Exploring the strategies to implement a sustainable energy program

Section 1: Foundation of the Study

The establishment of sustainable practice in healthcare institutions has been a

major concern in most developed countries because the healthcare institutions and the

public can benefit from it (McGain & Naylor, 2014; Qadir et al., 2014). A hospital

operates 24 hours a day and 7 days a week; the natural resources consumption for

maintaining a safe and stable operation is considerably high (Kaplan, Sadler, Little, Franz,

& Orris, 2012). Although global studies show that hospitals can reduce the negative

effects on the environment by implementing sustainable initiatives such as energy and

water preservation programs and waste management strategies only 30% of Hong Kong

hospitals employ an effective and applicable sustainable program. As healthcare costs are

rising globally, the hospital leaders or the management can reduce energy costs by

introducing a sustainable energy program at the hospital (Berwick & Hackbarth, 2012;

McGain & Naylor, 2014; Qadir et al., 2014).

Background of the Problem

The growth of the global population has depleted the natural resources in most

developed countries (Alam & Kabir, 2013). The rapid growth of healthcare services due

to increased demand and changes in disease etiology has contributed to an additional

burden of environmental pollution (Dall et al., 2013; McGain & Naylor, 2014).

Healthcare services in major developed countries are among the most polluting industries

(Berwick & Hackbarth, 2012; Short, Lomas, Giridharan, & Fair, 2012). Researchers have

suggested that healthcare leaders look for effective strategies to reduce greenhouse

emissions by developing and implementing a sustainable program for their healthcare

institutions (McGain & Naylor, 2014; Sadler & Guenther, 2015).

Corporate sustainability measures of an organization suggested the stakeholders’

well-being in three major areas including a social aspect, financial aspect, and

environmental aspect (Stoughton & Ludema, 2012). An organization can improve both

long- and short-term competitive advantages by incorporating sustainability into the

company strategy (Lloret, 2016). For the healthcare setting, the benefits of introducing a

sustainable program for hospitals include reducing costs, increasing the brand image, and

improving public health status by reducing pollution (Harvey, 2013; Trong, 2012).

Energy costs are high in Hong Kong public hospitals (Tong & Fong, 2014). A well

established sustainable energy program is promising for reducing energy costs (Rohde &

Martinez, 2015).

Implementing sustainable practices is a challenge to many business leaders

because it will incur changes to the company internally and externally (Stoughton &

Ludema, 2012). However, Hong Kong studies on how hospital leaders can successfully

employ a sustainable energy program are rare. Studies pointed out that the use of the

corporate sustainability model developed by Epstein in 2008 to design and implement

sustainable practice can be applied to business firms (Epstein & Buhovac, 2014; Kuei &

Lu, 2013; Stuart, 2013).

Problem Statement

Extensive hospital activities in Hong Kong have caused an increase in energy

consumption (Hospital Authority Annual Report, 2013). Tong and Fong (2014) indicated

that the energy expenditure of 42 public hospitals in Hong Kong was high, reaching

around 100 million U.S. dollars per year. A study estimated that a hospital can save up to

20 million U.S. dollars of energy cost in 5 years by implementing a sustainable energy

program (Kaplan et at., 2012). The general business problem is that hospital leaders are

often unable to control energy expenses that can lead to an increase in operating costs.

The specific problem is that the strategies necessary to develop and implement an

effective sustainable energy program in Hong Kong hospitals are not understood by some

leaders in that city-state.

Purpose Statement

The purpose of this qualitative, multiple site case study was to explore the

strategies necessary to develop and implement an effective sustainable energy program in

Hong Kong hospitals. The participants of this study were the hospital green committee

chairpersons of five public hospitals in Hong Kong that received outstanding

achievement recognition from the local government. Hospitals are one of the most

energy-intensive facilities; implementing a sustainable energy program will help to

reduce pollution and energy costs (McGain & Naylor, 2014; Qadir et al., 2014). The

implications for positive social change may include providing findings as a reference for

hospital leaders to redirect the saved resources from a sustainable energy program to

improve patient care and reduce pollution (McGain & Naylor, 2014).

Nature of the Study

I employed qualitative research methods with a multiple case study design to

explore the strategies for Hong Kong hospital leaders to develop and implement a

sustainable energy program to increase cost effectiveness. Fassinger and Morrow (2013)

showed that researchers can use a qualitative research approach to engage the participants

in a research study and to address their personal experiences, emotions, motivations, and

inner life in the study. Researchers can use the qualitative research method to understand

the phenomena by describing, decoding, translating, and understanding data (Sergi &

Hallin, 2011). For quantitative research, researchers can use it to investigate the observed

phenomena by statistical or computational techniques. Researchers using quantitative

research quantify data and generalize results from a sample of the population of interest

and measure the incidence of various views and opinions in a chosen sample (Yin, 2014).

The mixed method is an approach for the researchers to understand the phenomena by

combining both qualitative and quantitative methods to analyze data, and it is suitable for

researchers because the results from one study can support the other study (Klassen,

Creswell, Plano Clark, Smith, & Meissner, 2012). I used the qualitative research method

to understand the behavior of Hong Kong healthcare leaders in responding to sustainable

practice in the hospitals. I used the qualitative method in this study because it is a method

that researchers use to gather an in-depth understanding of a specific human behavior in a

group or organization, and social, political areas. A researcher can use the qualitative

method to explore human behavior on how the participants can apply measures to handle

the specific problem (Hyett, Kenny, & Virginia Dickson-Swift, 2014).

Yin (2014) suggested that researchers use a case study design when they are

looking for an answer to how and why questions, and when researchers cannot

manipulate the behavior of those involved in the study. Case study research design is an

approach to understanding a particular phenomenon within its context using a variety of

data sources, and researchers can use the case study approach to obtain an in-depth

appreciation of an issue, event, or phenomenon of interest, in a real-life context (Crowe et

al., 2011). The phenomenological design is a method to explore and understand the

participants’ living experience (Ardley, 2011). So that the phenomenological design may

not apply to address the research question of this study on what are the strategies for

Hong Kong hospitals leaders to develop and implement sustainable energy program to

reduce energy cost. Ethnographic design is an approach to explore the relationship

between the participants’ culture and behavior, but is not a suitable design for this study

(Christiansen, 2011; Nite & Singer, 2012)

Qualitative case study research design is an approach for the researcher to

understand a particular phenomenon within its context using a variety of data sources

(Lewis, 2015). Yin (2014) suggested that researchers should use case study design when

they are looking for an answer how and why questions, and when researchers cannot

manipulate the behavior of those involved in the study. Also, researchers can use case

study design to find out the contextual conditions because they believe they are relevant

to the phenomenon under study. Finally, Yin (2014) pointed out that the researcher

should use a case study design when they do not know the boundaries of the phenomenon

and the context is not clear. As a researcher, I did have the power to manipulate the

decision of the healthcare leaders to adopt sustainable energy practice at their hospitals. I

used the qualitative case study research design to understand why and how the local

healthcare leaders are developing and implementing a sustainable energy program in their

hospitals, and how to facilitate the incorporation of the sustainable energy program to

obtain costeffectiveness by reducing energy costs.

Research Question

The research question of this study is, “What strategies do the hospital leaders use

to develop and implement a sustainable energy program to reduce energy cost?”

Interview Questions

1. Can you tell me what corporate sustainability measures are implemented in your

hospital?

2. What are the external and internal driving forces/motivations to facilitate the

implementation of a sustainable energy program in your hospitals?

3. As the leader of the hospital green management committee, what is your role in

managing sustainable practice in the hospital?

4. What are your management strategies/approaches/tools to facilitate the successful

implementation of the sustainable energy program at your hospital?

5. How do you comment on the organization structure of green management

committee at your hospital?

6. How can you mobilize and motivate your staff/stakeholders to develop and

implement a sustainable energy program at your hospital?

7. What skill, knowledge, or training for your staff is needed for practice in a

sustainable manner?

8. What are the hospital performance measures for the sustainable energy program?

9. Can you tell me the challenges/barriers to implementing the sustainable energy

program at your hospital and how do you overcome them?

Conceptual Framework

The aim of this study was to explore the strategies for the Hong Kong public

hospital leaders to develop and implement a sustainable energy program to reduce energy

costs. The conceptual framework is the system of concepts, assumptions, expectations,

beliefs, and theories that support the design and the problem statement of the study

(Timmermans & Tavory, 2012). I used the corporate sustainability model as the

conceptual framework to explain the aim of the study in a systematic way and to view the

phenomenon of energy sustainability in hospitals.

The corporate sustainability model (CSM) developed by Epstein in 2008 provides

a description of the drivers of corporate sustainability performance (Epstein, 2008). The

CSM contains the elements of social, environmental, and financial dimensions of

sustainability as its foundation, and consists of four major drivers. The CSM is a

comprehensive approach to examining, measuring, and managing the drivers of corporate

sustainability, and has been tested and revised in both academic and managerial studies

(Epstein & Buhovac, 2014).

The CSM includes the drivers of corporate sustainability performance, and the

leaders can use them to affect the organization performance and the consequences of

those actions on corporate environmental, social, and financial performance (Epstein,

2008). In CSM the sustainable organization activities consist of inputs, processes, outputs,

and outcomes, which are necessary for the implementation of a sustainability strategy in

an organization (Epstein, 2008).

The inputs include (a) external context, (b) internal context, (c) business context,

and (d) human and financial resources (Epstein, 2008). The processes include (a)

leadership, (b) sustainability strategy, (c) sustainability structure, and (d) sustainability

systems, programs, and actions (Epstein, 2008). The outputs include sustainability

performance and stakeholder reactions (Epstein, 2008). Finally, the outcomes include the

long-term corporate financial performance and sustainability performance. Sustainable

practice at the hospital can increase cost effectiveness and can reallocate the saved

resources into other service improvement initiatives (McGain & Naylor, 2014). The CSM

is a valuable guideline for Hong Kong healthcare leaders to understand which strategies

are necessary to develop and implement a sustainable energy plan to improve cost

effectiveness and financial status for the public hospitals in Hong Kong.

Operational Definitions

Corporate sustainability: The ability of a firm to grow over time by effectively

meeting the expectations of diverse stakeholders in social, financial, and environmental

areas (Montiel & Delgado-Ceballos, 2014).

Corporate sustainability management: A management concept that states that the

viability of the company is closely related to the success of the company to provide profit

without neglecting the benefits of other stakeholders in social and environmental aspects

(Ameer & Othman 2012).

Corporate sustainability model (CSM): A conceptual framework that describes

the drivers of corporate sustainability performance that the management can use to

influence performance, and the outcomes of the sustainability actions for social,

economic, and financial performance (Epstein & Buhovac, 2014). The CSM describes the

sustainability activities in four major steps including input, process, output, and outcome

(Epstein & Buhovac, 2014).

Sustainable energy program: An important utility system resource that can also

reduce greenhouse gasses, save money for customers, and generate jobs. In response to

both economic concerns and climate change, legislators and regulators have supported

energy efficiency at unprecedented levels (American Council for an Energy-Efficient

Economy, 2012).

Sustainable healthcare: Sustainable healthcare is to provide high-quality health

services to the customer, the service should benefit the social, financial, and

environmental aspects, and without exhausting natural resources or causing severe

ecological damage (Patel & Soundararajan, 2015). Sustainable healthcare initiatives

involve greening the energy consumption, water consumption, waste management,

transportation, and building facilities to efficiently and responsibly use resources (Patel &

Soundararajan, 2015).

Assumptions, Limitations, and Delimitations

Assumptions

An assumption is a belief or feeling that something is true or that something will

happen, although there is no proof (Oxford University Press, 2014). The assumptions

include that the participants of this study answered the interview questions in an honest

and candid manner, and that they have all the required knowledge and experiences to

answer the interview questions. Also, the elements present in the literature review can be

transferred and applied across the healthcare industry, and each of these elements

supports the successful implementation of sustainable measures that will eventually lead

to long-term benefits for local hospitals.

Limitations

A limitation is a point or level beyond which something does not or may not

extend or pass (Oxford University Press, 2014). One of the limitations of this study is that

the participants’ responses to the research questions may not be the best information,

although they are the most appropriate individuals to participate in the study due to their

official positions on the hospital green committee. Another limitation is the fast

advancements in sustainable technologies. All of the participants’ input is according to

what current technologies can provide; technology advancement on the sustainable

measure will limit the value of the results of this study because technology improvement

can enhance sustainable value to the hospital in the future.

Cultural difference, government policy, readiness to practice green initiatives, and

corporate direction of the local hospitals are not comparable to the countries presented in

the literature review references of this study. Also, the findings of this study on what

strategy is required to develop and implement a sustainable energy program to save

energy costs are assumed to apply to Hong Kong because the local studies on healthcare

sustainability and a sustainable energy program for the hospital are rare.

Chairpersons of five hospital green committees participated in the interview, but

their views on what strategy is necessary for employing a sustainable energy program in

public hospitals in Hong Kong to effectively reduce energy consumption may not fully

reflect the views of the other 37 public hospitals in Hong Kong. The findings may apply

to hospitals of similar size, within similar regions, or in the same setting. The study was

during a period of good economic health; the 2014 gross domestic product is estimated to

be 272.5 billion U.S. dollars (Hong Kong Trade Development Council, 2014). The

findings of this study may not apply to a situation of the economic downturn.

Delimitations

Delimitation is the boundary set for the study, and which the researcher will not

look into in detail (Svensson & Doumas, 2013). The scope of this study was to explore

the strategy for local hospital leaders to employ a sustainable energy program in public

hospitals in Hong Kong to effectively reduce energy consumption using a qualitative

multiple case study approach. Quantitative findings, such as financial achievement of the

hospital by implementing a sustainable energy program and indicators of sustainability,

performance will not be the focus of this study.

The scope of this study did not include any proposal for management or an

operations framework for hospital leaders to implement a sustainable energy program.

The research interview data from five of the local public hospital green committee

chairpersons limits the ability to generalize the findings to the whole public hospital

system in Hong Kong. Finally, the researcher of this study did provide a solution to

improve sustainability performance for Hong Kong public hospitals because the study

will look into the sustainable energy program alone, which cannot reflect the other

criteria of corporate sustainability in healthcare.

Significance of the Study

The Sustainable Development Unit of National Health Service identified that

hospitals use up two and a half times more energy than commercial buildings, and they

spend more than 8.5 billion U.S. dollars annually on energy (Naylor & Appleby, 2013).

