for hospitals
to receive investments in technological innovations, which generate positive economic
impacts, increasing business sustainability, and social impacts, improving access and the
quality of patient care [48]. Therefore, it is advisable that hospitals “develop public–private
partnerships (PPP) (E22)” because this business model can reshape traditional healthcare
business models with savings and efficiency gains.
As with PPPs, corporate governance is another essential element that hospitals must
consider in managing sustainability. Corporate governance is a system by which an organi-
zation is controlled to ensure that organizations can be trusted with regard to transparency
and accountability; corporate responsibility; mechanisms to deal with conflict; methods to
improve the quality of systems and processes; and procedures, guidelines, and protocols
for decision making [67]. Sustainability management is a complex task and governance can
Sustainability 2022, 14, 9730 14 of 21

help hospitals in this challenge because it focuses on ensuring the integrity and seriousness
of organizational management. For this, it is recommended that hospitals “use corporate
governance in the management of sustainable systems and processes (E21)” to develop
sustainability strategies, acting in a way that adds value to the business, the community,
and the environment.
In this scenario, hospitals must focus on managing strategies, processes, and practices
that optimize healthcare considering sustainability aspects. Hospitals should develop a
strategic plan to help them define which direction to take to achieve and improve sustain-
ability effectiveness [43]. It is necessary to “define objectives, targets and key performance
indicators (KPIs) for hospitals (E11)”. This element, from strong governance, contributes
to the management of sustainability at the strategic, managerial, and operational levels,
helping in the processes of decision making, performance improvement, and the imple-
mentation of corrective actions, etc.
The ISO 14001 (Environmental Management) and ISO 50001 (Energy Management)
standards are being used in many hospitals with benefits evidenced in empirical studies.
They help hospitals to implement an environmental policy which results in the better
use of natural resources, the minimization of waste, the optimization of processes, and
increased productivity [44]. Sustainability management should “use management systems
in hospitals (E9)” to improve the eco-efficiency of hospital processes, which will certainly
make a difference in the quality of services provided, the preservation of the environment,
and the longevity of the business.
Health Technology Assessment (HTA) is a tool to evaluate the possible benefits and
risks at the moments of investment and disinvestment of health technologies in hospital
settings, considering the following aspects: safety; accuracy; efficacy; cost-effectiveness;
and equity, ethical, cultural, and environmental aspects [46]. Health technologies are
medicines, equipment, clinical and surgical procedures, and support systems in health
care for risk prevention, diagnosis, treatment, and rehabilitation [68]. Investment means
incorporating and using health technologies to achieve the maximum benefits from the
aspects mentioned above and disinvestment means the partial or total withdrawal of health
technologies that are not meeting these benefits [69]. It is recommended that hospitals “use
Health Technology Assessment (HTA) as a decision support tool (E7)” to achieve three
important benefits: 1. obtain information that will assist in the appropriate use of these
technologies through the assessment of their clinical properties and their possible effects
on patient health; 2. obtain financial resource savings through cost-effectiveness analysis
that will impact business and quality of care; 3. enable hospital managers to make more
assertive decisions during the investment and disinvestment of technologies in which they
will have financial, social, and environmental impacts.
Lean Six Sigma is a management method that, from the mapping of activities that do
not add value to operational processes, allows the elimination of waste and the reduction
of variability. In the hospital setting, this method contributes to the continuous improve-
ment of these processes, organizational productivity, patient care, and the rational use of
resources, thus positively impacting the economic, social, and environmental sustainability
of hospitals [32,70]. Thus, the element “implement Lean Six Sigma in hospitals (E29)” can
help hospitals become more efficient and sustainable in providing higher quality health
care services.

