Towards the development of a framework for monitoring and evaluating the multidimensional sustainability of healthcare organisations: a scoping review protocol

Abstract

Introduction

The literature on sustainability performance frameworks for healthcare organisations varies in its applicability to different types of organisations and settings, functions and activities, and definitions and dimensions of sustainability. This fragmentation creates implementation barriers which may be overcome by consolidating existing evidence in a format that can be linked directly to organisations’ business models. This protocol proposes a scoping review to assess the extent of the literature on frameworks for monitoring and evaluating the multidimensional sustainability performance of healthcare organisations and to assemble a consolidated framework in an operationally relevant format to support progress towards sustainable healthcare organisations.

Methods and analysis

The search strategy will be applied across Semantic Scholar, Google Scholar, Web of Science, MEDLINE, Embase, Academic Search Premier, CINAHL and Business Source Premier databases. Search results from 2009, coinciding with the publication of the WHO’s ‘Healthy Hospitals, Healthy Planet, Healthy People’ report, will be considered. The scoping review will include studies reporting on multidimensional sustainability monitoring or evaluation frameworks applied or developed for use at the level of healthcare delivery organisations. Studies relating to operational units within organisations or to healthcare systems will be excluded. The review’s context will be restricted to operational sustainability and will not consider the literature on sustainable design planning and construction of new facilities. No specific exclusion criteria will be applied to the types of healthcare delivery organisations nor participants implicated in the frameworks. Title and abstract screening against the inclusion and exclusion criteria, followed by full-text assessment of remaining articles, will be performed by two reviewers. Data from included studies will be extracted using a custom-designed extraction tool, analysed using topic or thematic analysis to consolidate themes and presented within the triple-layered business model canvas.

Ethics and dissemination

Only publicly available sources will be used; research ethics approval is not required. Findings will be submitted to a peer-reviewed journal and presented at scientific meetings.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This scoping review uses an established and transparent methodological approach to systematically map and synthesise existing evidence on sustainable performance monitoring in healthcare organisations, ensuring consistency and reproducibility throughout the review process.

• By including studies that address environmental, social and/or economic dimensions of sustainability, the review will capture the breadth and diversity of performance indicators and practices relevant to healthcare settings.

• The mapping of evidence across different organisational types will provide a comprehensive view of sustainability implementation in healthcare delivery organisations, highlighting patterns and gaps in current research.

• As is typical of scoping reviews, no formal critical appraisal or meta-analysis will be conducted, which limits the ability to assess the quality and comparative strength of included evidence.

Introduction

The development of a robust framework to assess and monitor the environmental performance of healthcare organisations has been gaining increasing attention¹ since the influential WHO report ‘Healthy Hospitals, Healthy Planet, Healthy People: Addressing Climate Change in Health Care Settings’.² By integrating environmental concerns into their organisational processes and practices, healthcare organisations attempt to become more sustainable.

There is no consensus on the definition of sustainability in the healthcare literature.³,⁵ Yet, sustainability is often conceptualised in accordance with the foundational Brundtland Report, which defines sustainable development as development that ‘meets the needs of the present without compromising the ability of future generations to meet their own needs’.⁶ This landmark definition balances economic growth with social equity and environmental protection, focusing on long-term resource capability. In line with this notion of three-dimensional (ie, environmental, social and economic) sustainable development,⁶,⁸ a sustainable healthcare organisation is one that successfully achieves its strategic objectives while providing high-quality, equitable and evidence-based care, all within a framework that enables continuous adaptation to environmental challenges.⁹,¹⁴

Traditionally, performance measurement in healthcare organisations has relied heavily on financial metrics, with systems incorporating key performance indicators (KPIs), benchmarks, recommended practices and action-planning tools.¹⁵ For example, one of the most prominent performance measurement tools adopted in healthcare in the early 1990s, the Balanced Scorecard (BSC), translates the vision and strategy of an organisation into performance indicators from four original perspectives (traditional financial as well as non-financial perspectives such as customers, the organisation’s internal processes and learning and organisational development processes).¹⁵,¹⁷ Despite the BSC’s financial orientation, these perspectives could potentially support sustainable objectives in social and environmental dimensions. Indeed, attempts to incorporate an environmental perspective have been made¹⁸ towards the development of a sustainable BSC.^{19 20}

More broadly, there is growing scholarly interest in sustainability within healthcare, yet the literature remains fragmented and poorly aligned with established performance management traditions such as the BSC. A recurring issue across reviews and frameworks is the absence of a clear and consistent definition of sustainability and a lack of differentiation across healthcare settings, which makes it difficult to identify context-specific drivers of sustainability performance. Recent advances have addressed parts of this problem.²¹ For example, Dolcini and colleagues identified six core environmental sustainability domains—energy management, waste management, water consumption, greenhouse gas emissions, transportation and mobility and site sustainability—and proposed 18 environmental KPIs¹ that constitute an environmental sustainability performance assessment framework for hospitals.

