Revista
de
Administração
http://rausp.usp.br/ RevistadeAdministração52(2017)26–35
Sustainability
Corporate
sustainability
practices
in
accredited
Brazilian
hospitals:
a
degree-of-maturity
assessment
of
the
environmental
dimension
Práticas
de
sustentabilidade
corporativa
em
hospitais
brasileiros
acreditados:
verifica¸cão
do
grau
de
maturidade
quanto
à
dimensão
ambiental
Prácticas
de
sostenibilidad
corporativa
en
hospitales
brasile˜nos
acreditados:
evaluación
del
nivel
de
madurez
en
la
dimensión
ambiental
Glauce
Nascimento,
Claudia
Affonso
Silva
Araujo,
Luciana
Albuquerque
Alves
∗UniversidadeFederaldoRiodeJaneiro,RiodeJaneiro,RJ,Brazil
Received19January2015;accepted13June2016 Availableonline17October2016
Abstract
ThemainobjectiveofthispaperistoassessthedegreeofmaturityofBrazilianaccreditedhospitalsinrelationtosustainablepractices,specifically theenvironmentaldimension.Therefore,aquestionnairewasconstructed,shapedbytheliteraturereviewandtheevaluationmethodoftheCorporate SustainabilityIndexofBMandFBovespa(n.d.).Furthermore,therelationshipbetweenthreecorporatesustainabilitytools(thecertificationofthe InternationalOrganizationforStandardization[ISO]14001,publishedsustainabilityreports,andtheexistenceofanareadedicatedtocorporate sustainability)andthematurityofhospitalsinrelationtosustainabilitypracticeswereassessed.Theresultsshowthat,ofthe38hospitalsthat participatedinthesurvey(43%ofsubjectsstudied),58%obtainedamaturityratingofveryhighorhighrating,accordingtotheestablishedcriteria. Inaddition,someresearchvariablesshowedstatisticallysignificantdifferencesamongthehospitalsthathaveISO14001certification,thosethat publishsustainabilityreports,andthosethathaveanareadedicatedtosustainability.Consequently,hospitalsshouldtakeactiontoincludemuch moresustainabilityactionsintheirstrategies,suchashowtoestablishaparticipatorydialogwithstakeholders,inordertoimproveandraisethe levelofmaturityofhospitals.
©2016PublishedbyElsevierEditoraLtda.onbehalfofDepartamentodeAdministrac¸˜ao,FaculdadedeEconomia,Administrac¸˜aoe
ContabilidadedaUniversidadedeS˜aoPaulo–FEA/USP.ThisisanopenaccessarticleundertheCCBYlicense(http://creativecommons.org/ licenses/by/4.0/).
Keywords: Sustainability;Environmentalsustainability;Accreditedhospitals;Maturitylevel
Resumo
Oprincipalobjetivo desteartigo éverificarograudematuridadedoshospitaisacreditadosbrasileirosem relac¸ãoàs práticasde sustentabil-idade, maisespecificamente nadimensãoambiental. Paraisso,um questionário foiconstruídoapartirdarevisãodeliteraturaedo método deavaliac¸ão do ÍndicedeSustentabilidade Empresarial daBM&FBovespa(n.d.). Além disso,verificou-se a relac¸ãoentre três ferramentas desustentabilidadecorporativa(certificac¸ão InternationalOrganization forStandardization [ISO]14001,apublicac¸ão derelatóriosde sus-tentabilidade e a existência deuma área dedicadaà sustentabilidade na empresa) e a maturidadedos hospitaisem relac¸ãoàs práticasde sustentabilidade.Osresultadosapontamque,dostrintaeoitohospitaisqueparticiparamdapesquisa(43%douniversoinvestigado),58%das instituic¸ões obtiveramclassificac¸ão dematuridademuitoalta ou alta deacordocom oscritérios estabelecidos.Ademais, algumasvariáveis investigadasapresentaramdiferenc¸as estatisticamentesignificativas entre oshospitaisque possuem acertificac¸ão ISO14001,que publicam
∗Correspondingauthorat:RuaPascoalLemme,355,CEP21941-918RiodeJaneiro,RJ,Brazil. E-mail:[email protected](L.A.Alves).
PeerReviewundertheresponsibilityofDepartamentodeAdministrac¸ão,FaculdadedeEconomia,Administrac¸ãoeContabilidadedaUniversidadedeSãoPaulo –FEA/USP.
http://dx.doi.org/10.1016/j.rausp.2016.10.001
relatóriosdesustentabilidadeequepossuemumaáreadedicadaàsustentabilidade.Assim,oshospitaisdevemadotaratitudesparainserircada vezmaisasustentabilidadeemsuasestratégias,comoestabelecerumdiálogoparticipativocomosstakeholders,quepoderãoaprimorareelevaro graudematuridadedasinstituic¸õeshospitalares.
©2016PublicadoporElsevierEditoraLtda.emnomedeDepartamentodeAdministrac¸˜ao,FaculdadedeEconomia,Administrac¸˜aoe ContabilidadedaUniversidadedeS˜aoPaulo–FEA/USP.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY(http://creativecommons.org/ licenses/by/4.0/).
