Future direction of sustainable development

in private hospitals: general similarities

and specific differences
Rocío Rodríguez and Göran Svensson
Kristiania University College, Oslo, Norway, and
Carmen Otero-Neira
Department of Marketing and Management, University of Vigo, Vigo, Spain

Abstract
Purpose – The purpose of this paper is to assess the future direction of sustainable development in the healthcare industry. This study aims to
reveal general similarities and specific differences between private hospitals and enabler or hinders of sustainable development.
Design/methodology/approach – Based on an inductive approach, judgmental sampling was applied to select relevant healthcare organizations.
Informants were identified according to their knowledge of their organizations’ sustainability initiatives.
Findings – In the context the homogeneity that could be expected, the studied hospitals range from having a very strong organizational conviction
as to the future direction of sustainable development to a very weak one. There are some general similarities and specific differences between them
reported.
Research limitations/implications – There is no common formula applicable across private hospitals to determine the future direction of their
sustainable development. Although hospitals benchmark best practices, others use them only as a general frame of reference. This scenario offers
opportunities for further research.
Practical implications – The economic, social and environmental sustainable development across private hospitals may evolve from general
principles or guidelines, but the specific sustainable development at each hospital may well evolve along tailored economic, social and
environmental actions.
Originality/value – Developing a framework considering similarities and differences between the sustainability actions of each hospital in the
healthcare industry is important for understanding future directions. This study provides insights into factors that could enable success or constitute
hinders of sustainable development. They can also guide the industry toward a common objective which improves the hospitals sustainability
actions in the future, also minimizing the effort required.
Keywords Healthcare, Spain, Sustainable development, Sustainability management, Private hospital
Paper type Case study

Introduction (2015a) indicated, in today’s service business strategies,

Since the earliest days of organizations, business and,
therefore, marketing between organizations have been
around (Hadjikhani and LaPlaca, 2013). For a meaningful
marketing perspective, the study of business-to-business
(B2B) relationships and networks of all stakeholders (e.g.
buyers, sellers, intermediaries) is significant (Hedaa and
Törnroos, 2008; Svensson et al., 2018a).
Accordingly, the interest in the topic of sustainability is
growing (Schulz and Flanigan, 2016). From early works in
the field, such as Porter and van der Linde (1995), there is
nowadays a clear acknowledgement that sustainability and
sustainable development generate competitive advantages
and profitability for firms (Lloret, 2016). As Enquist et al.
The current issue and full text archive of this journal is available on
Emerald Insight at: www.emeraldinsight.com/0885-8624.htm
there is a compelling need to incorporate current landscape
challenges, such as sustainability and stakeholders’
relationships (Ferro et al., 2017; Laurell et al., 2018;
Svensson et al., 2018a). In addition, Truffer et al. (2010)
indicated specifically that the healthcare sector has broad
implications for sustainable development, and that there is
plenty of room for improvement.
Sharma et al. (2010, p. 30) write that:
[. . .] while the importance of environmental sustainability for business
performance and competitive advantage are now better accepted, research
on appropriate strategies to implement environmentally sustainable
corporate programs are still in their infancy within business to business
marketing [. . .].
Furthermore, Saviano et al. (2010) argued that, particularly in
the healthcare sector, relationships and networks are very
complex. Spohrer et al. (2007, p. 75) affirm that sustainability
is an “[. . .] extremely relevant target [. . .]”, given that the

