Hospitals in Turkey and Australia: Green Supply Chain Management


In recent decades, the public’s degree of environmental consciousness has improved dramatically and especially in the light of several industries, including the healthcare business. The healthcare system is among the ones that contribute significantly to the pollution, use of unrecyclable materials, high volumes of waste, and consumption of unrenewable energy. The development of health care has resulted in expanded hospital operations and heightened awareness of hospital sustainability, among other environmental problems. These developments, among other things, have resulted in a worldwide effort that has targeted the formation of global standards to address concerns in many nations that are linked to global environmental management challenges. The goal of this study is to assess the link between green supply management (SCM) implementation, ISO 9001-2015, and ISO 14001-2015 compliance, using the case study from two hospitals. Green supply chain management is still a relatively new concept in hospitals, despite its widespread application in other industries.

According to the findings of this study, green SCM is a realistic option for hospitals in terms of lowering waste output and associated expenses. There are other benefits for private hospitals, such as enhanced reputation and patient confidence. Furthermore, it indicates that compliance with ISO 9001-2015 and ISO 14001-2015 may effectively enable a hospital to pursue environmentally-friendly practices. Having said that, implementing green SCM is linked with higher short-term expenses while the facility adapts to the new requirements. Furthermore, the long-term ramifications of ever-changing environmental research and the modifications required might result in additional costs. Finally, the technical capabilities of the hospital’s location must be examined since they might influence how environmentally friendly the hospital can be.

Though green SCM and its application to hospitals have not been extensively researched, there appears to be a significant promise for its adoption and use. While medical institutions have little possibility to influence their upstream supply chains, they may optimize their operations and reduce waste generation. Furthermore, both public and commercial hospitals have incentives to do so, such as lower long-term expenditures. Considering this, the present study shows that green SCM adoption is a process that cannot be efficiently carried out in a solitary institution. The environment in which it operates must be suitable for the purpose, which necessitates the presence and accessibility of various waste recycling facilities, among other things.

During this investigation, the researchers collected both quantitative and qualitative data by analyzing descriptive papers and statistical data analysis studies. A review of the literature aided in identifying existing procedures that both institutions that are the focus of this study are employing to adopt GSC and satisfy international standards. As a result, this study was undertaken to utilize the desk research approach, in which literature on the issue was collected and analyzed, with a primary focus on the history of SCM practices in healthcare systems in both states, Turkey and the US. The empirical findings were based on the study of both qualitative and quantitative data. Both descriptive and explanatory studies were employed to reach this purpose. The decision to do mixed methods research is supported by the necessity to conduct high-quality research that tackles the risks.



In recent decades, the level of environmental awareness among the public has increased significantly in relation to different sectors, including the healthcare industry. The health care expansion effect has led to increased hospital operations and increased sensitivity to hospital relatedness to sustainable management, among other environmental-related concerns. These changes, among other issues, have triggered a globalized effort that has led to the establishment of global standards to address concerns that link to global environmental management issues in different nations (Standards: ISO standards are internationally agreed by experts 2020). Various hospitals in Australia and other countries have tasked their agencies that relate to public health, such as the Australian department of public health, to ensure enrolments of the international standards such as ISO 22870, ISO 151197, and ISO 9001 in different health care industry operations. The application of the ISO standards ensures effectual quality service delivery satisfies all stakeholders’ preferences (International standards 2020). The application of the international standards, however, follows different actions to ensure success in the health care industry.

This research is an empirical study of the supply chain management SCM practices from two hospitals: one located in Turkey and the other in Australia. The first hospital is the Australian Hospital A that has 571 beds and helps over 500,000 patients, while the second study subject is the Derindere hospital, with 386 beds serving 10,000 patients. During the course of this study, the researcher will collect and interpret information about the SCM and sustainability practice in both facilities using the case study method. The goal is to use quantitative and qualitative methods to collect information about the hospitals’ SCM practices, green objectives, and the impact of these factors on their operations.