Palavras-chave:Sustentabilidade;Sustentabilidadeambiental;Hospitaisacreditados;Graudematuridade
Resumen
Elprincipalobjetivoenesteartículoesverificarelniveldemadurezdeloshospitalesbrasile˜nosacreditadosrespectoalasprácticassostenibles, específicamenteenladimensiónambiental.Paraello,uncuestionariofueconstruidoapartirdelarevisióndelabibliografíaydelmétodode evaluacióndelÍndicedeSustentabilidadEmpresarialdeBM&FBovespa.Además,seinvestigólarelaciónentretresherramientasdesostenibilidad corporativa(InternationalOrganizationforStandardization[ISO]14001,lapublicacióndeinformesdesostenibilidadylaexistenciadeunárea dedicadaalasostenibilidadenlaempresa)ylamadurezdeloshospitalesconrelaciónalasprácticasdesostenibilidad.Losresultadosmuestran que,delostreintayochohospitalesqueparticiparonenlaencuesta(43%deluniversoinvestigado),el58%obtuvocalificacióndemadurezmuyalta oalta,deacuerdoconloscriteriosestablecidos.Asimismo,algunasvariablesinvestigadaspresentarondiferenciasestadísticamentesignificativas entreloshospitalesquecuentanconlacertificaciónISO14001,quepublicaninformesdesostenibilidadyqueposeenun áreadedicadaala sostenibilidad.Deesamanera,loshospitalesdebenadoptaraccionesqueincluyancadavezmáslasostenibilidadensusestrategias,como,por ejemplo,establecerundiálogoparticipativoconlosstakeholders,loquemejoraráyelevaráelniveldemadurezdeloshospitales.
©2016PublicadoporElsevierEditoraLtda.ennombredeDepartamentodeAdministrac¸˜ao,FaculdadedeEconomia,Administrac¸˜aoe ContabilidadedaUniversidadedeS˜aoPaulo–FEA/USP.Esteesunart´ıculoOpenAccessbajolalicenciaCCBY(http://creativecommons.org/ licenses/by/4.0/).
Palabrasclave: Sostenibilidad;Sostenibilidadambiental;Hospitalesacreditados;Niveldemadurez
Introduction
From the 1980s, concern about the scarcity of natural resourcesandtheir conservationfor futuregenerationsmeant thatallsectorsoftheeconomybegantoassumeresponsibilityin thepursuitofsustainabledevelopment(Klabin&Aragão,2010). Oneoftheareasunderdiscussionishealth,morespecifically,the hospitalsector,whoseoperationshaveamajorsocialand envi-ronmentalimpact, sincetheyinvolveahugeamountofwaste tobedisposedofinlandfills(Jarousse,2012),aswellashigh consumptionofmaterialsandenergy(Weisz,Haas,Pelikan,& Schmied,2011).
Afirststepinthepursuitofsustainabilityinthesectoristo assesstheimpactofitsactivitiesbybuildingmetrics:theseare importantnotonlytoassessthecurrentstateofcompanies,but alsotoassistinsettingfuturegoalsforreducingenvironmental harmcausedby operations (Zucchi &Mwamakamba, 2011). Therefore,thisstudyaims toassessthedegreeofmaturityof Brazilianhospitalsinrelationtocorporatesustainabilityactions, particularlyintheenvironmentaldimension.
To this end, a questionnaire was created, inspired by the literature review and the Índice de Sustentabilidade Empresarial (CorporateSustainability Index/ISE), the Brazil-ian index that analyzes the performanceof companies listed onBM&FBovespaaccordingtoaspectsofcorporate sustaina-bility. Additionally, the degreeof commitment tosustainable practiceswasalsoevaluated,usingthreeparameters:(i) opera-tionalperformance,evaluatedbasedonISO14001certification; (ii) the relationshipwith society and transparency, evaluated basedonpublicationofaSustainabilityReport;and(iii) man-agementstructure,evaluatedbasedontheexistenceofaspecific sustainabilityarea.
Thepaperisorganizedasfollows:first,aliteraturereviewis presentedaddressingthekeyconceptsofcorporatesustainability anditselements,suchascorporatesustainabilitycertifications, reportsandindicators,etc.Environmentalsustainabilityissues for hospitals are looked at in depth. The methodology, the research questions andthe hypotheses are then described. A discussionoftheresultsfollows,witharatingofthehospitals accordingtothedegreeof maturity.Finally,themain conclu-sionsoftheresearcharepresented.
Reviewoftheliterature
Corporatesustainabilityanditstools
ISO14001certification
Inordertominimizethe negativeeffects of theiractivities ontheenvironment,companiesseektoadapttheiractivitiesto modernenvironmentalmanagement standards,ISO 14001,in particular (Alexander et al., 2008; International Organization forStandardization[ISO]2009;Jabbour,Teixeira,&Jabbour, 2013).ISO14001isavoluntaryandcertifiablestandardaimed at the continuous improvement of environmental standards, throughthe establishmentofmanagement objectivesand sys-tems (Oliveira, 2008). In addition, it provides strategies and generalguidelinesfor businesses’targetingofpolicies,plans, projects and environmental programs (Brouwer & Koppen, 2008;Korul,2005;Oliveira,2008).
