Sustainability management control in healthcare organizations - current state and future directions

Abstract

Environmental, social, and governance (ESG) considerations are increasingly vital for healthcare organizations (HCOs), which face rising pressures from climate change, limited financial resources, and regulatory obligations towards HCOs’ engagement for ESG-matters. Environmentally, the healthcare sector contributes around 4.4% of global CO₂ emissions, underscoring the urgency of green transformation. This study systematically reviews the academic literature to identify which types of sustainability management controls (SMCs) are used to support ESG-matters in HCOs and outlines avenues for future research. The review is global in scope and includes all types of HCOs. Drawing on strategic stakeholder and legitimacy theory, the most widely applied theories in ESG-accounting, this study explores the instrumental and socio-political dimensions of SMCs. The findings reveal a dominant emphasis on environmental sustainability, with cultural and administrative controls being the most frequently discussed, while cybernetic, planning and strategy, and reward and compensation remain under explored. The study highlights the lack of strategic-operational integration and offers a conceptual framework to guide researchers, practitioners, and policymakers in embedding ESG-driven management control systems more effectively.

Introduction

Motivation

Supranational organizations and nation-states have committed themselves to Agenda 2030 [1] to contribute to sustainable development (SD) by addressing the global challenges that mankind and ecosystems face, such as climate change and social inequalities. SD has many facets. It represents an effort to merge the increasing concerns about various environmental matters with socio-economic considerations [2]. The aim is to fulfill the needs of the present generation while also protecting the needs of future generations [3, 4].

In recent years, growing societal awareness of environmental and social challenges has led to increasing stakeholder demands for companies to contribute to SD. Therefore, many companies have started to demonstrate how they contribute towards SD by embedding symbolic or substantive sustainability in their corporate actions. Sustainability, another highly ambiguous term, refers to an organization’s ability to operate in a manner that ensures long-term ecological balance, social equity, and economic viability [5]. It involves aligning business practices with the responsible use of natural resources, fair treatment of stakeholder groups and economically sound strategies that support growth without compromising the well-being and needs of current and future generations [4, 6, 7].

In recent years, the legal and normative requirements for enterprises to contribute towards SD have increased. Pars pro toto, the growing importance of sustainability ratings (e.g., Dow Jones sustainability indices) or, since 2004 ESG (Environmental, Social and governance)-ratings (e.g. Institutional Shareholder Services ESG, EcoVadis, Sustainalytics) for stock exchange-listed companies, self-regulation initiatives of companies (e.g., UN Global Compact, Net-zero Banking Alliance), the strict environmental regulations for internationally operating Chinese companies, and the legal initiatives of the European Union (EU) such as the European Green Deal, the EU-Taxonomy, the Corporate Sustainability Reporting Directive (CSRD) [8] and the accompanying European Sustainability Reporting Standards (ESRS). The CSRD requires obligatory reporting for large enterprises across ESG dimensions. ESG covers the three key areas for assessing and managing an organization’s sustainability performance: environmental impact (e.g., emissions, energy consumption), social responsibility (e.g., equality, labor rights, health) and governance (e.g., transparency, compliance, ethical behaviors) [9, 10].

The healthcare sector plays an important role in achieving the United Nations (UN) Agenda 2030, particularly Sustainable Development Goal 3 (SDG 3 - Good Health and Well-being) [11, 12]. SDG 3 emphasizes the importance of ensuring healthy lives and promoting well-being for all [1]. Affordability, accessibility, and availability of health services, unhealthy lifestyles, and climate change impacts in combination with financial pressure are today’s key global challenges in health care provision [13].

A healthcare organization is defined as an institution that provides high-quality healthcare services and may be a for-profit or nonprofit organization. Healthcare services are provided to patients cover the entire human lifespan including primary and secondary prevention initiatives, acute care in both ambulatory and inpatient settings, the provision of medical devices, pharmaceuticals, and palliative care interventions [13, 14].

At the corporate level, an increasing number of healthcare organizations (HCOs) aim to contribute to SD. While societal or social sustainability (e.g., access to affordable health services, patient safety, and security of health service provision) for improving the number of healthy life years has been on the agenda of healthcare systems and HCOs for many years, ecological sustainability has gained importance more recently. The healthcare sector is responsible for around 4.4% of global CO2 emissions [15]. This is because HCOs are significant energy consumers (e.g., cooling and heating systems, sterilization equipment) with a high carbon footprint, as well as anesthetic gas and logistics requirements (e.g., for patients, medical goods, and food). HCOs are waste-intensive, not least due to the abundance of single-use disposable items [16, 17]. Budget constraints and regulatory requirements complicate the rapid adoption of sustainable practices.

To make a meaningful impact on SD and go beyond mere symbolism, HCOs need to incorporate sustainability management control (SMC) mechanisms and practices [18, 19], which refer to a collection of mechanisms and instruments used by organizations to monitor, quantify and regulate their ESG-impacts [19]. Integrating ESG-matters into management control (MC) systems is essential for meeting stakeholder expectations, including those of patients, employees, regulators, and communities.

Research gap and research question

Despite the growing importance for HCOs to steer their ESG-activities using SMC instruments and mechanisms, a systematic literature review (SLR) focused on HCOs has not yet been published. While other SLRs in the healthcare sector examine different sustainability aspects, such as identifying environmental impact factors and barriers to sustainable healthcare, there has been no review assessing whether and how (sustainability) MC instruments and mechanisms are utilized to manage HCOs’ ESG-activities. The research aim of this SLR is therefore to evaluate and synthesize the existing research on SMCs in HCOs and to identify avenues for further research. Consequently, the paper addresses the following research questions (RQ):

• RQ1: Which types of management controls are discussed in the academic debate to support sustainable development in healthcare organizations?

• RQ2: What directions should future studies on sustainability management controls in healthcare organizations pursue?

Contributions

This study contributes to the academic debate in several ways. To the best of our knowledge, this is the first SLR to systematically examine SMCs in the context of HCOs. It applies the Malmi and Brown’s [20], framework, on which Lueg and Radlach’s [19], classification of SMCs is built.

The findings regarding the present status of SMCs in HCOs are evaluated through two theoretical lenses, offering both instrumental and socio-political perspectives. The instrumental approach using strategic stakeholder theory and the socio-political approach using legitimacy theory [21]. These theories are among the most widely used in the ESG-accounting literature and for analyzing SMCs [22, 23]. The paper moves beyond taking stock of the academic body of research by identifying directions for further research. In addition, it develops a conceptual framework that supports the implementation of SMCs across all three ESG-dimensions. Practitioners in HCOs may benefit from insights on how to embed sustainability into MC systems to improve ESG-performance, while policymakers may find value in understanding how regulatory design can foster more effective sustainability management in the healthcare sector. Together, these contributions offer valuable guidance for researchers seeking to advance the field and practitioners aiming to operationalize sustainability in HCOs.

The paper is structured as follows: The section Theoretical Discourse and Conceptual Background provides the theoretical framework, including strategic stakeholder theory, legitimacy theory, and addresses the concept of MC to promote SD in companies. The next section, Methodology, outlines the methodology of the SLR, which adopts a global perspective, incorporating studies without geographical restrictions to assess key trends in the current academic debate on SMCs within HCOs. Findings present the descriptive and thematic findings of the SLR. The section Discussion evaluates the finding and suggests future research directions. The last chapter, Conclusion, Limitations and Practical Implications, provides a conceptual framework that aims to support the implementation of MC types across all three ESG-dimensions and concludes the study with its limitations.