In line with increased environmental awareness, administrators are tasked with significant roles that involve making critical decisions that alter different hospitals’ operations. In line with other environmental demands, the administrators have also employed critical approaches to supply management while refocusing on creating green supply chains (GSC) to reduce energy and resource consumption, address the lack of recycling, and improve waste management (Camgöz-Akdağ et al. 2016). The change necessary to address the problem involves altering hospital functional processes to rhyme with the systematic approach applied globally to improve hospital management and create other options that will result in sustainable management. The changes aim at critical issues started in international standards operations that involve customer satisfaction and continuous provision of high-quality products regardless of organizations’ scope of practice (ISO 9001:2015 2019). The significant changes are equally linked to environmental factors, which enhance environmental performance and achieve environmental sustainability objectives (ISO 14001:2015 (en) Environmental management systems — requirements with guidance for use 2020). In this context, hospitals are identified to face the challenge of increased expenses for using medical and non-medical supplies, and they are seeking ways to reduce both costs and the negative impact on the environment.

Despite the focus of modern organizations on applying the principles of green supply chain management (GSCM), the healthcare sector across the globe can be viewed as being at the initial stages of transitioning to GSCM. The reason is that hospital management has only recently begun to develop strategies that correspond with the requirements of ISO 14001-2015 and ISO 9001-2015 (Gerwig 2015). The key requirements of ISO 14001-2015 and ISO 9001-2015 involve developing hospital performance practices that incorporates the needs of stakeholder plus incorporating the needs of the changing environmental demands that do not alter the efficient operations of any organization (ISO 14001:2015 2020; Noviantoro et al. 2020). The recent implementation of the ISO standards has led to improved hospital operations including increased focus on patient operation promoted by employment of internal processes improvement decisions that promotes increase efficiency levels in hospitals operations. As Noviantoro et al. (2020) state, the integration of the ISO standards in GSC policies in different hospitals has involved this process of developing new operational principles that cater for the enhancing the environment sustenance level and in consequence improving the operational efficiency levels in different organizations.

In order to address the said situation, some hospitals in such countries as Australia and Turkey chose the principle of GSCM. Thus, managers from the healthcare industry have implemented GSC according to international based standards. The managers aim to increase environmental performance levels and improved hospital abilities to meet customer needs in providing its services (ISO 9001:2015 2019; ISO 14001:2015 (en) Environmental management systems — requirements with guidance for use 2020). These changes ensure guaranteed environmentally friendly management approaches (Stoimenova, Stoilova & Petrova 2014; Toprak & Şahin 2013). In this context, it is important to research what challenges were faced at the stage of implementing GSC in hospitals in both countries and what benefits were achieved. This chapter presents the background for the study, the rationale for this research, aims of the study, research questions, the contribution to theory and practice, the statement of significance, and a conceptual framework.

Environmental issues are a concern for the global community, including the governments and the general public. For example, the Doctors from Australia (no date, p. 1) report that “climate change is a health emergency that is contributing to deaths and life-threatening illness” and meeting the emissions standard outlined in the Parisian agreements Australia will have to reduce its emissions by 7.6% each year. This is a substantial reduction that requires efforts from the public, businesses, and the government, and the latter in particular will advocate for the change by issuing policies and prompting businesses and public service providers to change their operations and the management of their supply chains to address the target reduction. Doctors from Australia (no date, p. 1) also state that “net zero emissions by 2030 from the Australian healthcare sector, while desirable, are unlikely to be achievable due to the lack of a ‘road map’ and consistent measurement of carbon emissions to track changes.” Therefore, there is an emergent need for research and practice recommendations that hospital managers will be able to apply to reduce the carbon dioxide emissions and the environmental impact of their entities to help the state achieve the goals outlined in the Parisian agreements and to address the global environmental changes. Therefore, this paper makes a contribution to the understanding of how the ISO standards can be applied to rapidly enhance the efficiency of green practices used by hospitals and their management.