Toreceivethecertificationseal,thecompanymustidentify environmentalaspects;conduct environmentalaudits, andput procedures andplans in place inthe event of an emergency environmental nature (Abreu, 2011).As a result of the right applicationofthestandard,thecompanybenefitsfroman opti-mal useof resources andconsequently (i)reduction of waste orincreasedefficiency(Oliveira,2008);(ii)increasing competi-tivenessbasedonmeasurement,innovation,andprofits;and(iii) amorecredibleimagevis-à-vissociety(Korul,2005;Petroni, 2000). Thus, the literature indicates that hospitals with ISO 14001certificationaremoreadvancedintermsofsustainability practices thanthosewithout. Thisallows usto formulatethe followingnullhypothesis:
H01. Thereisnostatisticallysignificant differenceinterms
ofadoptedsustainabilitypracticesamonghospitalsthatdohave ISO14001certificationandthosethatdonot.
Sustainabilityreport
Thesecondtoolusedinthepursuitofcorporatesustainability isthesustainabilityreport,whichaimstosystematizeand dis-seminateinformation–quantitativeandqualitative–aboutthe environmentalperformanceofthecompany,fostering engage-mentandprovidingallstakeholderswithtransparency(Global ReportingInitiative[GRI], 2011;Oliveira, 2008).Amongthe main models of Sustainability Reports, the most used is the Global Reporting Initiative (GRI), a non-profit organization foundedin1997thatofferssustainabilityreportingguidanceand metricsforthestructuringofreportsaroundtheworld,regardless ofabusiness’ssizeorsector.
Sustainabilityreportsperformthefundamentalroleof repor-ting the activities carried out by institutions, systematically conveyingtransparencyandcommunicationwiththedifferent stakeholders(Oliveira, 2008; GRI, 2011). By doing so, such reporting can act inthe evaluation of the company’s perfor-manceandpositiononsustainable issues,denotingapossible influenceofsustainabledevelopmentinthecompany’sstrategy. Thus,theliteraturereviewedindicatesthathospitalsthatpublish sustainabilityreportsaremoreadvancedintermsof sustaina-bilitypracticesthanthosethatdonot.Thus,thefollowingnull hypothesis:
H02. Thereisnostatisticallysignificantdifferenceintermsof
adoptedsustainabilitypracticesamonghospitalsthatdopublish asustainabilityreportandthosethatdonot.
Specificarearesponsibleforsustainability
Havingteamsinplacethatareresponsiblefor establishing organizational goals, objectives andtimelines (planning) and monitoringimplementations,performancemetricsand evalua-tions(supervision)aresuccessfactorsinhospitalenvironmental sustainabilityprojectsthatpropelthecompanytowardthe adop-tion ofsustainablepractices(Hamilton,2008;Jarousse,2012; Turpin&Lee,2011).Theseteams(calledgreenteams)arebest staffedbyindividualsanddepartmentsfromthroughoutthe com-pany,and, ifpossible,ahiredmanager,suchas aDirectorof Sustainability, whowould be tasked with (i) supervising the sustainableinitiativesputinplacebyothermanagers through-outtheorganization;(ii)providingthecompanywithtechnical expertiseandoverseeingthetrainingandworkofthe sustaina-bilityteams;and(iii)fosteringoutreach withthesurrounding community(Hamilton,2008;Jarousse,2012).
Thus,thefollowingnullhypothesis:
H03. Thereisno statisticallysignificantdifference interms
ofthesustainabilitypracticesadopted,amonghospitalsthatdo haveaspecificareadedicatedtosustainabilityandthosethatdo not.
CorporateSustainabilityIndicators
TheCorporateSustainabilityIndicatorsarethenumbersthat arecapabletoreflectthedimensionsquotedintheTripleBottom Line(Siche,Agostinho,Ortega,&Romeiro,2007):theyallow managerstohaveanassessmentoftheenvironmentandsocial systems,bothinthemacro andmicrorealms,withshort-and long-term perspectives, thus helpingthem todetermine what actions shouldor shouldnotbetaken inthe pursuitofa sus-tainable society (Ness, Urbel-Piirsalu, Anderberg, & Olsson, 2007).Singh,Murty,Gupta, andDikshit (2011)highlightthe importanceofsustainabilityindicatorsaspowerfultoolsforthe adoptionofpoliciesandcommunicationsincetheycansimplify complexinformation.
Inthispaper,themethodologyforassessingtheISEwasthe basisfordevisingamaturityindexofsustainability-accredited Brazilianhospitals,asitwillbefurtherdetailedinthe method-ologysection.
Corporatesustainabilityinthehospitalhealthcareindustry
Hospitals–institutionsthatplayacentralroleinthe health-caresystem–canminimizetheirnegativesideandforgegains inhealthitselfby integratingsocialand environmental ques-tionsintothecorebusiness,i.e.,healthcareandpromotionof health(Weiszetal.,2011).Sustainabledevelopmentfor hospi-talsislinkedtotheoptimizationofthevariousqualitycriteria, notonlyintermsofthehospital’smainactivity,butalsoforits economicefficiency,andenvironmental(Jameton&McGuire, 2002)andsocial(Weiszetal.,2011)compatibility.Itis impor-tanttoemphasizethatsustainabilityprogramsshouldreflectthe uniqueneeds andcharacteristics of each organization;thisis becausetheimplementationofthistypeofprograminbusiness requires,inadditiontotime,asignificantculturalshift(Griffiths, 2006).Moreover,forhospitals,theseprogramsendup perme-atingallaspectsoftheinstitutionatalllevels,bothintermsof cultureandeducation(Hamilton,2008),includingfoodservice, materialsmanagement,andnursingstaff(Jarousse,2012).