Theoretical discourse and conceptual background

Theoretical discourse

Strategic stakeholder theory and legitimacy theory serve as theoretical lenses to analyze SMCs in HCOs. Strategic stakeholder theory, as an instrumental approach [21], stresses the importance of key stakeholders in achieving a company’s objectives [24]. The term stakeholder in the management literature goes back to the Stanford Research Institute and includes all internal and external groups critical for the continuous existence of a company [25, 26]. In 1984, Freeman popularized stakeholder management as a strategic management approach in his highly influential book, “Strategic Management: A Stakeholder Approach” [27]. Initially, Freeman embraced a wide stakeholder approach that aligned with normative stakeholder theory, emphasizing ethical obligations [25, 28]). However, in later years, Freeman and his coauthors [24, 29] shifted to a narrower stakeholder focus, highlighting the significance of strategic stakeholder groups crucial for organizational success, achieving a strategic advantage, enhancing organizational performance, and resource access [24]. The instrumental stakeholder perspective emphasizes that managers should cultivate relationships and foster communities with those strategically relevant stakeholder groups that are important for achieving an organization’s promised value [24].

HCOs are embedded in complex stakeholder structures due to their commitment to providing high-quality care and improving public health, while also being financially viable [30]. The stakeholders of HCOs include employees, patients, other healthcare providers, private and public health insurance companies, regulatory authorities, and communities, which increasingly demand a high degree of responsibility and sustainability in healthcare [12]. The involvement of strategically relevant stakeholders in HCOs is seen as crucial for ‘good governance’ in the healthcare sector [30].

Addressing stakeholder expectations regarding ESG-performance is an important driver of SMC implementation in HCOs. In line with strategic stakeholder theory, SMCs are instrumental in aligning sustainability efforts specifically with the interests of those stakeholders who have the greatest direct impact on the organization’s success [28]. Impactful sustainability management requires careful selection and implementation of MC mechanisms that respond to the ESG-concerns of these stakeholder groups.

SMCs not only offer strategic advantages but are also important for enhancing organizational legitimacy. According to legitimacy theory, which is a socio-political approach [21], organizations rely on stakeholder recognition for their right to operate in a particular context [31]. Suchman [31, p. 574] defines legitimacy as ‘‘[…] a generalised perception or assumption that an organisation’s actions are desirable, right, or appropriate within a socially constructed system of norms, values, beliefs, and definitions’. Legitimacy is achieved by aligning organizations with stakeholder expectations and adhering to a social contract of regulatory, normative, and cognitive standards that define acceptable behavior [32]. Legitimacy is essential for an organization’s survival, financial performance, and stakeholder support [33].

Addressing ESG-matters aligns corporate behavior on a symbolic or substantive level with societal values, fulfilling the social contract and securing a license to operate [32, 34]. SMC mechanisms and practices are essential for organizations to gain and maintain organizational legitimacy in the context of ESG-matters. SMCs help organizations achieve strategic goals while maintaining legitimacy in society’s view. For HCOs, SMCs demonstrate a commitment to sustainability practices that meet stakeholder expectations [35].

Conceptual background

There are different ways of categorizing MCs within MC systems. Malmi and Brown’s [20], approach focuses on a ‘management control package’ that combines informal (e.g., values and norms) and formal management controls (e.g., performance metrics and budgets). Their framework comprises five types of control: cultural controls, planning, cybernetic controls, reward and compensation and administrative controls. Malmi and Brown’s MC as a package idea is often referred to when analyzing the relationship between sustainability reporting and MC, especially in designing sustainability MC systems [19]. In their literature review, Lueg and Radlach [19] examined how organizations can use Malmi and Brown’s [20], MC types to promote SD. Lueg and Radlach [19] demonstrate that administrative and cybernetic controls are predominantly applied, followed by cultural controls, to guide SD.

The link between MCs and SMCs is displayed in Table 1 [19, 20]:

Table 1.

MCs and SMCs [19, 20]

Control type	MCs [20]	SMCs [19]
Cultural controls	Cultural values, clans and beliefs to influence employees’ behavior and promote organizational goals.	Implementation of environmental, social and governance initiatives for intrinsically motivating employees to become more involved in sustainability goals.
Planning	Processes and systems to set goals, develop strategies, allocate resources and monitor performance. In these processes, a distinction is made between long-term and action planning.	Incorporate short and long-term sustainability goals into local and central planning processes. Communicating sustainability through targets.
Cybernetic controls	Include budgets, financial, non-financial measurements and hybrid systems.	Corporate performance management, internal reporting, balanced scorecard, individual performance management and budgeting could be used to measure SD performance.
Reward and compensation	Include financial incentives, boni, promotions and non-financial rewards for aligning employees’ behavior with organizational targets.	Make no distinction between the types of reward and compensation.
Administrative controls	Include management structure, organizational design, policies and procedures.	Leadership commitment fosters understanding and sets the direction for SD goals. The implementation of new frameworks must be strengthened through training initiatives, effective communication channels, feedback mechanisms, active employee participation, collaborative cross-functional teams and prudent resource allocation.

Methodology

Reviewing and evaluating the existing academic literature is central to research. It requires a structured approach [36, 37]. Unlike traditional snowball methods, an SLR ensures a structured, transparent, comprehensive and methodical process for identifying, evaluating, and synthesizing the existing research [36, 38]. The selection process of a SLR is divided into stages and typically involves three overarching steps of sample selection: (1) Identification, (2) Screening, and (3) Disclosure of the review sample [36]. The final steps include synthesizing and evaluating the results obtained, and providing avenues for further research [37].

As a first step, a database-driven approach was adopted to ensure comprehensive interdisciplinary coverage of the field of SMCs in HCOs [36]. The literature search included peer-reviewed papers published up to July 2025, using the key terms management control, sustainability, and healthcare organizations linked by ‘AND’, while their corresponding synonyms were combined using ‘OR’. Irrelevant terms like ‘hotel*’, ‘food delivery’, and ‘restaurant*’ were excluded using the operator ‘NOT’. The keywords used in this review were carefully selected to ensure a comprehensive coverage of the relevant literature at the intersection of management control, sustainability, and healthcare. Keyword group 1 was derived from the MCS framework developed by Malmi and Brown [20] in combination with Lueg and Radlach [19]. Keyword group 2 captures core concepts related to sustainability, including ESG-dimensions, SD, and the triple bottom line. Keyword group 3 focuses on the healthcare context, encompassing a wide range of HCOs and settings. Finally, keyword group 4 was used to exclude irrelevant sectors such as hospitality and food services to maintain the review’s focus on HCOs. The entire search string is displayed in Fig. 1.

Fig. 1.

Search string (own source)

Databases included Business Source Premier and Medline via EbscoHost as well as Scopus, supplemented by forward and backward integration using Google Scholar [37], covering a period up to 2025. The search focused on English peer-reviewed journal articles, excluding other types of publications. Based on these inclusion and exclusion criteria, all articles found were checked for their content, i.e., whether they were related to SMCs within HCOs. Table 2 presents an overview of the inclusion and exclusion criteria.

Table 2.

Inclusion and exclusion criteria (own source)

Inclusion	Exclusion
Scientific articles	Non-scientific articles
Peer-reviewed articles	Book chapters and editorial notes
Only articles in English	Articles in languages other than English
Articles with relevance to sustainability management controls in healthcare organizations	Articles with no relevance to sustainability management controls in healthcare organizations
Articles whose journal is listed in the ABS journal guide 2024	Articles whose journal is not listed in the ABS journal guide 2024

In the first stage, 8951 articles were identified through database searches (5,170 from EbscoHost and 3781 from Scopus). For EbscoHost, access was restricted to the Medline and Business Source Premier databases. Within Scopus the subject area was limited to medicine, social sciences, environmental science and business, management and accounting. In the screening phase, a list of potentially relevant research items was analyzed for content that fits the predefined research question [36]. A total of 8356 articles were excluded because they were non-English, not included in the 2024 ABS journal guide, or duplicates.

