Supply Chain Management (SCM) is a field of growing academic interest, as reflected in the increase in related literature [1
]. The Council of Supply Chain Management Professionals [2
] (p. 187) not only defines SCM as the “planning and management of all activities involved in sourcing and procurement, conversion, and all logistics management activities,” but also emphasizes its role in the integration between players involved in the entire supply chain. SCM interest lies in its contribution to a competitive advantage, in terms of differentiation and the reduction of operating costs, especially in the current context of intense competition, globalization, and active consumer participation [3
]. It is argued that better SCM results in superior performance, through the adoption of exemplary practices [4
]. A wide range of publications support the existence of significant relationships between SCM practices and organizational performance, especially from the economic perspective [5
Beyond the previously mentioned economic focus, a recent trend in SCM study points to the consideration of its link to sustainability, which incorporates the environmental and social dimensions, for two reasons. First, global poverty, health, working conditions, and climate change indicators [9
], among others, have aroused worldwide interest in the promotion of sustainable development, defined as “the development that meets the needs of the present without compromising the ability of future generations to meet their own needs” [10
] (p. 41). Second, given that organizations are often responsible for both environmental and social problems including pollution and unacceptable working conditions, they also have a duty to help mitigate such effects, as well as contribute to economic development.
The concepts of the Triple Bottom Line (TBL) and Sustainable Supply Chain Management (SSCM) have become significant. The former was coined by Elkington [11
], and aims to consider the economic, environmental, and social dimensions to be equally important, since the economy is fundamental to support society, but doing business can become unfeasible in a depleted global ecosystem. The latter refers to the inclusion of environmental and social dimensions in the conventional notion of SCM, as proposed by Seuring and Müller [12
] (p. 1700), who define SSCM as, “the management of material, information, and capital flows as well as cooperation among companies along the supply chain while taking goals from all three dimensions of sustainable development, i.e., economic, environmental, and social, into account, which are derived from customer and stakeholder requirements.”
Hospital supply chains are often confronted by several economic, environmental, and social problems. From the economic point of view, increasing healthcare expenditures demand greater efficiency in the delivery of services [13
]. The Organization for Economic Co-operation and Development has estimated that hospitals account for approximately 40% of total health expenditures [15
]. Between 30% and 40% of a hospital´s budget is dedicated to supply chain costs [16
], which can be reduced by up to 8% through the use of best practices [17
]. In addition, said best practices allow clinical personnel to focus on their core mission of caring [16
Regarding the environmental dimension, hospital processes and services are intensive in terms of material, energy, and water consumption, generate significant amounts of waste (especially toxic waste, as compared to other sectors), and account for a large carbon footprint [14
]. In England, for instance, the Sustainable Development Unit of the National Health Service has calculated that healthcare’s footprint represents 39% of public sector emissions, from which procurement contributes 57%, energy contributes 18%, travel contributes 13%, and others account for 11% [20
]. Moreover, acute services are responsible for the largest portion, which is approximately 50% of the total.