Received 20 December 2018

Journal of Business & Industrial Marketing Revised 25 March 2019
© Emerald Publishing Limited [ISSN 0885-8624] 17 April 2019
[DOI 10.1108/JBIM-12-2018-0399] Accepted 24 April 2019
 Sustainable development
Rocío Rodríguez, Göran Svensson and Carmen Otero-Neira
growing demand for healthcare in developed countries
generates a context of scarce resources.
Consequently, the study of sustainable development within
the healthcare industry seems a significant aspect in the
development of B2B marketing theory. The value that suppliers
(private hospitals) in a service healthcare context drive to end
consumer is delivered: “[. . .] through a complex web of direct
and indirect relationships between value network actors [. . .]”
(Basole and Rouse, 2008, p. 53). Thus, understanding the
direction of sustainable development and those sustainability
initiatives developed will improve B2B knowledge because the
initiatives taken by firms in an industrial environment (Hsu
et al., 2013) go along the value chain and affect not only the
final consumer, but the different stakeholders of hospitals.
In addition, the focus on sustainable development in
research started with environmental issues, yet nowadays, the
marketing and management literature widely recognizes the
triple bottom line (TBL) framework (Ferro et al., 2019;
Svensson et al., 2016), developed by Elkington (1998), and
aiming at operationalizing sustainability and sustainable
development in firms. The TBL approach considers the need
to simultaneously achieve economic prosperity, environmental
quality and social equity as the basis for competitive advantage
in the long term (Carter and Easton, 2011; Lee and Lee Lam,
2012).
However, few studies consider the three dimensions of
sustainability simultaneously (Seuring and Muller, 2008),
though there are recent ones nowadays (Ferro et al., 2019;
Svensson et al., 2018b) Likewise, and besides the importance of
the sustainable development in hospitals (Berman, 1995),
“[. . .] the healthcare sector has not received systematic
attention [. . .]” (Jamali et al., 2010, p. 591). Although there are
some studies on sustainability focusing on healthcare (Ahsan
and Rahman, 2017; Campion et al., 2015; Pantzartzis et al.,
2017; Pinzone et al., 2016), to the best of the authors’
knowledge, there are rare (if any) empirical studies on the
future direction of sustainable development in specific
organizations. Thus, this study aims to contribute to knowledge
of sustainability and sustainable development by focusing on
the healthcare industry and those initiatives taken along the
value or supply chain considering the three dimensions of the
TBL.
Even acknowledging that research on sustainability is
growing in business and marketing literature, these studies fail
to clearly explain how to implement sustainability practices
(Pagell and Shevchenko, 2014; Seuring and Muller, 2008),
recognize the sustainable development in the context of
business and stakeholders’ relationships (Sharma et al., 2010)
and/or understand how sustainability initiatives taken by a
company evolve over time into the future (Høgevold et al.,
2014). Also, it is relevant to understand these issues in the
context of service industries, like the healthcare, where
stakeholder relationships are common and complex (Basole
and Rouse, 2008). Moreover, Golicic and Smith (2013)
claimed that the industrial process extends the focus of
sustainability beyond the company to include all members of
the supply chain.
Additionally, and according with the WCED (1987),
sustainability is future-oriented. In this regard, authors such as
Walker and Laplume (2014) and Høgevold and Svensson
Journal of Business & Industrial Marketing
(2016) confirm that sustainability requires a long-term
orientation. Likewise, the efforts made by firms in terms of
approaching sustainability over time (Dyllick and Hockerts,
2002) and firms might need to change the future direction of
their sustainability priorities (Høgevold et al., 2014) to adapt to
customer needs (Maletic et al., 2018).
Studies like Høgevold and Svensson (2016) and Høgevold
et al. (2014) consider evolutionary directions on sustainable
development, but from the past up to the present and without
taking into account the future. This lack of research yields only
scant knowledge on the appropriate hospital configuration or
how to approach the necessary changes to face new challenges
in the healthcare sector (Edwards and Harrison, 1999; Healy
and McKee, 2002). Therefore, we focus on the how
sustainability initiatives undertaken by private hospitals evolve
over time, aiming to understand their future directions of
sustainable development. Thus, the main significance and
contribution of this study is to develop a framework that
explores how sustainability initiatives evolve over time into the
future focusing on the domain of B2B networks in the
healthcare industry.
There is a need to connect strategic and operational aspects
of sustainability. In doing so, the research objective of this study
is to assess the future direction of sustainable development in
private hospitals, based on general similarities and specific
differences. The similarities provide the foundation for
sustainable development within the industry studied (here
healthcare), to assess the specific differences within the
organization (here private hospitals) in the same industry. For
this purpose, we use a case study methodology framed in
Spanish private hospitals.
On the basis of the above, this study focuses on common
denominators and differentiators between organizations’ future
direction of sustainable development. This manuscript is
structured as follows. First, the previous literature on the main
concepts, such as sustainability and the TBL approach or
sustainability in healthcare industry, are reviewed. The
methodology followed in the study is the next section and
describes the steps followed in the qualitative study. Then, the
empirical findings follow, and a subsequent discussion of the
findings is carried out. The general similarities and specific
differences are reported, as well as the implications for both
researchers and practitioners. Lastly, conclusions and
suggestion for the future are outlined.
Conceptual framework
Triple bottom line approach of sustainability to create
value
The relationships between firms must adapt to changes in their
environments if they want to remain competitive (Grewal et al.,
2007). In this regard, one of today’s major trends related to a
firm’s environment is the growing recognition of sustainability
issues along the value chain (Carter and Easton, 2011;
Enquist et al., 2015b). Business sustainability can be seen as
“[. . .] an organization’s efforts to manage [. . .] its impact on
Earth’s life and eco-systems [. . .] within its whole business
network [. . .]” (Svensson and Wagner, 2012, p. 544).
Sustainability is rapidly changing both the corporate
environment and the way in which firms do business
 Sustainable development
Rocío Rodríguez, Göran Svensson and Carmen Otero-Neira
(Linnenluecke and Griffiths, 2013), specifically in industrial
environments (Hsu et al., 2013). And importantly,
sustainability can make firms more competitive (Hallstedt et al.,
2013). Furthermore, Hussain et al. (2018) indicated that firms
can remain sustainable without detriment to their productivity
and profitability.
In this regard, sustainable development in business models
implies the need for economic, social and environmental
sustainability (Bocken et al., 2013; Carter and Rogers, 2008).
That is, firms need to achieve the so called TBL approach of
sustainability (Elkington, 1998). This TBL thinking integrates
profit, people and planet into corporate culture, strategy and
operations within a broad perspective (Kleindorfer et al., 2005).
It has been affirmed that this way to do business and the
associated view of responsibilities and managing them under
this TBL approach creates value (Yang et al., 2017) and
competitive advantages (Schulz and Flanigan, 2016). In fact,
sustainability is transforming the competitive landscape of
industries (Enquist et al., 2015a) and the relationships of the
firm with its stakeholders along the value chain (Basole and
Rouse, 2008; Golicic and Smith, 2013).
In marketing and management research, there is no doubt as to
the need to incorporate economic, social and environmental
considerations into managerial decisions to improve competitive
advantages (Hussain et al., 2018; Lloret, 2016). Blenkhorn and
MacKenzie (2017, p. 1173) claim that: “[. . .] in addition to
providing a superior value-based product or service, must
demonstrate that they produced it in an environmentally friendly
manner [. . .]”. And Schulz and Flanigan (2016; p. 449) affirmed
that rather than considering sustainability as a constraint, or a
cost, companies understand it “as a potential source of
innovation and competitive advantage by using better inputs,
achieving higher quality or improving product”. As a whole, the
TBL sustainability approach implies long-term change in the way
they do business, not only focusing on economic benefits, but
also seeking environmental and social ones (Elkington, 1998).
Sustainability initiatives
Kumar and Rahman (2015) indicate that there are two main
reasons for firms to adopt sustainability practices in the
industrial environment: external pressure and to seek
competitive advantages. In either case, the firm “[. . .] faces
certain economic, technological and operation-specific
barriers. Thus, firms require effective strategies to overcome
these barriers in order to make the supply chain more
sustainable [. . .]”.
Services firms are very much concerned about creating
sustainable value to the firm and its stakeholders. In fact, if
firms do not take note on sustainability issues, they will be at a
competitive disadvantage (Lash and Wellington, 2007). This
implies firms strategically managing sustainability
(Baumgartner, 2014), particularly in B2B contexts (Sharma
et al., 2010), and develop sustainable initiatives to be more
competitive (Hallstedt et al., 2013).
The opportunity to develop competitive advantages becomes
even more important as more firms develop sustainable
development programs (Schulz and Flanigan, 2016). In a B2B
context, a company pursuing sustainability “must be aware of
various stakeholders who influence or are influenced by
sustainability decisions” (Presley and Meade, 2010, p. 436).
Journal of Business & Industrial Marketing
Also, in seeking sustainability as a source of competitive
advantages, benchmarking capabilities is a very important tool
(Vorhies and Morgan, 2005), that is, benchmarking allows
firms to find and recognize those sustainability best practices
and, then, try to replicate them in their own company.
However, there are challenges involved in implementing
sustainability initiatives within a firm. In this regard, Daily and
Huang (2001) indicate that there is a lack of clarity on how to
implement sustainability in organizations. Leuenberger and
Bartle (2009) argue that a sustainable development plan must
integrate sustainability into the decision-making which is not
always easy. Moreover, Dyllick and Hockerts (2002) confirm
that sustainability initiatives evolve over time and require a
long-term orientation. Lloret (2016, p. 418) indicate that:
“[. . .] sustainability implies continuity [. . .]”. Therefore, and
keeping in mind that business sustainability implies satisfying
the needs of current and future stakeholders (Maletic et al.,
2014), there is a need to connect strategy and sustainability
along the timeline.
Sustainable development in the healthcare
industry
The healthcare industry has shifted from its traditional business
models (Hwang and Christensen, 2008). In particular, in the
European healthcare industry, there has been an increase in
private hospitals during the past few decades. These hospitals,
which are in fact private firms, need to face significant
challenges in adapting to their environment, such us the aging
European population or new and expensive medical and
technological developments (Anderson et al., 2018). The
increase in market competition forces also private hospitals to
be more market-oriented and face a radical redesign of their
strategies to obtain economic outcomes while still considering
all stakeholders in the network.
Berman (1995, pp. 19-20) indicate that: “[. . .] the increase in
healthcare consumption is antagonistic to sustainable
development [. . .]”. In this vein, the growth and increasing
amount of dangerous waste in the healthcare industry (Chung
and Meltzer, 2009) entails a direct responsibility with respect to
patient and community health. In such an environment, the
pursuit of sustainable development is an imperative, as private
hospitals need to integrate legislation with public opinion
(Jayaraman et al., 2007). Indeed, the interests of the
environment and society with firms’ operations coincide along
the value chain (Savitz and Weber, 2006). What is more, a
sustainable approach in the hospital to redesign processes
would engage the stakeholders in a more logical and consistent
decision-making process.
Given the dynamic nature of the healthcare industry, private
hospitals really do face significant challenges. An important one
is to perform their strategic, as well as operational, redesign
while taking into account a sustainable approach on the basis of
the TBL dimensions (economic, social and environmental), to
create value along the value chain and subsequently
contributing positively to sustainable development of the
industry (Baumgartner, 2014). The appropriate hospital
configuration for facing sustainability should be led by patient-
focused management, as well as an improvement of facilities
and a more cost-effective use of resources (MARU, 2001).
 Sustainable development
Rocío Rodríguez, Göran Svensson and Carmen Otero-Neira
Triple bottom line and sustainability initiatives in
the healthcare industry
Sharma (2003) confirms that the healthcare industry needs to
pursue sustainability practices to improve their economic and
social well-being, and Wijethilake (2017) indicates that
organizations should be proactive in terms of environmental,
economic and socially related practices. In this manner, private
hospitals are trigged to proactively undertake reforms and
radically redesign their strategies, to achieve a triple target of
efficiency, effectiveness and sustainability (Spohrer et al.,
2007). The TBL encourages private hospitals to add social and
environmental components to their financial assessment
(Schulz and Flanigan, 2016). By doing so, such hospitals will
offer a higher-quality service in accordance with the
population’s health needs, as well as economic outcomes for
stakeholders.
On the basis of these TBL dimensions, healthcare
sustainability creates value (Lopez-Casasnovas et al., 2005;
Stevanovic et al., 2017). In the healthcare sector, private
hospitals generate for their stakeholders, economic as well as
social and environmental benefits. Indeed, from an economic
point of view, healthcare services from private hospitals are
relevant and contribute to economic growth in Europe
(Suhrcke et al., 2005) while exerting a substantial impact on
local or regional-related industries in the B2B network (Lopez-
Casasnovas et al., 2005). For instance, when optimizing
procedures, a private hospital can improve local employment
prospects, workforce productivity and even lower labor costs in
the local supply chain (Suhrcke et al., 2005).
Apart from economic issues, private hospitals also participate
in environmental and social aspects throughout the healthcare
value chain, promoting and developing sustainability initiatives
that improve B2B relationships (Perkins and Brewer, 2010). In
fact, considering the social aspect, the healthcare sector is
directly responsible for overall population health (Lopez-
Casasnovas et al., 2005) and, thus, community well-being
(Chung and Meltzer, 2009). Likewise, improving population
health, together with local economic regeneration and the
development of local labor market, should lead private
hospitals to strengthen social cohesion within their scope of
influence (Watson, 2006).
Lastly, in terms of environmental concern, the focus on
reusing sustainability behavior in private hospitals is less
common regarding security and infectious risks, and the
growing increase in the use of medical disposables is neither
environmentally not financially favorable. Thus, other
sustainability initiatives such as the reduction of emissions,
improvement of energy efficiency, stricter control of wasted
water or recycling hospital waste have greater potential impact
on environmental sustainability. As sustainability decisions are
at the strategic level (Engeert et al., 2016) and the CEOs are the
ones with the authority to implement sustainability initiatives,
private hospitals need to change their entire organizational
culture toward sustainability to achieve success regarding such
actions. Moreover, the utilization of sustainable development
indicators in the healthcare sector would contribute to a
quantification of the economic, social and environmental
efforts of hospitals (Lopez-Casasnovas et al., 2005).
Journal of Business & Industrial Marketing
In all, and due to the need for private healthcare service firms
to survive in a competitive environment, with demanding
customers and the many stakeholders involved in the network,
understanding the management of sustainability issues and the
direction of sustainability initiatives, as well as the various
similarities and differences within industry, is highly relevant.
Private hospitals can and should contribute to improving
sustainability related to economic, social and environmental
issues. Therefore, developing a framework considering the
similarities and differences of the sustainability actions of each
hospital in the healthcare industry is important for
understanding future directions of sustainable development. At
the same time, this will help private hospitals to face and
overcome their future challenges in terms of sustainability
within the broader healthcare industry.
Methodology
The selection of private hospitals in the Spanish healthcare
industry is based on a spectrum from strong to weak
organizational conviction regarding the importance of engaging
in sustainable development, so as to reveal general similarities
and specific differences between them. Rahman et al. (2018,
p. 349) define private health services as: “[. . .] delivered by
individual and institutions not administered by the state
government [. . .]”.
Reasons of industry selection
The healthcare industry has been selected for several reasons.
The health of patients is indirectly related to care of the
environment, and the patients form society itself. Therefore,
attracting patients to the hospital is linked to the responsibility
of caring for society. Accordingly, the activities undertaken in
this industry are related to sustainable development.
Furthermore, this is one of the industries in which a
comparison between organizations is possible, because all of
them have to follow the same rules (although each private
hospital is a different organization), and it is a strictly regulated
industry, as shown by the Royal Decree 1277/03, which mainly
states aspects related to: available space, resource endowment,
accessibility of patients, mobility of patients, mobility of
sanitary waste and security measures.
In addition, this industry is one of those with progressive
sustainable development, in part because sustainability is
viewed as synonymous with hospital quality. Choosing just one
industry also helped to control the potential interference of
other factors, thereby avoiding contextual bias (Hartline and
Jones, 1996).
Qualitative approach
This study was based on an inductive approach (Tomas, 2006)
and also uses an inductive multiple case methodology, which
has various advantages. On the one hand, it facilitates the
understanding of complex phenomena whose analysis requires
interaction between the informant and the researcher and also
requires several sources of information Yin (2009). On the
other hand, our exploratory questions implicitly take into
account the experiences and context of the informants
(Eisenhardt, 1989).
 Sustainable development Journal of Business & Industrial Marketing
Rocío Rodríguez, Göran Svensson and Carmen Otero-Neira