The remaining 595 articles underwent a detailed abstract and keyword screening to assess their relevance specifically to HCOs and SMCs. An additional 449 articles were excluded at this stage due to insufficient focus on the research topic.

Finally, 146 articles were selected for full-text analysis. Given the nuanced terminology around control systems, the full-text analysis was essential to confirm each article’s relevance. Excluding another 110 articles which were outside of the scope and including nine additional articles via forward/backward integration resulted in 45 articles for analysis. Backward integration involves examining the reference lists of key articles to find earlier work that influenced them. In contrast, forward integration involves tracking which later publications have cited a particular article to find more recent research that builds on it [36]. A PRISMA chart illustrates the reduction process (Fig. 2) (based on [39, 40]).

Fig. 2.

PRISMA chart (based on [39, 40])

The articles underwent descriptive and thematic analyses. The descriptive analysis examined publication years, geographical focus, research methods, sample classification, and ESG-focus. The thematic analysis identified and grouped recurring themes related to SMCs in HCOs, forming thematic clusters that reflect how the studies conceptualized and applied MCs in sustainability contexts of HCOs. The main categories (MC type) used in the analysis were derived from the Malmi and Brown [20] framework combined with Lueg and Radlach [19], providing a structured base for classification.

Table 3 provides the coding scheme with examples of the keywords used for each type of control for the deductive thematic analysis.

Table 3.

Coding scheme (own source)

Main category - MC type	Example of keywords used for the deductive analysis
Cultural Controls	Motivation; Communication; Value; Ethics; Awareness; Training etc.
Planning	Long-range planning; Action-planning; Goal; Objective; Target; etc.
Cybernetic Controls	Measurement; Management System; Indicator; Budget; BSC; Benchmark; etc.
Administrative Controls	Policy; Committee; Governance; Leadership; Board; Structure; etc.
Reward and Compensation	Bonus; Benefit; Reward; Compensation; Incentive; etc.

Within these categories, sub-categories were developed inductively, based on patterns and themes that emerged from the data during full-text analysis. While we acknowledge that the formation of thematic clusters inherently involves a degree of subjectivity, we took several steps to enhance transparency and consistency. To ensure the quality of the literature review, the criteria for reliability according to Lincoln [41] were considered. Credibility was ensured through transparent documentation of the search strategy, the inclusion and exclusion criteria, and the evaluation processes (see description of the SLR). In addition, intercoder reliability was ensured by having several of the researchers involved code the identified sources and then jointly resolve any discrepancies. In line with the principle of multiple eyes, the categorization and interpretation were repeatedly reviewed in order to minimize bias and increase the traceability of the results.

The included articles of the SLR are marked with an asterisk (‘*’) in the reference list.

Findings

Descriptive analysis

The descriptive analysis of the 45 identified articles considered the criteria of publication trends, geographical focus, empirical methods and the ESG-focus.

1. Publications Over Time: Fig. 3 shows publication trends, beginning in 2000. Peak years include 2019 (five articles), 2020 (five articles), 2024 (eight articles) and 2025 (ten articles), reflecting a growing focus on SMCs in HCOs, likely driven by global initiatives that have emerged over the recent years (European Green Deal and the Inflation Reduction Act), and sustainability issues in the sector highlighted by crises such as the COVID-19 pandemic.

2. Geographical Focus: Fig. 4 presents a regional analysis, indicating that Europe is the most extensively studied region, with 15 articles. This is followed by Asia with 14 articles. Africa and Australia are each represented by three articles each, while South and North America are examined in two articles each. A global sample is examined in one paper. Five articles are only conceptual in nature and therefore no region is mentioned.

3. Empirical Methods: A methodological analysis reveals almost a balanced use of quantitative (18 articles) and qualitative (17 articles) approaches, with mixed methods combining both approaches in five articles. Additionally, five articles were only conceptual nature.

4. Sample Classification: Previous empirical research has indicated that the majority of HCOs were analyzed in a general context (19 articles), without distinguishing between private and public ownership. 11 articles focused on public hospitals, four on private hospitals, two on university hospitals, and nine on a combination of public and private hospitals.

5. ESG-focus: The analysis of the literature reveals a clear imbalance in the emphasis on the different sustainability dimensions within health-related research (Table 4). It is possible for a single paper to contain multiple assignments. The first group of authors, which includes 44 of the 45 papers examined, primarily focuses on environmental sustainability (e.g. energy efficiency, waste reduction and carbon emissions), underlining its dominant role in scientific discourse. In contrast, the second group of authors focuses on social sustainability aspects, such as employee wellbeing, patient equity and community engagement, and comprises only 18 papers, demonstrating a significantly lower level of attention. Governance-related issues such as political integration, institutional accountability and strategic leadership are addressed in 17 studies, as shown by the third group of authors. This gap suggests that while environmental concerns are highly prioritized in HCOs’ sustainability research, social and governance aspects are underrepresented, underscoring the need for a more holistic and integrated approach in future research.

Fig. 3.

Publications over time (own source)

Fig. 4.

Geographical focus (own source)

Table 4.

ESG-focus (own source)

ESG-category	Associated authors
E (44)	Dettenkofer et al. [42]; Cherrier et al. [43]; Ramirez et al. [12]; Chiarini and Vagnoni [44]; Pinzone et al. [45]; Ryan-Fogarty et al. [46]; Blass et al. [47]; Johansen et al. [48]; Rodríguez et al. [49]; Rodríguez et al. [50]; Al Hammadi and Hussain [51]; Clausen and Kragh [52]; Migdadi and Omari [53]; Pinzone et al. [54]; Seifert and Guenther [55]; Gallagher et al. [56]; Mousa and Othman [57]; Rodríguez et al. [58]; Rodríguez et al. [59]; Seifert and Guenther [60]; Borges de Oliveira et al. [61]; Khalid et al. [62]; Rattan et al. [63]; Suriyankietkaew and Kungwanpongpun [64]; Dion and Evans [18]; Han et al. [65]; Thomas and Suresh [66]; Tushar et al. [67]; Ziyadeh et al. [68]; Al Amosh and Khatib [69]; Messmann et al. [70]; Regragui et al. [71]; Sarwar and Shahzad [72]; Yang et al. [73]; Al-Balushi et al. [74]; Gökler and Boran [75]; Khalid et al. [76]; Luo et al. [77]; Mandal and Pal [78]; Mousa et al. [79]; Rouhana and Van Caillie [80]; Sahoo et al. [81]; Tessema et al. [82]; Yan and Rafiq [83];
S (18)	Ramirez et al. [12]; Johansen et al. [48]; Rodríguez et al. [49]; Rodríguez et al. [50]; Al Hammadi and Hussain [51]; Gallagher et al. [56]; Rodríguez et al. [58]; Rodríguez et al. [59]; Rattan et al. [63]; Suriyankietkaew and Kungwanpongpun [64]; Thomas and Suresh [66]; Tushar et al. [67]; Ziyadeh et al. [68]; Bosco et al. [84]; Messmann et al. [70]; Regragui et al. [71]; Gökler and Boran [75]; Rouhana and Van Caillie [80];
G (17)	Ramirez et al. [12]; Johansen et al. [48]; Gallagher et al. [56]; Rattan et al. [63]; Rodríguez et al. [49]; Rodríguez et al. [50]; Al Hammadi and Hussain [51]; Rodríguez et al. [58]; Rodríguez et al. [59]; Suriyankietkaew and Kungwanpongpun [64]; Thomas and Suresh [66]; Tushar et al. [67]; Ziyadeh et al. [68]; Bosco et al. [84]; Regragui et al. [71]; Gökler and Boran [75]; Rouhana and Van Caillie [80];

Thematic analysis

The 45 articles were subjected to a cluster analysis, with the resulting clusters organized according to the various SMCs in connection with HCOs. Multiple assignments per paper are possible. Table 5 provides a comprehensive overview of these clusters, accompanied by the (respective) authors, sorted chronologically in ascending order.