Badanta and colleagues²² and Nurmala and colleagues²³ emphasised organisational enablers such as leadership, employee engagement, individual behaviour and culture in fostering multidimensional sustainability in healthcare generally. These contributions tend to isolate environmental or organisational dimensions and provide limited guidance for adapting frameworks to other healthcare organisations. Efforts to integrate perspectives represent important steps forward,^{3 22 23} yet even the most comprehensive models fall short of producing an operationally relevant and empirically validated framework that consolidates environmental, social and economic dimensions into standardised indicators usable across healthcare organisations. This persistent gap underscores the need for a consolidated and context-sensitive framework capable of guiding the monitoring and evaluation of sustainability performance in hospitals and other healthcare delivery organisations. Such a framework would provide a common structure for defining indicators, aligning organisational actors around shared sustainability objectives and translating sustainability commitments into measurable targets that can inform managerial decision-making and organisational change.

Transitioning towards sustainability, however, involves considerable complexity. It demands a fundamental reconfiguration of how core organisational functions are integrated and how activities across the healthcare supply chain are coordinated, ensuring that value is created and delivered not only to patients but also to a broader range of stakeholders. The triple layered business model canvas (TLBMC) was developed to support such innovation towards more sustainable business models.²⁴ It extends the original business model canvas by adding two layers: an environmental layer based on a lifecycle perspective and a social layer based on a stakeholder perspective. When taken together, the three layers of the business model more explicitly describe how an organisation generates economic, environmental and social value (figure 1). This scoping review aims to exploit the TLBMC to structure a consolidated triple layered sustainability performance monitoring and evaluation framework based on the existing healthcare literature.

Figure 1. The triple layered business model canvas. Adapted from Joyce and Paquin.²⁴ The figure represents the three dimensions of the triple layered business model canvas (as listed on the left side) and their respective components (text boxes of matching colours). This figure was enhanced to meet BMJ Open’s minimum image resolution requirements. Image resolution is 300 dpi and 123×91 mm.

To this end, we propose a scoping review that aims to answer the following question: what are the existing monitoring and evaluation frameworks used for sustainability performance by hospitals and other healthcare delivery organisations? This review will contribute to addressing the fragmentation in existing approaches by systematically identifying and analysing frameworks for monitoring and evaluating the multidimensional sustainability performance of healthcare organisations. By using the TLBMC as a synthesis tool, we aim not only to organise the current body of knowledge but also to inform the development of context-sensitive and strategy-aligned sustainability performance monitoring and evaluation systems. This approach offers a novel pathway to integrate sustainability considerations into healthcare management in a structured and operationally relevant manner, supporting more coherent and actionable progress towards sustainable healthcare organisations.

The opportunity for knowledge development in relation to multidimensional sustainability performance frameworks in healthcare organisations lends itself to a scoping review methodology since the literature contains various definitions and dimensions of sustainability and applications across diverse business models. This provides us with an opportunity to map the key definitions, dimensions and concepts in the literature that underpin sustainability performance across the diversity of healthcare organisation business models, to clarify working definitions and conceptual boundaries, and to illustrate both what has been learnt and can be implemented in practice, and the gaps in knowledge that should drive future research.²⁵

A preliminary search of MEDLINE, the Cochrane Database of Systematic Reviews and Joanna Briggs Institute (JBI) Evidence Synthesis was conducted and identified seven recent reviews on the topic (n=3 scoping^{1 3 5} and n=4 systematic).²⁶,²⁹ These reviews differ in their foci on healthcare systems⁵ versus organisations^{1 28 29} and in the types of organisations and settings they address (eg, hospital-specific¹ vs ‘one-size-fits-all’ approaches).^{5 27 29} They further offer heterogeneous coverage of organisational functions, ranging from buildings, facilities and operational infrastructure^{1 27} to holistic managerial systems.^{28 29} Finally, they vary in their treatment of sustainability dimensions, from environmental-only^{1 5} to multidimensional.²⁶²⁸,³⁰ Our preliminary search also identified two protocols (one using realist review³⁰ and one scoping review³¹ methodology) that propose to review environmental sustainability outcome metrics, but exclusively in the context of healthcare quality improvement rather than a more comprehensive approach to healthcare organisations’ sustainability performance. Consequently, resulting frameworks may cover truncated dimensions of sustainability, provide incomplete depictions of organisational sustainability performance and lack applicability across varied healthcare organisation types. This scoping review seeks to consolidate this fragmented literature and to produce a framework of sustainability dimensions, criteria, indicators and metrics that can guide multidimensional sustainability performance monitoring and evaluation within any healthcare delivery organisation.