Asuccessfulenvironmentalsustainabilityprogramprovides the company withseveral advantages. First, the organization enjoysincreasedperformanceintermsofefficiencyand effec-tiveness(Donabedian,1998,ascitedinManzo,Brito,&Corrêa, 2012,p. 389).Theseincreasesareaccompaniedbyimproved outcomes in terms of clinical results, the experience of staff andpatients,systemreliabilityandcompany’sculture(Jarousse, 2012).Thesecondadvantageisthereductionofrisk,giventhe regulatoryoversightofenergyconsumptionandwastedisposal (Jarousse,2012).Thethirdbenefitisinreducedcosts:less con-sumptionofresourcesandlessgenerationofwaste(Hamilton, 2008;Gillmeister, 2012;Jarousse, 2012). At last, thereis an increaseinsociety’spositiveperceptions,duetothe conserva-tionofscarceresourcesandpromotionofthehealthofpatients andstaff(Graysonetal.,2011;Jarousse,2012).
Afteraliteraturereview,welistthefactorsconsidered deci-sive for the success of hospital environmental sustainability projects:
• Integrationofsustainabledevelopmentconceptsinthe com-pany’sstrategy(Gillmeister,2012;Jarousse,2012);
• leadership as a differentiating factor in the successful implementationofsustainableinitiatives(Gillmeister,2012; Jarousse,2012);
• measurementofrisksandimpactsofoperations,whichhelps teamswithconstructinggoalsandmetricsandmonitoringand evaluation(Hamilton,2008;Jarousse, 2012;Turpin&Lee, 2011).
• variablecompensationlinkedtotheachievementof sustain-ablegoals(Hamilton,2008;Jarousse,2012).
• watermanagementprograms:asustainablepracticethatseeks to optimize resources and reduce waste (Brega & Filho
Mancuso, 2003; Ilha, Nunes, &Salermo, 2006; Poland& Dooris,2010).
• energyefficiencyprogramsaimedatcuttingcostsand increas-ingprofit.
• sustainableprocurement,withmaterialsharmfultothe envi-ronment being replaced by those that are less aggressive (Hamilton,2008;Lamming&Hampson,1996);
• systematic communicationof performancetostakeholders, thusbringingtransparencytotheactionstakenand engage-mentoftheseparties(Hamilton,2008).
• educationalprogramsthatinfluencestakeholdersinvolvedin theprocess(Gillmeister,2012;Turpin&Lee,2011). • increasedindexesofefficiencyandeffectivenessdueto
sus-tainabilitypractices,thusprovidingincreasesincriticalcare tothesector,withoutimpactingotherareas(Jarousse,2012; Oliveira,2008).
• communicationwithouttheneedtodemandfrom stakehol-ders,whichisimportantfromthepointofviewofestablishing relations between the parties (Oliveira, 2008) and (GRI, 2011).
• start of sustainable actions by the waste management pro-gram, whichentails the institutioncutting costs(Jarousse, 2012).
• Creationofteamsresponsibleforsettinggoalsandshortand longtermgoals,timelines,supervisionofimplementations, measurementmetrics,andevaluationoforganizational per-formance,workingcloselywithkeyleaders,inparticular,the boardofdirectors(Hamilton,2008;Jarousse,2012;Turpin& Lee,2011).
Throughout the literature review, no papers were found that proposed evaluationmetricsfor sustainabilityactions by hospitals, or even undertaking a comparative assessment of engagement by hospitals or their degreeof maturity in rela-tion to sustainability practices. Although studies stress the needtoevaluateorganizationalperformanceinrelationto sus-tainabilitygoals(Gillmeister,2012;Jarousse,2012;Zucchi& Mwamakamba,2011)andtodevisespecificindexesforcertain economicpractices(Sicheetal.,2007)suchashospital activi-ties.Therefore,thisstudyaimstocontributetoasubjectlittle exploredintheory,seekingtoevaluatetheperformanceof the hospitalsectorinBrazilthroughmetricsdesignedspecifically forthistypeofeconomicactivity.
Method
75agreedtoparticipateinthesurvey;ofthese,only38actually completedthequestionnaire.
The questionnaire was based on the literature review, the questionnairesusedbytheauthorscitedinthereviewitself,and questions adaptedfromGroup E(coveringtheservice sector, includingmedicalandhospitalservices)oftheISEquestionnaire of2011.Thequestionnaireconsistsofthreeparts:
PartI–Demographicprofile,forcharacterizationofthe respon-dentandthe institution, basedon12questions. Open-ended questionswithanominal,nonparametricscale.
PartII– Sustainabilitypractices– overalldimension: issues relatedtothehospital’spositionastheleadingpracticein cor-porate sustainability.Forall questions,the Likert scaleof 5 pointswasadopted.
PartIII–Sustainabilitypractices–environmentaldimension: questionsregardingtheprofileoftheinstitutionwithregardto theenvironmentalsustainabilityactionstakenbythehospital. Forallquestions,the5-pointLikertscalewasadopted.
Thequestionnairewassubmittedtoapretestwithsixhealth professionalsinordertoevaluatetheclarityof theinstrument andthecorrespondenceofthebusinesstermstomedicalterms andviceversa.Tovalidatetheproposedscale,Cronbach’salpha, oralphacoefficient,wasusedasameasureofinternal consis-tencyofthescale.TheAlphacoefficientvariesbetween0and1, withacoefficientequaltoorgreaterthan0.7beingconsidered satisfactory(Hair,Black,Babin,Anderson,&Tatham,2009). TheCronbach’sAlphaobtainedinthisstudywas0.765,which showstheinternalconsistencyoftheadoptedscale.Following isadescriptiveandexploratoryanalysisofthedata,notonlyto tracethedemographicprofile,butalsotocompute thedegree
of maturityof the sample hospitalsin termsof sustainability actions. Finally,the nonparametric Wilcoxon–Mann–Whitney testforcomparisonofindependentsampleswasappliedinorder totestthehypotheses.