Social problems related to hospital supply chains are also tangible. From an internal perspective, although hospitals are large-scale employers, non-standard forms of employment are frequent, pay levels have decreased in comparison to other economic sectors, women are compensated worse and recognized less often than men, daily working hours exceed legal limits, and safety considerations are often neglected [21
]. Work characteristics such as shift work and long working hours not only increase the likelihood of occupational accidents, and developing burnout and additional psychological stress than in other jobs [14
], but also impact the quality of patient care [26
]. From an external standpoint, hospitals have a deep impact on the population because health services influence, in one way or another, peoples’ quality of life. Nevertheless, reported global problems include unsatisfactory health service coverage for the needs of the population, in terms of access and delivery [21
Therefore, the goal of accomplishing the triple challenge of being more efficient, more environmentally-friendly, and offering better conditions to both workers and communities served, leads to the subjects of SSCM practices and sustainable performance. No matter the way that practices are defined, whether as organizational routines, rules, or standard procedures [29
], best practices are linked to the objective of that which is recognized as superior by a majority [16
]. In other words, poor performance can be considered a consequence of a lack of best practices [30
Numerous publications demonstrate that SSCM is a field of increasing interest. As Carter and Washispack assert in a review, “we have reached a point of saturation” [31
] (p. 242), in terms of appraising the structure and main themes of SSCM literature. However, specific relationships between constructs remain unexplored. Some empirical studies stress that SSCM practices and sustainable performance constructs have not been clearly or consistently defined [32
]. Besides the primacy in the study of operational and economic topics, the environmental dimension has been more often addressed than the social dimension [35
]. Moreover, the integration of the three sustainability dimensions has not been sufficiently robust [39
], and industry-specific issues have not been elucidated to the extent to which they could be [34
Despite dramatic growth in the SSCM literature [31
], this is not the case when delimited to hospital settings. Academic database searches yield results on hospital SCM or hospital sustainability, but almost none appear to address hospital SSCM as such. Therefore, both SCM and sustainability may be relevant for hospitals, but they have likely been addressed in a fragmented manner in the literature. To the authors´ knowledge, there are no existing reviews which address the intersection between hospital SCM and sustainability. Reviews focused on the healthcare supply chain [45
] have not explicitly considered environmental and social issues, whereas reviews on hospital sustainability [50
] have highlighted the environmental dimension.
In response, the aim of this article is to present a systematic review and an integrative framework for SSCM practices that can contribute to sustainable performance in hospital settings. Three research questions are specifically addressed: (1) What are the main SSCM practices applied by hospitals? (2) What are the main sustainability performance metrics used by hospitals? (3) How can the relationships between SSCM practices and performance be framed in the hospital setting?
This paper is organized as follows. In Section 2
, the methodology is presented and explained. Section 3
discusses the main findings, considering two main components. The SSCM practices applied by hospitals and sustainable performance metrics used by hospitals. In Section 4
, an integrative framework, derived from the systematic literature review, is developed. Section 5
examines future avenues for research. Lastly, a relevant set of conclusions are presented in Section 6
2. Materials and Methods
In order to address the proposed research questions, this study is based on a systematic literature review. Contrary to narrative reviews, systematic reviews are characterized by their explicitness and transparency regarding the methods used to find reasonable evidence on a given topic [51
]. In management, it has been increasingly asserted that systematic reviews are a useful way to identify relevant scientific contributions, inform research and practice, and enhance a field’s body of knowledge, by applying rigorous principles that have been traditionally used in medical research [52
As shown in Figure 1
, the methodology implemented to undertake this review involves three stages: planning, conducting, and reporting, which is in line with several suggestions [51
]. The planning stage was accomplished through the identification of need, based on the research questions proposed, as well as through the definition of the search strategy, the selection criteria, the quality assessment criteria, the data extraction strategy, and the data synthesis approach. The conducting and reporting stages were accomplished from the contents of findings and discussion sections. In parallel, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist [54
] was also followed to ensure rigor of the review process.
Search strategy: Scopus and Web of Science (WoS) were selected for the search, due to their strengths in terms of extension, coverage, and the possibility of classifying sources in accordance with impact criteria [55
]. For Scopus, publications throughout history, up to February 2019, were considered. For WoS, the time horizon was set between 2001 and February 2019, as the core collection of this database was available beginning in 2001. Based on the intersection between the topics addressed and the research questions, the executed string was as follows: (TITLE-ABS-KEY (“supply chain management” OR “healthcare logistics”) AND practice AND hospital) OR (TITLE (sustainab* AND hospital)).
The term “performance” was excluded from the search string, as some publications only address practices, irrespective of their link to performance. Along with supply chain management, the term “healthcare logistics” was employed, considering that both have been used interchangeably [56
]. Regarding the connection between sustainability and hospitals, as keywords cover broad and diverse sustainability subtopics, the search was performed by the title, in order to ensure enhanced delimitation. The publications selected for this study were primarily in English, since the intention was to explore the topic globally [57
]. Database search result duplicates were eliminated.