5.5. Applying Technological Innovations

Hospitals have been investing in Technological Innovations (TIs), such as use of 3D
printing technology, telemedicine, cloud computing, electronic medical records, virtual real-
ity, smart wearable devices, big data, internet of things, robotics, automated dosing medical
equipment, and artificial intelligence, among others [71,72]. Incorporating technological
innovations plays a key role in hospital sustainability management benefiting patients and
employees, hospitals, the members of the supply chain, and the environment [20].
Sustainability 2022, 14, 9730 15 of 21

TIs assist hospital management and hospital supply chain resilience and directly
and positively impact economic sustainability [47]. From them, it is possible to obtain
information that assists in decision making; in the exchange of patients’ medical data within
and between health institutions; and in tracking patient data, bringing agility and security
to operational processes and clinical care. They also allow hospitals to integrate real-time
information between administrative departments; reduce overcrowding and queues; reduce
costs from simulations and “smart” savings; and integrate the supply chain, expanding
communication, data sharing, flexibility, and productivity [45]. Therefore, hospitals should
“adopt technological innovations to aid economic sustainability in hospitals and the links
of their supply chain (E10)” as a driver for sustainability management.
TIs also contribute positively to environmental sustainability in hospitals by mitigating
negative impacts from hospital operational processes [48]. Some examples of its application
are the use of telemedicine enables remote care, which reduces the amount of travel and
consequently the emission of pollutant gases [20]; electronic medical records limit the use
of paper and decrease the amount of waste [71]; real-time energy consumption tracking
software assists in energy management and efficient energy use [60]; and automated
weighing systems assist in waste management [56], etc. Therefore, it is advisable to “adopt
technological innovations to improve environmental sustainability (E17)” because based on
them, it will be possible to manage natural resources more efficiently; reduce the emission
rate of pollutant gases; and control the generation, treatment, and disposal of waste.
In addition, TIs have positive impacts for social sustainability from the benefits they
bring to patients and employees. For patients, these impacts are present from face-to-face
care to care that can also be provided virtually outside the hospitals [71]. In addition, these
innovations increase the ability of patients to control their own illnesses with the direct
and remote supervision of healthcare professionals. This is made possible by telemedicine
equipment, such as cameras, sensors, and telephone/internet connections, that record vital
signs and other patient parameters that are sent directly to the responsible physicians [48].
Regarding healthcare professionals, technological innovations improve the assertiveness of
diagnoses, reduce errors, and assist in computer-aided drug dosage calculation systems,
etc. These and countless other benefits make healthcare services more efficient and effective.
In turn, healthcare professionals can make better decisions; access information remotely
and in real time; reduce emotional stress, etc. [20,73]. Therefore, hospitals should “adopt
technological innovations to improve social sustainability (E20)” because based on them it
will be possible to make better diagnoses and prescribe more effective treatments, increasing
the life chances of many patients and promoting employee satisfaction, health, and safety.
By presenting and discussing the proposed drivers, this study answered the following
research question: how is it possible to develop and manage sustainability in hospitals?
Based on the content analysis performed on the selected scientific literature, it can be
determined that the proposed drivers will help hospitals manage sustainability in a systemic
way because they encompass the three dimensions of sustainability (TBL), which in the
business field is called corporate sustainability. According to [74], when actions aimed
at CS are developed in order to encompass more than one dimension of sustainability
by integrating these dimensions, the results of these actions can be enhanced. Thus, this
study proposes drivers directed to the development and management of CS in hospitals
that are transversal to the TBL dimensions, i.e., they encompass the economic, social, and
environmental dimensions. Moreover, they are interrelated and the development of each
one supports the development of the others.
However, it is important to emphasize that some hospitals are more developed than
others in sustainability management and face some challenges with greater or lesser in-
tensity depending on their peculiarities. In this sense, the proposed drivers should be
developed and prioritized according to the degree of development in sustainability (aware-
ness of the theme, development of actions and projects, availability of resources, etc.) of
hospitals. Thus, they can be implemented sequentially or even in parallel.
Sustainability 2022, 14, 9730 16 of 21