WeightingsystembasedontheÍndicedeSustentabilidade Empresarial(ISE)(CorporateSustainabilityIndex)
In order to compute the degree of maturityof the hospi-talssurveyedintermsofsustainabilityactionsandperformthe non-parametrictest,theweightingmethodologyappliedbythe ISE wasadopted. Theindexhasseven dimensionscomposed of criteria whichhavespecificindicators basedon whichthe questions are formulated. The criteria have different weights assigned according to their relevance to society, taking into accountthecontextofbusinessmanagement(Critérios&Pesos ISE2011/2012).
Inthisresearch,twodimensionswereadaptedfromISE:(i) general,applicabletoallgroupsandsectorsinvestigatedbythe index, pertainingto the commitmentto sustainability andits development, through due concern for the future viability of thecompany;(ii)environmental(forservicecompanies,suchas healthinstitutions), pertainingtopolicy, management, perfor-manceandlegalcompliance.Thecriteria,indicatorsandweights ofeachdimensionarelistedinTable1.
The General dimension has four criteria: Commitment, Alignment,Transparency,andCombatingCorruption.Because itwasoutsidethescopeofthiswork,“FightingCorruption”was removedfromthestudyanditspointswereredistributedamong theothercriteria,perTable2.Thequestionsinthissection(1 to4)weretakenfromtheISEindexitself,thusmaintainingthe directcorrelationbetweenquestions,criteriaandindicators.
Table1
GeneralandenvironmentalISEdimensions.
Dimension Criterion Indicator Weight
General
Commitment BasicVoluntarycommitmentcommitments 15 Alignment ConsistencyPolicyofengagementofcommitmentswithstakeholders 25 Transparency RemunerationReports 40 Fightingcorruption Fightingcorruption 20
Environmental
Political Commitment,scopeanddissemination 5
Management
Environmentalresponsibility
55 Planning
Managementandmonitoring Managementsystems
Communicationwithstakeholders Globalcommitment:biodiversity
Performance
Consumptionofenvironmentalresources–inputs
25 Emissionsandwaste
Criticalemissionsandwaste
Legalcompliance
Permanentpreservationarea
15 Legalreserve
Table2
Weightingandscoringsystem.
Dimension Variable Itemweight Dimensionweight Maximumscore Totalscore
General
1.Insertioninthestrategy 14.28
100
71.4
500 2.Measurementofrisksandimpacts 23.81 119.05
3.Variableremuneration 23.81 119.05
4.Impactmonitoring 38.1 190.5
Environmental
5.Systematiccommunicationtostakeholders 15.79
100
78.95
500 6.Communicationindependentofdemand 15.79 78.95
7.Educationalprograms 2.63 13.15 8.Efficiencyandeffectiveness 15.79 78.95 9.Independencefromfinancialresults 2.63 13.15 10.Beginningatwastemanagement 7.895 39.475 11.Securityofexecutors 7.895 39.475 12.Reuseofhospitalitems 7.895 39.475 13.Energyefficiencyprograms 7.895 39.475 14.Watermanagementprograms 7.895 39.475 15.Sustainableprocurement 7.895 39.475
Theenvironmentaldimensionhasfourcriteria:Policy, Man-agement,PerformanceandLegalCompliance.Becauseitwas outside the scope of this work, “Legal Compliance” was removedfromthestudyanditspointswereredistributedamong the other criteria, per Table 2. The correlation of questions vis-à-vis criteria was established by adapting the content of the question to the definition of the criterion. Thus, the cri-terion Policy added questions 7 and 9 – dealing with the company’scommitmentandstrategy.ThecriterionManagement encompassedquestions5and6–whichrelatetotheindicator communicationwith stakeholders– and8 – whichrelates to operatingefficiencyandeffectiveness.Questions10to15belong tothecriterionPerformance,whichassessesthemonitoringof consumptionofresources.Inordertofacilitatethecalculations, thevaluesare redistributedtothe sumof onehundredpoints betweentheelevenquestions, i.e.,newweights aregenerated bydividingthetotalvaluebytheweightofeachquestion, as expressedinTable2.
Asalreadypointed,the5-pointLikertscalewasused,sothe weightsweremultipliedby5inordertofindthemaximum pos-siblescores,whichrepresentthemaximumdegreeofmaturity intermsofsustainabilityactions(Table2).
Calculationofthedegreeofmaturityofhospitalsinterms ofsustainabilityactions
Afterperformingtheweightings,onecancalculatethedegree of maturityof the hospitals surveyed in terms of sustainable practicesandclassifytheminquartiles,eachintervalcontaining 199points.Thisnumberwasobtainedbyadjustingthedivision of the total range of 799 points(i.e., the difference between 999and200,maximumandminimum,respectively-1 point, equivalenttothebenchmark,wasremoved)by4,or25%ofthe totalrange.Thus,belowistheproposedratingsystem,indicating thedifferentmaturitylevelsofsustainablepractices:
• Rating 4, or Very High (VH): the hospital has adequate managementofsustainablepractices.Between800and999 points.