Inclusion, exclusion, and quality assessment criteria: Publications with direct applicability to hospitals, from a comprehensive perspective, were included. Those that moved away from these entities as focal organizations, or on the contrary, focused on very specific chains, such as blood or laboratory, were excluded. Studies were also filtered based on their relationship to the TBL approach. Thus, contributions that referred to sustainability as the continuity of the specific health programs implemented, in order to analyze the effectiveness of such programs, were excluded. Articles and reviews from peer-reviewed journals were primarily considered. However, by review of publications’ references, additional studies and international guidelines were considered suitable, such as References [58
], since they specify SSCM practices applied in hospitals worldwide. Co-authors acted as coders to decide whether each publication retrieved from the search should be included or not. In cases of disagreement, these were discussed until consensus was achieved.
Data extraction strategy and synthesis approach: In accordance with the structure employed by most articles, as well as the information provided, the variables selected for data extraction, analysis, and synthesis were as follows: sustainability dimensions addressed, practices identified, performance metrics identified, and research suggestions. Concerning the data synthesis method, a mixture of interpretative and explanatory approaches was adopted, in an attempt to exceed description [51
], as the pursued goal, being conceptual in nature, was the development of an integrative framework to facilitate the understanding of what, how, and why SSCM practices influence economic, environmental, and social performance in hospitals.
4. A Proposed Framework for Hospital SSCM
In response to the third research question, this section presents an integrative framework for SSCM practices that may impact sustainable performance in hospital settings (see Figure 4
). This can be considered innovative in at least three ways. First, as found in the reviewed literature, several publications have outlined relevant sustainability issues, but little attention has been given to the amalgamation of scattered practices and performance measures in a single and articulated framework. Most of the previous research on hospital supply chain management focuses on logistics from a cost reduction perspective, which is indisputably crucial for sustainability, but is insufficient from the TBL approach. Moreover, the publications identified with the sustainability label pivot primarily on the environmental dimension and leave aside the social dimension.
Second, the wide-ranging identification of practices and performance metrics achieved in the literature review, which gave rise to the proposed framework, likely allows to delineate a clear path toward empirical validation and the managerial implications of practice implementation and performance measurement. While a considerable number of frameworks provide valuable insights on interactions in sustainable supply chain management [40
], healthcare supply chain management in the emerging economy with the sustainable lenses [121
], and supply chain sustainability in the service industry [122
], the degree of operationalization of the categories and exemplified relations presented in this case has not been detected in previous reviews.
A third contribution to highlight is the worldwide applicability of the proposed framework and its possible extension to other service sectors. On the one hand, health services are not new to humanity. Hospitals are necessary in any country and have always existed. Similarly, sustainability issues are of global concern. On the other hand, although the framework was developed from the hospital perspective, this does not prevent it from being used as a reference for other service sectors, if properly adapted. Just as it is extremely important for hospitals to adopt supply chain management concepts and practices that have proved successful in other sectors such as food, research focused on hospitals can be a source of learning [13
The proposed framework is composed of two main blocks: practices and performance, whose corresponding exploded views are depicted in Figure 5
and Figure 6
. For practices, contributions that conceptualize the logistics management process and supply chain integration [3
], health care operations management [123
], and hospital logistics [124
] were considered. Accordingly, components traditionally related to internal supply chains, namely purchasing, warehousing and inventory, and transportation and distribution management, are placed at the center, and serve the care units through which patients flow, which include emergency, outpatient, diagnostic and therapy, operating theater, and inpatient [123
]. Undirected arcs connect these units, which means the multiple directions in which patient flow occurs, since varied medical needs create customized sequences [125
]. Clothes and laundry management as well as general services management are included, along with medical goods, food, energy, water, and waste management, since they are considered hospital logistic fields [124
], account for resource consumption, and influence healthcare delivery, quality of patient care, and patient satisfaction [123
]. In addition, strategic management and leadership, as well as information flow and technology management are key constituents of the framework, as they can influence and support supply chain relationships.