6. Conclusions
This work proposes a framework containing drivers to develop and manage sustain-
ability in hospitals, thus filling the scientific gap that indicated the need to develop solutions
for sustainability adapted to the reality of healthcare institutions settings. Reaching this
goal also enabled the research question “in what way is it possible to develop and manage
sustainability in hospitals?” to be properly answered. This work was carried out using the
method of “content analysis“ of the 30 most influential articles on SH between 2016 and
2021. As a result, five drivers for the management and development of SH were proposed,
enabling public and private hospitals to develop actions in the three pillars of TBL.
This work contributes scientifically and theoretically to the academic maturation of the
topic of sustainability in hospital settings by systematizing elements and adding insights
to the state of the art on SH. The proposition of drivers based on structuring elements
deepens and expands the studies already conducted on the subject, providing a basis for
the development of new research and a reference point for the analysis and discussion
of empirical studies. As an applied-managerial contribution, the proposed drivers assist
public and private hospital managers in developing and managing sustainability in order
to make their businesses fairer, greener, and more prosperous and fulfill their commitments
to the well-being of their employees and society.
The provision of hospital services based on sustainability has the potential to con-
tribute to sustainable development by evidencing environmental, social, and financial
benefits that go beyond the hospital itself. A collective movement for the development
of sustainability in hospitals will positively impact the other companies that are part of
their supply chain, reflecting in gains for society and the ecosystem. In this work, the three
dimensions of sustainability were dealt with jointly, culminating in drivers to help hospitals
equate sustainability in an integrated manner, providing a basis for a movement towards
the premises of the United Nation’s Agenda 2030. This agenda signals the need to create
strategies that improve health and education, reduce inequality, stimulate economic growth,
and combat climate change. Therefore, it is imperative that hospitals make contributions,
act cooperatively by sharing knowledge among themselves, and be inspiring examples to
other service sector companies.
The framework proposed in this study can be expanded if a larger number of articles
is considered in future research because, in this way, other important aspects for the
development and management of sustainability in hospitals can be added. Therefore, it is
recommended that future studies increase the number of papers analyzed and continue the
study of the fundamental bases of the development and management of sustainability in
hospitals developed in this work, adding new elements to the drivers, or even proposing
new drivers for the continuous scientific advancement of this topic. Other opportunities
for future studies concern how other health care organizations, such as clinics, laboratories,
dental offices, and veterinary offices and their workforces, can become sustainable by
adopting practical solutions that strengthen their social, environmental, and economic roles.

Author Contributions: Conceptualization: K.B.d.O.; Formal analysis: K.B.d.O.; Investigation: K.B.d.O.;

Methodology: K.B.d.O.; Writing—original draft: K.B.d.O.; Funding acquisition: O.J.d.O.; Supervision:
O.J.d.O.; Validation: O.J.d.O.; Writing—review and editing: O.J.d.O. All authors have read and agreed
to the published version of the manuscript.
Funding: This research was funded by Coordination for the Improvement of Higher Education
Personnel (CAPES), grant number 001 and National Council for Scientific and Technological Devel-
opment (CNPq) grant number 312538/2020-0.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.
Sustainability 2022, 14, 9730 17 of 21

Appendix A

Table A1. The 30 most cited articles in Corporate Sustainability in Hospitals from 2016 to 2021.