• Rating3or High(H):thehospitalappliesmostofthe con-ceptsofsustainablepracticesresearchedinitsmanagement; however,thisapplicationisnotcomprehensive.Between600 and799points.
• Rating2,orLow(L):indicatesthattheinstitutionappliesonly someofthesustainableconceptsandinaninconsistentway. Between400and599points.
• Rating1or VeryLow(VL):indicatesthattheinstitutionis unawareofordoesnotapplysustainablepractices.Between 200and399points.
Thedegreeofmaturityofthehospitalisdefinedbythesum oftheresultofmultiplicationofthevariablesineachweighted dimension bytherespondent’sagreement withthe statements (onascaleof 1to5).Tocharacterize themanagementof the institutionasabenchmarkintermsofsustainabilitypractices, themaximumscoreisrequiredonallthecharacteristics,i.e.,a scoreof1000points.
Results
Therespondentsrepresented43%ofthepreviouslydefined population.Thevastmajorityareprivate(92%)andlocatedin theSoutheastregion(76%).Withregardtosustainability man-agementtools,11%ofhospitalshaveISO14001certification, 18%publishsustainabilityreports,and45%haveaspecificarea toaddresssustainabilityissues.
Degreeofmaturityofsustainablepracticesinhospitals
Amongthe38hospitalsinthesample,7(18%)wereratedas 4,i.e.,VeryHigh(VH);15(39%)wereratedas3,i.e.,High(H); and15(39%)wereratedas2,i.e.,Low(L).Onlyonehospital (4%)wasratedas1,i.e.,VeryLow,(VL).Nohospitalwas con-sidered abenchmark. Thehospital withthebestperformance scored 885 points and the hospital with lowest performance scored350points,i.e.,arangeof535points.
othertwoobtainedaratingof4.Thisconcentrationof hospi-talscertifiedatthehighestlevelsofmaturitysupportstheview thattheISO14001isassociatedwithminimizingthenegative effects ofbusiness activitiesonthe environment,indicatinga highdegree of maturityin terms of the sustainable practices ofthoseinstitutions(Petroni,2000;Brouwer&Koppen,2008; ISO,2009;Korul,2005;Oliveira&Serra,2010;Oliveira,2008). Allfiveinstitutions(13%)having aspecificareadedicated totheplanningandsupervisionofsustainableactionsactivities alsoachievedthebestresults:Twoachievedaratingof3(H)and threeobtainedaratingof4(VH).Thisresultindicatesthat hospi-talswithanareadedicatedtosustainabilityaremoredeveloped –orevenmature–intermsofsustainabilityactions,an obser-vationthatgoesalongwiththeliteraturereviewed(Hamilton, 2008;Jarousse,2012;Turpin&Lee,2011).
Regardingsocialreports,norelationshipwasfoundbetween theirpublicationandagreaterdegreeofmaturityintermsof sus-tainabilitypractices.Ofthesevenhospitalsthatpublishreports ofthistype(18%),onlyonewasratedas4(VH);threewererated as3(H);theremainingthreewereratedas2(L).Alikelyreason forthesedivergentratingsisthelackofstandardizationamong publications:differentcommitmentsvis-à-visreleaseofactions andrelationshipswithstakeholders.Forthisreason, organiza-tions,such asGRI,seektostandardizemetricsforstructuring reports,therebybymakingthemcomparable.
Mann–Whitneytest
Testofhypothesis1:ISO14001
Ho1. Thereisnostatisticallysignificant differenceinterms
ofadoptedsustainabilitypracticesamonghospitalsthatdohave ISO14001certificationandthosethatdonot.
As can be seen in Table 3, significant differences were observedforsevenofthevariablesunderstudy;thatis,thenull hypothesiswas rejectedfor seven of the15 variables investi-gated.ThesurveyedhospitalsthathaveISO14001certification obtainedhigherscoresfortheitems“inclusioninthecompany’s strategy,”“measurementofrisksandimpacts,”“variable remu-neration”and“watermanagement”(p<0.05),andfortheitems “systematic communication with stakeholders,” “educational programs”and“efficiencyandeffectiveness”(p<0.10).In sum-mary, the hospitalsthat haveISO 14001certification showed significant differences in terms of the adopted sustainability practices,butonlyforsevenofthefifteenvariablesinvestigated in thisstudy. Thus, hypothesis H01 was partially hypothesis rejected.
Testofhypothesis2:reportspublication
Ho2. Thereisnostatisticallysignificantdifferenceintermsof
adoptedsustainabilitypracticesamonghospitalsthatdopublish asustainabilityreportandthosethatdonot.
AscanbeseeninTable4,whenperformingthetesttocheck if thereweresignificant differencesinterms of sustainability practicesbyhospitalsthatdopublishsustainabilityreports, com-paredtothosethatdonot,significantdifferenceswereobserved
Table3
Hypothesis1Mann–Whitneytest.