Methods and analysis

The proposed scoping review is planned from June 2026 to May 2027. It will be conducted in accordance with the JBI methodology for scoping reviews.^{32 33} Any deviations from this protocol will be reported and justified in the methods section of the final scoping review paper.

To develop the research questions, we followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guide³³ (online supplemental appendix I) and adopted the recommended Population, Concept, Context (PCC) mnemonic³²:

RQ: What monitoring and evaluation frameworks (concepts) do hospitals and healthcare delivery organisations (population/participants) use to assess sustainability performance (context)?

Sub-questions

sRQ1: How do these frameworks define sustainability, and which dimensions (eg, environmental, social, economic) do they include?

sRQ2: What criteria, indicators, metrics, data sources and benchmarks do these frameworks use to measure sustainability performance?

sRQ3: What practices are recommended for monitoring, evaluating, and responding to sustainability performance?

The objective of this scoping review is to map the literature on frameworks for monitoring and evaluating the multidimensional sustainability performance of hospitals and other healthcare delivery organisations. Specifically, we seek to identify key sustainability dimensions, indicators and metrics, and recommended monitoring and evaluation practices. We also aim to propose a consolidated framework in an operationally relevant format to support implementation and progress towards more sustainable healthcare organisations.

Eligibility criteria

Population and participants

This scoping review is focused on the sustainability performance monitoring and evaluation of hospitals and other healthcare delivery organisations; we will therefore exclude articles which describe frameworks clearly designed to measure performance at the smaller levels of individual operational units, such as the operating department within a hospital, and likewise at the larger levels of national or sub-national health systems. This delimitation is consistent with conceptual distinctions in the healthcare delivery literature between healthcare organisations and health systems, which differ in their governance structures, scope of decision-making and operational characteristics. Healthcare delivery organisations—such as hospitals, clinics or integrated provider organisations—represent the level at which managerial processes, organisational structures and care delivery practices are implemented and monitored. In contrast, health systems are typically defined as the broader organisation of people, institutions and resources that deliver healthcare services to a population at national or regional levels and are generally governed through policy and regulatory mechanisms rather than organisational management processes.³⁴ Because sustainability monitoring and evaluation frameworks developed for health systems often rely on macro-level policy indicators, population-level metrics or governmental accountability mechanisms, their criteria and indicators may not be directly applicable to the operational decision-making context of individual healthcare organisations. Consequently, this review focuses on frameworks designed for use within healthcare delivery organisations, where sustainability monitoring and evaluation can inform managerial decision-making and organisational performance improvement.

The WHO has defined a health system as all organisations, people and actions whose primary intent is to promote, restore or maintain health.³⁵ This definition alone, however, may be insufficient when screening articles for selection as it may not adequately distinguish between a sub-national health system and an integrated healthcare organisation. Therefore, to define healthcare organisations and distinguish between integrated healthcare organisations and healthcare systems, we will use the framework developed by the Agency for Healthcare Research and Quality’s (AHRQ) Effective Healthcare Stakeholder’s Group (SG) which characterises the structure and function of health delivery organisations and systems using 28 key elements grouped by 6 domains.³⁴ Applying this full framework in screening for article selection would not be feasible and is not necessary for our purpose. We will primarily adopt the framework element of Integration (Domain 5: Care processes and infrastructure) to distinguish between integrated healthcare delivery organisations (which will be included) and healthcare systems (which will be excluded). This element will prompt our reviewers to consider the extent to which a network of organisations or units within a single organisation provides or arranges to provide a coordinated continuum of services to a population and is willing to be held clinically and fiscally accountable for the outcomes and health status of the population served. If the answer to this question is ‘to a large extent’ then it represents an integrated service delivery organisation, if it is otherwise, it is more likely to represent a health system.