The total annual energy consumption of hospitals and clinics of the Hong Kong Hospital

Authority was around 35,000,000 gigajoules in 2012–2013, and the rising trend of energy

consumption is due to the increase in hospital activities (Hospital Authority Annual

Report, 2013). Tong and Fong (2014) indicated that the energy expenditure of 42 public

hospitals in Hong Kong was high, reaching around 100 million U.S. dollars per year.

Energy usage can cost between 1-3% of a hospital’s operating budget and hospital

leaders can apply a sustainable energy program to save money on energy costs and

reallocate the resources to other hospital initiatives to improve service quality (McGain &

Naylor, 2014). Hospitals in Hong Kong operate 24 hours a day and 7 days a week, and

the use of energy in providing medical services in Hong Kong hospitals is comparable to

the U.S.

Contribution to Business Practice

Business leaders may benefit from the results of my study because I explored the

strategy necessary for local public hospitals to develop and implement a sustainable

energy program. The study suggests that hospital leaders can reduce energy costs by

implementing sustainable energy at their hospitals (Kaplan et al., 2012). Also, there are

few external drivers that the local hospitals must face in budgeting for energy expenditure

to maintain their financial well-being, which includes the increase in energy costs, supply

challenges, and the globalization of climate regulations (Naylor & Appleby, 2013).

Implication for Social Change

Society may benefit from the results of my study because the report of the Hong

Kong Environment Protection Department (2015) revealed that only 13 out of 42 local

public hospitals had a sustainable plan for waste and carbon reduction, and there were

only six public hospitals that had implemented a sustainable energy plan and received the

Hong Kong Green Organisation Certification Award in 2014. According to the Hong

Kong Hospital Authority annual report (2013), they estimated that the total healthcare

expenditure of the local public hospitals was 2.5% of the total Hong Kong gross domestic

product. Although the Hong Kong government supports the entire healthcare cost of the

local public hospitals, the saved money is a valuable resource for other service

improvement initiatives to achieve the organizational goals. By exploring a strategy for

local hospital leaders to employ a sustainable energy program in public hospitals in Hong

Kong to reduce energy consumption, the healthcare leaders can cut energy costs and

reallocate resources to other hospital activities to improve service quality (McGain &

Naylor, 2014).

Healthcare is a major contributor to climate change; energy consumption accounts

for 24% of the carbon dioxide emissions in England (Barna, Goodman, & Mortimer,

2012). In addition to the financial benefit of implementing a sustainable energy program,

the reduction of carbon emissions from hospitals can help alleviate climate change, which

can reduce the incidence of disease caused by environmental pollution such as asthma,

respiratory disease, and further improve the healthcare financial burden (Thompson, Frith,

& Pencheon, 2013).

A Review of the Professional and Academic Literature

I expanded the academic literature related to the topic of this study to exploring

the strategy for Hong Kong hospital leaders for employing a sustainable energy program

in public hospitals to reduce energy consumption. The literature and peer-review journals

related to this topic help explain the topic of this study. A literature review involved the

selection, synthesis, and evaluation of the published articles on healthcare sustainability

and the effect of sustainable practice in hospital on cost effectiveness. The content of the

literature review also included the currently available research on sustainable energy

measures in hospitals to improve energy efficiency and cost effectiveness. A literature

review could help to build my research on the top of existing research on the same topic

and fill in the gaps in current knowledge (Denney & Tewksbury, 2013).

The literature search of peer-reviewed journals in this section provided a better

understanding of the basic knowledge on the current sustainability issues related to

healthcare services. This part further investigated the definition of sustainability practice

in hospitals, the effect of energy-saving plans in hospitals, a conceptual framework for

developing and implementing sustainable practices, and driving factors for sustainability,

which will lead to suggestions for the topic of this study. The online databases used to

find the selected articles in the literature review included Academic Search

Complete/Premier, Business Source Complete, PubMed, Emerald Management Journals,

ProQuest Central, Sage Premier, and Science Direct. This selection of journals’ databases

contains peer-reviewed journals on corporate sustainability practices in healthcare

settings. I searched the peer-reviewed journal for the topic of this study by using

keywords that included corporate sustainability, corporate social responsibility,

sustainable healthcare, green practice in hospitals, and sustainable energy programs in

healthcare or a hospital, and energy efficiency programs.

The initial search provided an overview of the literature that discussed these

topics. A further refinement of limiting the research to scholarly peer-reviewed literature

published after 2009 allows additional in-depth article on the topic of this study. There

were 99 reference articles in the literature review, which included dissertations, technical

reports, books, and relevant internet websites in the search process, and 95 of them,

representing 96% of these findings, were current. Among these 99 articles, 87 of them,

representing 88%, were peer-reviewed journals with publication dates within 5 years of

my anticipated graduation date of 2017. Table 1 illustrates the classification of the

sources reviewed in this literature review. The literature review consists of five themes,

and these themes helped to provide an overall understanding of current research on

healthcare sustainability and paved the way for the development of my research topic: the

necessary strategies for Hong Kong hospital leaders to develop and implement a

sustainable energy program in Hong Kong public hospitals to increase cost-effectiveness.

I organized my thesis into seven major topics which includes the following (a)

conceptual framework for corporate sustainability, (b) sustainable issues of healthcare, (c)

definition of sustainable healthcare, (d) governance and strategic framework of

sustainable practice in healthcare organization, (d) financial issues of sustainable practice

in healthcare organization, (e) assessment of hospital suitability performance, (f)

opponents of the corporate sustainability, (g) barriers to corporate sustainability, and (h)

overview of the healthcare system and hospital green practices in Hong Kong. I reviewed

the relevant current literature on each topic to explore the corporate and healthcare

sustainability issues in details.

Table 1

Synopsis of Sources in the Literature Review

Reference type

Number

Less than 5

years

Greater than

5 years

Research-based peer-reviewed journal

Dissertation

Book

Website

Total

Conceptual Framework for Corporate Sustainability

The CSM developed by Epstein in 2008 provides a description of the drivers of

corporate sustainability performance (Epstein, Buhovac & Yuthas, 2010). The CSM uses

the social, environmental, and financial dimensions of sustainability as its foundation and

consists of four major drivers. The CSM provides a comprehensive approach to

examining, measuring, and managing the drivers of corporate sustainability and has been

extensively tested and revised in both academic and managerial studies and

implementations (Epstein & Buhovac, 2014).

Epstein (2008) suggested that there are four drivers of corporate sustainability

performance in the CSM: inputs, processes, outputs, and outcomes, which the manager

can apply to affect the sustainability performance and financial benefit for the

organization. The inputs include (a) external context, (b) internal context, (c) business

context, and (d) human and financial resources. The processes include (a) leadership, (b)

sustainability strategy, (c) sustainability structure, and (d) sustainability systems,

programs, and actions (Epstein & Buhovac, 2014). The outputs include sustainability

performance and stakeholder reactions. Finally, the outcomes include the long-term

corporate financial performance and sustainability performance.

Scholars’ studies on corporate sustainability model. Scholars use Epstein’s

CSM because it is a well-established conceptual framework for corporate sustainability

studies in the business field (Borkowski, Welsh, and Wentzel, 2012; Kuei & Lu, 2013;

Stuart, 2013). Stuart (2013) used CSM to study the relationship of leadership with

building corporate sustainability branding and suggested that transformational leader is

favoring an organization in implementing corporate sustainability. Two scholars used

CSM as the framework to look into the way to implement sustainability management for

quality performance measurements and suggested a quality management conceptual

framework that contains corporate sustainability as one of the essential elements (Kuei &

Lu, 2013). Borkowski, Welsh, and Wentzel (2012) used CSM to measure the success of

an international organization in implementing corporate sustainability and suggested

improvements for sustainability reporting.

Kaplan et al. (2012) suggested that a sustainable practice at a hospital can increase

cost-effectiveness, and leaders can reallocate the saved resources into other services’

improvement initiatives such as increasing staff strength, employee development,

technology advancements, and facilities improvement. The CSM provided a valuable

guideline for Hong Kong healthcare leaders to understand the concept of corporate

sustainability and to determine the strategies necessary to develop and implement a

sustainable energy plan to improve cost effectiveness and financial status for the public

hospitals in Hong Kong.

Contexts for corporate sustainability. The external context, such as government

regulations on the environment, waste disposal, nondiscrimination, and safety working

conditions, will have a significant effect on the formulation and implementation of a

sustainability program (Epstein & Buhovac, 2014). Ioannou and Serafeim (2014)

examined the effect of mandatory sustainability reporting on several measures of socially

responsible management practices in 58 countries, and suggested that the sustainability

performance in these countries has improved. The improvements included sustainable

development, employee training for sustainability measures, and corporate sustainability

governance. Similarly, Yuan, Kang, Yu, and Hu (2011) identified in their study that the

external context has a significant effect on the sustainability performance; China reduced

energy consumption by 19.1% after implementing an energy conversation policy in 2006.

The internal context is another input driver to facilitate sustainability performance.

A company that has a strong vision and mission to carry out corporate sustainability will

help the company to accomplish their goal (Epstein & Buhovac, 2014). Thompson (2013)

identified that healthcare organizations should include a sustainability element in their

organizations’ vision to facilitate sustainability development and implementation. Studies

show that a sustainability vision is crucial in successful sustainability performance.

Factors that determine the success of corporate sustainability management include the

ability to integrate sustainability into an organization’s vision, effectiveness to articulate

the vision to the employees, and ensure that the sustainability vision is part of decision

making and company activities (Caprar & Neville, 2012; Robinson & Boulle, 2012).

The business context, such as the nature of the industry, affects the corporate

sustainability performance of a company. Companies with high impact of social, and

environmental may have a sustainability performance (Epstein & Buhovac, 2014).

However, Ameer and Othman (2012) argued that companies that participate in public

utility and energy production perform better in environmental protection than other

industries such as healthcare, financial, and customer service. Internal and external

business contexts are the important driving forces to implement corporate sustainability

in an organization. Studies suggested driving forces such as governance, leadership, and

company strategy on corporate sustainability are playing an important role in corporate

sustainability development.

Governance and strategic framework for sustainable practice. Robinson and

Boulle (2012) suggested that there are three levels of sustainability achievement, namely,

non sustainability, weak sustainability, and strong sustainability. Strong sustainability

will need the engagement of management. Also, studies have shown that corporate

sustainability is an easy concept to understand but difficult to implement (Ameer &

Othman, 2012; Robinson & Boulle, 2012). Effective governance is the key to success in

implementing a sustainable practice in an organization, and the leader is responsible for

setting up principles and practices that will help institutionalize the sustainability concept

in the organization (Epstein & Buhovac, 2014).

Galpin, Whitttington, and Bell (2015) indicated that the sustainability-centered

cultures reinforce a view that environmental and social values are important to the

organization and guide the behavior of managers and employees, and that these cultures

can influence the attitudes of other stakeholders. Galpin and Lee Whittington (2012)

further supported the importance of leaders’ role in corporate sustainability. Galpin and

Lee Whittington (2012) suggested a sustainability leadership model, which explains that

the sustainability outcome of a firm is the result of the leaders’ work in setting up the

vision and values and engaging the workforce. The model has macro and micro levels of

activity. The macro level includes setting up the mission, values, goals, and strategy (Lee

Whittington, 2012). The authors use the human resource value chain theory to illustrate

the micro level in staff recruitment, orientation, engagement workforce, and sustainability

outcome measures (Lee Whittington, 2012). Studies suggested governance is an

important element for an organization to practice in corporate sustainability. The

commitment and strategic direction from the top management can drive the company

leaders and activities and to facilitate performance to achieve the company goals (Chan,

Watson, & Woodliff, 2014).

Governance and leadership in corporate sustainability. Commitment from the

management level is an essential element in most of the current sustainability frameworks

for effectively implementing sustainable practices. Eccles, Ioannou, and Serafeim (2014)

concluded that successfully implementing sustainability direct link to engagement of the

management board. Studies suggested that there is a strong link between governance and

leadership and successful corporate sustainability implementation. Epstein (2008)

discussed the CSM in his study and suggested that leadership, strategy, structure, and

system are important inputs for implementing sustainable practices in a company. Lozano

(2013) noted that sustainability strategies are top-down initiatives and are effective with a

commitment from the management. Klettner, Clarke, and Boersma (2014) developed a

process model for the governance of corporate responsibility that is implemented via a

cyclical process of linking commitment, leadership, implementation, and communication.

Another study on how management affects the implementation of a sustainable program

by Rahardjo, Idrus, Hadiwidjojo, and Aisjah (2013) further suggested five factors for

management that can assist the company in implementing sustainable practices. The

factors are (a) commitments of shareholders to encourage the management engaged in

sustainable issues; (b) the strength of a humanist paradigm adopted by the management;

(d) the ability of management to manage a strong sustainability culture; and (e) the ability

of management to have mutually beneficial collaboration with the stakeholders. Similarly,

Milne and Gray (2013) further identified in their study that commitment from the

company is necessary for implementing a triple bottom line in an organization. Corporate,

business, and functional level strategies should incorporate sustainability initiatives to

implement successful corporate sustainability.

A sustainability-centered culture reinforces the core value of environmental and

social responsibilities and engages stakeholders to collaboration in a sustainable business

(Galpin et al., 2015). Another study by Galpin and Lee Whittington (2012) suggested a

sustainability leadership model, which explains that the sustainability outcome of a firm

is the result of the leaders’ work in setting up vision and values and engaging the

workforce. However, Schneider and Meins (2012) argued that the management

implementation of sustainability-oriented organizational structures and managerial

instruments is not promising for sustainability performance. Stoughton and Ludema

(2012) provide an integrative model for how a commitment to sustainability emerges at

the organizational, functional, and individual levels within organizations. If a company

wants to have long-term success in sustainability, it should have strategies at the

organizational level, the functional level, and individual level. Senior staff should define

sustainability, and align sustainability with business purposes and drive the sustainability

priorities. However, the lack of strategic leadership in corporate sustainability measures

may end in failure in some organizations (Strand, 2014). Leadership is one of the most

important elements to assist an organization to go through a cha

nge (Holten & Brenner, 2015). Studies suggested that a company with strong

leadership would help the company to develop, implement and outperform in corporate

sustainability (Milne & Gray, 2013; Stoughton & Ludema, 2012).