Upstream and downstream linkages are represented by Supplier Relationship Management (SRM) and Customer Relationship Management (CRM), respectively. Patient demand heads the list of inputs, as internal operations depend thereupon [123
], and healthcare demand has unique characteristics. Rather than desire, healthcare services are grounded on necessity [126
], which implies that typical marketing approaches to stimulate demand are minimal, if at all applicable, in healthcare. Other framed inputs include suppliers, medical and non-medical supplies and equipment, staff, other hospitals and providers, health insurers, government agencies, and regulators, which is in line with previous healthcare operations definitions and the numerous players that provide goods, services, and information to make operations possible [123
]. Regarding outputs, these comprise the health status that reflects in clinical indicators, the client perception that indicates how well staff and patient expectations are met, and the use of resources that denote operation efficiency [123
In accordance with the scope of the CRM concept, identified practices in the reviewed literature may fall short. It was struggling to identify it as a clear construct because these practices are scarce in healthcare [128
], despite the fact that their influence on performance has been widely studied in manufacturing [5
]. In such publications, CRM practices have been operationalized into management of customer complaints, evaluation of customer satisfaction, determination of customer expectations, frequent interaction with customers to set standards, and consideration of information from customers for business design and planning. To fill the existing void in healthcare, Reference [128
] emphasizes the need to fortify the adoption of CRM practices, considering that they can lead to better understanding of patient profitability, and that there is some evidence of their contribution to patient health and loyalty.
Recent studies on SSCM and specific social healthcare problems also lead to the inclusion of additional practices in the proposed framework. On the one hand, among the issues addressed by employee-centered social practices are wages, worker safety, and occupational health working conditions, employee participation, career planning for staff development, and the provision of opportunities for employees continuing their education [33
]. On the other hand, community-centered social practices encompass labor laws, no child labor and human rights compliance, environmental awareness training, promotion of corporate social responsibility in the industry, sustainability reporting, donation to philanthropic organizations, provision of employment or business opportunities to the surrounding community, support of local health, educational, and cultural development, and volunteering at local charities [33
In alignment with the TBL approach, performance components are framed in terms of economic, environmental, and social dimensions. From both non-financial and financial perspectives, economic metrics point to measure operational issues and the costs of classical logistics processes such as purchasing, warehousing, inventory, transportation, and distribution management. However, market-specific metrics are also included in non-financial metrics, since they were reiterative in the reviewed literature. Analogously, general metrics intended to reflect outcomes of the entire hospital, such as profitability, cost of services, and return on investment, are included in financial metrics. Moreover, environmental performance is sometimes converted into financial terms by quantifying actual and potential savings due to efficiency and conservation improvements in energy, water, travel, food, and waste [19
], while social investment volume is used to economically measure social performance [72
Environmental performance metrics are classified in accordance with the topics of purchasing, energy, water, travel, food, hospital design, and waste. To a certain extent, it could be said that carbon emissions reduction is the last target of environmental interventions, since it depends upon other metrics such as the reduction of resources, materials, drugs, and packaging consumption, increases in the use of clean and renewable energy, decreases in car use, percentage of locally and sustainably sourced procured foods, and avoidance of improper waste mixing. For example, it has been found that 5% of the carbon footprint of acute organizations comes from anesthetic gases [136
]. Similarly, waste incinerators emit toxic air pollutants, such as dioxin and mercury [19
]. Therefore, emissions can be reduced as consumption and waste generation decrease.