ISO14001certification U Z p-value 1.Insertioninstrategy 16 −2.601 0.009**
2.Measurementofrisksandimpacts 22.5 −2.224 0.026**
3.Variableremuneration 22.5 −2.31 0.021**
4.Impactmonitoring 37 −1.543 0.123
5.Systematiccommunicationtostakeholders 34.5 −1.652 0.099*
6.Communicationindependentofdemand 56 −0.586 0.558
7.Educationalprograms 34 −1.688 0.091*
8.Efficiencyandeffectiveness 35 −1.651 0.099*
9.Independencefromfinancialresults 64.5 −0.18 0.857
10.Beginningwastemanagement 45.5 −1.178 0.239
11.Securityofexecutors 54 −0.686 0.493 12.Reuseofhospitalitems 59.5 −0.418 0.676 13.Energyefficiencyprograms 50 −0.933 0.351 14.Watermanagementprograms 19 −2.43 0.015** 15.Sustainableprocurement 50 −0.886 0.376
*Differencesstatisticallysignificantat10%. **Differencesstatisticallysignificantat5%.
Table4
Hypothesis2Mann–Whitneytest.
Publicationofreports U Z p-value 1.Insertioninstrategy 84 −0.97 0.332
2.Measurementofrisksandimpacts 100 −0.329 0.742
3.Variableremuneration 93 −0.623 0.533 4.Impactmonitoring 98.5 −0.394 0.694 5.Systematiccommunicationtostakeholders 92.5 −0.625 0.532 6.Communicationindependentofdemand 42.5 −2.55 0.011** 7.Educationalprograms 55 −2.103 0.035** 8.Efficiencyandeffectiveness 100 −0.337 0.736 9.Independencefromfinancialresults 73 −1.448 0.148
10.Beginningwastemanagement 55.5 −2.197 0.028**
11.Securityofexecutors 94 −0.562 0.574
12.Reuseofhospitalitems 85.5 −0.896 0.37
13.Energyefficiencyprograms 87.5 −0.862 0.389
14.Watermanagementprograms 56.5 −2.042 0.041**
15.Sustainableprocurement 107 −0.058 0.953
**Differencesstatisticallysignificantat5%.
(p<0.05)forfourvariablesinvestigatedinthisstudy: commu-nicationindependentoftheneedofdemandfromstakeholders; educational programs; beginning of sustainable practices for wastemanagement,andwatermanagementprograms.In sum-mary, the hospitals that publishsustainability reports showed significant differences interms of the sustainabilitypractices adoptedinfourofthefifteeninvestigateditems.Thus,hypothesis H02waspartiallyhypothesisrejected.
Testofhypothesis3:specificarearesponsibleforplanning andoversightofsustainabilityissues
H03. Thereisno statisticallysignificantdifference interms
ofthesustainabilitypracticesadopted,amonghospitalsthatdo haveaspecificareadedicatedtosustainabilityandthosethatdo not.
Table5
Hypothesis3Mann–Whitneytest.
Sustainabilityarea U Z p-value 1.Insertioninstrategy 31 −2.339 0.019**
2.Measurementofrisksandimpacts 33.5 −2.174 0.03**
3.Variableremuneration 41.5 −1.89 0.059*
4.Impactmonitoring 46.5 −1.627 0.104
5.Systematiccommunicationtostakeholders 32.5 −2.238 0.025**
6.Communicationindependentofdemand 60.5 −0.975 0.33
7.Educationalprograms 34 −2.186 0.029**
8.Efficiencyandeffectiveness 47.5 −1.59 0.112
9.Independencefromfinancialresults 82 −0.023 0.981
10.Beginningwastemanagement 53 −1.402 0.161
11.Securityofexecutors 69.5 −0.578 0.563 12.Reuseofhospitalitems 75 −0.335 0.738 13.Energyefficiencyprograms 63.5 −0.894 0.371 14.Watermanagementprograms 41 −1.869 0.062* 15.Sustainableprocurement 64 −0.827 0.408
* Differencesstatisticallysignificantat10%. ** Differencesstatisticallysignificantat5%.
planning and oversight of sustainability issues, compared to thosewithoutsuchanarea,asignificantdifferencewasobserved insixvariables:insertioninthestrategy;measurementofrisks andimpacts;systematiccommunicationtostakeholders; educa-tionalprograms;variableremuneration;andwatermanagement programs.Inshort,thehospitalsthathaveaspecificarea respon-siblefortheplanningandsupervisionofsustainabilityactions showed significant differences in terms of the sustainability practicesadoptedinsixofthefifteenitemsinvestigated.Thus, hypothesisH03waspartiallyhypothesisrejected.
Conclusion
Theresultsofthisstudypointtoahighlevelofadoptionof theinitiativesdescribedintheliterature,wheresevenhospitals (18%)hadaratingof4(VH),and15hospitals(39%)hadarating of3(H);hence,58%ofhospitalswereratedintheupper quar-tiles.Ontheotherhand,15hospitals(39%)hadaratingof2(L); andonehospital(3%)hadaratingof1(VL).Thehospitalsthat haveISO14001certificationandaspecificareafortheplanning andsupervisionof sustainable activitiesrankatthetop, with ratingslevelsof4and3.Thesecharacteristicsaredirect indi-cationsofastructuredconcernonthepartoftheseinstitutions withregardtotheimpactoftheiractivitiesontheenvironment. Their rankingat these higher levels also demonstrates a for-mal treatment onthe part of the administration; indeed,they madeinvestmentsinanenvironmentalcertificationsealandin anorganizationalhierarchy,throughasustainabilityarea.
Asforthepublicationofreports,thisparameterwasperceived atlevels4,3 and2,whichthusdidnot allowfurther conclu-sionstobemadeinthatregard.Inpractice,acertaindifference amongthereportsconsultedhadalreadybeenperceived:only theinstitutionsthatexternallypublishedsuchdocumentswere considered. Thus,it canbeconcluded that the publication of reports, withoutany specificstandardization, wasnot able to contributedirectlytoahigherrankingofdegreeofmaturityin termsofsustainablepractices.