Strategy for corporate sustainability. Corporate sustainability concerns the

impact of the business activities on the ecosystems, societies, and environment of the

future. Sustainable corporations should plan their business activities according to their

strategy (Ameer & Othman, 2012). A clear and good business strategy is the key for a

company to gain a competitive advantage and achieve high performance (Chen & Jermias,

2014). Strategies for corporate sustainability from the top management with an effective

reward system are essential for successful implementation of sustainable activities

(Klettner et al., 2014). Management shall establish a clear strategy for accomplishing

environmental, social, and financial outcomes. Global companies believe sustainability is

becoming important to their business strategy, but most of them do not properly align

their business activities and value for a long-term sustainability outcome (Galpin & Lee

Whittington, 2012). A corporate sustainability strategy for an organization is an

important driver for successful sustainable development, and it directs the company to the

challenges of social, legal, political and economic requirements under the conditions of

market competition (Schaltegger, Lüdeke-Freund, & Hansen, 2012). In a recent review of

governance for corporate sustainability, some authors suggested that the commitment of

management to a robust organizational structure and strategy is necessary for successful

implementation of sustainable practices in a company for financial rewards (Klettne et al.,

2014).

Another study on sustainability strategies suggested that linking the company

strategy to sustainable outcomes is related to profitability and shareholder interests

(Butler, Henderson, & Raiborn, 2011). A conceptual framework related to sustainability

strategy management, named Sustainability as an integral part of strategy, suggested that

when a company decides to achieve sustainability outcomes, management should take

sustainability measures into account during their decision-making process and

incorporate them into corporate, business, and functional levels (Galpin et al., 2015). A

company that have a clear business strategy from the management is an essential element

for them to obtain good performance and achievement. Studies suggested that a company

should have a clear business strategy to successfully implement and outperformance in

corporate sustainability (Ameer & Othman, 2012; Butler, Henderson, & Raiborn, 2011;

Chen & Jermias, 2014).

Sustainability framework for healthcare. For healthcare services, the

Sustainable Development Unit of National Health Service (2013) identified the

importance of introducing the concept of corporate sustainability in healthcare, and they

established a route map for sustainable health, which explained the crucial role of

governance and leaders in achieving sustainable health services. The route map has

system governance as one of the six themes for healthcare services to become sustainable

care, and suggested that leaders should embed sustainability into mandatory board

business, annual reports, regulatory framework, and training. Recent studies provide

successful stories in the sustainable journey and suggest that healthcare or hospitals can

use the NSH sustainable route map as a framework to develop strategies and implement

sustainable activities to improve sustainable initiatives (Pencheon, 2015; Sadler &

Guenther, 2015).

Stakeholder management in corporate sustainability. Stakeholder engagement

is an essential step in for both the business strategy and sustainable development (Smith,

Ansett, & Erez, 2011). Business leaders must identify their stakeholders and engage them

to obtain a long-term relationship for achieving organizational goals (Crilly, 2011).

Strong corporate governance is essential for successful implementation of corporate

sustainability, and stakeholder engagement is one of the integral elements for corporate

governance (Jo & Harjoto, 2012). The stakeholder approach is also a major strategy for

sustainability management (Montiel & Delgado-Ceballos, 2014). However, Peloza,

Loock, Cerruti, and Muyot (2012) noted that companies that did not communicate well

on the sustainability activities with their stakeholders including investors, employees, and

the customers could damage the sustainability performance..

The authors of one study investigated 180 companies in the United States of

America on their sustainability performance and showed that stakeholder engagement

processes were outperformed in companies that adopted a comprehensive set of corporate

policies related to the environment, employees, community, products, and customers.

Stakeholder engagement processes can help the company to reduce resistant, improve

communication, and ensure long-term financial achievement in these high sustainability

companies (Eccles et al., 2014). The authors of a study investigating sustainability

management have suggested that the ability of management to build mutually beneficial

collaboration with the economic stakeholders is one of the important factors for

successful sustainability implementation (Rahardjo et al., 2013). Researchers of a study

in the healthcare setting have suggested that healthcare professionals in England are not

engaged in corporate sustainability activities and encouraged educational events to

improve their engagement (Charlesworth, Ray, Head, & Pencheon, 2012). Studies

suggested that stakeholders’ management is crucial in corporate sustainability

development in an organization. Involvement of different level of staff, good

communication with the company strategy on corporate sustainability, and balance

between mutual benefits are helpful implement corporate sustainability in a company

(Charlesworth, Ray, Head, & Pencheon, 2012; Eccles et al., 2014; Jo & Harjoto, 2012)

Sustainable Issues of Healthcare

Health is a dynamic state of well-being characterized by a physical and mental

potential, which satisfies the demands of life commensurate with age, culture, and

personal responsibility (Bircher, 2005). A healthcare institution or organization is

responsible for providing healthcare services to primary, secondary, tertiary, and public

health levels. However, healthcare activities including the procurement of goods and

services, energy use by healthcare facilities, transport of staff, visitors, patients and

suppliers, and the generation of waste have contributed to the serious pollution issue.

Countries with an advanced healthcare system are the major contributors to

climate change. England has a serious situation of environmental issues; their health

services produce 25 million tons of carbon dioxide each year (Naylor & Appleby, 2013).

In 2009, the American health care sector reported that they accounted for nearly 10% of

the country’s carbon dioxide footprint (Chung & Meltzer, 2009). There is no national

analysis of healthcare carbon dioxide emissions in Australia, but the situation is close to

the estimation in England (McGain & Naylor, 2014). Even in China, the largest country

with rapid development of healthcare service, the carbon emissions from hospitals

increased the burden on the environment and healthcare in some developed regions (Jiang

et al., 2012; Liu, Zong, Zhao, Chen, & Wang, 2014).

Researchers of current studies have been working on the relationship of climate

change with human health issues. Climate change is the biggest health threat for humans

today, including the spread of infectious diseases and an increase in cardiovascular and

respiratory diseases due to extreme heat weather (Altizer, Ostfeld, Johnson, Kutz, &

Harvell, 2013; Franchini & Mannucci, 2015; McMichael, 2013). Healthcare leaders can

implement measures to reduce carbon emissions than will help to reduce the negative

health effect caused by climate change, and which can alleviate the financial burden of

health services (Thompson et al., 2013; Woodward et al., 2014). Hospitals and healthcare

facilities require a large amount of energy supply to operate 24 hours a day and seven

days a week. Fossil fuel combustion and its associated emission of greenhouse gasses,

and the high level of electricity consumption of the healthcare system contribute to high

healthcare costs due to increased asthma and other respiratory illnesses (Barnes, 2014;

Kolokotsa, Tsoutsos, & Papantoniou, 2012).

The environmental effect is a long-term concern to human health. In addition to

scholarly work on how pollution affects human health, the World Health Organization

reported in the Quantitative risk assessment on the effects of climate change on selected

causes of death estimated that climate change is expected to cause approximately

250,000 additional deaths per year between 2030 and 2050 (Hales, Kovats, Lloyd, &

Campbell-Lendrum, 2014). The environmental problems generated by the healthcare

system and hospitals have serious effects on human health. There is an obvious urgency

to reduce the environmental harm by the healthcare services.

The World Health Organization recognized the importance of the population

problem caused by global healthcare services and endorsed a sustainable work plan on

how to prevent healthcare services from putting further stress on the environment. The

WHO work plan includes raising awareness that climate change is a fundamental threat

to human health, to coordinate with partners to ensure health is properly represented in

climate change, to review scientific evidence of the effect of global health services on the

environment, and to help hospitals reduce the harm to climate change (Barna et al., 2012).

The current pollution problem caused by global healthcare services is worsening.

Healthcare leaders in the world have been working on a strategy to reduce the degree of

damage to the environment by healthcare services. According to Thompson et al. (2013),

countries with advanced healthcare systems have implemented measures in response to

this worsening situation. The United Kingdom aims to reduce carbon emissions by 80%

by 2050 and suggested that a sustainable strategy should seek transformational change

and genuinely foster sustainable models of care (Killip, 2013). The United States is

committed to reducing greenhouse gas emissions by 17% below the 2005 level by 2020,

and The European Commission aims to reduce greenhouse gas emissions by 8% by 2012

(McGain & Naylor, 2014).

Definition of Corporate Sustainability and Sustainable Healthcare

In the past three decades, companies in the world have studied and implemented

corporate sustainability measures to maintain their competitive advantage and to benefit

their stakeholders. Hannon and Callaghan (2011) stated that sustainable issues are

currently ranked as a high priority strategy for global companies because the company

can improve short and long-term competitive advantages by adopting corporate

sustainability. Leaders of the organization need to focus not only on shareholders’

interests but also on external stakeholders’ concerns because a study showed that

companies that have sustainability practices can sustain better (Van & Greenwood, 2011).

The business world will keep investing and developing sustainable practices. Choi and

Ng (2011) estimated that companies would spend hundreds of millions of dollars on

sustainable development to maintain competitive advantages.

The concept of corporate sustainability started more than 30 years ago. The World

Commission on Environment and Development Report defined healthcare sustainability

development as meeting the needs of today without compromising the ability of future

generations to meet their needs (Burton, 1987). Klöpffer and Ciroth (2011) further

supported Burton’s definition of sustainability in their study. Sustainable healthcare is to

provide high-quality health services to the customer in a benefit of social, financial, and

environmental considerations, and without exhausting natural resources or causing severe

ecological damage. Sustainable healthcare initiatives involve greening the energy

consumption, water consumption, waste management, transportation, and building

facilities to ensure resources are efficiently and responsibly used (McGain & Naylor,

2014). Thompson et al. (2013) identified a similar viewpoint on sustainable healthcare in

their book; a healthcare institution should provide the best quality of care, promote

healthy living, and avoid harming the environment. Wilkinson (2013) declared that

sustainability is about harmony with the environment and different industries. In contrast,

Li (2011) argued that sustainability is related to a strategic management method to ensure

change and uncertainty, and Tregida, Kearins, and Milne (2013) suggested that

sustainability in businesses focuses on addressing organizational self-sufficiency and

autonomy instead of stakeholders’ interests. However, Montiel and Delgado-Ceballos

(2014) argued, after reviewing 16 scholarly works, that no one single standard definition

for corporate sustainability exists.

Although there are plenty of studies suggesting the benefits of implementing

sustainability measures for a company to adopt a successful corporate sustainability, the

company will need a conceptual framework to follow for developing, implementing, and

controlling sustainable practices (Baumgartner, 2014). Elkington (1997) suggested a

triple bottom line (TBL) sustainability framework that attracted scholars’ attention and

investigations in the last two decades. The TBL focuses on the organization’s efforts in

three areas, namely, people, the environment, and finances, to achieve sustainability for

an organization. The benefits must be mutually beneficial to all, rather than exclusive.

The balance between economic progress, social responsibility, and environmental

protection can lead to a competitive advantage.

The TBL framework also provides a performance assessment standard for the

management to measure their efforts regarding people and environmental, social, and

financial aspects (Schneider & Meins, 2012). Researchers have been conducting studies

on corporate sustainability adhering to the TBL framework, which focus on the scope of

environmental sustainability, financial sustainability, and social sustainability in the last

two decades. However, it is not common to find research studies on TBL in healthcare.

For the healthcare service industry, Mohrman and Shani (2012) suggested that a

healthcare organization should focus on TBL to achieve sustainability and improve

service quality. The study on sustainable healthcare started in the 1980s (Jamaludin,

Habidin, Shazali, Alil, & Khaidir, 2013) and there are various definitions of sustainable

healthcare. These definitions focus on the mutual benefits of meeting present healthcare

service needs, sustaining healthcare institution business, and preserving the environment.

One of the largest healthcare organizations in the world, the Nation Health Service (NHS)

of Britain, further supported the definition of sustainable healthcare as a health system

that addresses needs today without prejudicing our ability to do the same in the future

(Sustainable Development Unit, 2013).

Financial Issues of Sustainable Practices in Healthcare Organizations

Companies are adopting corporate sustainability activities to achieve long-term

benefits (Chabowski, Mena, & Gonzalez-Padron, 2011). Companies that have

implemented sustainability activities including modifying existing products and

processing or developing new products and processes can obtain financial benefits

(Kurapatskie & Darnall, 2013). One study suggested that a company with high

sustainability standards can achieve better financial performance because they have

human capital, more reliable supply chains, and are more competitive in the sustainability

business by introducing new products and processes. Furthermore, a high sustainability

company can also avoid costly controversies with nearby communities (Eccles et al.,

2014). A study involving the top 100 sustainable global companies suggested that

companies with a higher level of sustainability initiatives have better financial

performance in term of sales, return on assets, and profit before taxation (Ameer &

Othman, 2012). In addition to solving the environmental problems caused by the heath

service providers, becoming sustainable can benefit the healthcare organization’s cost

effectiveness aspects.

Healthcare energy costing: Healthcare costs are increasing in the United States

(Keehan et al., 2012). Spending on energy accounts for a larger portion of the total

hospital costs, and the hospital energy costs rose 56% from $3.89 per square foot in 2003

to $6.07 per square foot in 2008; these costs are predicted to continue to rise in the near

term (Li & Yan, 2012; Teke & Timur, 2014). A study and survey carried out by the major

developed countries in the world suggested that the energy costs for hospitals are

expensive. The U.S Department of Energy estimated that in 2013, the total energy cost

spent on U.S. hospitals was more than nine billion dollars a year. Canada encounters the

same problem. The NHS estimated that their hospitals are spending more than 750

million Euros on energy cost each year (Naylor & Appleby, 2013). Hospitals in the Asian

region are having a similar problem. A survey done by Tong and Fong (2014) showed

that the energy cost for Hong Kong public hospitals is reaching 100 million U.S. dollars

per year. The price of fossil fuels is on the rise, and the cost of energy is also rising

(Thompson et al., 2013).

Financial concerns of energy sustainability in the hospital. Hospital

management should seek a sustainable energy efficiency program to improve the cost

effectiveness of the hospitals. One study showed that corporate sustainability could

improve the financial performance of a company (Ameer & Othman, 2012; Rahim,

Jalaludin, & Tajuddin, 2011). Similarly, Charlesworth, Pencheon, and Stern (2011) and

Wormer et al. (2013) pointed out that healthcare organizations could save money by

implementing sustainable practice. Kaplan et al. (2012) suggested that a sustainable

energy program at a hospital could save money and increase cost effectiveness.