For example, we may need to decide whether to include or exclude an article reporting a framework designed for the Veteran’s Health Administration (VHA) which one may consider a system, with its 146 Veterans Affairs (VA) Medical Centres with integrated outpatient clinics, 772 Community Based Outpatient Clinics and 134 VA Community Living Centres (VA Nursing Home) Programmes (which one may consider as organisations in their own right). Using the above definition, we would conclude that the VHA is better classified as an integrated healthcare organisation than a sub-national system, and we would include the article. The definition would also lead us to include an article reporting a framework designed for a Kaiser Permanente Regional Health Group as an integrated healthcare organisation, but to exclude one at the level of the Kaiser Permanente integrated managed care consortium, due to the clinical and fiscal accountability being dispersed to the distinct and independent entities (ie, the Kaiser Foundation Hospitals, the regional Permanente Medical Groups, and the Kaiser Foundation Health Plan). The diversity of health systems and health organisation structures around the world will surely present us with other challenges of classification and thus impact on our article selection, but we will use this framework to guide our decision making and consensus discussions where needed.

We will include all types of healthcare delivery organisations in this scoping review which we will characterise using the AHRQ-SG Framework.³⁴ This includes but is not limited to organisations that provide acute and chronic primary (eg, primary health clinics), secondary (eg, hospitals) or tertiary (specialised) care to human populations, and organisations that provide healthcare through short-term and long-term residential care. We do not intend to apply any specific exclusion criteria beyond the distinction between organisations and systems.

Moreover, the multidimensional sustainability of healthcare organisations implicates the full spectrum of actors within organisational ecosystems. This includes staff (managerial, business support, clinical, hospitality, engineering, technical and support services), patients and visitors, as well as actors within their networks (eg, supply chains, referral networks, etc). This review will not place any specific exclusion criteria on the types of participants or actors focused on by the identified studies.

Concept

Performance monitoring or evaluation frameworks consist of metrics, KPIs and/or benchmarks, set against criteria or strategic goals.¹⁵ Articles that do not contain, at minimum, one of either metrics, KPIs or benchmarks set against environmental, social, economic or other sustainability criteria will be excluded. Performance monitoring or evaluation frameworks may, in addition, include recommended practices and action-planning processes and tools such as Life Cycle Assessment and Multi-criteria Decision Analysis, etc. All three dimensions of sustainability—environmental, social and economic—will be included in the review. However, to limit the scope to a feasible project, articles must include the environmental dimension of sustainability and may also include other sustainability dimensions such as social and economic. Articles that include only the economic or social dimension of sustainability will not be considered.

Context

The context of the review is sustainable healthcare, applied at the level of the healthcare delivery organisation. Sustainability in healthcare organisations has three main dimensions—environmental, social and economic—^{3 4}although others such as political, have been considered.³⁶ Although we will use search terms specific to the three main dimensions of sustainability, we will not exclude articles that contain other dimensions. A significant literature exists defining sustainability in healthcare in terms of the maintenance of therapeutic outcomes.^{21 37 38} This definition does not align with the intentions of this review, and such articles will therefore be excluded. We also focus this review on the operational sustainability of healthcare delivery organisations and will not consider literature related to sustainability at the stage of design, planning and/or construction of new healthcare facilities. Although it is interesting to consider sustainability across the life cycle and we acknowledge the major contribution of new builds to the environmental impact of healthcare,^{39 40} we do not believe it to be of practical value to extend new build-related performance measures into ongoing healthcare sustainability performance management systems. We will however include articles which report relevant building and facility-related criteria and indicators in the context of ongoing healthcare operations.

Information sources

This scoping review will consider all study designs involving quantitative, qualitative or mixed methods. In addition, systematic, scoping and narrative (traditional literature) reviews, as well as opinion papers that meet the inclusion criteria will also be considered, so long as the work presents a consolidated framework. In these cases, the review’s findings, not the individual articles reviewed, will be the unit of analysis. Books, book chapters, reports, conference proceedings and abstracts, theses and dissertations will be excluded due to uncertainty of peer review; however, grey literature from key global, national and local (Québec, Canada) healthcare authorities will be considered due to the practical and contextual relevance to the scoping review objective.

Search strategy

The main search strategy will aim to locate published, peer-reviewed studies and will be developed by an academic librarian (FB) in collaboration with the research team. In brief, an initial limited search of MEDLINE (PubMed) and Google Scholar was undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles, were used to develop a full search strategy which will be adapted for each database and information source (online supplemental appendix II).

Studies published from 2009 onwards, coinciding with the publication of the WHO’s ‘Healthy Hospitals, Healthy Planet, Healthy People: Addressing Climate Change in Health Care Settings’ report,² which laid the foundations for the current generation of sustainability performance monitoring and evaluation in healthcare, will be considered. No other restrictions, including language, will be applied.