The specifics of the hospital supply chain management are linked to both the constraints of the healthcare systems and the legal frameworks under which the SCMs have to operate and the economic system that prevails globally. According to Moons et al. (2019, p. 205), “the medical supply costs constitute the second-largest expenditure in hospitals, after personnel costs.” This means that SCM is among the essential elements that allow the healthcare facilities to deliver the services of care to the patients, making it important to consider the recent trends and directions of development for the SCM. A sustainable healthcare supply chain can be achieved by combining the triple bottom line, industry 4.0, and the corporate social responsibility statements (Dau et al., 2019). Hence, hospitals have to maintain a balance between ensuring that the SCM practices they use do not endanger the patients, which in many cases means that they are required to work following strict standards, such as have uninterruptable energy sources within their facilities or work with suppliers who have obtained a state verified certification for their products and the recent trends towards environmentally friendly practices. Phillips (no date) states that the latter is the outcome of the Circular Economy, which is the system where the focus is not on merely the production of goods and services but also on combatting the global challenges.

Climate change is one of such challenges since it is affecting all the nations and will continue to impact the next generations and because the companies and facilities operating in different parts of the world are all contributing to this environmental change. Apart from this, the Circular Economy deals with the issues of losing the planet’s biodiversity, excessive waste, and pollution (Phillips, no date). In contrast to this, the linear economies, under which the majority of the businesses and SCM systems currently operate, are designed to produce items that will eventually become waste without regard for what will happen to this product after it has fulfilled its purpose and how the process of procuring raw materials and operations of the production facility contribute to the pollution and greenhouse emissions. Although linear economies have successfully satisfied the demand for products and services in the past, climate change and environmental damage prompt managers and policymakers globally to change the way they approach production and SCM in particular and adopt strategies consistent with the Circular Economy principles.

The SCM practices that align with the Circular Economy system have to consider the broader consequences of production and product use. Invernizzi et al. (2020) define the following methods that can be used under this principle: reuse, refurbish, recycle, remanufacture, establish a closed-loop system, and use minimum resource inputs. However, for hospitals, due to the safety and sanitation standards, not all of these methods can be used. According to WHO (2018), the coverage of the closed-loop economy practices for the healthcare facilities and suppliers has been limited, suggesting that this industry still requires a plethora of research and evidence-based practices implementation and testing to establish a clear framework that balances the healthcare standards and environmental consciousness. Moreover, a broad set of stakeholders is involved and affected by the attempt to transform the healthcare system towards one that is sustainable. WHO (2018, p. vii) states that these are “intergovernmental organizations, governments of WHO Member States, the public sector, the business sector, non-governmental and civil society organizations, the research community, the mass media, and the general public.” Form this; one can conclude that the issue of environmental practices application in healthcare is important since it impacts a broad range of people and organizations, and considering the underlying implications of why the Circular Economy has emerged, this issue is meaningful not only for people who use healthcare services but also for the future generations who will be affected by the depleted resources, change in the climate, and pollution.

The issue of SCM using green practices has broader implications and, ideally, should be addressed at the initial stages of developing a project for a future healthcare facility. Dau et al. (2019) examine the potential barriers and established business practices that might become barriers to the transition towards the circular economy in healthcare since suppliers in GSCM systems still have to maintain their profitability and operate under conditions that make their businesses viable. For healthcare institutions, the integration of the sustainability practices has to be reflected in the corporate social responsibility statements of these facilities because they show the commitment of these organizations towards transitioning to the better use of resources. Moreover, Dau et al. (2019) argue that apart from the SCM practices that support the immediate needs of the hospitals, the executives should also pay attention to the supply of the materials and cooperation with contractors when building new facilities, such as new hospital wings or units. This attention is required because new technology, such as the use of solar panels and electricity and light resources on the stage of designing a facility, can significantly affect the future demand of this facility for the things such as electricity or light or waste management, which are a part of SCM. The present study can serve as a blueprint for future hospital projects because it will outline the practices that are currently employed by two hospitals that have the ISO certifications, meaning that the structure and the facilities of these buildings can be developed considering the future resource use.