Hospitals are one of the most energy-intense types of building (McGain & Naylor,

2014). Naylor and Appleby (2013) further estimate that an energy efficiency plan can cut

the energy bill by 20%, and help to save €150 each year in hospitals under the Nation

Health Service.. Studies note that hospitals can reinvest the resources saved by

implementing a sustainable energy program into other hospital initiatives to improve

service (McGain & Naylor, 2014). McGain and Naylor (2014) further argued that

sustainable practice in health services will help healthcare leaders to save money,

resources, and improve health and suggested that hospitals can use the resources saved in

the energy efficiency program to empower staff strength and to purchase advanced

equipment for service quality improvement.

Assessment of Hospital Suitability Performance

Implementing sustainability practices in an organization has resource implications

including investment in green technologies, educational activities, and administrative

input (Papagiannakis, Voudouris, & Lioukas, 2014). To ensure the success of

implementing sustainability to improve cost effectiveness, assessments for measuring

sustainable practices can serve this purpose. A proper assessment tool is also necessary

for the company to formulate improvement plans for corporate sustainability and to avoid

strategies that deviate from the corporate direction (Epstein & Buhovac, 2014).

Epstein and Buhovac (2014) suggested six objectives that business leaders should

consider in formulating their assessment tool for measuring the success of sustainability.

The six objectives for measuring sustainability performance are (a) make strategic

objective clear, (b) focus on core cross-functional process, (c) focus on critical success

variables, (d)identify early warning signals for problems ahead, (e) identify critical

factors going awry, and (f) link to reward. Epstein and Buhovac (2014) mentioned that an

effective assessment should include measuring the input of money and the workforce

used to implement sustainability activity, a system used to deliver an output, and

sustainable and financial performance. Rahardjo et al. (2013) identified five factors for

the management of the success of corporate sustainability practice, and the factors are: (a)

the commitment of shareholders to encourage the management engaged in solving social

and environment issues, (b) the strength of a humanist paradigm adopted by the

management, (c) the ability of management to achieve a higher level sustainability

performance, (d) the ability of management to build and run a strong sustainability

culture that reflects the principles of sustainability properly, and (e) the ability of

management to build a mutually beneficial collaboration with the economic stakeholders.

A Thai study on measuring corporate sustainability indicated that management

perseverance and resilience are two direct predictors of a firm’s ability to perform

corporate sustainability in an organization (Kantabutra, 2014).

Sustainability Assessment Tools of the Hospital

Implementing sustainability in a hospital requires additional resource investments.

An effective evaluating tool can help the leaders to manage the sustainable activities.

Sahamir and Zakaria (2014) suggested that hospitals use a systematic assessment system

to measure the success of their sustainability initiatives. Sahamir and Zakaria (2014)

compared and contrasted three major green assessments for hospitals: BREEAM

(Building Research Establishment’s Environmental Assessment Method) used in U.K,

the LEED (The Leadership in Energy and Environmental Design) green building rating

system used in U.S, and the GREEN STAR rating system used in Australia. Sahamir and

Zakaria (2014) wrote that the healthcare system or hospitals have to select the appropriate

assessment according to requirements that can assist the leaders to evaluate the success of

the sustainable activities.

Opponents of Corporate Sustainability

Although the majority of researchers on corporate sustainability have suggested

that being sustainable can benefit the organization, studies on the opposite positions are

available. Researchers have found that sustainable corporate activities can enhance a part

of the financial performance (Gupta, 2012). Lanoizelle (2011) stated that corporate

sustainability activities do not provide a better financial performance, and sustainability

management cannot improve the competitive advantage of a company. Kiron, Kruschwit,

Haanaes, and Velken, (2012) demonstrated in their study that implementation of

corporate sustainability management does not always contribute to financial success,

better collaboration with stakeholders, and cooperation with society. Scholars have

shown that the radical change in the management thinking style and the lack of

assessment tools for detecting sustainable stages of a company can lead to failure in the

identification of business opportunities related to corporate sustainability (Calabrese,

Costa, Menichini, Rosati, & Sanfelice, 2013).

Barriers to Sustainable Practice

Implementing change in healthcare is an uneasy task; it involves human, social,

and organizational factors that may not lead to successful change. Leaders must

understand the barriers to change to figure out a solution (Kuipers et al., 2014). Barriers

to achieving corporate sustainability are suggested to contribute to implementation failure,

and the barriers include: (a) lack of consensus at the high management level; (b) costs of

sustainability and economic conditions; (c) lack of sustainability standards and

appropriate regulations; and (d) misalignment of short-term and long-term strategic goals

(Giunipero, Hooker, & Denslow, 2012). Barriers to implementing corporate sustainability

can come from three sources individual, cultural, and organizational (Lozano, 2013).

Lozano (2013) suggested that the individual level barriers to corporate sustainability

include the lack of communication, lack of trust, and job insecurity. The group level

barriers include group conflict and group culture, and the organization level barriers

include lack of management commitment and strategy. Also, a study identified

implementing sustainable practices as requiring additional costs in equipment, facilities,

and human resources implications, and the benefits of corporate sustainability may not

come in the short term (Papagiannakis et al., 2014).

Beare, Buslovich, and Searcy (2014) pointed out in their study on corporate

sustainability reporting that a lack of direction from the government on sustainable

corporate practices one of the key barriers to the organization. A New Zealand study

showed that the key barriers to sustainability for an organization are a lack of knowledge

and unclear return on investment in sustainable technologies (Bond & Perrett, 2012). An

Australian study pointed out that the key obstacle for healthcare providers to perform

sustainable practices is the lack skill and knowledge training on sustainability in a

healthcare setting. Healthcare providers think they are not qualified to carry out

sustainable practice in their daily work and fear conflict and professional ostracism

(Dunphy, 2013). Also, a lack of a widely accepted assessment tool and reward system for

measuring environmental sustainability in healthcare is another key barrier to

implementing sustainable practices in healthcare (Naylor & Appleby, 2013).

Overview of the Healthcare System and Green Hospital Practice in Hong Kong

The Hospital Authority (HA) is a statutory body managing all the public hospitals

and institutes in Hong Kong. It is under the governance the Secretary for Food and Health

of the Hong Kong Government. The HA has been responsible for managing Hong

Kong’s public hospital services since December 1991. The HA is funded primarily by a

Hong Kong Government subvention, which amounted to 42.5 billion Hong Kong dollars

for 2012–2013. It takes care of 90% of primary and secondary health services in Hong

Kong. They are accountable to the Hong Kong Special Administrative Region

Government through the Secretary for Food and Health, who formulates overall health

policies for Hong Kong. According to the HA official website, it currently has a

workforce of around 67,000 people and manages 42 hospitals and institutions,

47 specialist outpatient clinics, and 73 general outpatient clinics. They provide a total of

27,440 beds, or about four beds for every 1,000 members of the public (Hospital

Authority, 2013).

Green Practice in Hong Kong Public Hospitals

According to the 2014 Certificate of Merit of The Hong Kong Awards for

Environmental Excellence (the HKAEE) co-organized by Environmental Campaign

Committee alongside the Environmental Protection Department of Hong Kong (The

Hong Kong Awards for Environmental Excellence, 2015), there were six hospitals

received the awards in 2014. These six hospitals were awarded the Certificate of Merit

from the HKAEE and had a green management committee in each hospital as the

sustainable energy program governing structure. There are 42 public hospitals in Hong

Kong, and the number of hospitals involved in sustainable energy practice represents

14% of the total public hospitals in Hong Kong. The green activities of those six hospitals

included initiatives on water preservation, waste management, and energy saving the

program in the carbon reduction program content. The energy saving initiatives for those

six hospitals involved in the carbon reduction program used administrative measures and

energy saving technologies to reduce energy consumption.

According to the Hong Kong Awards for Environmental Excellence (2015), the

local hospitals implemented green technologies as one of the strategies for an energy

saving program and used administrative measures as well to reduce energy consumption.

The energy saving technologies included (a) use of a heat pump system to replace diesel

boilers, (b) use of solar energy, (c) lighting retrofitting, (d) overall thermal transfer value

enhancement, (e) installation of energy savers on window type air conditioners, (f)

introduced equipment retrofitted for LED exit sign lighting system and lift lighting, (g)

use of electric vehicle for outreach service, and (h) introduction of cook-chilled patient

food system (Nguyen & Aiello, 2013; Todorovic & Kim, 2014). The local hospitals also

included energy saving administrative measures for energy saving activities including

promotion and education approaches, and the establishment of guidelines and policies

(Zuo & Zhao, 2014).

Energy measures in Hong Kong hospitals. Hospitals use 1-3% of the operation

budget in energy expenditure and is a significant contributor to greenhouse gas emissions

and carbon dioxide emissions (Kaplan et al., 2012). Hospital leaders may consider

implementing energy efficiency measures to reduce energy cost (Teke & Timur, 2014).

Energy saving measures that can help hospitals to save energy expenditures include

adjusting and installing a variable speed drive into the heating, cooling, and lighting

system in unoccupied areas, purchasing more energy-efficient equipment and a

renewable energy system, and adjusting the ventilation system (Gago, Muneer, Knez, &

Köster, 2015; Saidur, Mekhilef, Ali, Safari, & Mohammed, 2012). A recent study by

Peterman, Kourula, and Levitt (2012) developed a conceptual framework called Strategic

Drivers for Energy Efficiency Program Implementation for commercial building energy

efficiency management. The energy efficiency conceptual frameworks describe five

major strategic drivers and how these drivers can assist the company, staff, and manager

to accomplish energy efficiency in a commercial building. The five major drivers are

energy policy, economic incentives, certifications, alliances and partnerships, and internal

company programs; hospital leaders may consider using this conceptual framework to

introduce an energy saving program in the hospital.

Transition and Summary

The objective of this qualitative study with a multiple case study design was to

explore the strategy for employing a sustainable energy program in public hospitals in

Hong Kong to effectively reduce energy consumption. The background information in

Section 1 contained a foundation of knowledge about the current situation and

consequences of corporate sustainability in both commercial and healthcare settings.

Furthermore, Section 1 also contained theories, conceptual frameworks, and strategies

that facilitate the Hong Kong hospital leaders to develop and implement corporate

sustainability. Hong Kong hospital leaders realize the urgency and importance to

incorporate sustainable practice in their hospitals to reduce energy costs and improve cost

effectiveness. Also, the readers can obtain useful information on the barriers and

opponents to corporate sustainability, which they can find helpful in planning sustainable

activities in their organizations.

Section 2 includes the purpose of the project; I discuss my role as the researcher,

the details of the participants, research methods, and research design of this study.

Section 2 also includes a discussion on data collection and the analysis approach and the

work to ensure reliability and validity of this research study. To conclude, I discuss the

results and conclusion in Section 3.

Section 2: The Project

The increasing healthcare financial burden is one of the major driving forces for

healthcare institutions to apply sustainable measures. Studies indicate that hospitals can

obtain both long-term and short-term financial benefits by introducing sustainable

measures in their hospitals (Keehan et al., 2012). Applying a sustainable energy program

in the hospital is a promising approach to reduce operating costs, and leaders of the

hospitals can reallocate the resources for other service enhancement initiatives. A

hospital’s sustainable policy, strategy, and leadership are the key elements for hospital

leaders to successfully implement sustainable measures (Berwick & Hackbarth, 2012).

The majority of Hong Kong hospitals do not have a robust sustainable energy program in

place, yet six local public hospitals have introduced sustainable activities with

recognizable achievements (Hospital Authority, 2013). This section elaborates on the

purpose of this study, the role of the researcher, a description of the participants, the

research method, description of population and sampling, data collection, data analysis,

reliability, and validity.

Purpose Statement

The purpose of this qualitative, multiple case study was to explore the strategies

necessary to develop and implement an effective sustainable energy program in Hong

Kong public hospitals. The participants of this study were the hospital green committee

chairpersons from five public hospitals in Hong Kong that received outstanding

achievement recognition from the local government. A hospital is one of the most

energy-intensive facilities; implementing a sustainable energy program will help to

reduce pollution and energy costs (McGain & Naylor, 2014; Qadir et al., 2014). The

implications for positive social change include providing findings as a reference for

hospital leaders to redirect the saved resources from a sustainable energy program to

improve patient care and reduce pollution (McGain & Naylor, 2014). Also, the reduction

of pollution and greenhouse gas emissions from the hospitals will reduce the incidence of

human disease, and it will further improve the financial burden of public hospital services

(Kaplan et al., 2012).

Role of Researcher

A researcher of qualitative research with a multiple case study design collects,

organizes, and analyzes, categorizes, and interprets primary data from face-to-face

semistructured interviews with questions (Doz, 2011). I conducted a face-to-face

semistructured interview with five chairpersons of the hospital green committees to

explore the strategies needed to develop and implement a sustainable energy program in

the hospital to reduce energy cost. The interaction between the researcher and

participants and the analysis of the qualitative data can lead to an understanding of the

research question of this study and can provide foundational information for future

research (Doz, 2011; Shaw, 2013). A researcher in a study needs to determine which

research approach can answer the research questions, to make good decisions to produce

evidence of the highest possible quality, and learn about the actual behavior, attitudes, or

real motives of the people (Vaismoradi, Turunen, & Bondas, 2013).

According to the Belmont Report (2014) by the U.S. Department of Health and

Human Services, my role as the researcher in this study is part of the ethical aspect to

ensure the participants are respected as autonomous agents.Also, I made sure that the

study would not cause any harm to the participants, and ensured a maximum of possible

benefits and a minimum of possible harms to them. I also needed to ensure that the

participants would receive equal treatment throughout the study. The participants signed

an informed consent that contains the details of the risks of the study; they participated on

a volunteer basis.

I established an interview protocol to ensure the reliability of the study and to

guide the data collection process to reduce bias from my personal point of view (Yin,

2014). The interview protocol contained four sections including (a) overview of the case

study, (b) data collection procedures, (c) data collection questions, and (d) guide for the

case study report documented in Appendix B. Yin (2014) suggests that a researcher can

use observations, document reviews, and member checking to enhance the credibility of

the study alone with interviews (Lewis, 2015). I returned the final interview summary to

the participants for their review to ensure that my interpretations reflect their experiences

and feelings accurately. I did not interview the hospital chairperson or vice chairperson of

the green management committee in the hospital where I work to avoid bias in collecting

and analyzing data.

As an allied health professional, I have worked in different clinical settings and

administration departments of the Hospital Authority, which is the largest health

institution in Hong Kong since 2003. In these 11 years of service, I participated in

various clinical and management-related projects at functional, business, and corporate

levels. I chose to study healthcare sustainability because the majority of the public

hospitals in Hong Kong do not have a sustainable program to control energy consumption.