Table6
Summaryofobservations–hypothesistesting.
Variable ISO
14001
Report Sustainability area 1.Insertioninstrategy ** **
2.Measurementofrisksandimpacts ** **
3.Variableremuneration ** *
4.Impactmonitoring
5.Systematiccommunicationto stakeholders
* **
6.Communicationindependentof demand
**
7.Educationalprograms * ** **
8.Efficiencyandeffectiveness *
9.Independencefromfinancialresults
10.Beginningwastemanagement ** 11.Securityofexecutors
12.Reuseofhospitalitems 13.Energyefficiencyprograms
14.Watermanagementprograms ** ** *
15.Sustainableprocurement
* Differencesstatisticallysignificantat10%. **Differencesstatisticallysignificantat5%.
Anotherobjectiveofthisresearchwastoinvestigatethe rela-tionshipbetweentheISO14001,thepublicationofreports,the presenceof aspecificareadedicatedtosustainability,andthe adoptedsustainabilitypractices.Thethreenullhypotheseswere partiallyrejected.ThisinformationwasgroupedinTable6.
For ISO 14001 certification, the null hypothesis H01 was partiallyrejected.Since,forsevenvariablesasignificant differ-encebetweenhospitalsthathaveandthosethatdonothavethis certificationwasobserved.Thus,itcanbeconcludedthatthese aspectsdeservetheattentionofhospitalmanagerswhoseekto enhancetheirpracticesofsustainabilityinitiatives,inparticular attheenvironmentaldimension.Regarding thepublicationof reports,because forfourvariablestherewasasignificant dif-ferencebetweenhospitalsthatdopublishasustainabilityreport andthosethatdonot,nullhypothesisH02waspartiallyrejected. Regardingtheexistenceofaspecificarearesponsiblefor plan-ningandsupervisionofsustainabilitypractices,nullhypothesis H03waspartiallyrejected,sinceforsixvariablestherewasa significant difference betweenhospitals that dohave such an areaandthosethatdonot.Therefore,itcanbeconcludedthat theseareaspectsthatdeservetheattentionofhospitalmanagers, whomustcreatethisspecificareawithduecaretothecontentof suchremit.Moreover,inobservingTable4,itappearsthatthe educationalprogramsandwatermanagementvariablesshowed statisticallysignificantdifferencesinthethreecasesstudied.In addition,theISO14001certificationshowedagreaternumberof variableswithsignificantdifferences,showingsupremacyover theotherfactorsinthesamplestudied.
canobtainhigherratingsandwillultimatelyhavegreater com-mitmentiftheyadoptanewbehavioraspartoftheirroutine.It ispossiblethattheinstitutionswithlowermaturitylevels (rat-ings1and2),basedonthelongertrajectorytobetraveled,have greaterdifficultieswithregardtoraisingawarenessandalsoto changetheattitudeofcollaborators.Itisthereforenecessarynot onlytoregulareducationalprogramsthatarecarriedoutaswell asgarneringthesupportoftheleaders.Otherfactorstobe con-sideredandadoptedaretheidentificationofdriversandongoing auditing.
Researchcontributions
Thisstudybringstogetheracademicandmanagerial contrib-utionstotheknowledgeofsustainabilityinthehospitalsector. Foracademicpurpose,thepaperpresentsthepropositionofa weightedrating scalefor assessing the degreeof maturityof sustainablepracticesinhospitals.Regardingthebusiness com-munity,theresearchcanhelpmanagerstoconstructmodelsof sustainable management inhospitals: the study identified the relationshipbetweenspecificfactorsandthemoststatistically significantvariablesforthedegreeofmaturityofsustainability practices.
Suggestionsforfutureresearch
Seekingtobroadentheunderstandingofsustainability prac-ticesinthehealthsector,thechoiceofamorespecificuniverse is suggested.Forexample, only hospitalsin the state of São PauloorRiodeJaneiro–andnotnecessarilyaccreditedones, sincesomehospitals canbe unaccredited yet havegood sus-tainablepractices.Furthercomparativestudiesbetweenregions, locations,andaudiences could alsobe made.Additionally, it wouldbeinterestingtoconductasurveyaimedatunderstanding howthefactorsstudied–ISO14001certification–publication of reports– specificareaforsustainability–explain,through the15sustainableactionssurveyed, thedegreeof maturityof accreditedhospitalsinBrazil.
Because this work addressed a single aspect of sustaina-bility,i.e.,theenvironmentaldimension,furtherresearchonthe socialandfinancialdimensionsofthetriplebottomlineis sug-gested.Itwould alsobeinterestingtosee,usingaqualitative study,whetherconsumersofhospitalservicesareinfluencedby sustainablefactorswhenchoosingapointofcare.
Finally, because the focus of this study was the hospital sector, it would be appropriate to extend the study of sus-tainabilitypracticestootherplayersinthehealthsystem(e.g., analysis/diagnosis laboratories, the pharmaceutical industry, equipmentsuppliers),therebyaffordinganunderstandingofthe industry as a wholeand enabling the formulationof general andcomprehensivemetricsfromthelegislativeandgovernment actionpointofview.
Conflictofinterest
Theauthorsdeclarenoconflictsofinterest.
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