Table 5.

Overview of thematic clusters including associated authors (own source)

Deductive/Inducutive identified	Main category - MC type	Associated authors
Deductive	Cultural Control (27)	Dettenkofer et al. [42]; Ramirez et al. [12]; Ryan-Fogarty et al. [46]; Pinzone et al. [45]; Blass et al. [47]; Johansen et al. [48]; Rodríguez et al. [50]; Seifert and Guenther [55]; Clausen and Kragh [52]; Pinzone et al. [54]; Gallagher et al. [56]; Mousa and Othman [57]; Rodríguez et al. [58]; Rodríguez et al. [59]; Borges de Oliveira et al. [61]; Suriyankietkaew and Kungwanpongpun [64]; Tushar et al. [67]; Dion and Evans [18]; Ziyadeh et al. [68]; Bosco et al. [84]; Luo et al. [77]; Sarwar and Shahzad [72]; Yang et al. [73]; Al-Balushi et al. [74]; Sahoo et al. [81]; Tessema et al. [82]; Mousa et al. [79];
	Cybernetic Control (21)	Dettenkofer et al. [42]; Chiarini and Vagnoni [44]; Ryan-Fogarty et al. [46]; Blass et al. [47]; Migdadi and Omari [53]; Seifert and Guenther [55]; Rodríguez et al. [59]; Seifert and Guenther [60]; Borges de Oliveira et al. [61]; Khalid et al. [62]; Rattan et al. [63]; Tushar et al. [67]; Dion and Evans [18]; Regragui et al. [71]; Bosco et al. [84]; Messmann et al. [70]; Sarwar and Shahzad [72]; Al-Balushi et al. [74]; Gökler and Boran [75]; Khalid et al. [76]; Rouhana and Van Caillie [80];
	Administrative Control (21)	Dettenkofer et al. [42]; Cherrier et al. [43]; Ramirez et al. [12]; Chiarini and Vagnoni [44]; Ryan-Fogarty et al. [46]; Rodríguez et al. [49]; Rodríguez et al. [50]; Al Hammadi and Hussain [51]; Clausen and Kragh [52]; Rodríguez et al. [59]; Seifert and Guenther [60]; Khalid et al. [62]; Suriyankietkaew and Kungwanpongpun [64]; Thomas and Suresh [66]; Al Amosh and Khatib [69]; Bosco et al. [84]; Luo et al. [77]; Mandal and Pal [78]; Mousa et al. [79]; Tessema et al. [82]; Yan and Rafiq [83];
	Reward and Compensation (5)	Al Hammadi and Hussain [51]; Mousa and Othman [57]; Han et al. [65]; Sarwar and Shahzad [72]; Mousa et al. [79];
Inductive	Strategy and Planning (7)	Blass et al. [47]; Rodríguez et al. [49]; Rodríguez et al. [50]; Migdadi and Omari [53]; Regragui et al. [71]; Bosco et al. [84]; Al-Balushi et al. [74];

1. Cultural controls

Green Human Resource Management (GHRM)

Green Human Resource Management (GHRM) has consistently been shown to positively influence environmental and social sustainability of HCOs [79]. Rather than acting in isolation, GHRM supports broader sustainability goals by equipping employees with relevant skills, shaping environmental values, and embedding sustainability into corporate culture [18, 42, 47, 54, 55, 68, 72, 79, 82]. For instance, green training and participation in environmental initiatives, such as waste separation, water conservation, and energy saving, enable employees to contribute meaningfully to sustainability practices [46, 48, 55, 61, 67, 72, 74, 81]. To develop the necessary skills and competencies, hospital managers can guide and mentor staff by leading them through case studies, applied projects and other interactive and experiential learning activities [12].

GHRM also plays a foundational role in shaping a pro-environmental organizational climate. GHRM fosters green workplace behaviors, with individual green values acting as a mediating factor [42, 57, 72, 81]. This interplay between human resource (HR) practices and personal values reinforces sustainable corporate culture and behavior [57, 77]. Moreover, GHRM is linked to improvements in ESG-dimensions, as it supports employees in aligning with environmental, social and governance policies and institutional norms [54, 77].

One of the biggest challenges in sustaining change lies in the persistence of “deep structures”, the implicit, long-standing patterns of behavior, relationships and communication that shape organizational life. Even when new strategies or behaviors are introduced, these underlying structures often remain untouched and silently undermine change efforts [52]. Khalid et al. [62] also emphasize the need to recruit sustainability experts and align financial incentives, noting that internal barriers such as limited knowledge and resistant organizational cultures can slow progress. Overcoming these constraints is essential for embedding environmental performance into routine management practices.

Employee Engagement and Communication

Employee involvement is another cultural lever that is critical for sustainable transformation in HCOs. Sustainability initiatives succeed when staff are engaged, aware, and empowered to act [45, 48, 52, 58, 79, 81]. Rodríguez et al. [50] point out that, especially in private hospitals, the sustainability initiative requests come from internal stakeholders and are mainly focused on social sustainability. Active participation is facilitated by trust, strong internal relationships, and strategic communication, elements that change agents can foster through persuasion, social capital, and political skill [56, 79]. Organizational culture evolves when management is visibly committed to sustainability, policies are aligned with environmental goals, and staff are included in decision-making processes [18, 45, 84]. For example, Dion and Evans [18], emphasize the importance of making the environmental and financial impact of resource misuse transparent to motivate that staff behavior changes.

Communication, both internal and external, is a strategic tool to reinforce sustainable practices [58, 61]. Internally, tools like digital dashboards, emails, and intranet rankings (e.g., energy use by department) have been shown to increase staff engagement [18, 55, 61]. Continuously reinforcing green values through education, feedback, and motivation programs keeps sustainability on the organizational agenda [79]. Externally, transparent performance communication builds legitimacy and trust with stakeholders [64].

However, employee engagement and communication not come without challenges. Educating staff about both the environmental and financial consequences of their actions is essential to drive long-term commitment, but it is also a question of financial resources [46]. Sustained awareness-building efforts, including formal training and informal communication, are vital [45, 46, 73]. One of the major challenges in implementing sustainable practices within the hospital setting is the constant tension between environmental goals and the pressing demands of patient’s’ medical care. Often, limited budgets and the need to prioritize urgent healthcare delivery overshadow sustainability initiatives. Additionally, high staff turnover—particularly among rotating doctors and nursing personnel—complicates the implementation of long-term behavioral changes, as new employees must be continuously reoriented to environmental procedures and values [46].

In summary, GHRM fosters environmental and social sustainability in HCOs by embedding green values, skills, and behaviors into workplace culture. While employee engagement and communication play a crucial role in this process, challenges such as financial constraints, complex organizational structures, and high staff turnover hinder progress. Overcoming these barriers is essential for successfully integrating sustainability into daily operations and aligning it with long term long-term strategic goals.

• (b) Administrative controls

Leadership, Top Management and Board of Directors

This subcluster connects closely with cultural controls, particularly through the influence leadership has on shaping values, motivating staff, and embedding sustainability into daily operations. Leadership plays a pivotal role in the achievement of organizational sustainability goals within HCOs, whether in private or public hospitals. Green leadership, defined by active participation in and advocacy for environmental sustainability, can inspire employees, shift organizational culture, and support the long-term integration of environmental goals [12, 44, 46, 48–52, 59, 64, 66, 77–79, 82, 83]. When leaders exemplify environmentally conscious behavior, they set a tone that affects organizational norms and influences employee engagement [78].