There are various benefits for an organization to practice sustainability including lower

operation costs, improved branding, and reduced staff attrition (Epstein & Buhovac,

2014). Local hospitals should allocate efforts for sustainability to improve the

competitive advantages by reducing energy costs and improve service quality.

Participants

I conducted my study by selecting the participants from major local hospitals who

have implemented a sustainable program; this was because a researcher may conduct a

qualitative study using a single unit with multiple participants within the same setting

(Yin, 2014). Lewis (2015) pointed out that a researcher in a qualitative study should

select participants that have thorough knowledge of the phenomena for the study question.

Elo (2014) also suggests that researchers select a participant composition that can best

represent the expertise in the research topic to enhance study reliability. In general, the

participants of this study were the chairpersons of the green management committees

currently working in public hospitals located in Hong Kong. It is assumed that they have

the best knowledge and experiences in developing and implementing sustainable

measures at their hospitals.

Dworkin (2012) suggested that five to 50 samples are appropriate for a qualitative

study. Six Hong Kong public hospitals received awards from the Hong Kong government

on energy saving, but one of the hospital green committee chairpersons resigned from the

position; therefore, I only interviewed the chairpersons of the five green management

committees who had already implemented a sustainable energy program at their hospitals

and received an award and recognition from the government. This group of people has

the best knowledge and experience on how to implement a sustainable energy program in

the hospital. I used a semistructured questionnaire to collect the data for analysis because

a semistructured questionnaire is an effective way to collect qualitative data in the case

study design (Yin, 2014).

Gaining access is an important part of doing a qualitative research interview

because the quality of access affects what information is available to the researcher

(Doody & Noonan, 2013). After obtaining consent from the study participants, I sent

them an invitation via electronic mail and arranged the semistructured face-to-face

interviews at the participants’ convenience. Follow-up phone calls to the participants

were made to explain the interview purpose; the process is a close communication

approach with the participants, which can facilitate a successful interview (Kondowe &

Booyens, 2014).

Consent is crucial in gaining access to the participants by informing them of the

purpose of the study and the participants’ rights; this will help to establish rapport with

participants and will provide study access and yield valid data (Lewis, 2015). I provided

the consent form, informing the participants of the intentions and scope of this study. The

participants confirmed their voluntary participation in this study. The consent form

identified the right of the participants to opt out of the study at any time for any reason.

The participants replied to my electronic mail with the word, “I consent,” agreeing to

participate in the study voluntarily and accepting an audio recording of the interview. I

informed the participants of the coding design of responses to protect their identity and

the study design to store responses for 5 years after the completion of this study (Searle &

Hanrahan, 2011). I stored the collected data in locked storage, and will keep the data for

5 years after I publish my study.

A successful qualitative study requires a good working relationship with the

participants (Swauger, 2011). The participants of this study were the chairpersons of the

green management committee at the largest local health organization. Although I worked

in the organization for 11 years, there are 42 hospitals in the health organization, and the

size of the organization will not allow me to establish the working relationship between

the participants with me in this study. For this reason, I used the following strategies to

motivate them to participate in my study. I interviewed the chairpersons of the green

management committee who had successfully implemented sustainable practices in their

hospitals and collected their strategies and views of their achievements to avoid rejections

of my invitation. Building rapport and frequent communication with the participants can

help to maintain a good working relationship (Kondowe & Booyens, 2014). I made a

phone call to the participants before sending the invitation and consent form via

electronic mail, and before visiting them to conduct the interview because a well-

prepared researcher is more likely to be engaged, listen attentively, and respond

appropriately in the interview (Doody & Noonan, 2013). I also acknowledged them for

their contributions to my study to motivate them to join my study.

The five participants were the chairpersons of the hospital green management

committee, who have made achievements in leading the hospital to develop and

implement a sustainable energy program. The participants were the best people to

interview, with the knowledge of and experience with the factors necessary to develop

and implement a sustainable energy plan to reduce operating costs (Searle & Hanrahan,

2011). Also, according to the Hospital Annual Report 2013, these five hospitals, of the 42

hospitals in Hong Kong, had introduced sustainable energy measures, which further

strengthen their targeted role as participants in my study (Hospital Annual Report, 2013).

Research Method and Design

I used a qualitative research method and multiple case study design to explore the

strategies necessary for Hong Kong hospital leaders to develop and implement a

sustainable energy program to reduce energy costs and to increase cost effectiveness.

Qualitative research is a method that the researcher uses to gather an in-depth

understanding of a specific human behavior in a group or organization, and in social and

political areas (Hyett at al., 2014). The research method is a procedure the researcher uses

to obtain and evaluate data, and to provide additional knowledge to the current research

(Petty, Thomson, & Stew, 2012). After reviewing all of the common research methods

including qualitative, mixed method, and qualitative method, I decided to choose the

qualitative method because it can help answer my research question.

Method

By conducting the qualitative study, the researcher will understand why and how

a behavior works in a particular setting, and will usually involve a small group of samples

for collecting data (Lewis, 2015). A researcher can use the qualitative method to provide

an explanation and analysis of results of the data by investigating the patterns and themes

of the data, whereas quantitative research investigates the observed phenomena by

statistical or computational techniques (Yin, 2014). I used qualitative study method in

this study to investigate the business elements that require for the local public hospitals to

develop and implement a sustainable energy program by analyzing the data from the

semistructured interviews and the document reviews.

There are three research methods, namely, quantitative, mixed method, and

qualitative. Quantitative research is a method to predict and describe the observed

phenomena, and the researchers use statistical analysis tools to understand the observed

behavior, whereas qualitative study researchers will use interviews, observations,

document reviews, and a focus group to collect data for analysis (Lewis, 2015). A mixed

method, however, is an approach for researchers to understand the phenomena by

combining both qualitative and quantitative methods to analyze data, and it is suitable for

researchers to use results from one study to support the other study (Klassen et al., 2012).

However, a qualitative study approach is more appropriate for studying social and

cultural phenomenon such as specific business behaviors (Doz, 2011). Therefore, I used

the qualitative research method in this study because I can understand the phenomena for

my research question by describing, decoding, translating, and understanding the data

(Sergi & Hallin, 2011). I used the qualitative research method to understand the behavior

of the healthcare leaders in responding to sustainable practice in the hospitals.

Design

There are three major methods in qualitative study designs, namely, an

ethnography study, case study, and phenomenological study (Wisdom, Cavaleri,

Onwuegbuzie, & Green, 2012). A qualitative case study research design is an approach to

understanding a particular phenomenon within its context using a variety of data sources,

and the researcher can use the case study approach to obtain an in-depth appreciation of

an issue, event, or phenomenon of interest, in a real-life context (Crowe et al., 2011).

There are other types of design research methods in the qualitative study including

phenomenology and ethnography. The phenomenological design is a method to explore

and understand the participants’ living experience that may not apply to the research

question about the strategies for Hong Kong hospital leaders to develop and implement a

sustainable energy program to reduce energy cost (Ardley, 2011). The ethnographic

design is not suitable for this study because the ethnographic design is an approach to

explore the relationship between the participants’ culture and the behavior (Christiansen,

2011; Nite & Singer, 2012).

There are a variety of methods of data collection in qualitative research, including

interviews, observations, document reviews, and focus groups to collect data for analysis

(Lewis, 2015). I conducted a semistructured interview with the chairpersons of the green

management committee of five hospitals with outstanding achievements to learn the

factors required for other hospitals to develop and implement a sustainable energy

program to reduce energy costs. Also I used the document review to understand further

the details of the sustainable energy program in their hospitals. The case study approach

can offer additional insights into the gaps in current hospital strategies on sustainable

practice and why other Hong Kong hospital leaders do not have a sustainable energy

program in their hospitals (Crowe et al., 2011).

Yin (2014) suggested that researchers use a case study design when they are

looking to answer how and why questions, and when researchers cannot manipulate the

behavior of those involved in the study. Also, researchers can use a case study design to

learn the contextual conditions because they believe that they are relevant to the

phenomenon under study. Finally, Yin (2014) pointed out that the researcher should use a

case study design when they do not know the boundaries of the phenomenon and the

context is not clear. As a researcher, I did not have the power to manipulate the decisions

of the healthcare leaders to adopt sustainable energy practices at their hospitals. I used the

qualitative case study research design to understand why the local healthcare leaders

developed and implemented a sustainable energy program in their hospitals, or why they

do not do so, and how the leaders incorporate a sustainable energy program to obtain cost

effectiveness by reducing energy costs.

Data saturation is a tool used for ensuring that adequate and quality data are

collected to support the study (Walker, 2012). Unless reaching data saturation,

researchers must continue to collect data until no new information or patterns exist to

ensure quality and the content validity of the study (O’Reilly & Parker, 2012). Data

saturation means that there is enough information to replicate the study (O’Reilly &

Parker, 2012; Walker, 2012). Dibley (2011) suggested that the researcher may need to

collect data in both good qualitative and quantitative perspectives to reach data saturation.

The researcher can take many interviews to reach data saturation and interview of people

that one would not normally consider avoiding overshadowing the data (Walker, 2012).

I conducted a semistructured interview with most of the potential participants

because one of the chairpersons in the target group resigned from the position. The five

chairpersons of the hospital green committee of local hospitals had received recognition

from the government for their achievement in energy preservation. By including all

potential targeted participants, I could enhance the data saturation for my study.

A focus group interview is another way to elicit multiple perspectives on a given

topic, and the application of triangulation will enhance the reliability of results and move

to data saturation (Walker, 2012). However, due to the workforce limitation and

participants’ accessibility constraint for the public hospital, I did not conduct a focus

group for this study.

Population and Sampling

There are 42 public hospitals in Hong Kong serving more than 90% of the

population. Among these 42 public hospitals, I selected six of them as the targeted

experimental sites because they have implemented a sustainable energy program and

received the 2014 Certificate of Merit of the Hong Kong Awards for Environmental

Excellence (the HKAEE) co organized by the Environmental Campaign Committee

alongside the Environmental Protection Department of Hong Kong (The Hong Kong

Awards for Environmental Excellence, 2015). However, since one of the targeted

participants resigned from the position, and did not reply my electronic mail invitation, I

conducted only five interviews with the targeted participants. These five hospitals were

awarded the Certificate of Merit from the HKAEE and had a green management

committee in each hospital as the sustainable energy program governing structure. The

five hospitals include both acute and convalescence settings and are under the Hospital

Authority. The awarded hospitals are (a) Castle Peak Hospital, (b) Haven of Hope

Hospital, (c) Pamela Youde Nethersole Eastern Hospital, (d) Pok Oi Hospital, and (e)

Princess Margaret Hospital. The chairpersons of the five hospital green management

committees were my targeted participants for the interviews.

The research question of this study was to explore the strategies for local hospital

leaders to develop and implement a sustainable program to reduce energy costs. I

conducted a semistructured interview with the chairpersons of the green hospital

committee who led the hospital to the successful implementation of the sustainable

energy program; they would have the best information and knowledge to respond to my

interview questions. Also, these five leaders of the green management committees

demonstrated outstanding achievements among other Hong Kong public hospitals and

received recognition from the government body of energy conservation, and should have

valuable experiences to fortify my data for analysis.

I used the purposive sampling method in my study on what strategies contribute

to the Hong Kong hospital leaders’ development and implementation of a sustainable

energy program to reduce energy costs. Research can use purposive sampling and starts

with a specific purpose in mind and selects the targeted participants (Walker, 2012).

Ando, Cousins, and Young (2014) suggest a sample size of 12 participants as a viable

sample size for reaching saturation. Suri (2011) suggested that a researcher use a

purposive sampling method to access the targeted participants who have the key

knowledge and information on the research topic.

To achieve data saturation, I conducted five semistructured interviews with the

chairpersons of the outstanding hospital green management committees who received the

Certificate of Merit by the HKAEE in 2014. Purposeful sampling is one of the most

common sampling methods and is appropriate for a case study design, and the number of

participants for a study to reach saturation could range from five to 50 (Dworkin, 2012).

For the interview setting, Scheibe, Reichelt, Bellmann, and Kirch, (2015) suggest that the

interview area be in a relaxed atmosphere to facilitate participants to respond freely and

ask a question. I conducted the semistructured interview with my participants in a private

meeting room that could maximize their chances to ask questions and respond to my

interview questions.

Ethical Research

The procedures of this study followed the ethical requirements of Walden

University. I received the approval of Walden University Institutional Review Board with

the number 09-29-16-0460679 and then I conducted the data collection procedures. All

participants in this study signed a consent form and were volunteers with no involvement

of any form of coercion or other unethical practice. According to the consent form, all

participants understood the background and the nature of the study, intention of the study,

the use of data collected, risk and benefits of the study, clarification of no incentive

statement for this study, and the terms and right to discontinue participation at any time

with no responsibility or adverse effects. I sent the consent form to all participants one

week before the interview date and conducted the interview only if I received a reply

with the consent form from the participant. Also, the consent contained information on

how I would handle the data with privacy and a confidentiality approach to protect the

participants.

To protect the rights and confidentiality of the participants, I have kept their

information anonymous in this study. I will keep all of the participants’ information and

data collected in locked and safe storage for 5 years after the publication of this study,

and then I will destroy the data and participants’ information after the 5 years period.

Data Collection Instruments

As the researcher of this study, I participated as one of the data collection

instruments. Semistructured interviews and a company document review are the types of

collection instruments that can define the areas of interest by obtaining detailed

information from participants on the views, experiences, beliefs, and motivations on a

specific topic (Peters & Halcomb, 2015). I conducted a semistructured interview with

five chairpersons of the hospital green committees and also performed a document review

to collect data for the analysis process. The semistructured interview is flexible,

accessible, and intelligible, and capable of disclosing important and hidden facets of the

specific topic of interest (Qu & Dumay, 2011). A semistructured interview is one of the

most common qualitative research data collection methods, but the researcher should

have the right interview skills to collect valid data. The interview skills include probes or

prompts to encourage elaboration or explanations, the use of comprehensible language

that is relevant to the interviewees, and starts with easy questions then moves to difficult

questions (Doody & Noonan, 2013).

Yin (2014) suggested that a documentation review is relevant to most case study

research because it can provide a wide range of information on the topic of interest, and

which is related to the participants or organization. Researchers can review official

documents including reports, publications, information on the official website, and others

that are related to the document review process in the qualitative research (Lewis, 2015).