Furthermore, the exploratory stage of the research is development. Furthermore, all of the hospitals were from
reflected in the industry practice, which to date, lacks different healthcare regions in Spain.
comprehension of the future direction of sustainable
development. Qualitative research offers potential for Interview characteristics
understanding the practices related to implement sustainability The research team was interviewing two profiles in each private
(Eisenhardt, 1989). In addition, the case study designs enable hospital. First one was the CEO of each hospital who
us to drive properly the social desirability bias associated with commented to the research team the main lines of sustainability
all sustainability studies. The researchers avoid this bias by planning. The CEO is the maximum responsible of all the
framing the interview questions and relying on data activities in the private hospital and has general and complete
triangulation (Crane, 1999). information. The second profile was the person responsible in
charge of the detailed sustainability planning that was the
communication director of the hospital, who provided insights
Research process not documented elsewhere (e.g. annual reports and websites).
The theoretical propositions developed by Yin (1994) guided This profile grouped the detailed sustainability planning of all
the data collection and the analysis. Figure 1 summarizes the the departments in private hospitals, the entire organization.
methodology and procedure. For more than two years, the research team had performed a
series of in-depth interviews with all of four hospitals, to
Sample selection understand the changes in their planning for future sustainable
Fischhoff and Bar–Hillel (1982) provided the basis for selecting development. Table I shows the main characteristics of these
hospitals through a judgmental sampling procedure. First, the hospitals. Hospitals were asked about their plans for sustainable
research team contacted the CEO of 33 private hospitals of all development in different areas through a wide range of
ages, kind of ownerships and locations in Spain, as the main questions aimed at assessing the direction of sustainable
development, as outlined by Høgevold et al. (2014) and
requirement to be included in this study was that the
Høgevold and Svensson (2016).
organization had an explicit interest in sustainability and had
planned for sustainable development in the future. And, 11 of
33 hospitals declared this interest, but only four were (self-
declared) aware of sustainability as fundamental to the
hospitals’ activities. The research team established contact with Table I Sample characteristics
the CEO and organized a screening interview focusing on the Hospital Ownership Age Total of beds Location
organization’s sustainable development planning for the future. PriHosp1 Investor group 19 120 Murcia
Our final sample was, therefore, composed of four private PriHosp2 Family-owned 70 85 Murcia
hospitals of different sizes and approaches to sustainability, PriHosp3 Religious order 46 40 Castilla la Mancha
which enabled the research team to observe a broad variety of PriHosp4 Foundation 184 238 Asturias
contingences inherent in organizational sustainability

Figure 1 Methodological research process

PROCEDURE OBJECTIVE OUTCOME

Knowing the future

General

33 screening interviews
direction of sustainable
with CEO of private A preliminary
development in private
hospitals understanding of
Pre-Study

hospitals.
the future
sustainable
development in
11 screening interviews
Specific

Selecting hospitals private hospitals

with CEO of private considering sustainable was formed
hospitals development in future.
Identifying knowledgeable
individuals

Three series of in-depth

interviews during 2,5 Qualitatively analysis of Initial qualitative
Main Study

years with 4 private future sustainable findings from

hospitals development based on a private hospital
time-oriented framework perspective were
obtained

Analysis of documents
and direct observations
of sustainability
protocols
Additional series of in-
Post-study
Initial validation of
findings
Data triangulation
and validation of
findings were
achieved