However, integrating sustainability into executive thinking is not without challenges. Cherrier et al. [43] identified six prevailing discourses on how top management views environmental protection: three as supportive (technicists, holists, eco-preneurs) and three as resistant (pragmatists, traditionalists, observers). This highlights the tensions and competing values that play a role within corporate identity and underscores the need for change strategies that take these different perspectives into account.

Despite these challenges, recent trends suggest that sustainability is gaining importance in top management. Seifert and Guenther [60] argue that sustainability-oriented boards are more inclined to approve budgets for voluntary environmental measures, showing that board-level commitment directly influences resource allocation for green transition. Managers who prioritize environmental values positively shape pro-environmental organizational decision-making [60], and such top-level commitment is essential for the successful implementation of systems like the Eco-Management and Audit Scheme (EMAS) [42, 60, 84].

Corporate Governance

Governance structures also significantly affect how sustainability is implemented across different types of HCOs [69]. A strong environmental governance in combination with high environmental innovation enhances initiatives to reduce environmental impacts (e.g., carbon emissions) [69].

For-profit hospitals often lack understanding and implementation of good governance practices, while not-for-profit hospitals have a stronger alignment with these principles and a greater focus on corporate social responsibility (CSR). Similarly, clinical governance holds HCOs accountable for continuously improving service quality and maintaining high standards of care. Management is encouraged to play an active role and to take responsibility for the social and environmental impact of its decisions [84].

Organizational Structures

Organizational structures are essential for embedding ESG-matters at the operational level. Environmental committees serve as central hubs, linking waste management, hygiene protocols, and ongoing environmental planning [42]. However, their activity is often limited to short-term involvement. The involvement of external experts can further enhance these structures. Al Hammadi and Hussain [51] report that some public hospitals have established their own departments or groups. These are often composed of individuals from different departments. In contrast, private hospitals frequently lack clearly defined sustainability structures. Instead, responsibility for specific initiatives is typically assigned to individual persons [50].

In summary, administrative controls, through leadership, governance, and organizational structure, are essential for embedding sustainability in HCOs. Green leadership and board-level commitment drive cultural change and resource allocation for ESG-matters, while strong governance ensures accountability. Organizational structures, such as environmental committees, support an operational implementation.

• (c) Cybernetic controls

Key Performance Indicators (KPIs)

In HCOs, green key performance indicators (KPIs) serve as essential tools for tracking and improving environmental sustainability. Commonly used KPIs include paper and fuel consumption, water and energy usage, GHG emissions, hazardous and non-hazardous waste, and electricity consumption [53, 61, 67, 70]. Among these, reductions in fuel use and direct emissions have shown the greatest potential to improve SD.

Several studies underscore the importance of monitoring resource usage to drive change. For example, energy and water consumption, waste production, and CO₂ emissions are key metrics used to track SD [47, 55, 61, 70]. These indicators are not only environmental but also carry financial implications, offering hospitals an opportunity to achieve both environmental and economic efficiencies through waste reduction.

Sustainability-oriented performance measurement increasingly incorporates social KPIs as well. Metrics such as patient and employee safety, workplace accidents, illness tracking, and employee satisfaction are central to holistic sustainability assessments [70, 75]. Additionally, the many single used items are largest contributor to HCOs’ carbon footprints. These goods require targeted attention to reduce the environmental burden. Measures such as improving energy efficiency, transitioning to renewables, promoting digitalization and telemedicine, and reducing the overuse of medical services are all strategic levers for sustainability [84].

To respond to the growing demand for value-based healthcare, Rattan et al. [63] developed a sustainability measurement model focused on ESG-values. This tool supports healthcare policy alignment of HCOs with the SDGs and offers a structured approach for integrating sustainability into performance evaluation.

In the future, artificial intelligence (AI) and data-based systems could open up new possibilities for defining, measuring, and optimizing key performance indicators. With the help of such technologies, energy and resource consumption, as well as processes such as medication administration, can be made more efficient [74].

Management Systems

To operationalize sustainability, HCOs increasingly rely on structured performance management systems. Green performance management systems, that incorporate environmental performance measures into organizational performance appraisals, ensure that employees are held accountable for their environmental behaviors. Research has demonstrated that green performance management positively influences sustainability in healthcare settings. The establishment of environmental sustainability targets and the subsequent evaluation of organizational performance against these targets have been shown to redirect employee focus towards environmental objectives [72].

By adopting a performance management system, HCOs can facilitate the integration of environmental, social and economic factors into decision-making processes [80]. The Sustainability Balanced Scorecard (SBSC) is referred to it. It integrates environmental and social goals alongside traditional financial and operational metrics (Regragui et al., [71, 76, 80]). Regragui et al. [71] proposed combining the SBSC with hybrid fuzzy Delphi techniques to help decision-makers to assess and improve hospital sustainability, based on five criteria: patient satisfaction, efficiency, effectiveness, access to care, and waste generation. The successful implementation of such frameworks depends on the organizational readiness. The SBSC is a useful tool when it comes to recognizing and distinguishing between a (public) health system’s internally generated environmental practices, such as the disposal of surgical waste products, and exogenous environmental risk factors, such as the effects of climate change, natural disasters and pandemics [76].

Additionally, energy management systems like ISO 50001 offer specific tools for achieving affordable and clean energy [18, 59, 61]. Dion and Evans [18], recommend setting consumption targets, monitoring indicators, and initiating continuous improvement processes. Key actions include energy mapping, data tracking, and integrating these efforts into hospital-wide strategies to reduce energy consumption. Another essential component is the Environmental Management System (EMS), particularly those aligned with the EUs EMAS standards. These systems enable HCOs to systematically manage environmental impacts and improve sustainability performance [42, 44, 46, 60, 84]. An EMS reduces emissions, optimizes resource use, and offers long-term cost savings, particularly in terms of energy, transport, and heating [84]. However, broader adoption remains limited. Seifert and Guenther [60] point out that external stakeholder pressure to implement systems like EMAS is low within hospitals initiatives. Without strong external stakeholder pressure, internal motivation alone is insufficient to ensure long-term sustainability in hospitals. That highlights the importance of stakeholder alignment in driving system-wide change.

Other obstacles preventing HCOs from adopting environmentally friendly measurement methods include a lack of understanding of energy cost comparisons or low motivation among owners and management to invest in environmentally friendly measures. Heavily subsidized fossil fuel prices, the need for financial investment in energy-efficient technologies, and fragmented decision-making structures for energy consumption also hinder the consistent monitoring of environmental impacts and related measures [18].

To sum it up, cybernetic controls, including green KPIs and performance management systems, are essential for tracking sustainability in HCOs. Tools like ISO 50001 and the SBSC help integrate primarily environmental goals and to a lesser extend social goals into daily practices. While these systems offer both environmental and financial benefits, their impact is limited by low external stakeholder pressure, internal resistance, and financial constraints, which underscores the need for stronger stakeholder alignment and leadership commitment.

• (d) Strategy and planning

Environmental sustainability is becoming an increasingly central component of HCOs’ strategies. Recent studies highlight how both internal priorities and external influences shape the strategic orientation of HCOs toward SD. For instance, Regragui et al. [71] underscore the growing impact of environmental initiatives such as Practice GreenHealth and environmental legislation like the UK Environmental Protection Act, in prompting HCOs to incorporate environmental sustainability into their core strategies. These regulatory and industry pressures have catalyzed a shift from ad hoc environmental actions to more structured and intentional planning processes. In public hospitals, sustainability initiatives are planned from a long-term perspective, compared to private hospitals, where sustainability performance is based on a short-term perspective [49, 50]. The study conducted by Al-Balushi et al. [74] emphasized the specific objectives established by hospitals. In addition to a general focus on the SDGs, the study also mentioned the introduction of initiatives using artificial intelligence to help optimize sustainability. Specific objectives such as the transition to paperless processes and the promotion of green infrastructure were also mentioned.