I reviewed the official publications of the hospital green committees on the governance

and organization structure, the terms of reference, green initiatives, reports, and related

publications or documents that are available on the hospital official website for review.

After I received the Walden University IRB approval with the approval number

09-29-16-0460679 and the signed consent from the participants, I started interviewing my

participants. Semistructured questionnaires, as the major data collection tool, consisted of

nine questions regarding the topic of corporate sustainability and healthcare sustainability

according to the conceptual frameworks stated in the literature review section of this

study. I arranged face-to-face interviews with my participants at their convenience, and

each interview lasted 30 minutes. I used interview techniques to ensure the quality of the

data collected, and the techniques included note taking, careful planning, intensive

listening, and scheduled and unscheduled probes (Qu & Dumay, 2011).

To ensure study reliability and validity, I used data triangulation to enhance the

internal validity and member checking to enhance the reliability of my study (Crowe et

al., 2011; Thomas & Magilvy, 2011). Semistructured interviews and documentation

reviews are the major data collection methods used in this study, and a triangulation

approach to ensure internal validity (Chen, Hailey, Wang, & Yu, 2014). Member

checking is a technique that researchers can use to help improve the accuracy, credibility,

validity, and transferability in qualitative research (Morse, 2015; Thomas & Magilvy,

2011). I shared the findings of my study with the participants to ensure that the

information is accurate and reflects participants’ experience and feelings to enhance the

study reliability.

Data Collection Technique

I used a semistructured interview with nine questions and a documentation review

to collect the data for exploring the strategies necessary for Hong Kong hospitals leaders

to develop and implement a sustainable energy plan to reduce energy costs. After I had

received approval from the Walden University IRB with the approval number 09-29-16-

0460679 and the consent from the participants, I sent them an email invitation to arrange

the interview at a convenient time and location.

The interview location was a private conference room to avoid distractions and to

protect participants’ privacy. The participants received a copy of the interview protocol

(Appendix A) that contains information on the duration and procedures of the interview.

To prepare for the interview, I arrived at the interview venue 10 minutes before the

scheduled time. The interviews lasted for 30 minutes, and I informed the participants that

I would take notes and record the interview data during the entire session. The

participants had the right to refuse to answer my interview questions at any time for any

reason.

Documents of the subject hospitals were available for review on the official

websites of these hospitals. Documents including green committee governance and

organizational structure, the terms of reference, green initiatives, and reports were

available on the hospitals’ official websites for review.

I used interview to collect the data from the participants of this study. An

interview is a useful technique to collect qualitative data to understand the topic of

interest at an in-depth level, but poor preparation and inadequate interview skills may end

up with disappointing results of the data collected (Qu & Dumay, 2011). Another benefit

of using the interview to collect data is that an interview has the potential to generate a

range of insights and understandings that might be useful (Rowley, 2012; Doody &

Noonan, 2013). However, one of the limitations of conducting an interview in a

qualitative study is that it cannot study a very large or random sample of people, due to

the large amount of time and effort involved (Qu & Dumay, 2011).

I did not conduct a pilot study after I received IRB approval from Walden

University for two reasons. First, there are only six targeted hospitals involved in this

study and they might not provide extra qualified participants for an interview. Second,

the process of conducting a pilot study in the Hospital Authority would require a separate

application to the ethics committee that may affect the chance of getting approval for my

interviews with the six targeted participants.

To ensure data reliability, I used member checking after I collected all the data

from the five participants. Member checking is a technique to ensure the reliability of the

interview data (Crowe et al., 2011; Thomas & Magilvy, 2011). The participants received

my organized data and findings to make sure I had a good understanding of their answers

and to confirm the validity of the details I collected.

Data Organization Technique

I conducted five semistructured interviews with nine questions and review

documents related to green activities of the targeted hospitals to collect data for analysis

and to explore the strategies for Hong Kong hospitals leaders to develop and implement a

sustainable energy program to cut energy costs to improve cost effectiveness.

Data organization after the interview is important for the trustworthiness of the

study; also, a software program that can integrate information across many different

functions and purposes can help to manage data for further analysis (White, Oelke, &

Friesen, 2012). NVivo is a computer software for qualitative data analysis. I used NVivo

10 to code, organize, and store the qualitative data collected from the interview and

information and details of all participants. NVivo 10 is also a data management software

that can assist in data management for further analysis, and it can manage a large amount

of qualitative data. White, Oelke, and Friesen, (2012) used the former version of NVivo

10 to organize, code, and analyze qualitative data from 167 interviews in their nursing

study. I used NVivo to analyze the data and came up with findings from the pattern of the

intevew for result resentation purpose.

Also, I used Microsoft Word to record all other interview details including data,

time, location, and participant’s information in a coding system with a case number to

identify the participant. A coding system can protect the confidentiality of the

participants (Searle & Hanrahan, 2011). I categorized all documents and artifacts of the

participants’ information, transcript, consent form, and audio interview recording, and

stored them in safely-locked storage for 5 years.

Data Analysis Technique

I conducted a semistructured face-to-face interview with five chairpersons of the

hospital green committees to collect the data to answer the research question on the

strategies required for hospital leaders to develop and implement a sustainable energy

plan to improve cost effectiveness. Document review can strengthen the data

triangulation of the case study research in addition to data collected from the interviews

(Walshe, 2011). Therefore, I reviewed relevant documentation of the hospital green

initiatives on each of the five hospital official websites.

After the data collection procedure from semistructured interviews and document

reviews, I used the qualitative data analysis software NVivo 10 for data management.

The data management process includes data input, storage, coding, figuring out patterns,

and creating themes using the NVivo 10 software. The advantages of using NVivo 10 for

data management and analysis include a better alignment of original data to the

categories and themes in the data, and increased rigor in qualitative research (Leech &

Onwuegbuzie, 2011; Smith & Firth, 2011).

For the qualitative data analysis approach, I used a framework approach to

explore the research question of my study. Smith and Firth (2011) note that a framework

approach can assist the researcher to apply systematically the principles of undertaking

qualitative analysis to a series of interconnected stages that guide the data analysis for

qualitative research. The framework approach is suitable to analyze cross-sectional

descriptive data collected from the interview and document review. The researcher can

use the framework approach to enable different aspects of the phenomena under

investigation to be captured, increase the transparency of the researcher’s interpretation

of the participants’ experiences, strengthen the rigor of the research process, and enhance

the validity of the findings. I used the CSM developed by Epstein (2008) as the major

conceptual framework for this study. The CSM consists of four major parts of 12 driving

factors that provide a systematic approach to understanding and applying sustainability in

an organization (Epstein, 2008). I developed my interview questions according to the

CSM and I analyzed my data collected from interview and document review to explore

the strategies required for Hong Kong hospital leaders to develop and implement

sustainable energy plan in their hospital based on each driving factors described in the

CSM (see Figure 1).

Figure 1. Corporate Sustainability Model developed by Epstein (2008).

For the data analysis process, I used the five phases qualitative data analysis

process suggested by Yin (2014) (a) compiling, (b) disassembling, (c) reassembling, (d)

interpreting, and (e) concluding. In the compiling process, I categorized and sorted the

data of this study and labeled the data into specific words, phrases, and sentences. The

second step was to separate the data into a meaningful grouping. The disassembling of

data includes assigning a code to each element in the literature review and conceptual

framework used in this study.

The reassembling process consists of linking the coded materials to identify any

specific pattern and theme in the data by using the computer software NVivo 10. I then

interpreted the patterns and themes identified from the reassembling step, according to

the CSM driving forces, to highlight and explain the findings on how to address my

research question about strategies that could help the Hong Kong hospital leaders to

develop and implement a sustainable energy plan in their hospitals to reduce costs. The

computer software NVivo 10 provided the theme and patterns according to the raw data

collected in the qualitative data collection procedure (Woods, Paulus, Atkins, & Macklin,

2015). The last step in the analysis process was the conclusion. The researcher draws

conclusions according to the findings identified in the whole data analysis process, and

explains how the findings can help the readers to understand the research question (Elo et

al., 2014).

Reliability and Validity

The rigor of method, transparency on the analytical procedures, reliability on the

data collected, and researcher bias are the most controversial parts of the qualitative

research (Noble & Smith, 2015). Reliability is the extent to which another researcher can

repeat the study method at any time, at any place with any other conditions or instruments,

and they should obtain the same findings (Drost, 2011).

Dependability is refereeing to the extent that another researcher can repeat the

study when following my study protocol, and the strategies to enhance dependability

include having peers participate in the analysis process, and provide a detailed

description of the research methods (Thomas & Magilvy, 2011). I invited peers to review

my study protocol and make sure another researcher could repeat the study without

showing the participants’ information. Another method to increase the dependability is to

establish a detailed guideline of the research method describing the step by step approach

to the procedure of my study.

I used member checking to increase the credibility of this qualitative study on

how Hong Kong hospitals can develop and implement a sustainable energy program to

improve cost effectiveness. I conducted interviews with five hospitals green committee

chairpersons to obtain the data; participants received the findings and data for their

review and to check to ensure that the content truly reflects their experiences and feelings

(Thomas & Magilvy, 2011).

Triangulation is a tool to enhance credibility of qualitative and it is referred to

increase the trustworthiness of the data collected in a qualitative study by including

multiple resources (Houghton, Casey, Shaw, & Murphy, 2012). In this study on exploring

the strategies necessary for Hong Kong hospitals leaders to develop and implement a

sustainable energy program to reduce costs, I used semistructured interviews consisting

of nine questions related to the conceptual framework of this study.

Transferability is the ability to transfer research findings or methods from one

group to another (Houghton et al., 2012; Thomas & Magilvy, 2011). Strategies to

enhance the transferability of a qualitative study include a detailed description of the

accounts of the context, the research methods, examples of raw data, population and

sampling, demographics and geographic boundaries of the study for readers to interpret

(Houghton et al., 2012; Thomas & Magilvy, 2011). To enhance the transferability of my

study, I included a detailed description of the relevant information in the introduction,

research method and design, sampling, data organization, collection, and data analysis

technique of my dissertation (Houghton et al., 2012). For the raw data examples, I

inserted the raw data in Appendix B without identifying the participants’ details to

increase further the transferability of the study.

Confirmability refers to the researcher’s ability to demonstrate that the data

represent the participants’ responses and not the researcher’s biases or viewpoints (Cope,

2014). I included the quotes from my participants in Appendix B without the participants’

identification or details. Including quotes from the participants is a technique to enhance

study confirmability because readers can understand that the conclusion and discussion of

the findings are derived from the raw data collected from the participants (Cope, 2014).

Saturation is a tool used for ensuring that adequate and quality data are collected

to support the study and to ensure that the researchers reach data saturation by collecting

enough information to replicate the study (O’Reilly & Parker, 2012; Walker, 2012). I

tried to include all of the potential targeted participants in my interview who have the

expertise and real life experience on how to develop and implement a sustainable energy

program to improve cost effectiveness, because increasing the number of participants can

help the researcher to reach data saturation (Walker, 2012). However, one target

participant did not join my interview because he resigned from his position. Also, I

conducted a document review for the targeted hospitals and ensured there were no

additional findings or data available for exploring my research question to enhance the

data saturation of the study.

Transition and Summary

Section 2 of this proposal includes the criteria for selecting the participants and

the details of the research method and design. I included the supporting documents for

sampling method and the ethical consideration for data collection process in the section.

This section contains the details of data collection instruments, organization techniques,

and analysis strategies. Finally, I present the strategies to enhance the study reliability

and validity in the last part of this section. Section 3 of this study will explain the findings,

implications for social change, recommendation for action, recommendations for further

research, reflections, and the conclusion of my study.

Section 3: Application to Professional Practice and Implication for Change

The problem was that the majority of the hospital leaders in Hong Kong did not

implement a sustainable energy program in their hospitals, which induced high energy

consumption costs. I used the research questions of this study to collect qualitative data

through semistructured interviews with the hospital green committee chairpersons who

had successfully implemented a robust sustainable energy program and received

recognition from the local government. I also used a document review to collect relevant

information from the subject hospitals’ official websites for increasing the reliability of

the data quality.

This section of the study contains the results of the interviews with the conclus the

participants who had the best knowledge and experience on developing and

implementing a sustainable energy in Hong Kong public hospitals and from the hospital

document review for data analysis. This section includes an evaluation of the interview

results about the research question. The end of this section contains a conclusion and a

recommendation for future study.

Overview of the Study

The purpose of this qualitative multiple sites case study was to explore the

strategies required for Hong Kong hospital leaders to develop and implement a

sustainable energy plan to save energy costs. Six public hospitals received the Hong

Kong Awards for Environmental Excellence in 2014; I planned to invite all six

chairpersons to my semistructured interviews to achieve data saturation. However, one of

the chairpersons resigned from his previous position and the participant did not reply to

my invitation and was not involved in my interviews. Dworkin (2012) suggests that five

to 50 samples are appropriate for a qualitative study; five chairpersons from the hospital

green committee participated in my interviews, and I collected and analyzed the data to

create the themes of this study. The data came from five semistructured interviews with

the chairpersons and a document review of the five public hospitals’ green management

committee, and the study results showed the strategies that the hospital green committee

chairpersons used to successfully develop and implement a sustainable energy program at

their hospitals.

The study findings revealed that to successfully develop and implement a

sustainable energy program in a public hospital, the external and internal driving forces

are crucial factors. The external driving force is the sustainability policy of the local

government, and the internal force includes corporate and hospital green initiatives.

Having a skillful leader is also an important strategy to mobilize staff to comply with and

participate in the sustainable energy program. Findings of this study indicate that strong

leadership skills such as communication skills, influencing tactics, stakeholder

engagement, and a people-centered approach are essential for a hospital leader to

implement a sustainable energy program at a local hospital. Governance and top

management commitment contributed as strong drivers to the implementation and

execution of a sustainable energy program in the hospital. The study findings also

suggested that a sustainable culture could be very helpful to facilitate staff to practice in a

sustainable manner. Capacity-building and knowledge-building are important to enhance

and maintain the sustainability culture in the local public hospital. Finally, performance

measures including meeting the key performance indicator, achieving the targeted saving

unit, and receiving awards from nongovernment organizations are effective strategies and

motivators for the hospital to implement the sustainable energy program and evaluate its

effectiveness.

Presentation of the Findings

The research question of this study was: What are the strategies for hospital

leaders to develop and implement a sustainable energy program to reduce energy costs?