No. Times Cited (17

Title Author(s)/Year Journal February 2021)
A hybrid multi-criteria decision-making method
1 approach for selecting a sustainable location of Chauhan and Singh (2016) Journal of Cleaner 73
Production
healthcare waste disposal facility
Progressing in the change journey towards Journal of Cleaner
2 Pinzone et al. (2016) 72
sustainability in healthcare: The role of ‘Green’ HRM Production
Navigating the sustainability landscape: a systematic Lennox, Maher, and Reed
3 Implementation Science 54
review of sustainability approaches in healthcare (2018)
Sustainable supplier selection in healthcare industries
using a new MCDM method: Measurement of Computers and Industrial
4 Stević et al. (2020) 49
alternatives and ranking according to Engineering
Compromise solution
Exploration of social sustainability in healthcare Journal of Cleaner
5 Hussain et al. (2018) 37
supply chain Production
A review of sustainable energy access and Sustainable Energy
6 technologies for healthcare facilities in the Franco et al. (2017) Technologies and 31
Global South Assessments
Envisioning smart and sustainable healthcare: 3D
7 Aquino et al. (2018) Futures 29
Printing technologies for personalized medication
Social sustainability in healthcare facilities: a rating
8 tool for analyzing and improving social aspects in Capolongo et al. (2016) Annali dell’Istituto 29
Superiore di Sanita
environments of care
Cataract surgery and environmental sustainability:
9 Waste and lifecycle assessment of Thiel et al. (2017) Journal of Cataract and 25
Refractive Surgery
phacoemulsification at a private healthcare facility
The impact of green human resource management
10 Journal of Cleaner 24
practices on sustainable performance in healthcare Mousa and Othman (2020) Production
organizations A conceptual framework
Public healthcare practices and criteria for a
Chiarini, Opoku, and Journal of Cleaner
11 sustainable procurement A comparative study 23
Vagnoni (2017) Production
between UK and Italy
A proposed healthcare supply chain management
framework in the emerging economies with the Resources, Conservation &
12 Scarvada et al. (2019) Recycling 22
sustainable lenses: The theory, the practice, and
the policy
The healthcare sustainable supply chain 4.0: The
13 circular economy transition conceptual framework Daú et al. (2019) Sustainability 22
with the corporate social responsibility mirror
Lean six sigma and environmental sustainability: A Zhu, Johnson, and Sarkis
14 Supply Chain Forum 22
hospital perspective (2018)
Does intellectual capital promote the shift of
Cavicchi and Vagnoni Journal of Cleaner
15 healthcare organizations towards sustainable 21
(2017) Production
development? Evidence from Italy
Fulfilling a new obligation: Teaching and learning of
16 sustainable healthcare in the medical education Tun (2019) Medical Teacher 19
curriculum
Enhancing the sustainability and climate resiliency of
17 Pan American Journal of 19
health care facilities: a comparison of initiatives Balbus et al. (2016) Public Health
and toolkits
Sustainability in health care by allocating resources
effectively (SHARE) 3: examining how resource Harris, Allen, Waller et al. BMC Health Services
18 18
allocation decisions are made, implemented, and (2017) Research
evaluated in a local healthcare setting
Sustainability in Health care by allocating resources
effectively (SHARE) 1: introducing a series of papers Harris, Green, Ramsey BMC Health Services
19 18
reporting an investigation of disinvestment in a local et al. (2017) Research
healthcare setting
Sustainability 2022, 14, 9730 18 of 21

Table A1. Cont.

No. Title Author(s)/Year Journal Times Cited (17

February 2021)
Healthcare sustainability and the role of Journal of Intellectual
20 Cavicchi (2017) 18
intellectual capital Capital

21 Big Data for the Sustainability of Healthcare Visconti and Morea (2019) Sustainability 17
Project Financing
Sustainability in Health care by Allocating Resources
Harris, Allen, King et al. BMC Health Services
22 Effectively (SHARE) 2 identifying opportunities for 17
(2017) Research
disinvestment in a local healthcare setting
Development of a healthcare building sustainability
23 assessment method - Proposed structure and system Castro, Mateus, and Journal of Cleaner 17
Bragança (2017) Production
of weights for the Portuguese context
Health technology performance assessment: International Journal of
24 Real-world evidence for public Guerra-Júnior et al. (2017) Technology Assessment in 16
healthcare sustainability Health Care
Motivators of social sustainability in healthcare Sustainable Production
25 Khan et al. (2018) 15
supply chains in the UAE-Stakeholder perspective and Consumption
Sustainability in health care by allocating resources
effectively (SHARE) 4: exploring opportunities and BMC Health Services
26 Harris et al. (2017) 15
methods for consumer engagement in resource Research
allocation in a local healthcare setting
Identification of core objectives for teaching
27 Teherani et al. (2017) Medical Education Online 15
sustainable healthcare education
Can Public-Private Partnerships Foster Investment
28 Moro Visconti et al. (2019) Sustainability 14
Sustainability in Smart Hospitals?
Implementation of a multi-variable regression
analysis in the assessment of the generation rate and
Waste Management &
29 composition of hospital solid waste for the design of a Al-Khatib et al. (2016) 14
Research
sustainable management system in
developing countries
Healthy and Sustainable Hospital Evaluation-A
Brambilla and Capolongo
30 Review of POE Tools for Hospital Assessment in an Buildings 13
(2019)
Evidence-Based Design Framework

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