Resource efficiency has emerged as a dominant strategic concern. Migdadi and Omari [53], identify resource management as the top strategic priority for private hospitals, highlighting the importance of effective waste and energy management in driving environmental performance. Even in the absence of formal environmental frameworks, many private hospitals adopt cost-driven strategies with a strong emphasis on resource and waste reduction, as shown by Blass et al. [47]. These findings suggest that economic incentives and environmental goals can align, particularly in settings where natural resource constraints drive operational efficiency.

Strategic alignment with stakeholder expectations is another critical success factor [50, 84]. Bosco et al. [84] argue that sustainability strategies are not only strategic tools but also mechanisms of accountability, compelling hospital leadership to consider the broader social and environmental implications of their decisions. This requires rethinking traditional organizational structures to accommodate cross-functional collaboration and a more holistic approach to governance.

In summary, sustainability is no longer peripheral to HCOs’ strategy; it is becoming a strategic imperative, shaped by external policy, internal resource pressures, and the evolving expectations of stakeholders.

• (e) Reward and compensation

Reward and compensation play a critical role in aligning employees’ motivation with HCOs’ environmental goals. They can significantly strengthen employee motivation, identification, and commitment to sustainability goals and promote a positive organizational climate [51]. Green rewards, which include both financial and non-financial incentives, are designed to support pro-environmental behavior by recognizing and reinforcing individual and collective contributions to environmental sustainability [72]. However, these practices remain among the least implemented elements of GHRM. Despite their low adoption, evidence suggests that green reward systems can significantly enhance organizational support for environmentally friendly practices. When implemented effectively, such systems contribute to building a culture of environmental responsibility by increasing employee awareness and encouraging sustainable behavior [57, 72, 79]. These systems are particularly valuable for reinforcing the principles of environmental stewardship in the workplace.

Nonetheless, Mousa and Othman [57] identified a persistent gap in healthcare settings, where reward mechanisms tend to prioritize productivity and service quality over sustainability outcomes. Consequently, employees are often motivated by goals that are disconnected from environmental performance, limiting the effectiveness of green rewards in driving behavioral change. This challenge is compounded by the organizational context. HCOs that already exhibit higher levels of environmental performance or commitment are more likely to implement green reward systems, suggesting a reinforcing loop between sustainability maturity and the use of incentive mechanisms [57]. To bridge this gap, healthcare managers must proactively design and integrate reward structures that directly support environmental initiatives and recognize both individual and team efforts through tangible benefits and symbolic recognition.

At the organizational level, as an incentive to integrate more environmental protection into the organization, the US now presents the Environment Excellence Awards. These awards recognize hospitals that achieve particularly good environmental performance in areas such as energy, water, waste, transportation, and chemical management [65].

In summary, while green rewards hold strong potential as a lever for sustainability, their effectiveness depends on broader organizational alignment, leadership commitment, and a shift in what is valued and incentivized in employee performance.

Synthesis of the findings

Table 6 presents a synthesis of the findings, which are further discussed in the following section.

Table 6.

Key findings (own source)

MC type		Key findings
Cultural Controls	GHRM	GHRM improves environmental and social sustainability in HCOs. It shapes a green corporate culture and values. Green training empowers employees to participate in environmental practices.
	Employee Engagement and Communication	Selective steps are taken to increase awareness building on environmental matters, but the present situation is far away that ESG-matters become deeply embedded in the organizational culture.
Administrative Controls	Leadership, Top Management, and Board of Directors	Leadership influences sustainability practices. Top management enables better sustainability strategies. Boards with a strategic focus on environmental sustainability are more likely to fund green initiatives, as their governance practices align with long-term ecological priorities. Commitment to sustainability varies depending on the values of the management team.
	Corporate Governance	For-profit hospitals are less focused on corporate governance principles than non-profit public hospitals, which prioritize CSR. Corporate governance promotes accountability.
	Organizational Structures	The establishment of environmental committees ensures systematic environmental management. Many HCOs do not have their own environmental officers, and policy decisions are often made by non-environmental staff, which limits sustainability efforts.
Cybernetic Controls	Key Performance Indicators (KPIs)	Green KPIs include paper/fuel consumption, greenhouse gas emissions, waste and electricity consumption. Reducing hospital waste and managing procured goods can support SD. Optimizing energy efficiency and driving digitalization are key strategies.
	Management Systems	Systems such as the SBSC, ISO 50001 and EMAS improve sustainability. Effective management systems reduce waste, optimize resources and monitor energy consumption. However, the pressure from stakeholders to introduce such systems is limited.
Strategy and Planning		Sustainability strategies focus on resource management and waste reduction. Stakeholder orientation and compliance with environmental legislation promote sustainability-oriented management.
Reward and Compensation		Green rewards motivate employees to achieve environmental goals, but are rarely implemented. External incentives often drive sustainability, while internal reward systems focus on productivity and service quality and neglect environmental goals.

Discussion

Regarding the RQ1 – Which types of management controls are discussed in the academic debate to support sustainable development in healthcare organizations? – the findings show that the types of SMCs in HCOs have been discussed selectively so far. The literature has primarily focused on the integration of the environmental dimension within SMCs. Social and governance dimensions are less often addressed, although they are crucial for HCOs.

Looking more closely at each control type, cultural controls (27 articles) were the most frequently addressed in the reviewed literature. The findings indicate that cultural controls, particularly through GHRM and internal communication, are commonly used to foster mainly environmental sustainability awareness in HCOs. These controls help embed green values and norms through practices such as green training, employee engagement, and awareness-building, and support to a bottom-up approach. This bottom-up orientation is especially evident in private hospitals, which often rely on employee-led initiatives and decentralized decision-making structures to promote sustainability-related values and behaviors [49, 50]. As noted by Lueg and Radlach [19], such cultural mechanisms are typically aimed at building awareness and guiding behavior rather than formalizing sustainability in organization-specific terms.

Moreover, administrative controls (21 articles) facilitate the implementation of sustainability matters within organizational processes, as concrete procedures and the integration of ESG-dimensions in the governance structure support SD. This is a step in the right direction that managers or leaders are increasingly prioritizing environmental sustainability, which also lead to budgets for voluntary sustainability measures being approved more generously. Both the findings of the SLR and the framework by Lueg and Radlach [19] emphasize the role model effect of top management in pursuing the organization’s SD. Nevertheless, leadership alone is not sufficient to implement sustainability in an organization. As stated in the reviewed literature, many HCOs do not yet have an environmental officer or committee. HCOs need to put more effort into reorganizing internal structures, hiring sustainability experts to champion a broader sustainability vision, promoting better use of resources, and creating dedicated units or committees that specialize on sustainability. There is a size effect regarding the existence of sustainability units with full-time staff. If other staff units have to take over this function, it should be discussed which position is suitable for this function. Factors such as influence, staff shortages and time must be considered here.

Currently, organizational structures are only implemented very sporadically and selectively. Nevertheless, the call for more organizational structures must be considered in light of the fundamental challenges the healthcare sector is facing, such as staff shortages and the associated bottlenecks in patient care. Additionally, discussing the administrative controls in HCOs is closely linked to the healthcare system and country-specific regulations.

The cybernetic controls (21 articles) focus primarily on a selective range of environmental KPIs that highlight specific aspects of environmental performance. Such an approach lacks a structured connection between the overarching strategic objectives and the specific operational measures required to achieve them, resulting in gaps in alignment and a reduced overall effectiveness in implementing sustainability strategies. Environmental management systems (e.g., EMAS, ISO 50001) provide a more structured approach than selective environmental KPIs. For a more holistic approach across all three sustainability or ESG-dimensions, an SBSC is suggested. Such an integrated approach is necessary to avoid creating a fragmented impression, which ESG-sensitive stakeholders might view as impression management.