depth interviews with Final validation of

four different private findings
hospitals
 Sustainable development
Rocío Rodríguez, Göran Svensson and Carmen Otero-Neira
A substantial amount of unstructured data were gathered about
future sustainable development to assess the direction of each
hospital. All interviews lasted about 1 to 1.5 h. During the
interviews, the research team took notes that were transcribed
afterward to structure the information and create a summary
report.
To verify the consistency and accuracy of the results, the
research team carried out an additional series of in-depth
interviews with four private hospitals that were not part of the
initial sample and were located in different regions of Spain.
Empirical findings
In this section, we consider the empirical findings on the future
direction of sustainable development across the studied private
hospitals (i.e. PriHosp1, PriHosp2, PriHosp3 and PriHosp4).
We report the general similarities and specific differences found
for each hospital.
The relative future sustainable conviction of each studied
hospital is summarized at the end of case description.
Subsequently, we report each hospital from the strongest
conviction to the weakest, based on the findings gathered.
PriHosp1 on its future direction of sustainable
development
PriHosp1 commented that: “[. . .] we will promote actions for
sustainable development in the surrounding environment [. . .]”
The hospital is, therefore, a member of IniDress, a national
association that promotes actions for sustainable development
in the Spanish healthcare industry.
PriHosp1 stated that: “[. . .] our hospital will prioritize a
combination of environmental, social and economic actions for
sustainable development [. . .]” For example, an annual
financial budget will be assigned to sustainable development.
The hospital stressed that: “[. . .] we will work on structuring
our social sustainable development according to the main lines
of actions undertaken [. . .]”. One of the most important social
issues considered by the hospital is communication with
stakeholders in society (e.g. sending a CSR report each year to
the relevant entities related to the hospital). This is a reason
why PriHosp1 will promote events or associations, such as an
organization of business women (OMEP – Organizaci on de
Mujeres Empresarias y Profesionales). PriHosp1 asserted that:
“[. . .] the only way to achieve awareness about sustainable
development is through communication with society [. . .] [. . .]
we will start with the local one [. . .]”.
The hospital explained that: “[. . .] we will also stress
environmental actions to enhance our sustainable development
[. . .]”. Furthermore, PriHosp1 commented:
[. . .] our hospital is a living entity and we will have to take into account the
investment in energy efficiency with every step we take, this is not something
that has been done in the past [. . .].
For example, PriHosp1 will implement a protocol to classify
and separate the waste material at its origin at each center of the
hospital. The separation of waste into different containers will
be based on the use of colors and labels.
PriHosp1 will promote economic actions: “[. . .] through the
organization of conferences or meetings, invitating of the most
important national and local healthcare entities [. . .]”. For
example, the hospital explained that these events may have
Journal of Business & Industrial Marketing
themes such as: “[. . .] medical prescription and the cost of
pharmacy [. . .]” and “[. . .] could brand drugs be substituted for
generic drugs? [. . .]”.
The hospital has outlined four strategic areas of sustainable
development, as follows:
 employment integration for the physically disabled,
because of the belief that: “[. . .] everyone has the right to
decent work aligned to the skills and faculties of each
individual [. . .]”;
 promotion of social, artistic, scientific culture because of the
belief that: “[. . .] a more trained and educated society will
evolve in a more satisfactory manner [. . .]”, and the
promotion of sports activities: “[. . .] mainly soccer, running
and cycling, but it could be any other physical activity [. . .]”.
The latter is so because PriHosp1 equates sports to taking
care of one’s health. PriHosp1 mentioned that:
[. . .] any sports activity is a good habit, which positively influences the
quality of life and the health of our patients [. . .] [. . .] we know that time
goes by and everyone has to come to the hospital sooner or later [. . .] [. . .]
better later than sooner [. . .].
 research and teaching, mainly in nursing and general
medicine, but this can be a useful input to various medical
specialties. PriHosp1 commented that: “[. . .] the public
university has an agreement with us and other hospitals in
the region to engage in research and teaching [. . .]”. There
is a limit to the number of students who can attend and do
their practical training in public hospitals, so: “[. . .] we
have an agreement with a private university [. . .]”.
Nowadays, the most demanded professionals in the local
healthcare market according to PriHosp1 are:
[. . .] nurses and doctors who must do their specialty after their Resident
Medical Internship (RMI), which is a term used in some countries to
describe a doctor who has a medical degree but can’t practice medicine
unsupervised [. . .].
Furthermore, PriHosp1 claims that: “[. . .] we will benchmark
our sustainable development in relation to other hospitals to
assess best practices in the healthcare industry [. . .]” However,
the current focus of the hospital on environmental certifications
will be less prioritized, so as to focus more on healthcare quality
(HQ) certifications, which is a pioneering and innovative
system that recognizes excellence in quality assurance for
public and private health organizations that understand quality
as a culture of continuous improvement.
The hospital will continue to maintain its organizational
values, such as: “[. . .] the quality of medical care and assistance
and patient security at high levels, taking into account the DRG
(Diagnosis Related Groups) indicators and adapting to their
evolution [. . .]”. This is done to engage in sustainable
development, although PriHosp1 is a business-driven hospital,
being well aware of that this orientation is relevant and valuable
marketing tool to be used in the market itself and society more
generally.
PriHosp1 commented that it is really difficult nowadays to
develop a competitive advantage in relation to the other
hospitals:
[. . .] all general hospitals provide similar services [. . .] [. . .] society is smarter
than in the past, and it needs to know that the hospital not only cares about
its patients, but also the society in general [. . .].
 Sustainable development
Rocío Rodríguez, Göran Svensson and Carmen Otero-Neira
Therefore, CSR and quality can be the elements, which all
determine the difference between one hospital and the
others.
PriHosp1 explained told that: “[. . .] we will continue
working with interest groups (e.g. local business women
association, local healthcare government and hospital
suppliers) to make them aware of the importance of sustainable
development [. . .]”. For example, the hospital sends out emails
with its CSR report, donates money to social events (e.g.
musical concerts, theater productions and local festivities and
events) and collaborates with NGOs (e.g. the Red Cross).
The hospital stated that: “[. . .] we are working on improving
our sustainability strategy to enhance the organizational
sustainable development [. . .]” For example, both modified
and new quality indicators of sustainable development will be
assessed.
The organizational actions of sustainable development will
be organized by areas. PriHosp1 commented that:
[. . .] we tried integrate the sustainable development into all the functions
of the hospital [. . .] [. . .] but realized that some areas are related more to
social or environmental sustainable development [. . .] [. . .] so although
there is a general committee, we give each department its own
responsibility [. . .].
For example, pharmacy and stocks are linked more to
environmental actions, but pharmacy follows the drug waste
protocol and inventory the general one. The communication
department is related more to social actions and is responsible
for meeting social demands.
Finally, PriHosp1 wants to raise the overall societal
awareness of sustainable development in the healthcare
industry. PriHosp1 commented that:
[. . .] we believe that sustainable development is the right way to maintain
our own activity and the general activity of society in the future: it is our
responsibility to commit to this issue [. . .].
For example, it requests that the suppliers obtain various
certifications, such as ISO (International Organization for
Standardization).
In conclusion, PriHosp1 has in relation to the other studied
hospitals (i.e. PriHosp2, PriHosp3 and PriHosp4) the strongest
conviction as to the importance of engaging in future
sustainable development actions.
PriHosp2 on its future direction of sustainable
development
PriHosp2 told that: “[. . .] our hospital will prioritize achieving
environmental certifications, as the hospital needs to improve
its image and level of sustainable development to participate in
public bids [. . .]”. PriHosp2 asserted that:
[. . .] nowadays, we need to compete with the rest of the private hospitals in
the region [. . .] [. . .] the hospital that is seen as better, will have more
patients from the public healthcare system [. . .].
The subsequent priority of PriHosp2 will be social sustainable
development:
[. . .] we cannot forget that the hospital is a private business, which needs a
good image [. . .] [. . .] social actions are more visible to patients than
environmental ones [. . .] [. . .] therefore it will be our second priority [. . .]
[. . .] 80 per cent of our patients come from the public system and 20 per
cent from personal and private funds [. . .].
PriHosp2 commented that:
Journal of Business & Industrial Marketing
[. . .] it will require substantial efforts to change the hospital’s organizational
culture for sustainable development [. . .] [. . .] nurses and personal assistants
have been working here for years, so it is difficult to change the way they
work [. . .] [. . .] for example, we are in the process of becoming a paperless
hospital and nurses are not used to working with computers [. . .].
Sustainable development is necessary: “[. . .] because the
market demands it and society will expect it in the long run
[. . .]”. However, the hospital does not have the financial and
human resources to do it all.
It will, therefore, take a long time to get to what PriHosp2
wants to achieve with its sustainable development. PriHosp2
points out: “[. . .] we want to achieve QH-3 STAR certification
[. . .]”. It is the highest level of quality of hospital care services; it
will try to adapt to the demands, expectations and trends
emerging in the market and society.
In conclusion, PriHosp2 has a strong conviction, but less
than PriHosp1, and stronger than PriHosp3 and PriHosp4, of
the importance of engaging in future actions of sustainable
development.
PriHosp3 on its future direction of sustainable
development
PriHosp3 expressed that: “[. . .] we will maintain the same actions
of sustainable development as today [. . .] [. . .] focus on social
assistance and help, such as: charity canteen [. . .]”. Furthermore,
the hospital’s sustainable development will be value-driven,
rather than business-driven, PriHosp3 commented that:
[. . .] this is a religious hospital [. . .] [. . .] part of the personnel are nuns [. . .]
[. . .] although the hospital does not receive public funding, it has to follow
its Christian values [. . .] [. . .] they are the essence of the hospital and the
priority is human charity [. . .].
PriHosp3 said that: “[. . .] the commitment to actions of
sustainable development will depend on the causes that emerge
during the year [. . .] [. . .] rather than planning actions in
advance [. . .]”. The reason is that the financial resources are
limited, being a private hospital, and that the main actions will
be initiated and undertaken by PriHosp3’s human resources.
PriHosp3 explained that:
[. . .] our sustainable development will take into consideration the demands
and expectations of the market and society, but will depart from an internal
perspective of the organization being rather reactive than proactive [. . .].
PriHosp3 mentioned that:
[. . .] we have a pediatric project, but we usually attend to the most primary
human needs, such as food and clothing [. . .] [. . .] during the economic
crisis, we did not know how the society was affected until people started to
come to our social canteen [. . .].
In conclusion, PriHosp3 has a less strong conviction, weaker
than PriHosp2, but not as weak as PriHosp4, of the importance
of engaging in future actions of sustainable development. This
hospital’s focus is on religious values than rather on sustainable
ones, although both (religious and sustainable) share the social
component.
PriHosp4 on its future direction of sustainable
development
PriHosp4 stated that: “[. . .] our hospital will keep on doing the
same sustainable development actions as today (i.e. oncology
research) focusing only on what has to be done only [. . .]”.
Sustainable development will not be prioritized, so only minor
attention will be paid to it, such as maintaining our guide for
 Sustainable development Journal of Business & Industrial Marketing
Rocío Rodríguez, Göran Svensson and Carmen Otero-Neira