Data sources included semistructured interviews with the hospital green committee

chairpersons and a document review of the five public hospitals that had received the

Hong Kong Awards for Environmental Excellence 2014. The five chairpersons of the

green committees were the hospital general manager that led the hospital to develop and

implement the sustainable energy program. All of the participants must have had more

than 10 years management and administration experience to be the hospital general

manager, according to the employment requirement of the Hong Kong Hospital Authority.

The subject hospitals included acute and convalescent settings, and the size of the

hospital ranged from 300 to 1,800 beds. Participants received a draft of the interview

summary for members’ checking purpose, and I reached data saturation after the fourth

interview with the participants.

Several themes emerged from the data analysis process. The leader of an

organization should introduce corporate sustainability measures to enhance an

organization’s competitive edge and to sustain it in both the short and long-term (Bansal

& DesJardine, 2014). Several themes emerged from the data analysis procedure across all

participants: (a) external and internal driving forces, (b) leadership, (c) governance, (d)

sustainable culture building, and (e) performance measures. According to Boulle (2012),

strong corporate sustainability organizations have few important attributes of sustainable

measures, including strong awareness, robust policy, and effective investment in

sustainable equipment. The findings of this study revealed that all of the participants’

hospitals in this study demonstrated a strong level of corporate sustainability. Table 2

shows the themes that emerged and shows that the leaders of Hong Kong nonprofit public

hospitals require a multicomponent strategy to effectively lead their hospitals in

achieving the sustainable energy initiatives when dealing with cultural and organizational

considerations.

Table 2

Frequency of Primary Themes from Data Collected from Semistructured Interviews

Themes

% of frequency of occurrence

Internal and external driving forces

22.22%

Leadership

36.5%

Governance

14.29%

Building sustainable culture

12.7%

Performance measure

14.29%

Emergent Theme 1: Internal and External Driving Forces

All five participants pointed out that external and internal driving forces were

essential elements to develop and implement a sustainable energy program in their

hospitals. The government policies and guidelines on energy conservation and

greenhouse gas emissions are the fundamental measures that a public hospital should

follow. Government regulations such as energy saving targets and carbon dioxide

reduction provided a clear framework for all subject hospitals to establish a direction and

action plan for their energy saving initiatives. Three documents from the subject hospital

green committees revealed that government regulation on environmental protection was

one of the motives for them to introduce sustainable programs. The findings confirmed

the previous studies that government policy is an effective and essential driver to

facilitate an organization to implement and outperform in the corporate sustainability

measures and activities (Dobbs, Dobbs, van Staden, & van Staden, 2016; Epstein &

Buhovac, 2014; Ioannou & Serafeim, 2014). Two of the participants revealed that the

recent change in stakeholder awareness and expectations of environmental protection was

another external driving force to facilitate their hospitals to implement a sustainable

energy program, which provided findings similar to another study on the external drivers

on corporate sustainability (Lozano, 2015; Naylor & Appleby, 2013).

The hospital’s goal in the sustainable energy direction was an external driving

force for the hospitals to develop and implement a sustainable energy program. The Hong

Kong Hospital Authority, a statutory body providing public hospitals and related services

to the citizens of Hong Kong, governs all subject hospitals (Hospital Authority Annual

2014). All participants pointed out that corporate initiatives were a strong internal driving

force to encourage them in developing and implementing a sustainable energy program.

With a clear mandate and support from the corporate level, all of the participants pointed

out that the hospital can set a strategy and position on energy savings, which was another

main driving force for their energy saving activities. All of the subject hospitals have a

clear energy saving policy or statement posted on their website, which further strengthens

the hospital’s direction on the green measures as an important driving force for them to

develop and implement a sustainable energy program. The findings from the interviews

on internal driving forces confirmed the current literature that an organizational goal and

strategy on corporate sustainability is a strong internal driving force to develop and

implement a successful sustainable energy program (Caprar & Neville, 2012; Dobbs et al.,

2016; Lozano, 2015; Robinson & Boulle, 2012).

Four participants pointed out that financial support from the corporate level was

crucial to invest in sustainable equipment in their hospitals because they have not funded

their regular operation costs, and hospitals have difficulty providing extra budgets for

such substantial investments. The findings from these four participants added to the

current knowledge on corporate sustainability because previous studies on private or for-

profit organizations view financial support as an external driving force that can create

financial benefits or return on investment (Ameer & Othman, 2012; McGain & Naylor,

2014; Naylor & Appleby, 2013). However, local public hospitals treated the financial

support from the corporation as an essential resource allocation to comply with the

hospitals’ sustainable energy goal. All public hospitals in Hong Kong have received

subsidies from the Hong Kong Government, and additional resources require a

submission of an annual resource allocation plan with a nonmonetary deliverable set by

the government, which is different from the for-profit or private hospitals.

The CSM by Epstein 2008 was the conceptual framework for this study. The

CSM consists of input and output, and this study’s findings on the internal and external

driving forces echoed the theories suggested by the CSM in the internal and external

context parts. The CSM identified a few important external and internal contexts as input

for successfully implementing corporate sustainability practices in an organization

(Epstein, 2008). Internal contexts are company goals and mission of corporate

sustainability, and external contexts are government corporate sustainability or

environmental policies and regulations. The findings of this study on the internal and

external drivers confirmed that hospital leaders could also use CSM as a conceptual

framework to introduce a sustainable energy program in Hong Kong public hospitals.

Emergent Theme 2: Leadership

Current literature on corporate sustainability suggested that good leaders could

help an organization to successfully implement sustainable measures (Eccles, Ioannou, &

Serafeim, 2014; Strand, 2014). Other studies have also identified leadership skills as an

essential element to build up a sustainable culture and to motivate staff to obtain a good

outcome on green activities (Galpin et al., 2015; Whittington, 2012). The findings of this

study confirmed that good leadership skills, including communication skills, influencing

tactics, stakeholder engagement, and a people-centered approach, could help the hospitals

to implement a sustainable energy program and to obtain ideal performance outcomes.

Communication skills. Business studies support that effective communication is

one of the most important for leaders to achieve the organization’s goals (Robles, 2012;

Phelan & Sharpley, 2012). Study findings from four participants noted that they used

effective communication skills to facilitate the implementation of the sustainable energy

program. The sustainable policy or hospital goal on corporate sustainability was well

articulated in all levels of staff using both verbal and nonverbal forms of communication.

Presentations and sharing sessions were conducted with the top management and

frontline staff. Leaders of the green committee presented the sustainable program

outcomes at the management meetings to further encourage staff to participate in in the

hospital energy saving activities. The participants listened to staff concerns and ideas on

new energy measures and provided feedback and support regarding their concerns. The

subject hospitals sent posters, electronic mail, and printed materials to all staff to

encourage them to practice in a sustainable energy manner. The study findings of the four

participants confirmed the current studies on business practices on the use of good

communication skills to lead the staff to achieve the company’s goal.

Influencing tactics. Successful leaders can use influencing tactics to mobilize

staff to comply with the company goal and mission (Gregoire & Arendt, 2014). All five

participants pointed out that they used different influencing tactics to mobilize their staff

to comply with the hospital’s goal and mission in the energy saving program. Instead of

using a top-down approach, four participants used a win-win approach to facilitate the

implementation of the sustainable energy program. Staff received benefits/incentives for

complying with the energy saving measures. For example, one of the hospitals introduced

a new material for their uniforms to reduce the energy used to clean and dry them, and

this measure can also help the hospital to solve the uniform shortage and supply problem

due to the long cleaning process. The use of influencing tactics on achieving hospital

energy saving initiatives in all of the study’s hospitals confirmed that the use of

influencing skills could help the organization achieve a company goal. Two participants

used the influencing tactics of creating peer pressure among staff by reporting the

performance outcome in the senior meetings and the staff forum. Using peer pressure to

enhance performance in these two participant hospitals confirmed the current study on

healthcare performance management (Zidarov, Sicotte, Menon, Hallé, & Poissant, 2016).

Stakeholder engagement. Recent studies on how stakeholder engagement can

help the leaders to achieve the organization’s goals confirmed that stakeholder

engagement is crucial in a successful business strategy and activity implementation. The

findings of this study also echoed the current studies on stakeholder engagement. All five

participants pointed out that stakeholder or staff engagement is one of the most important

steps to facilitate the early stage of sustainable energy program implementation, and

motivate and mobilize staff to practice energy saving initiatives. The participants also

pointed out that it was important to identify the right person or leaders to join the green

committee to facilitate the change in practices in the hospital. All of the participants

suggested that engaging stakeholders from different levels is the key to implementing

such administrative initiatives in a large hospital with different professional staffs,

suppliers, and patients. Three participants revealed that they introduced a large-scale

stakeholder engagement program in their hospitals from different staff levels,

nongovernment organizations, and patients to facilitate the change in practices. For

example, one participant hospital recruited more than 140 environmental protection

ambassadors from all departments to promote and encourage other staff to comply with

the hospital mission in energy savings. Document reviews of four subject hospitals

suggested that their efforts are injected into stakeholder engagements. These three

documents included the key stakeholders on their green committee, and others

nongovernment organizations and patient groups in their sustainable activities.

Transformational leaders. The study identified transformational leadership as

helping the company to successfully adopt the change in practice in green measures

(Metcalf & Benn, 2013). Transformational leadership is a leadership style that can lead

the followers to successfully achieve a company goal by leading by example, inspiring

followers, using a people-oriented approach, and growing with the followers (Choudhary,

Akhtar, & Zaheer, 2013). The people-centered approach is one of the major organization

values of the Hong Kong Hospital Authority. Four participants pointed out that a people-

centered approach was used to implement the sustainable energy program in their

hospitals. Four participants pointed out that one of their main leadership roles was to

inspire their staff in the development of a sustainable energy program and grow with the

staff on the hospital’s green journey. The findings of this study confirmed the current

studies that a transformational leader’s style is favorable to help the company to achieve

the goal of corporate sustainability.

Leadership belongs to the process part of the CSM. The supporting literature from

the conceptual framework focused on how different leadership types, such as a

transformational leader, can help the company to build up sustainable culture, instead of

which specific leadership skill is required to perform the task. The CSM suggested that a

transformational leader is a more effective leadership style to help the organization to

achieve their goal in corporate sustainability (Epstein, 2008). However, the CSM did not

elaborate in detail on which leadership skills of transformational leadership styles are

required in the framework and supporting literature to implement corporate sustainability

successfully. The findings of this study provided additional knowledge on which specific

leadership skills are necessary for a Hong Kong public hospital to develop and implement

a sustainable energy program to reduce energy costs. Strong communication skills, good

influencing tactics, and stakeholders’ engagement are the main leadership skills that

hospital leaders can apply to achieve their goal in a sustainable energy program.

Emergent Theme 3: Governance

One study showed that a company with strong corporate governance can obtain

good performance in corporate sustainability activities (Jo & Harjoto, 2012). An

Australian study suggested that good governance structures put in place to ensure that

senior management is involved in sustainability strategy development can assist the

company to obtain benefits (Klettner et al., 2014). The findings of this study confirmed

the current studies on how good governance can be an effective approach to facilitate the

development and implementation of the sustainable energy program at local public

hospitals. All five participants pointed out that top management commitment and the

involvement of relevant hospital leaders with the green committee were helpful in

developing and implementing sustainable activities in their hospitals. The hospitals’

leaders, with top management commitment, can deliver the hospitals’ vision on

sustainability to their staff at different levels. Also, these hospital leaders can influence

their subordinates to practice the hospital energy saving programs. Five documents

collected from the hospital green committee revealed that these hospitals have a robust

governance structure at local hospital or corporate level with highest management

commitments and involvements. The hospital general managers were all involved as the

chairperson, and these hospital green committees are under the supervision of a higher

governance structure of the hospital led by the hospital chief executive to drive the

development and implementation of such green activities including the sustainable

energy program at their hospitals.

Studies suggested that the top-down approach is an effective strategy to facilitate

change in sustainable measures (Asif, Searcy, Zutshi, & Fisscher, 2013; Lozano, 2013).

However, all five participants pointed out that although they have a good governance

structure for the hospital green committee, the top-down approach was not the major

strategy used for the implementation of sustainable energy initiatives at their hospitals;

instead, leadership skills with strong influencing tactics and communication skills are

frequently applied for non-clinical services at a public hospital in Hong Kong. The

conceptual framework of this study, the CSM, also suggested that a top-down governance

initiative could be an effective approach for implementation of sustainable measures in an

organization (Epstein, 2008). The findings of this study supported the CSM on the

importance of having a strong governance structure on corporate sustainability initiatives,

but leaders of local public hospitals mainly applied leadership skills to facilitate the

development and implementation of the sustainable energy program at their hospitals.

Emergent Theme 4: Building sustainable culture

Five hospital leaders in the study pointed out that one of the steps to ensure the

successful implementation of a sustainable energy program was to build up and maintain

a strong sustainable culture in their hospitals. A leader can help an organization to

achieve its corporate sustainability goal by building up a strong organizational culture

(Strand, 2014). Organizational culture is the norm and the way the staff thinks and acts in

the company (Liu, Li, Zhu, Cai, & Wang, 2014). Another study showed that an

organization with strong corporate sustainability culture can outperform in sustainable

measures and is more capable of obtaining benefits for the company (Engert &

Baumgartner, 2016). To enhance the sustainable awareness, all five participants

introduced a series of culture-building activities in their hospitals including a training

program for new staff, regular knowledge sharing, a promotion carnival, and energy

saving competition programs. To strengthen the sustainable culture, three of the subject

hospitals incorporated corporate sustainability into their hospital strategy. However, two

participants reported that the patient-centered culture was one of the barriers for them to

build up a sustainable culture because two cultures may have contradictions in a hospital

that operates 24 hours a day and seven days a week. The findings of this study confirmed

the current studies on the effect of building a strong sustainable organizational culture as

a strategy to help a company to implement and outperform in corporate sustainability

measures.

The findings of this study suggested that leaders of the hospital green committees

spent efforts to build up a sustainable culture in their hospitals by introducing various

capacity building activities, and intergraded it into the hospital strategy to facilitate the

development and implementation of sustainable measures, including an energy saving

program. The findings on sustainable culture-building also confirmed the CSM that

integrating sustainability into organizational culture can help formulate and implement

related activities and achieve desirable outcomes in corporate sustainability initiatives

(Epstein, 2008).