The triple bottom line, as one of the components of a sustainable supply chain, is the assessment of the impact that the business has on the environment. As opposed to the traditional concept of a “bottom line,” which is solely based on the income that a particular company can generate, the triple bottom line also considers the stakeholders and the broader implications of the company’s operations, which is also applicable to the private hospitals and healthcare suppliers (Miller, 2020). This concept consists of three elements: “profit, people, and the planet,” which means that a successful business, under the triple bottom line model, has to earn revenue, have a positive impact on the customers and the community where it operates, and use practices that do not harm the planet (Miller, 2020, para. 5). From the viewpoint of the hospitals, this approach means that they should account not only for the patients whom they help as part of their daily operations and the revenue versus expenditures that result from these but also the broader implications of how the resources that the employees use and the patients need are affecting the environment.

Based on this assessment of the Circular Economy and the triple bottom line, one can assume that the management of the supply chains in the hospitals has to change eventually since there is a global trend among businesses to adjust the practices towards the ones that will provide the owners not only with the profits but also will not affect the environment negatively. These changes are inevitable also due to the public’s awareness of the environmental issues and their impact on the planet since, according to Phillips (no date) and TORK (2019), 94% of patients care about the hospital’s sustainability practices. Therefore, these patients will select the facilities that have a corporate social responsibility strategy and which voice their SCM practices and how that help preserve the planet and the climate. This matters in particular for the countries with private healthcare, one of which is Turkey, where the healthcare system is a mix between private and public facilities, and the patient is essentially a consumer whose preferences will affect whether this entity will gain profits. For public hospitals, the issue of patients’ awareness of the environmental issues and GSCM practices is linked with the allocation of insurance payments because individuals have the opportunity to choose a provider. Therefore, this paper explores the specifics of GSCM not only due to the trends towards the sustainability and environmental friendliness that prevail in the global economy, but also because of the increasing attention from the general public towards the specifics of corporate social responsibility, resource use, and SCM practices at a given facility. Therefore, the results of this study will provide hospital managers with insights into the issues of green supply chain management and the best ways of implementing the ISO sustainability standards into a healthcare facility’s operations, regardless of whether the hospital operates as a public or private entity.

GSCM is a concept that emerged fairly recently, and it relates to the suppliers adjusting their practices, such as production methods, materials they use, the in-house energy consumption levels to reduce the amount of carbon footprint and the waste that is normally generated by these businesses entities. The overall goal of GSCM, not only in the context of healthcare, is to help address concerns beyond the mere satisfaction of the demand for a certain type of healthcare product, such as syringes, and instead, satisfy the demand in a way that minimizes the impact of this process on the environment and helps preserve the planet.

The reason why this study examines GSCMs in the context of hospitals is that they are among the most significant contributors to greenhouse emissions globally, and in Australia and Turkey in particular. Therefore, by enhancing the understanding of how the two hospitals already use GSCM developed under the ISO standards, one will be able to create recommendations for all healthcare entities that will provide effective and proven methods of changing the supply chain management to the type of system that is both effective in satisfying the demand for the healthcare products and services and is not affecting the environment negatively, as the existing systems do.

ISO was selected as a standard for this case study because it is an internationally recognized framework for regulating the different elements of business operations that are used internationally. Hence, the ISO standards selected for this paper allow examining the consistency of applying the SCM and GSCM practices across varied settings. The benefit of using an ISO standard is its applicability across different healthcare settings that will allow utilizing the results of the present study for the improvement of the management of the hospitals in countries beyond Australia and Turkey. Moreover, this study will help examine whether the ISO standard for GSCM is adequate for setting up an SCM system that will operate both efficiently from the viewpoint of business operations and which will address the environmental concerns of the hospital’s greenhouse emissions and resource use.

The main concerns regarding the “environmentally unfriendly” practices of the healthcare facilities include generating large quantities of unrecyclable waste, emitting pollutions, and using nonrenewable energy not efficiently. Despite the fact that authors and the general public have raised concerns and discussed the environmentally damaging practices that are routinely applied by the hospitals, not many changes are made by these facilities to this day. An example of such discussion is a report by PA Consulting, written by Phillips (no date), who argues that hospitals consume large quantities of nonrenewable energy, which is supported by the research from Yale University where healthcare facilities were found to be the second-largest energy consumers in the United States. In terms of the carbon footprint ratio, they account for 10% of the overall emissions in the state, and the amount of carbon dioxide they emit has increased by almost 30% between 2006 and 2016 (Phillips, no date). Although these findings are relevant for the United States, one can generalize the numbers to describe the current state of emissions by healthcare entities in other developed nations as well.