stakeholders in society about the nine good environmental
actions:
1 travel sustainably;
2 consume energy effectively;
3 consume water responsibly;
4 manage waste properly;
5 take full advantage of paper and reuse it;
6 use equipment adequately (e.g. computers and copy
mashies);
7 save resources;
8 take care of our city and its surroundings; and
9 be an active part of sustainability.
PriHosp4 will therefore be reactive to demands and
expectations in the market and society: “[. . .] our actions of
sustainable development will be either top-down or bottom-up,
depending on who sees the need for it in the market and society
[. . .]”. Furthermore: “[. . .] our actions of sustainable
development will focus on internal issues and there will be only
minor planning and no specific budget will be assigned in
advance [. . .]”.
In conclusion, in relation to the other studied hospitals (i.e.
PriHosp1, PriHosp2 and PriHosp3), PriHosp4 has the weakest
conviction as to the importance of engaging in future actions of
sustainable development.
Discussion of findings
Table II summarizes the common denominators of general
similarities and specific differences between the studied private
hospitals regarding their future direction for sustainable
development. Once the research team had interviewed
the respondents, data were categorized and tabulated. The
categories are represented on rows in Table II. The conviction
of each hospital about sustainability was obtained linking the
answers of each hospital to these categories, as well as the extra
information that the respondents offered through their
comments to the open questions. This was the manner to
detect which hospitals had stronger or weaker conviction of
sustainability.
Insert Table II about here.
Table II has been organized to show that the studied hospitals
range from having a very strong organizational conviction on the
future direction of sustainable development to a very weak one (i.
e. from PriHosp1 to PriHosp4). Nevertheless, as shown in
Table II, there are to some extent general similarities and specific
differences between them, beyond their respective levels of
conviction to sustainable development.
General similarities
In line with Enquist et al. (2015a) suggestion, in the new
business landscapes, private hospitals aim to include
sustainability and TBL thinking to achieve competitive
advantages and business excellence. In fact, there has been
overall progress in the studied hospitals, which has evolved
significantly regarding their notions of sustainable
development. However, the costs determine the progress which
is contrary to the idea that sustainable development will make
firms more competitive without harming cost-effectiveness
(Hussain et al., 2018; Schulz and Flanigan, 2016). The study
shows that the actions or initiatives undertaken are determined
ultimately by the costs for the hospital as the funding has a
specified destination which is not usually directed toward
supporting sustainable organizational development. Also, the
studied hospitals benchmark the sustainable development of
other hospitals in an effort to compare themselves with others