Emergent Theme 5: Performance measure

Implementing sustainability measures has resource implications such as

equipment investments (Papagiannakis, Voudouris, & Lioukas, 2014). An effective

evaluation tool or method can help the leaders to evaluate the success of the sustainable

activities (Sahamir & Zakaria, 2014). A good assessment tool can also help the

organization to determine the insufficiency of the current sustainable measures and to

formulate an improvement plan (Epstein & Buhovac, 2014). The findings of this study

revealed that performance measures of a sustainable energy program could help the

hospital to engage staff, to develop an improvement plan, and to further strengthen

sustainable culture in their hospitals. All of the subject hospitals used various

performance measures to evaluate their programs’ effectiveness. Two of the common

approaches used were awards from other recognized green organizations and

performance outcomes set by the hospital green committee for each program. Four

participants pointed out that they regularly present the sustainable evaluation results to

both frontline staff and management to enhance stakeholders’ awareness and to formulate

an improvement plan. Two participants said that by comparing the results to their

previous performance across departments, frontline managers and staff increased

compliance in the hospital sustainable energy initiatives due to the effect of peer pressure.

Three hospital leaders said the awards from other recognized green organizations were

good encouragement for strengthening the sustainable culture and for recognizing their

efforts on the sustainability programs. Four participants pointed out that meeting the

energy saving targets set by the green committee and report in the hospital management

board is a mandate for the program initiated by the corporate level management.

The findings of this study confirmed the current literature on the functions and

benefits of applying performance measures or assessments on the sustainable programs

include monitoring, controlling, evaluating, and improving current sustainable practices

in an organization (Epstein & Buhovac, 2014). The findings of this study also provided

additional knowledge on the current corporate sustainability practices in the public

hospitals. The authors of a study reviewed 101 studies on sustainability performance

measurements, and found that private organizations used mainly financial benefits to

assess their company performance on corporate sustainability (Goyal, Rahman, & Kazmi,

2013). However, according to the findings of this study, Hong Kong public hospital

leaders did not assess their sustainable measures performance with financial achievement.

Instead, they used non-monetary indicators such as awards from other green

organizations and the energy saving unit of each program set by the hospital green

committee for performance evaluation. According to the participants of this study, thery

pointed out that sustainable energy performance measures can be an effective influencing

tool to motivate staff to improve performance in their hospitals because departments and

dvisions are comparing their results to each other. Also, the findings of this study on

performance measures aligned with the conceptual framework in this study that leaders

can use it as a driver to introduce, execute, and outperform in sustainability business

(Epstein, 2008).

Application to Professional Practice

The results of this study may serve to the hospital leaders in the public sector for

filling the knowledge gap in which strategies could help the local public hospital to

develop and implement a sustainable energy program. The findings of this study provide

additional references for Hong Kong public hospital leaders to establish a strategy to

handle the persistent problem of the rate of high energy consumption among other Hong

Kong public hospitals. By analyzing the interview data and document reviews of the five

local hospitals who have received government recognitions, local hospital leaders can

explore the external and internal driving forces, apply proper leadership skills and

governance structure, build a sustainable culture, and introduce the performance

measures when developing and implementing a sustainable energy program at their

hospitals. According to a review study, an organization needs a conceptual framework

that the management can rely on to develop, implement, control, and improve corporate

sustainability strategies to obtain desirable outcomes (Baumgartner, 2014). All of the

participants’ hospitals have a clear framework or guideline on corporate sustainability

measures committed by strategic level management. The hospital green committee can

formulate strategies and action plans according to the framework for the staff to comply

with the requirements. All participants used the external and internal driving forces to

initiate and sustain their sustainable energy program. Studies suggested that a lack of

drivers to change is one of the barriers to corporate sustainability development (Lozano,

2013). Also, as a government subsidiary organization, government policy, hospital

support, and public expectations are the important drivers for adopting a sustainable

practice.

All participants used both soft and hard skills to facilitate the development and

implementation of the sustainable program. Galpin and Lee Whittington (2012)

suggested that a transformational leadership approach is more effective to help the

company to implement change to a sustainable practice. One of the main strategies used

by the participants in this study is to apply transformational leadership skills to influence

the change in practice in the hospitals, and leadership skills included good

communication, influencing tactics, stakeholder engagement, and a people-centered

approach. Lozano (2013) pointed out that changing existing company culture is a barrier

to the implementation of corporate sustainability. All participants observed a culture

change throughout their green journey by injecting efforts in building a corporate

sustainability culture in their hospitals. Measures to build a sustainable culture included

provide knowledge sharing and training, conducting promotion activities, and distributing

printed and electronic education materials to the staff.

The literature shows that a company can implement performance measures to

manage and to improve current sustainability achievements (Epstein & Buhovac, 2014;

Searcy, 2012). All of the participants in this study observed positive effects after

introducing performance measures as one of the strategies for their corporate

sustainability management. Increased compliance in the sustainable program

strengthened the sustainable culture, and enhanced motivation on sustainable initiatives

are the positive effects resulting from introducing performance measures such as targets

set by the hospital green committee and awards from other green organizations.

Implication for Social Change

Society may benefit from the results of my study because Hong Kong hospital

energy consumption is reaching 100 million Hong Kong dollars annually (Tong & Fong,

2014). The Hong Kong Government is funding approximately 50 billion Hong Kong

dollars to all 42 public hospitals (Hong Kong Hospital Authority, 2014). According to

current studies on sustainable energy, implementing a sustainable energy program at the

hospitals can reduce energy consumption by 20% (Naylor & Appleby, 2013). Also, the

energy cost is equivalent to around 1-3% of hospitals’ operating costs (McGain & Naylor,

2014). As a government subsidiary, public hospitals provide a quality healthcare service

for more than 90% of the population. Thus, proper use of public money can be one of

their challenges. Therefore, the findings of this study are the analysis results of five local

public hospitals that successfully implemented a sustainable energy program and received

recognition from the government body. The findings of this study can provide additional

knowledge to existing frameworks or guidelines for the development and management of

sustainability business in the hospital. The results add value to the existing CSM by

Epstein by incorporating culture and organizational considerations. Hospital leaders can

use these findings to develop and implement the sustainable program and to reduce

energy consumption and reallocate the resources to other patient service quality

improvement initiatives (McGain & Naylor, 2014).

Improvement in environmental pollution is another implication of this study for

social change. Hospitals are one of the most polluting industries because of their

operating model of 24 hours a day and seven days a week (Alemayehu, Alemayehu, &

Assefa, 2015). Environmental pollution causes climate change, which further increases

the incidence of other infectious, respiratory, and cardiovascular diseases that further

worsen the financial burden of our healthcare system (Watts et al., 2015). Air pollution in

Hong Kong caused more than 3,000 premature deaths and a monetary loss of 39 billion

Hong Kong dollars in 2012 (South China Morning Post, 2015). Local hospital leaders can

implement measures according to the added knowledge to reduce carbon emissions. The

reduction in environmental pollution can further reduce the negative health effects caused

by climate change, which can alleviate the financial burden of health services (Thompson

et al., 2013; Woodward et al., 2014).

Recommendation for Further Action

The Hong Kong Hospital Authority establishes its annual plan every year

according to the strategic intent suggestions in the 5 years strategic plan. The annual plan

includes well-written strategic intentions and program details for all Hong Kong public

hospitals to follow. Hospital activities’ development and implementation are following

the strategic intents set by the corporate management. Studies and findings of this study

identified that strategic or top management commitment is the key to success in corporate

sustainability development (Chen & Jermias, 2014; Galpin et al., 2015; Goyal, Rahman,

& Kazmi, 2013; Klettner et al., 2014). To formulate and implement a sustainable energy

program in all public hospitals, strategic or corporate level management should consider

incorporating the corporate sustainability initiatives into their annual plan. Also,

corporate level management should consider adopting a corporate sustainability

conceptual framework to facilitate the development because the study and the findings of

this study suggest that hospitals that have good development and performance of

sustainable energy measures adopted a clear framework and guideline for sustainable

practice (Baumgartner, 2014).

Strategic and hospital management levels should consider formulating a robust

governance structure on corporate sustainability management and development. A

governance structure that is engaged with all stakeholders can help the hospitals in Hong

Kong to formulate strategies and action plans in a multidisciplinary hospital setting. Also,

due to a collaboration culture in Hong Kong public hospitals, a governance structure on

corporate sustainability can further enhance the employee compliance with the hospital

sustainable energy activities and initiatives. However, instead of focusing on a top-down

approach to mobilizing staff to comply with sustainable energy measures, hospital leaders

should apply soft skills such as good communication skills, influencing tactics,

stakeholder engagement, and a people-centered approach. The findings of this study

showed that the leaders of the subject hospitals frequently used a more transformational

leadership style to accomplish the hospital sustainable energy goals. Being people-

centered is one of the organizational values of the Hong Kong Hospital Authority

(Hospital Authority Annual Report, 2013), and a transformational leader uses a people-

oriented strategy to help the company to achieve its goal (Choudhary et al., 2013).

Hospital management can consider providing training on leadership to the hospital green

committee members to strengthen their competency in managing a sustainable energy

program at their hospitals.

Lozano (2015) noted that a leader could build a culture of corporate sustainability

in the organization to facilitate implementation and to obtain a desirable performance in

the sustainability business. The local hospital management may consider introducing

measures to build up, enhance, and maintain a strong sustainable culture for the

sustainable energy management. Chairpersons of the subject hospitals implemented a

series of programs to enhance the sustainable culture in their hospitals. Measures have

included staff competency-building, exchange of site visits, promotional activities, and

internal and external energy saving competitions. The participants pointed out that these

awareness-building activities can help the hospitals to incorporate the sustainability

mindset into the hospital culture and drive the staff to change in practice. However, as a

public hospital with a high service workload and limited budget, to ensure these programs

or activities are sustainable, leaders should consider the resources and service provision

implications before introducing the culture-building activities.

Management of local hospitals may introduce performance measures to their

sustainable activities for monitoring, controlling, evaluating, and improving their purpose.

The participants of the study hospitals used performance to find out any insufficiency in

their sustainable energy program and to formulate a future improvement plan. Also, these

hospitals used the performance measures as their strategies to further strengthen the

sustainable culture in their hospitals. Hospital green committees can set the specific goals

for each sustainable energy program and report to the management and frontline staff.

The participants reported that staff increased compliance by comparing their

performances to other departments. Hospital green committees can participate in energy

savings competitions organized by other recognized green organizations such as the

Hong Kong Awards for Environmental Excellence by the government sector.

Encouragement and achievement in these awards can enhance staff motivation and

participation in the hospital energy saving initiatives. However, none of the hospital

leaders in this study used monetary indicators for measuring their performance because

financial benefits for the hospital is not a high priority task in the public sector.

Recommendation for Further Research

The public hospitals may consider conducting a study on the benefits of

implementing a sustainable energy program on patient service quality. At a public

hospital, the participants used non-monetary indicators to measure the effectiveness of

their sustainable energy program. Ensuring quality and safe service is one of the major

strategic intents in the 2013 Hospital Annual Plan. Leaders of local public hospitals can

investigate the improvements on service quality by reinvesting the money saved from the

sustainable energy programs. Service quality improvement may have resource

implications, for example, the employment of additional staff, procurement of new drugs,

and advancement on new healthcare devices (Hussey, Wertheimer, & Mehrotra, 2013). A

future study on how a sustainable energy program can benefit patient service quality may

further encourage local hospital leaders to adopt a sustainable energy program at their

hospitals.

Hong Kong public hospital leaders may consider conducting a study on the

development or adoption of a conceptual framework that fits the local healthcare context.

A sustainability framework will help the hospital leaders formulate and implement a

successful sustainable energy program. However, currently, the majority of local public

hospitals do not have a clear sustainable framework to follow. Researchers may

collaborate with local hospitals leaders to design a framework that can include the culture

and organizational difference into account. The NHS developed a sustainable route map

that provides direction for clinical leaders in achieving successful guideline

implementation (Higuchi, Downey, Davies, Bajnok, & Waggott, 2013). Hong Kong

public hospitals leaders may consider studying how this English framework can fit the

local healthcare setting.

Reflections

Before beginning a healthcare management doctorate in the business

administration program, I have been working as a clinician in the public sector for more

than 10 years. I am also involved in other community health promotion and policy-

making projects with the local government. One of my main duties is to conduct clinical

and community research or service evaluation projects. Until I started this degree, I

discovered that there is another world in healthcare research that I had never noticed

before. The knowledge and skills in healthcare management research helps me to plan,

manage, monitor, and evaluate the daily clinical and administration duties. Besides, by

understanding healthcare management knowledge, I can align all of my clinical projects

or service developments to the corporate and hospital level strategic intentions. This

ability is very helpful for me to accomplish my plan and project according to the hospital

and corporate directions.

Another valuable thing I learned from this doctorate is the academic skill and

knowledge that was applied in writing my dissertation. Starting from the literature review,

writing the proposal, and getting approval from the committee members and IRB, these

experiences are very important for my future career development. Although it was a

difficult journey for me, I overcame these difficulties with the support of my teacher,

advisors, friends, and family. I finally completed the requirements for a doctoral student

and can now apply the high level academic skills and knowledge learned in this program

to further enhance my capacity in pursuing my career in the Hong Kong healthcare

industry.

Conclusion

Hospitals are one of the most polluting industries. The 24 hours-a-day and seven-

days-a-week operation model consumes a high level of energy. Hong Kong public

hospitals are facing a high energy consumption problem. Studies have shown that

introducing a sustainable energy program can help hospitals to save around 20% of its

energy consumption. Hospital leaders in Hong Kong may consider looking for strategies

to implement a sustainable energy program to reduce costs.

The findings of this study show that local public hospitals can successfully

implement a sustainable energy program with a multicomponent strategy approach. The

highest level of management should consider adopting a corporate sustainability

framework to formulate a strategy and develop programs. A robust governance structure

with the commitment of the top management and engagement of all major stakeholders

can help the hospital to deliver the green message and to achieve a desirable performance.

Leadership skills such as good communication techniques, influencing tactics,

stakeholder engagement methods, and a people-centered approach are promising for

developing and implementing a sustainable energy program at local public hospitals.

Hospital leaders should introduce culture-building activities as one of the strategies for

developing and implementing sustainable energy programs. It is important to incorporate

the sustainability culture into the organizational culture for sustainability in the long term.

Finally, performance measures are crucial to the development and implementation of a

sustainable energy program in local public hospitals. Hospital leaders may consider

introducing performance indicators for their initiatives to obtain good compliance with

and ideal performance of their sustainable energy programs.

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