Except a few data regarding percental decrease in injuries caused by improper disposal [19
] and improvements in awareness, education, and efficiency [86
], hospital social performance metrics are scarce or vaguely addressed in the reviewed literature. For example, Reference [72
] mentions employee satisfaction, work life quality, proportion of working hours to those planned, staff absenteeism, and employee privacy as concepts of hospital SCM, without distinguishing between practices and performance variables. Thus, contributions that focus on SSCM and manufacturing settings are taken as a basis for the framework [32
]. In particular, metrics are divided into internal and external ones, and the latter, in turn, into community and society [137
Metrics derived from the quality of patient care are included in the social external perspective, since hospital supply chains are social by nature, and failures in service provision may have fatal consequences on health and life [18
]. Reference [60
] found significant differences between leading, developing, and under-developed hospitals, in terms of performance on quality indicators, which means that a lower death rate and higher timely provision of healthcare are perceived by those hospitals with the greatest extent of applying healthcare SCM practices. In the same way, quality of patient care has been operationalized in terms of patient experience criteria [72
] and perceptions in comparison with other hospitals [30
In the proposed framework, relationships between sustainable performance dimensions are drawn. First, it is noted that the environmental dimension influences the economic and the social dimensions. Second, the social dimension influences the economic dimension. Those cases reported by References [19
] are only a few of the studies that highlight specific economic outcomes of implementing initiatives through which the consumption of resources, such as energy and water, is reduced. According to Reference [58
], improved environmental performance prevents health systems from incurring costs, and positively impacts the social dimension by reducing diseases caused by climate change.
Lastly, the economic dimension is thought to be influenced by the social one. Despite the lack of financial indicators that reflect the management of social issues in the supply chain, a significant number of studies (albeit not focused on hospitals) have concluded that social performance positively impacts economic performance [110
]. In particular, Reference [110
] argues that the implementation of SCM practices that seek to enhance social issues results in greater loyalty, legitimacy, socially responsible investment, and trust, as well as in lower stakeholder criticisms and risk, which, in turn, lead to cost reduction and increased economic benefits.
5. Further Research Agenda
In accordance with the reviewed literature, avenues worthy of future research comprise both methodological and conceptual issues. Most suggestions are concerned with limitations of generalizability, research methods, and scope.
Some contributions recommend using wider samples [50
] and replicating studies in other cities and countries [16
], since more information from different populations and geographical areas might help validate existing research and explain heterogeneities. The broadening of moderating variables is also emphasized. Reference [141
], for instance, found that different priorities are held by public and private hospitals in terms of sustainability dimensions, since pressures undergone appear to be dissimilar for both organization types. Apart from hospital type and size [67
], suggested moderators include operations outsourcing [83
], information applications by type [67
], forms of technology [63
], nature of purchases [69
], and contingent factors that affect the inventory [79
Directions for the research methods employed depend largely on the types of studies covered in the reviewed literature. For instance, papers with an analytical and mathematical foci advocate addressing parameters that allow the simplification and improvement of proposed models [75
]. Similarly, other studies posit that qualitative data is desirable to complement quantitative results [60
], whereas those based on qualitative data require empirical validation through quantitative tools, as mentioned by Reference [69
]. Moreover, some researchers point out the limitations of cross-sectional studies, and, therefore, recommend the use of longitudinal designs, in order to learn about supply chain relationships over time [69
], and to unveil the effects of these practices on performance in the long run [39
]. Ultimately, the concept of being sustainable implies a long-term vision and a strategic approach [39
The need to dig deeper into what is meant by hospital SSCM practices and their influence on sustainable performance is brought to light in several ways. Technological, clinical, and organizational innovations that help hospitals be more sustainable are bound to being more explored [50
]. In addition, the documentation of less successful practices, in contrast with the most successful ones, is stressed as an issue that needs additional attention [61
], albeit more dissemination of exemplar cases is also required to encourage the adoption of practices [89
]. Furthermore, much can be said about the impacts of hospital supply chains, but the measurement of the effects themselves represents a challenge for hospitals. As Reference [61
] found, few hospitals use a wide range of indicators for purchase and inventory management. Reference [63
] recommends including patient safety as a performance dimension. From an environmental standpoint, Reference [50
] highlights the measurement of footprints across internal hospital supply chains as imperative.