The search strategy will be applied across Semantic Scholar, Google Scholar, Web of Science, MEDLINE, Embase, Academic Search Premier, CINAHL and Business Source Premier databases to provide wide coverage across health, social care, management and other academic disciplines. A separate search of grey literature from key global, national and local (Québec, Canada) healthcare authorities will be considered, as policy documents and institutional reports often contain valuable evidence on sustainability initiatives and performance practices that are not captured in the peer-reviewed literature. Including local sources is particularly important to account for the distinctive governance structures, health system organisation and environmental policy frameworks shaping sustainability performance in this jurisdiction.

Screening, data collection and extraction

Following the search, all identified citations will be imported into Covidence.⁴¹ Following a pilot test of the inclusion and exclusion criteria, titles and abstracts will be screened by two or more independent reviewers. The full texts of potentially relevant articles will be retrieved and assessed in detail against the inclusion and exclusion criteria by two or more independent reviewers. Reasons for exclusion at this stage will be recorded and reported in the scoping review. Any disagreements that arise between the reviewers at each stage of the selection process will be resolved through discussion or with an additional senior reviewer/s. The results of the search and the study inclusion process will be reported in full in the final scoping review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.³³

Data extraction

Data from the included studies will be extracted by two independent reviewers into a custom-designed extraction tool. This tool will include: article characteristics (citation details, geographic scope, study objective, study design characteristics, participant description, key findings), basic organisational characteristics (sectoral context (eg, healthcare, aged care, social care, etc), care settings (eg, home, community, primary care, hospital, etc), system context (eg, public, private, other, etc)), and framework characteristics (dimensions, criteria, data, metrics, KPIs, benchmarking, recommended monitoring and evaluation practices and action-planning guidance).

The draft data extraction tool (online supplemental appendix III) will be modified and revised as necessary during the process of extracting data from each included evidence source. Modifications will be detailed in the scoping review. Any disagreements that arise between the reviewers will be resolved through discussion or with an additional reviewer/s. If appropriate, authors of papers will be contacted to request missing or additional data.

A second phase of data charting will be conducted to characterise all healthcare organisations within which frameworks had been studied within the selected literature. This will be done using the AHRQ-SG Framework.³⁴ This phase will likely require searching information sources beyond the selected articles (eg, organisation’s websites, annual reports, etc). We will use these data to generate organisation typologies, by which the review results will be presented.

Critical appraisal of individual sources of evidence, based on the grading systems developed by Atkins and colleagues,⁴² will only be performed to the extent of recording the overall study design. This will be used as a proxy for overall strength of evidence where we will consider systematic or scoping reviews of empirical studies the highest level of evidence, individual empirical studies (quantitative, qualitative or mixed methods) moderate level and narrative reviews or opinion papers the lowest level of evidence. This is generally not required for scoping reviews however our intention is to develop a consolidated framework of elements from the included studies and thus it will be useful to understand the evidential basis for each included element.

Data analysis and presentation

Following data extraction, we will use topic or thematic analysis,⁴³ as appropriate, to analyse sustainability definitions and associated dimensions (sub RQ1), framework characteristics (criteria, indicators, data/metrics, benchmarks) (sub RQ2) and recommended practices for monitoring, evaluating and responding to performance issues (sub RQ3).

We plan to present the results as a consolidated framework. To do this, we will map the results to the three canvass layers (environmental, social, economic) of the TLBMC²⁴ (figure 1 and online supplemental appendix IV) which will serve as a tool to aid healthcare organisations to develop sustainability performance monitoring and evaluation systems customised to their business models. Where the evidence supports the inclusion of sustainability dimensions beyond the anticipated trio of environmental, social and economic, we will represent these as additional canvass layers while attempting to maintain the vertical and horizontal integrity of the TLBMC. A narrative summary will accompany the tabulated and graphical results and will describe how the results relate to the review’s objective and questions.

Ethics and dissemination

This study does not involve human participants or the collection of primary data. It will rely exclusively on publicly available and previously published sources. Therefore, research ethics board approval is not required. The review team will adhere to principles of research integrity and transparency throughout the process, including systematic documentation of search and screening decisions, proper citation of all sources, and compliance with copyright and fair-use standards. No personal, confidential or sensitive information will be collected or reported. All records will be managed securely on password-protected institutional servers accessible only to the research team.

Findings from this scoping review will be disseminated through publication in a peer-reviewed journal and presentations at national and international conferences focusing on health services management, environmental sustainability and healthcare policy. In addition, the results will be shared with Canadian and Québec healthcare stakeholders to inform ongoing sustainability performance initiatives.

Data statement

Where feasible, the dataset supporting the review (eg, list of included studies and data extraction chart) will be made available through an open-access repository such as the Open Science Framework. This will promote transparency, facilitate knowledge transfer and support future comparative analyses of sustainability performance in healthcare organisations across jurisdictions.