The present study will be a significant contributor to understanding the current GSCM practices in the context of the healthcare environment and will serve as a guide for hospital managers who want to implement the ISO standards into their operations but who are not sure how these standards work in practice and how they align with the day to day operations of a healthcare facility. Some general recommendations that Phillips (no date) outlined include updating the procurement management strategies, such as enhancing the waste management strategies. This can be achieved through partnerships with medical device suppliers to develop alternatives for single-use devices. Such partnerships can help the manufacturers dress the issues associated with infection control by developing protocols and control systems that are directly monitored by their partner hospitals. Additionally, Phillips (no date) recommends applying recycling in non-hygiene-related areas, such as the management and delivery of food across the hospital. These simple steps can help improve the hospitals’ operations in regard to their environmental footprint; however, these are theoretical developments. This paper addresses the lack of case studies and other related developments that would guide the facility managers in the direction of evidence-based sustainability.

Supply chain management, in general, is a complex subject and the integration of green practices makes it even more challenging for healthcare managers. According to Moons et al. (2019, p. 205), “a well-defined supply chain strategy is needed for aligning internal logistics processes and controlling supply chain costs in a hospital.” Moreover, in such supply chains, measuring the performance loss points and parts of the logistics where improvements can help save costs become essential. Moons et al. (2019) define two supply chain domains that require attention from a GSCM perspective: the delivery of items to the hospitals and the distribution of these to the points of care. Moreover, the ethical aspects of healthcare imply that the providers distribute not only the physical goods required to provide the services, but they are also responsible for the information flows that are directed at a patient.

Finally, the justification for using the ISO standards as opposed to examining the general practices of the hospitals that are under the sustainable category should be provided. First and foremost, this study aims to help healthcare managers globally, in line with the Circular Economy theory, where entities have to account for their impact on the global society and the planet. Hence, there is a need to use a set of standards that could be applied across different nations as opposed to focusing on the sustainability practices that are outlined in the regulations of the Australian or Turkish governments. Secondly, the use of ISO and the comparison of the two hospitals in different states can make it possible to healthcare managers from public and private sectors to find insights for themselves, since there are differences in the way the public and the private entities operate and in particular how they manage their suppliers. Hence, this case study will be applicable to different healthcare systems, which will make it more universal. Finally, based on the findings, the authors will propose an improved framework for the ISO standard and some recommendations for hospitals that want to implement these. This is necessary to address some inconsistencies and the areas of the unknown in relation to how the ISO is implemented in real life. Hence, the results of this study should contribute significantly to the research and practice in the area of SCM sustainability for hospitals, both private and public.

As for the gaps in the existing literature, the main issue is the lack of empirical studies that would show the benefits and downsides of applying the green SCM in the healthcare industry sector. For example, there are theoretical papers from 1982; however, to this day, there are few case studies or research papers that managers can use to learn about the implementation of green SCM (Asgari et al., 2016). Moreover, Agi et al. (2021) and Haiyun et al. (2021) also point to the problem of not having data or best practices that would guide the management towards the effective implementation of GSCM.

This research has allowed one to determine some of the benefits of greening in the long run. For example, green SCM is beneficial for waste management, which means that the hospital can reduce the amount of recyclable and non-recyclable trash. Additionally, the green wing allows saving energy resources, which is also beneficial for the financial management of the facility.

UN-SDG goal addressed by this research is number 11, “sustainable cities and communities” (UN, no date). As hospitals, whether public or private, are essential institutions for communities, ensuring that their operations are efficient and do not harm the environment becomes essential. COPD30 strives to affect global climate change, and goal four of this initiative is the following: “accelerate action to tackle the climate crisis through collaboration between governments, businesses and civil society” (‘COPD30′, para. 4). Hospitals are a part of civil society, and the management of these facilities has to align with the goals for minimizing the impact of climate change. Therefore, the motivation for this research is the need to gather and analyze empirical data that hospitals’ management can use to effectively implement the GSC management practices.