Table II Common denominators – general similarities and specific differences between hospitals on their future direction of sustainable development
PriHosp1 PriHosp2 PriHosp3 PriHosp4
Organizational conviction Very strong Strong Weak Very weak
General similarities
Significant evolution  
Costs determine sustainability    
Benchmark with other hospitals  
Sustainability and quality are linked    
Promote social sustainability    
Proactive efforts  
Employee involvement    
Hard implementation    
Government/laws influence    
Size hospital influence    
Specific differences
Sustainability communication  
Integration with public system  
Conservative sustainability values  
Integrate sustainability in daily functions  
Own resources 
Own budget 
Religious influence 
Medical research influence 
Change management influence  
 Sustainable development
Rocío Rodríguez, Göran Svensson and Carmen Otero-Neira
with similar characteristics and to learn from them. Therefore,
in the healthcare industry, as theory has noted, benchmarking is
an important tool to seek for performance (Presley and Meade
(2010, and “a route to sustainable competitive advantage”
(Vorhies and Morgan, 2005, p. 80).
Sustainability and quality concerns are linked. In truth, as
literature has argued this component of sustainability has
received lots of attention and, in fact, developed many metrics
to measure quality and environmental impact (Schulz and
Flanigan, 2016). For example, the sustainable development
was initially environmentally focused in the studied hospitals so
that the environmental initiatives and actions were performed
by the units at hospitals which assess quality performance.
However, in the healthcare industry, the focus of sustainable
development has evolved including social initiatives and actions
in line with Sharma (2003), but sustainable development is still
considered as based on the medical quality of the hospital.
Subsequently, the studied hospitals promote socially
sustainable development, as it is perceived not to be at the
desired level.
The studied hospitals consider that their sustainable
development needs to pay more attention to being more
proactive, if they are achieving the organizational objectives of
sustainable development. This result goes in line with
Wijethilake (2017) who indicated that firms should be
proactive in economic, social and environmental issues. They
also strive to involve staff, because there is an overall awareness
of sustainability in society, a basic example being an awareness
of recycling. Again, this is also in agreement with Schulz and
Flanigan (2016) argument of corporate managers’ mission to
influence and proactively engage all stakeholders.
In addition, as literature pointed out, in the studied hospitals,
the implementation of robust and integrated initiatives and
actions are troublesome (Leuenberger and Bartle, 2009),
because a hospital is an organization with considerable diversity
(Saviano et al., 2010), on the one hand, involving many human
resources, and on the other hand, different departments. In
addition, stakeholders relationships are quite complex in this
industry (Basole and Rouse, 2008). All of this heterogeneity
must be interconnected and, sometimes, urgently so that it is
complicated to include a newly integrated sustainability system
into all hospital activities. The influence of government and
laws will influence the sustainable development in the studied
hospitals in line with Ahsan and Rahman (2017), Kumar and
Rahman (2015) or Schulz and Flanigan (2016):
 positively, if hospitals are not required to engage in
excessively costly actions to ensure quality; and
 negatively, if judicial requirements generate excessively
high costs, limiting other initiatives and sustainable
development actions.
The size of the hospital influences the initiatives and actions
mainly in terms of:
 funding to engage in sustainability initiatives depend on
size, with a larger hospital having more capacity to
dedicate resources to sustainable development and
achieve robust or well-integrated planning; and
 however, a larger hospital suffers from increased
difficulties in implementing initiatives and actions of
sustainability throughout the hospital across areas and
Journal of Business & Industrial Marketing
generating an awareness of organizational sustainable
development.
Specific differences
The communication of initiatives and actions of sustainable
development differs between the studied hospitals in this
adaptation to the surrounding society, in line with the
arguments stated by Jamali et al. (2010). The studied hospitals
will strive toward integration to a varying extent into the public
healthcare system.
The studied hospitals will focus partly on inherently
organizational sustainability values that are not business- or
profit-oriented, but entail a genuine interest to engage in
sustainable development. The integration of initiatives and
sustainability actions into daily functions will be specific to each
hospital. It is important for the studied hospitals sustainability
initiatives to be integrated according to a plan of
implementation. This is important to avoid those difficulties in
sustainability implementations (Daily and Huang, 2001).
The hospitals rely on their own resources that are dedicated
to maintaining and promoting sustainability initiatives. By
extension, initiatives and actions of sustainable development
will have a separate financial account. However, the initiatives
and actions of one of the studied hospitals does not come from
sustainability values, but from religious values. This result is
logical and in concordance with Jamali et al. (2010, p. 598)
who, specifically in the healthcare sector, indicated that “social
responsibility seemed to stem from the preference of the owners
[. . .], the mission and goals [. . .], or the religious beliefs [. . .]”.
Sustainable development in the studied hospitals does not
derive from organizational values themselves, but from the
interests of the medical doctors in research in one of the studied
hospitals, not for economic reasons, but related to true
sustainability values.
Sustainable development in the studied hospitals is related
more to management than to the rest of the hospital. This is
concordant with the recent study made by Ahsan and Rahman
(2017, p. 195) who indicated that management support in the
healthcare industry is important because “it helps to mobilise
necessary resources in the development and implementation”
of any initiative. The organizational culture of sustainable
development will, therefore, not be fully implemented or well
considered without the management support. In fact, with
change in management, sustainability initiatives may pause or
stop altogether.
Research implications
The empirical findings reported and summarized in Table II
yield several research implications based on the two axes.
Figure 2 illustrates two-dimensional axes framing common
denominators and organizational conviction so as to
characterize the future direction of sustainable development in
private hospitals.
The framework is in relation to the studied private hospitals’
future direction of sustainable development:
 common denominators; and
 the degree of organizational conviction.
 Sustainable development
Rocío Rodríguez, Göran Svensson and Carmen Otero-Neira
Figure 2 Two-dimensional axes framing future direction of sustainable
development in private hospitals
Common
Denominators
General
Similarities
Organizational
Conviction
Weak Strong
Specific
Differences
One axis reflects the range from weak to strong organizational
conviction regarding private hospitals’ future direction or for
sustainable development, while the other axis ranges from
general similarities to specific differences.
The empirical findings categorized and summarized in
Table II offer several lessons to be learned. For example, there
are similarities between the future direction of sustainable
development in the studied private hospitals, but it occurs
merely at a general level. The differences in relation to the
future direction of sustainable development in the studied
private hospitals occur mostly regarding specifics adapted to
the capabilities and characteristics of each organization, in line
with Daily and Huang (2001) who indicate that there is a lack
of clarity on how to implement sustainability in organizations.
The organizational conviction of sustainable development also
varies across the private hospitals that are as well related to the
capabilities and characteristics of each organization.
Consequently, the findings indicate that there is no common
formula, such as proposed by Høgevold and Svensson (2016)
and Høgevold et al. (2014), that at least are applicable across
private hospitals, for determining the future direction of their
sustainable development. Although some hospitals benchmark
best practices, others use them only as a general frame of
reference. Subsequently, hospitals determine the direction of
sustainable development based on intra-organizational
capabilities and characteristics rather than inter-organizational
ones. Nevertheless, the market and society play a key role in
determining what to do next and what to avoid (Enquist et al.,
2015a; Lloret, 2016).
It is logical that there is a spread across the studied hospitals
regarding the future direction of sustainable development, as
the organizational conviction may differ substantially between
them. It is, therefore, relevant to take into consideration this
conviction in relation to the general, as well as specific, actions
undertaken to approach future sustainable development.
This study focuses on organizations with differing ownership
structures, sizes, historical backgrounds and corporate cultures.
Journal of Business & Industrial Marketing
Nevertheless, all were hospitals working in the same industry,
thus enabling to make comparisons between them and the
identification of a limited number of similarities and
differences. The gathering of this information offers the
possibility to create a complementary framework to existing
ones:
 First, to determine the level of each organization with
respect to its future sustainable development (strong,
medium or weak).
 Second, to facilitate each organization the path to follow
in the future of the sustainability position that it wants to
achieve.
 Third, the identification of general differences and specific
similarities of different organizations from different
regions offers a framework that is not only useful for each
organization, but also as a method that can help to
structure the whole industry. Sustainability is a goal for all
organizations and the industry itself, so this information
could help to share efforts at stimulating sustainable
development in a transactional manner in the industry.
Furthermore, though the general similarities and specific
differences did not change in practice during the period of
the study (more than two years), it became evident that the
future direction of sustainability development is quite static
and slow. This is contrary to what we would expect, because
of the link between sustainability and quality in the
healthcare industry. Nevertheless, this is in line with the fact
that in the healthcare industry, the three TBL elements
(environmental, social and economic) are considered and
have a balanced importance/priority. This is in line with Lee
and Lee Lam (2012) and Carter and Easton (2011) who
consider the need to balance and simultaneously achieve
economic prosperity, environmental quality and social
equity as the basis for competitive advantage in the long
term. In all, as Enquist et al. (2015a) suggested in the new
business landscape of the healthcare industry, hospitals aim
to include sustainability and TBL thinking.
Managerial implications