According to Lueg and Radlach [19], strategic alignment and planning (7 articles) is crucial for long-term organizational sustainability. This aligns with the analyzed papers, which indicate an increased integration of sustainability into corporate strategies of HCOs. In public hospitals, the sustainability initiatives are planned on a long-term perspective, compared to private hospitals, where the sustainability performance is based on a short-term perspective. To date, the literature also calls that sustainable strategies are harmonized with stakeholder expectations. The challenge here is to evaluate and prioritize these very diverse expectations. However, the focus remains on the environmental aspects, highlighting the need for a more comprehensive understanding of all three ESG-dimensions. In the healthcare sector, social aspects like access to healthcare services or equity are crucial. Another major weakness is that strategy and operational actions are not systematically linked.

The findings on reward and compensation (5 articles) show that motivating employees becomes challenging due to the absence of incentives and/or reward systems. Due to limited green incentives, the potential to motivate employees to engage in green activities has not been fully utilized. As far as incentives are concerned, studies show that only very limited efforts are made to promote employee commitment to SD, although this plays a crucial role in realizing ESG-matters. Non-financial incentives and recognition are particularly important to promote intrinsic motivation. The discussion about incentives should also focus more on possible tensions between incentives and resource issues (e.g., time, scarce staff, financial viability).

Assessing the current state of the art from the package idea [19, 20], there is still a lack of a holistic approach to SMCs in HCOs, which would be necessary to consider all areas in which contributions to SD can be made [85]. To achieve SD, it is essential to understand the interconnection between the five MC types for a integral integration of ESG-matters. In terms of organizational change, the SMCs that have been implemented are still too selective. The findings show a focus on environmental activities rather than the holistic integration of all three ESG-aspects. The so far neglected social and governance dimensions are particularly critical for HCOs promoting diversity and inclusion. Strong governance promotes transparency and accountability, while social initiatives address patient safety and staff wellbeing, security of service provision and quality of health provision.

Although some steps have been taken at the awareness level, organizational adoption is still in its infancy and far from fundamental changes.

Regarding RQ2 - What directions should future studies on sustainability management controls in healthcare organizations pursue? - the review of the current literature shows that this area is still emerging, as evident by the limited number of peer-reviewed publications on this topic (45). Over the years, the number of publications has increased, possibly due to legal requirements and the increasing challenges posed by climate change and the COVID-19 crisis. As Fig. 4 showed, there is an imbalance in the regional focus. Out of the 15 papers focusing on Europe, Spain is the most researched country.

An analysis of the included studies shows an almost balanced use of qualitative (n = 17) and quantitative (n = 18) methods, whereas a mixed-methods approach is much lesser chosen. This indicates a methodological gap, as mixed methods are well suited to capture both the measurable and contextual aspects of SMCs. Future research should adopt more integrative designs that combine these perspectives. Additionally, the lack of longitudinal studies limits insights into how SMCs evolve over time. Notably, the environmental dimension is often explored through quantitative studies, while social and governance-related aspects are primarily examined qualitatively. This suggests the need for a more balanced, multidimensional research approach.

Further research on the drivers or motivators for adopting SMCs is necessary. Comparative studies could be useful and further factors explaining the different scope and focus of SMCs, such as cultural differences, the type of healthcare systems (mainly Beverage or Bismarck health care system, extend of government funding, and the role of private health plans), as well as country- or region-specific characteristics, could be examined. Moreover, future studies should further distinguish between different actors within the healthcare system to clarify differences among various types of healthcare providers.

Table 7 provides an overview of further research areas, ordered from the least investigated MC type to the most investigated control type in previous literature.

Table 7.

Future research areas (own source)

Reward and Compensation	Strategy and Planning	Cybernetic Control	Administrative Control	Cultural Control
• analysis of the nature of incentive systems in HCOs • analysis of types of financial and non-financial rewards in HCOs • analysis of rewards and incentives for promoting SD goals in individual HCOs • investigation of the linkage between ESG-criteria and incentive systems • analysis of the impact of recognition programs and career advancement opportunities tied to sustainable practices on motivating HCOs employees • group rewards: investigation of the effectiveness of group rewards that encourage collaboration on sustainability • examination of the long-term behavioral changes induced by sustainability-related rewards and compensation	• analysis of long- and short-term corporate goals with regard to SD in HCOs • investigation of the focus on sustainability in operational activities and strategies • analysis how the focus on sustainability influences decisions and the determination of the overall direction of the HCO • societal mandate alignment: investigation how HCOs align sustainability efforts with societal health and climate goals • stakeholder expectations analysis • analysis of the form of stakeholder dialogue, the intensity of stakeholder involvement and the function of stakeholders in the organizational transformation process	• analysis of the development of KPIs in relation to all three ESG-dimensions • investigation of the linkage between strategy and operational measures • exploration of performance management systems • investigation of the development of audit and certification practices regarding the upcoming CSRD • investigations of steps necessary to increase the interconnection of sustainability management controls	• analysis of the changes following CSRD implementation in EU HCOs • analysis on how organizational structures are adapted over time in different world regions and what impact they have on SD • analysis of the impact of the Omnibus-Initiative in EU HCOs • investigation of the development of corporate policies and procedures with regard to SD • investigation of the role of ethics, leadership, and governance have in embedding sustainability in different geographic contexts	• analysis of the core values and beliefs of HCOs for promoting SD • exploration of the role of codes of ethics in the context of SD • analysis of the development of vision and mission with regard to SD • analysis of how HCOs’ culture evolve internally to prioritize SD issues • exploration of how ESG-matters become embedded in the organizations’ culture and are taken for granted • analysis of cultural transformation for promoting SD within HCOs and in comparison, to other service providers with a strong professional logic

In addition to the many avenues for further research for each control type, the package idea is not taken into account [20]. The full potential of SMCs can only be reached if the interconnectivity of the control types is honored.

These reflections and areas for further research also show a lack of knowledge on the connections between non-financial reporting practices and SMCs. A comprehensive study could investigate the extent to which the content presented in the reports is implemented in practice.

Discussing the findings of the strategic stakeholder theory, the following can be stated. Selective stakeholder groups within HCOs, like patients, providers, regulators, or communities, are of central importance in the context of SD [30], which in turn speaks in favor of following the strategic stakeholder approach [24]. Organizational sustainability needs the inclusion of the most important stakeholders. Particularly in the context of cultural controls and strategic considerations, there are repeated appeals in the literature to include the perspectives of strategically relevant stakeholders, continuously communicate changes and considerations to stakeholders, and involve them. There are different approaches to integrate the most important stakeholder groups to move from an occasion-driven, selective expertise-driven, or power-driven integration to a fully-fledged stakeholder dialogue. The type of involvement also depends on the group of stakeholders. According to Clarkson [86], primary stakeholders are directly involved in an organization. In HCOs, that includes employees, workers in the value chain, patients, suppliers, health provision network partners, local communities of the HCOs, financial institutions, and funding bodies. In the analyzed literature, the employees were the most focused stakeholder group. Other primary stakeholder groups have so far been investigated to a lesser extent. Secondary stakeholders are the governments and international organizations as legislators and standard setters, sector regulators, media, and non-governmental organizations. In contrast to primary stakeholders, they are not directly involved with the HCOs [25, 87], but set compliance requirements or serve as watchdogs. The role media as watchdogs play, is critical for the ESG-reputations of HCOs. This is totally under-researched and so far, legislative bodies, standard setters and regulators are too much treated as a homogeneous block. An effective stakeholder prioritization is a highly political endeavor as the expertise and the interests of the stakeholders are highly diverse. In the literature on stakeholder theory, many classifications exist for stakeholder prioritization, with the one by Mitchell et al. [88] as the most often referred to. All these classification systems require that the top management decides how narrow or broad the circle of involved stakeholder groups should be. Identifying the most important stakeholder groups is a prerequisite for HCOs to start a structured process of considering the material interests of key stakeholders, as this is the only way to ensure proper development across all ESG-dimensions. Recognizing stakeholder needs fosters trust, responsiveness, and accountability, which are vital in healthcare, where ethical obligations and social impacts are of great importance. By implementing SMCs aligned with stakeholder interests, HCOs can better manage risks, increase long-term value, adapt to changing regulations and patient expectations, promote resilience, and have a lasting impact on community health and well-being. However, in the healthcare sector, it is difficult to reconcile the differing and sometimes conflicting interests of diverse stakeholders. Pereno and Eriksson [89] suggest a multi-stakeholder vision for sustainable healthcare. To achieve SD, stakeholders in the healthcare system should be viewed as collaborators within a network. Therefore, when implementing SMCs, HCOs should evaluate their stakeholder system, which includes a variety of heterogeneous stakeholders, to develop a shared vision of SD in healthcare [89].