In addition, further analysis of the influences of practices on performance is outlined. It is important to disclose the ways in which specific practices affect specific performance indicators [60
], at the time that the incorporation of sectorial, social, and cultural issues into hospital SSCM research becomes prominent. While it can be a good practice to hire and train well-qualified supply chain professionals [17
], it can be equally vital to know which concrete skills are required by supply chain managers in hospital settings [16
]. While the relevance of promoting active travel is almost indisputable, the determinants of travel behavior remain unclear [50
]. While adjusting menus to offer healthier dishes in hospital cafeterias is urgent, preference for less healthy food is rooted in the mindsets of the majority [91
]. Consequently, since social and cultural factors can hinder or facilitate the implementation of practices [89
], it is of paramount importance for sustainability improvement to gain understanding about the ways in which behaviors and culture need to change [50
], and what kind of incentives and motivations lead staff and communities to demand, adopt, and promote better practices [91
Lastly, the extant need of additional integrative research on hospital SSCM and sustainable performance merits mention. Most studies address the economic dimension, whereas few address the environmental one, and fewer yet address the social one. Unfortunately, although the under-representativeness of the social dimension is not unusual in the field of SCM [109
], and it is difficult to ignore the economic rationality on which SCM research is based, it is clear that hospitals have social concerns that, if ignored, will make a growing healthcare deterioration more evident. This is more than serious, which takes into account the interdependence between health and sustainable development, since one of the goals of sustainable development is oriented toward health improvement, but health is a condition for sustainable development [14
Framing both SSCM practices and sustainable performance metrics at once is not an easy task. The concept of practice, per se, is difficult to define. Practices take various forms and can represent technologies, processes, ways of doing things, or ways of organizing work [65
]. In addition, they can have different meanings or rationales from a sustainability approach and, for this reason, can overlap whichever categories have been established for their classification. In this way, a practice such as serving locally grown food can be conceived to improve food freshness and nutritional quality, favor the environment by avoiding transport activities, or strengthen local economies. Multiple purposes and interconnections among practices are more than visible and demonstrate the massive opportunities for action and impact that an integrated approach for sustainability provides, as well as its complexity.
Regarding performance, the main difficulty is that many effects of practices are not completely clear because there have not been enough empirical studies completed, and even less so regarding the interactions and trade-offs that may arise between dimensions. Moreover, indicator operationalization and validation are still incipient. For instance, not all the items encompassed by the review and the proposed framework have been measured in the literature. On one hand, it might be indicative of the exploratory status of current research, and the nascent interest in disclosing the elements that make up hospital SSCM. On the other, this could be interpreted as a symptom of the low level of adopting metrics and measurement systems, to such an extent that it would be more important to learn whether hospitals use indicators to measure performance than to calculate the values of such indicators.
The proposed framework can serve as a starting point for studying SSCM practices implementation in hospitals, in order to improve performance in this type of organizations, from a holistic sustainability approach. However, it needs to be validated and refined by using both quantitative and qualitative research methods. The practices and performance metrics covered are examples extracted from the literature to allow for a complete overview, rather than an instruction manual to be followed uncritically, since hospitals vary in accordance with their range of services, capacities, types, complexities, technologies, problems, impacts, needs, and more. Furthermore, it would be useful to prioritize elements of the framework, such as through multiple-criteria decision analysis techniques.
Apart from further validation required of the proposed framework, this review has several limitations. Additional databases and languages could be used. Since a search strategy that separately includes each of the topics of SCM or sustainability in hospitals was not formulated, the resulting analysis is comprehensive, but leaves room for improvements in exhaustiveness. The identification of categories of practices and performance could be an input with which to carry out a more thorough, detailed search for evidence, and enhance forthcoming debates on existing relationships. In addition, an interesting way to refine the definition of SSCM practices could be by covering literature that addresses drivers, barriers, and enablers. These were not fully or directly considered in the paper at hand, due to the early development of the proposed framework, but these could delineate a way for, or even help to explain which practices are or should be adopted, and why. Another limitation refers to subjectivity regarding the selection of keywords and paper classification, as well as in terms of established categories for practices and performance metrics, despite three researchers that have been involved throughout the review process. Recognized methodology guidelines have been referred to and followed.