The Spanish private healthcare industry with respect to its
future direction of sustainable development may be affected by
several phenomena, in such ways as:
 certifications may be more expensive to achieve for the
hospitals, because they will be more specialized and
detailed in their work, requiring additional resources and
extended time-cycles;
 sustainable development may generate extra costs for
hospitals, because actions are more specific and concise;
 there may also be extended certifications, because
hospitals want to extend their quality image to all areas
(e.g. at the beginning, anesthesiology and pain unit and
ambulatory surgical unit were the most common to
certify, but now hospitals are extending the certification to
the whole area);
 there may be areas all of which will be compulsory for
certification, while others will be optional (e.g.
immunology may be compulsory, but traumatology may
not be, because some areas are more sensitive or delicate
than others);
 Sustainable development
Rocío Rodríguez, Göran Svensson and Carmen Otero-Neira
 global certifications may be too general and lose value to
regions, thus making less sense in the local context; and
 the concept of sustainable development may return to
genuine values, such as caring more for the treatment,
security and well-being of patients and according less
importance to the quality awards.
Furthermore, it appears, according to the findings previously
reported, that the studied private hospitals will not prioritize the
same future directions of sustainable development.
Nevertheless, actions of sustainable development will be
extended somewhat jointly:
 between private hospitals, which includes the QH
certification (e.g. management of dangerous or biological
waste, substitution of conventional light bulbs for led
ones to save energy and sustainability protocols
systematization); and
 between private and public ones, such as meetings and
conferences about common sustainability initiatives and
the possibility of establishing common funds to maintain
some sustainability aspects such as the management of
dangerous waste, e.g. as RX waste or cancer prevention
campaigns, or healthy habits. This is aligned with the
perspective from Hedaa and Törnroos (2008) and
Svensson et al. (2018a) about the significative importance
of the relationships and networks in the study of B2B and
falls in with Berman (1995) who indicated that
appropriate health sector policies are needed in any
country.
Regional governments will support hospitals’ sustainable
development in some regions of Spain, directly with public
hospitals (through public funding) and indirectly with private
ones (through public bids criteria). Private hospital associations
will promote the future direction of sustainable development
among its members to improve the image and position of
private hospitals in the market and society, thus enabling them
to compete for public bids in the Spanish healthcare industry.
This goes in line and confirm Ahsan and Rahman’s (2017,
p. 196) conclusions in their study of public healthcare sector in
Australia, that “the health sector must work closely with the
government legislative body”.
Furthermore, stakeholders (e.g. patient associations, health
insurance firms, local governments and suppliers) in the market
and society will require private hospitals to extend their
sustainable development actions, in line with Enquist et al.
(2015a) who indicated, in today’s service business strategies,
there is a compelling need to incorporate current landscape
challenges, such as sustainability and stakeholders’
relationships, and Presley and Meade (2010) who indicated the
need for a company, in a B2B context, to consider all
stakeholders in the network to pursue sustainability. The
demands and expectations of sustainable development in the
market and society will make the healthcare industry more
business-driven. Quality certifications will be more specialized
in the industry.
In all, in accordance with Lloret (2016, p. 418) who affirmed
that “sustainable practices are the key to company’s survival”,
the healthcare industry is a clear example of an industry where
firms are increasing their sustainability efforts (Spohrer et al.,
2007). Also, as Jamali et al., 2010, p. 600) claimed “hospitals
Journal of Business & Industrial Marketing
should be proactive role models”. In fact, private hospitals drive
the sustainable development at a general level, because of their
greater interest in improving their opportunities in the market
and society, in line with Enquist et al. (2015b). The sustainable
development of a hospital that is business-driven is faster than
one that is value-driven in its sustainable development, and for
two reasons:
1 value-driven sustainable development means doing what
is just good enough, if there is no goal to be accomplished
in the short, medium or long time horizon; and
2 value-driven sustainable development strives to make it
robust, rather than economically, socially and
environmentally optimal.
Finally, a synchronization dilemma in the Spanish healthcare
industry is that 17 regional governments in each autonomy will
have to agree on homogeneity criteria to promote and assess
sustainable development. The central Spanish government
will, therefore, have to act to clearly outline the future direction
in this sense.
Conclusions and suggestions for the future
This study reveals that, although organizational conviction
on the future direction of sustainable development may vary
in an industry, there are general similarities as well as
specific differences. This study, therefore, suggests that the
economic, social and environmental sustainable
development across private hospitals may evolve according
to general principles or guidelines (e.g. from local
governments or expectations in the market and society).
However, the specific sustainable development at each
hospital may evolve along tailored economic, social and
environmental actions (i.e. intra-organizational, top-down
and bottom-up initiatives).
By showing the general similarities and specific
differences that are important for the successful future
direction of sustainability development in organizations,
this study provides insights into factors that could promote
success or constitute barriers. The revealed similarities and
differences can help to create a framework for positioning
the organizations in relation to their future direction of
sustainability development. They can also guide the
organizations in their organizational conviction of
sustainability development, as well as guiding the industry
toward a common objective which improves the hospitals
sustainability actions in the future, also minimizing the
effort required. This study works as complement of studies
such as Høgevold and Svensson (2016) and Høgevold et al.
(2014), which consider evolutionary directions on
sustainable development without taking into account the
future.
A limitation of this study is the sample size that restricts
generalizations. However, it reflects a spectrum from strong to
weak organizational conviction regarding the importance of
engaging in sustainable development. Future studies may serve
the purpose of verifying and contrasting the results in other
hospitals. Other future research can focus on other countries
too and even compare the healthcare industry with other
different ones.
 Sustainable development
Rocío Rodríguez, Göran Svensson and Carmen Otero-Neira
References
Ahsan, K. and Rahman, S. (2017), “Green public procurement
and implementation challenges in Australian public
healthcare sector”, Journal of Cleaner Production, Vol. 152,
pp. 181-197.
Anderson, S., Rayburn, S.W. and Sierra, J.J. (2018), “Future
thinking: the role of marketing in healthcare”, European
Journal of Marketing, available at: https://doi.org/10.1108/
EJM-10-2017-0779
Basole, R.C. and Rouse, W.B. (2008), “Complexity of service
value networks: conceptualization and empirical
investigation”, IBM Systems Journal, Vol. 47 No. 1,
pp. 53-70.
Baumgartner, R.J. (2014), “Managing corporate sustainability
and CSR: a conceptual framework combining values,
strategies and instruments contributing to sustainable
development”, Corporate Social Responsibility and
Environmental Management, Vol. 21 No. 5, pp. 258-271.
Berman, P. (1995), “Health sector reform: making health
development sustainable”, Health Policy, Vol. 32 Nos 1/3,
pp. 13-28.
Blenkhorn, D.L. and MacKenzie, H.F.(H.) (2017),
“Categorizing corporate social responsibility (CSR)
initiatives in B2B markets: the why, when and how”, Journal
of Business & Industrial Marketing, Vol. 32 No. 8,
pp. 1172-1181.
Bocken, N., Short, S., Rana, P. and Evans, S. (2013), “A value
mapping tool for sustainable business modelling”, Corporate
Governance: The International Journal of Business in Society,
Vol. 13 No. 5, pp. 482-497.
Campion, N., Thiel, C.L., Woods, N.C., Swanzy, L., Landis,
A.E. and Bilec, M.M. (2015), “Sustainable healthcare and
environmental life-cycle impacts of disposable supplies: a
focus on disposable custom packs”, Journal of Cleaner
Production, Vol. 94, pp. 46-55.
Carter, C.R. and Easton, P.L. (2011), “Sustainable supply
chain management: evolution and future directions”,
International Journal of Physical Distribution & Logistics
Management, Vol. 41 No. 1, pp. 46-62.
Carter, C.R. and Rogers, D.S. (2008), “A framework of
sustainable supply chain management: moving toward new
theory”, International Journal of Physical Distribution &
Logistics Management, Vol. 38 No. 5, pp. 360-387.
Chung, J.W. and Meltzer, D.O. (2009), “Estimate of the
carbon footprint of the US health care sector”, Journal of the
American Medical Association, Vol. 302 No. 18,
pp. 1970-1972.
Crane, A. (1999), “Are you ethical? Please tick yes or no. on
researching ethics in business organizations”, Journal of
Business Ethics, Vol. 20 No. 3, pp. 237-248.
Daily, B.F. and Huang, S.C. (2001), “Achieving sustainability
through attention to human resource factors in
environmental management”, International Journal of
Operations & Production Management, Vol. 21 No. 12,
pp. 1539-1552.
Dyllick, T. and Hockerts, K. (2002), “Beyond the business
case for corporate sustainability”, Business Strategy and the
Environment, Vol. 11 No. 2, pp. 130-141.
Journal of Business & Industrial Marketing
Edwards, N. and Harrison, A. (1999), “The hospital of the
future: planning hospitals with limited evidence: a research
and policy problem”, BMJ: British Medical Journal, Vol. 319
No. 7221, p. 1361.
Eisenhardt, K.M. (1989), “Building theories from case study
research”, Academy of Management Review, Vol. 14 No. 4,
pp. 532-550.
Elkington, J. (1998), Cannibals with Forks: The Triple Bottom
Line of 21st Century Business, New Society Publishers, Stony
Creek.
Engeert, S., Rauter, R. and Baumgartner, R.J. (2016),
“Exploring the integration of corporate sustainability into
strategic management: a literature review”, Journal of Cleaner
Production, Vol. 20 No. 4, pp. 2833-2850.
Enquist, B., Johnson, M. and Rönnbäck, Å. (2015a), “The
paradigm shift to business excellence 2.0”, International
Journal of Quality and Service Sciences, Vol. 7 Nos 2/3,
pp. 321-333.
Enquist, B., Sebhatu, S. and Johnson, M. (2015b),
“Transcendence for business logics in value networks for
sustainable service business”, Journal of Service Theory and
Practice, Vol. 25 No. 2, pp. 181-197.
Ferro, C., Padin, C., Svensson, G., Høgevold, N. and Sosa
Varela, J.C. (2019), “Validating and expanding a framework
of a triple bottom line dominant logic for business
sustainability through time and across contexts”, Journal of
Business & Industrial Marketing, Vol. 34 No. 1, pp. 95-116.
Ferro, C., Padin, C., Svensson, G., Sosa Varela, J.C., Wagner,
B. and Høgevold, N. (2017), “Validating a framework of
stakeholders in connection to business sustainability efforts