In recent years, the role of stakeholder groups has become more important in the organizational legitimacy theory [33], which stresses that the expectations of the organization or the sector’s relevant key stakeholders have to be fulfilled for gaining and maintaining legitimacy. Legitimacy theory states that HCOs seek to align their practices with societal norms and expectations to gain legitimacy and trust [33]. The development of SMCs by HCOs can be viewed from this perspective. On the global level, the UN Agenda 2030 or the SDGs, in particular SDG 3, could serve as reference points. On the national or state group level, the legislative requirements have to be fulfilled. The mere compliance with legislative or regulatory requirements regarding the ESG-dimensions is not enough. As the number of SD-related practices or fully-fledged corporate sustainability strategies is still very limited, much remains to be done before an integrated and more balanced way across all three ESG-dimensions is achieved. HCOs’ increased focus on environmental SMCs reflects their endeavor to include environmental stakeholder expectations in terms of corporate responsibility and environmental stewardship. A critical point to note is that HCOs have so far implemented SMCs in less complex areas, such as cultural controls, the role model function of management, or simple ecological KPIs. Transforming HCOs’ business models towards carbon neutrality and net-zero requires significantly more investment than simply picking the low-hanging fruits, where financial and environmental sustainability go hand in hand. There is still plenty of scope for a more balanced approach from SMCs. For gaining and maintaining organizational legitimacy, HCOs should improve in a first step their ESG-signaling and perform a cost-benefit analysis if and what voluntary accreditation, certifications and quality management schemes support their organization’s transformation process in the three ESG-dimensions and an integrated perspective. To move from a symbolic to a substantive ESG-integration, HCOs should honor more the idea of SMCs as a package.

In summary, it can be said that the SMC focus of HCOs is much more in line with the instrumental approach of strategic stakeholder theory, in which sustainability is primarily pursued as a means of achieving organizational goals such as efficiency and stakeholder satisfaction, and much less with a more differentiated and transformative SD implementation that positions HCOs as pioneers and proactive agents of systemic change in SD and assumes social responsibility beyond immediate organizational interests.

Conclusion, practical implications and limitations

This SLR highlights the various MC types used by HCOs to promote SD. Although SMCs are not entirely new to HCOs, existing research reveals a wide range of SMCs currently in use, which reflects a complex and diverse approach to managing SD. This study is the first SLR to specifically examine the application of SMCs in HCOs and demonstrates that this area of research is gaining momentum. Many studies have highlighted the growing influence of regulatory requirements and environmental challenges.

Cultural controls are used the most to implement SD in HCOs, followed by administrative controls. In contrast, cybernetic controls, strategy and planning, as well as reward and compensation, are still underrepresented. Within cybernetic controls, very selective KPIs are implemented and a systematic link between strategy and operational measures is missing. Research indicates that the resource-intensive organizational processes to support and implement SD in HCOs are still in their infancy.

Despite this progress, significant gaps remain, particularly in establishing more balanced SMCs [19, 20, 85]. Previous articles on SMCs in HCOs have primarily focused on the environmental dimension, while social and governance aspects receive comparatively less attention. While cultural and administrative controls are the most widely used, cybernetic, strategy, and reward controls are underutilized. The selective nature of the KPIs and the disconnect between strategy and operations exacerbate these issues. Overall, organizational processes to support SD in healthcare are still at an early stage.

This study is relevant not only to academics engaged in research on SMCs but also to practitioners, particularly for HCOs planning to implement SMCs. Considering the practical implications for HCOs and policymakers, the following observations can be made. As a result of the SLR and the theory-informed discussion, which showed that their it still much groundwork to do from an instrumental perspective which Hansen and Schaltegger [21] link to strategic stakeholder theory. To advance the implementation of a SMC system (SMCS) the following framework (Fig. 5) was developed for HCOs. The framework illustrates the current types of SMCs in HCOs and identifies their interdependencies. Additionally, the framework provides transition steps for achieving a more holistic approach to the SMCS implementation in all three ESG-dimensions within HCOs. The expectations of internal as well as external stakeholders influence the stakeholder involvement. As previously emphasized, stakeholder involvement in strategic decisions at HCOs is seen as crucial for ‘good governance’ in the healthcare sector [30, p. 64].

Fig. 5.

Framework for sustianability management control systems for HCOs (own source)

It is necessary to better align the five dimensions of MC with each other. The overall recommendation on the action level is that ESG-matters should be fully embedded in daily practices. That means: Employees should actively drive sustainability initiatives, governance structures should ensure accountability, comprehensive KPIs measure progress across ESG-issues, long- and short-term strategies should be aligned with ESG-goals, incentives should be developed to motivate employees and reinforce a sustainability-oriented culture. Selected recommendations for each control type are shown in the framework.

The geographical external context has an influence on the possibility of designing the SMCS. For example, the health system, the country context (e.g., developed vs. developing country), or political influences have to be considered.

Policymakers should take into account the regulatory burden costs that the legislation causes. The same is true for the very expensive quality management, accreditation and certification processes as other sources of coercive pressures. So far, all these normative requirements are not harmonized, and each voluntary and mandatory requirement leads to specific implementation costs. In the view of the authors, SMCS as a package must move beyond a mere compliance instrument. For a business model transformation, meeting compliance is only the first step.

Like every study, this study is subject to limitations. The most significant limitations pertain to the sample selection, the orientation towards the framework proposed by Malmi and Brown [20] and the methodology of an SLR. The sample selection depends on the quality of the keywords, the inclusion and exclusion criteria and the types of publications included. The SLR was conducted in an emerging field with 45 papers. The framework of Malmi and Brown [20] was selected for classifying MC types because Lueg and Radlach [19] later adapted it for SMC systems in line with the then-current academic body of research. In addition, the assignment of articles to thematic clusters is somewhat subjective, despite steps taken to reduce this subjectivity. A further methodological limitation is that all the included studies themselves also have limitations, vary in their focus on the three ESG-dimensions and are context-specific. Therefore, while a narrative SLR is an established method for identifying, evaluating and synthesizing the existing academic literature in a structured manner [36], it can only show foci and trends in the existing body of academic research. Narrative SLRs do not yield statistically testable results and there are limits to the generalizability of the findings.

Author contributions

PB and LK jointly designed the study, collected and interpreted the data and wrote the manuscript. DG and BGM led the analysis of the data and contributed to the preparation of the article. DG provided guidance and valuable input in drafting the manuscript. All authors read and approved the final manuscript.

Funding

Supported by theJohannes Kepler Open Access Publishing Fund and the federal state of Upper Austria.

Data availability

Those articles that can be attributed to the systematic literature review are marked with * in the reference list.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.