in supply chains”, Journal of Business & Industrial Marketing,
Vol. 32 No. 1, pp. 124-137.
Fischhoff, B. and Bar-Hillel, M. (1982), “Focusing techniques
as aids to inference”, Decision Research Report, Vol. 82 No. 4.
Golicic, S.L. and Smith, C.D. (2013), “A meta-analysis of
environmentally sustainable supply chain management
practices and firm”, Journal of Supply Chain Management,
Vol. 49 No. 2, pp. 78-95.
Grewal, R., Johnson, J.L. and Sarker, S. (2007), “Crises in
business markets: implications for interfirm linkages”,
Journal of the Academy of Marketing Science, Vol. 35 No. 3,
pp. 398-416.
Hadjikhani, A. and LaPlaca, P. (2013), “Development of B2B
marketing theory”, Industrial Marketing Management, Vol. 42
No. 3, pp. 294-305.
Hallstedt, S.I., Thompson, A.W. and Lindahl, P. (2013), “Key
elements for implementing a strategic sustainability
perspective in the product innovation process”, Journal of
Cleaner Production, Vol. 51, pp. 277-288.
Hartline, M.D. and Jones, K.C. (1996), “Employee
performance cues in a hotel service environment: influence
on perceived service quality, value, and word-of-mouth
intentions”, Journal of Business Research, Vol. 35 No. 3,
pp. 207-215.
Healy, J. and McKee, M. (2002), “Implementing hospital
reform in Central and Eastern Europe”, Health Policy,
Vol. 61 No. 1, pp. 1-19.
Hedaa, L. and Törnroos, J. (2008), “Understanding event-
based business networks”, Time & Society, Vol. 17 Nos 2/3,
pp. 319-348.
 Sustainable development
Rocío Rodríguez, Göran Svensson and Carmen Otero-Neira
Høgevold, N. and Svensson, G. (2016), “Framing the
development and directions of business sustainability
efforts”, Corporate Governance: The International Journal of
Business in Society, Vol. 16 No. 4, pp. 709 -725.
Høgevold, N., Svensson, G., Wagner, B., Petzer, D.J.,
Klopper, H.B., Sosa Varela, J.C., Padin, C. and Ferro, C.
(2014), “Sustainable business models corporate reasons,
economic effects, social boundaries, environmental actions
and organizational challenges in sustainable business
practices”, Baltic Journal of Management, Vol. 9 No. 3,
pp. 357-380.
Hsu, C.C., Tan, K.C., Suhaiza, H.M.Z. and Jayaraman, V.
(2013), “Supply chain drivers that foster the development of
green initiatives in an emerging economy”, International
Journal of Operations & Production Management, Vol. 33
No. 6, pp. 656-688.
Hussain, N., Rigoni, U. and Orij, R.P. (2018), “Corporate
governance and sustainability performance: analysis of triple
bottom line performance”, Journal of Business Ethics,
Vol. 149 No. 2, pp. 411-432.
Hwang, J. and Christensen, C.M. (2008), “Disruptive
innovation in health care delivery: a framework for business-
model innovation”, Health Affairs, Vol. 27 No. 5,
pp. 1329-1335.
Jamali, D., Hallal, M. and Abdallah, H. (2010), “Corporate
governance and corporate social responsibility: evidence
from the healthcare sector”, Corporate Governance: The
International Journal of Business in Society, Vol. 10 No. 5,
pp. 590-602.
Jayaraman, V., Klassen, R. and Linton, J.D. (2007), “Supply
chain management in a sustainable environment”, Journal of
Operations Management, Vol. 25 No. 6, pp. 1071-1074.
Kleindorfer, P.R., Singhal, K. and Van Wassenhove, L.
(2005), “Sustainable operations management”, Production
and Operations Management, Vol. 14 No. 4, pp. 482-492.
Kumar, D. and Rahman, Z. (2015), “Sustainability adoption
through buyer supplier relationship across supply chain: a
literature review and conceptual framework”, International
Strategic Management Review, Vol. 3 Nos 1/2, pp. 110-127.
Lash, J. and Wellington, F. (2007), “Competitive advantage on
a warming climate”, Harvard Business Review, Vol. 85 No. 3,
pp. 94-103.
Laurell, H., Lindgren, J., Pehrsson, T., Karlsson, N.,
Andersson, S. and Svensson, G. (2018), “Cross-Country
comparison and validation of firms’ stakeholder
considerations in their efforts of sustainable business
practices”, Corporate Governance: The International Journal of
Business in Society, Vol. 8 No. 3, pp. 408-424.
Lee, C.K.M. and Lee Lam, J.S. (2012), “Managing reverse
logistics to enhance sustainability of industrial marketing”,
Industrial Marketing Management, Vol. 41 No. 4,
pp. 589-598.
Leuenberger, D.Z. and Bartle, J.R. (2009), Sustainable
Development for Public Administration, M. E. Sharpe,
New York, NY.
Linnenluecke, M.K. and Griffiths, A. (2013), “Firms and
sustainability: mapping the intellectual origins and structure
of the corporate sustainability field”, Global Environmental
Change, Vol. 23 No. 1, pp. 382-391.
Journal of Business & Industrial Marketing
Lloret, A. (2016), “Modeling corporate sustainability
strategy”, Journal of Business Research, Vol. 69 No. 2,
pp. 418-425.
Lopez-Casasnovas, G., Rivera, B. and Currais, L. (2005),
Health and Economic Growth. Health and Economic Growth:
Findings and Policy Implications, MIT Press, Cambridge,
Mass.
Maletic, M., Maletic, D., Dahlgaard, J.J., Dahlgaard-Park,
S.M. and Gomiscek, B. (2014), “Sustainability exploration
and sustainability exploitation: from a literature review
towards a conceptual framework”, Journal of Cleaner
Production, Vol. 79, pp. 182-194.
Maletic, M., Maletic, D. and Gomiscek, B. (2018), “The role
of contingency factors on the relationship between
sustainability practices and organizational performance”,
Journal of Cleaner Production, Vol. 171, pp. 423-433.
MARU (2001), Building a 2020 Vision: Future Healthcare
Environments, Nuffiel Trust an Royal Institute of British
Architects, London.
Pagell, M. and Shevchenko, A. (2014), “Why research in
sustainable supply chain management should have no
future”, Journal of Supply Chain Management, Vol. 50 No. 1,
pp. 44-55.
Pantzartzis, D., Edum-Fotwe, F.T. and Price, A.D.F. (2017),
“Sustainable healthcare facilities: reconciling bad capacity
and local needs”, International Journal of Sustainable Built
Environment, Vol. 6 No. 1, pp. 54-68.
Perkins, M.K. and Brewer, B. (2010), “Sustainability in the
B2B world”, available at: www.triplepundit.com/2010/08/
sustainability-in-the-b2b-world/, retrieved on November
2018.
Pinzone, M., Guerci, M., Lettieri, E. and Redman, T. (2016),
“Progressing in the change journey towards sustainability in
healthcare: the role of ‘green’ HRM”, Journal of Cleaner
Production, Vol. 122, pp. 201-211.
Porter, M. and van der Linde, C. (1995), “Toward a new
conception of the environment-competitiveness
relationship”, Journal of Economic Perspectives, Vol. 9 No. 4,
pp. 97-118.
Presley, A. and Meade, L. (2010), “Benchmarking for
sustainability: an application to the sustainable construction
industry”, Benchmarking: An International Journal, Vol. 17
No. 3, pp. 435-451, available at: https://doi. org/10.1108/
14635771011049380
Rahman, M.S., Mannan, M., Hossain, M.A. and Zaman,
M.H. (2018), “Patient’s behavioral intention: public and
private hospitals context”, Marketing Intelligence & Planning,
Vol. 36 No. 3, pp. 349-364.
Saviano, M., Bassano, C. and Calabrese, M. (2010), “A VSA-
SS approach to healthcare service system. The triple target of
efficiency, effectiveness and sustainability”, Service Science,
Vol. 2 Nos 1/2, pp. 41-61.
Savitz, A.W. and Weber, K. (2006), The Triple Bottom Line:
How Today’s Best Run Companies Are Achieving Economic,
Social, and Environmental success – And How You Can Too,
Sage, Thousand Oaks, CA.
Schulz, S.A. and Flanigan, R.L. (2016), “Developing
competitive advantage using the triple bottom line: a
conceptual framework”, Journal of Business & Industrial
Marketing, Vol. 31 No. 4, pp. 449-458.
 Sustainable development
Rocío Rodríguez, Göran Svensson and Carmen Otero-Neira
Seuring, S. and Muller, M. (2008), “From a literature review to
a conceptual framework for sustainable supply chain
management”, Journal of Cleaner Production, Vol. 16 No. 15,
pp. 1699-1710.
Sharma, A., Iyer, G.R., Mehrotra, A. and Krishnan, R. (2010),
“Sustainability and business-to-business marketing: a
framework and implications”, Industrial Marketing
Management, Vol. 39 No. 2, pp. 330-341.
Sharma, S. (2003), “Research in corporate sustainability: What
really matters?” in Sharma, S. and Starik, M. (Eds), Research
in Corporate Sustainability: The Evolving Theory and Practice of
Organizations in the Natural Environment, Edward Elgar,
Cheltenham, pp. 1-29.
Spohrer, J., Maglio, P.P., Bailey, J. and Gruhl, D. (2007),
“Steps toward a science of service systems”, Computer,
Vol. 40 No. 1, pp. 71-77.
Stevanovic, M., Allacker, K. and Vermeulen, S. (2017),
“Hospital building sustainability: the experience in using
qualitative tools and steps towards the life cycle approach”,
Procedia Environmental Sciences, Vol. 38, pp. 445-451.
Suhrcke, M., Rechel, B. and Michaud, C. (2005),
“Development assistance for health in Central and Eastern
European region”, Bulletin of the World Health Organization,
Vol. 83, pp. 920-927.
Svensson, G., Ferro, C., Høgevold, N., Padin, C. and Sosa
Varela, J.C. (2018a), “Developing a theory of focal company
business sustainability efforts in connection with supply
chain stakeholders”, Supply Chain Management: An
International Journal, Vol. 23 No. 1, pp. 16-32.
Svensson, G., Ferro, C., Høgevold, N., Padin, C., Sosa Varela,
J.C. and Sarstedt, M. (2018b), “Framing the triple bottom
line approach: direct and mediation effects between
economic, social and environmental elements”, Journal of
Cleaner Production, Vol. 197, pp. 972-991.
Svensson, G., Høgevold, N., Ferro, C., Sosa Varela, J.C.,
Padin, C. and Wagner, B. (2016), “A triple bottom line
dominant logic for business sustainability: framework and
empirical finding”, Journal of Business-to-Business Marketing,
Vol. 23 No. 2, pp. 153-188.
Svensson, G. and Wagner, B. (2012), “Business sustainability and
E-footprints on earth’s life and ecosystems: generic models”,
European Business Review, Vol. 24 No. 6, pp. 543-552.
For instructions on how to order reprints of this article, please visit our website:
www.emeraldgrouppublishing.com/licensing/reprints.htm
Or contact us for further details: permissions@emeraldinsight.com
Journal of Business & Industrial Marketing
Tomas, D. (2006), “A general inductive approach for analyzing
qualitative evaluation data”, American Journal of Evaluation,
Vol. 27 No. 2, pp. 237-246.
Truffer, C.J., Keehan, S., Smith, S., Cylus, J., Sisko, A., Poisal,
J.A. and Clemens, M.K. (2010), “Health spending
projections through 2019: the recession’s impact continues”,
Health Affairs, Vol. 29 No. 3, pp. 522-529.
Vorhies, D.W. and Morgan, N.A. (2005), “Benchmarking
marketing capabilities for sustainable competitive
advantage”, Journal of Marketing, Vol. 69 No. 1, pp. 80-94.
Walker, K. and Laplume, A. (2014), “Sustainability
fellowships: the potential for collective stakeholder
influence”, European Business Review, Vol. 26 No. 2,
pp. 149-168.
Watson, P. (2006), “Unequalizing citizenship: the politics of
Poland’s health care change”, Sociology, Vol. 40 No. 6,
pp. 1079-1096.
WCED (1987), Our Common Future: Report of the World
Commission on Environment and Development, Oxford
University Press, Oxford.
Wijethilake, C. (2017), “Proactive sustainability strategy and
corporate sustainability performance: the mediating effect of
sustainability control systems”, Journal of Environmental
Management, Vol. 196, pp. 569-582.
Yang, M., Vladimirova, D. and Evans, S. (2017), “Creating
and capturing value through sustainability”, Research-
Technology Management, Vol. 60 No. 3, pp. 30-39.
Yin, R. (1994), Case Study Research: Design and Methods, 2nd
ed., Sage Publishing, Thousand Oaks, CA.
Yin, R.K. (2009), Case Study Research: Design and Methods, 4th
ed., Sage Publishing, Thousand Oaks, CA.
Further reading
Wanamaker, J. (1899), “A little handbook of Philadelphia
together with certain annals of the Wanamaker system”,
American Academy of Political and Social Science, Vol. 15
No. 13, pp. 123-135.
Corresponding author
Rocío Rodríguez can be contacted at: rociro@gmail.com