Context Chapter

The following paragraphs will provide the context for this research and the issue of sustainable hospital management and greening of SCM. On the one hand, sustainability and green practices within the SCM systems promise an enhanced way of managing the suppliers, the one that does not harm the environment while providing the necessary supplies on time and in required qualities. On the other hand, there is a risk of making the SCM system costly and ineffective when focusing on the greening of supply chains and omitting the business aspect of operations, which is important for hospitals, both private and public.

The current practices of supply chain management of the hospitals imply the use of supply chains that allow the hospitals to save money while receiving the products and services they need to operate (Fahimnia et al., 2018). Little attention is given to the issue of sustainability and the use of green practices in general, despite the fact that the notion of GSCM has existed for over thirty years (Fahimnia et al., 2018). Moreover, the main reference for GSM currently is the ISO standard since few research papers or case studies exist that would explain the best practices of GSCM. Hence, many healthcare facilities have already begun to transform their SC to comply with the ISO 9001-2015 standard, but the lack of research and empirical data makes it challenging to do this effectively.

Another issue is the balance between creating an effective supply chain, which is the one that allows receiving the resources that the hospitals’ employees require to provide the healthcare service with the green practices. For example, Fahimnia et al. (2018, p. 129) note that “both greening and buttressing can be costly, green supply chains are most sensitive to disruption, robust supply chains have strong long term benefits, and buttressing a green supply chain is a good investment.” Hence, despite the positive effect on the environment, GSC management remains expensive and not as effective as the traditional SCM practices. Moreover, greening practices are “requiring suppliers to be green and requiring additional greening investments may result in having fewer suppliers, influencing overall SC robustness,” which means that green supply chains are not equally effective for all industries (Farhime et al., 2018, p. 129). Therefore, this research helps determine whether GSCM is an adequate practice for private and public healthcare institutions.

Institutions and business organizations are facing pressure from the stakeholders to implement sustainable and green practices into their operations. Fahima et al. (2018, p. 129) state that “new environmental regulatory mandates and tighter sustainability reporting regulations” are the evidence that organizations have to adopt green practices into their operations. In addition, the COPD30 and UN-SDG initiatives draw the public’s and government’s attention towards the enhancement of the SCM and the need to focus on sustainability and the reduction of the environmental impact of human activities, which includes hospitals as well. Thus, this research helps managers explore the effective ways of managing the green SC and have a balance of robustness and environmental sustainability.

Thus, these two government and private hospitals require an in-depth study because their management has already begun the process of implementing GSM, and their examples, including the positive and negative effects of greening, can help avoid the potential mistakes for other healthcare facilities. Ther experience in managing green SC can help other healthcare institutions implement the same practice considering the experience, mistakes, and best practices described in this paper.

Research Background

The application of effective management practices in hospitals plays a key role in contributing to the healthcare industry’s better performance. Studies indicated that the adoption of the most efficient and evidence-based management practices in hospitals guarantees reductions in patient mortality rates, improvements in patient outcomes, enhancements in providing care, and positive changes in operations and workforce’s activities (Dobrzykowski et al. 2014; Machado, Scavarda & Vaccaro 2014). In this context, effective management practices include techniques associated with organizing the work of staff, delivering care, distributing funds, using equipment, and promoting retention, among others (Chiarini 2015). This section presents the discussion of healthcare management practices adopted in hospitals of Australia and Turkey, focusing on the review of SCM principles followed in the healthcare sector to provide the background for the current research

Healthcare Management Practices in Hospitals in Australia

The healthcare system of Australia includes both public and private sectors. The annual healthcare expenditure for this industry in the country is about $AU100-110bn (The Royal Australian College of General Practitioners 2015). The public sector represents about 70% of the industry in terms of provided funding covered by the federal government (40% of funding) and state governments (60% of funding). Thus, about 30% of the industry are privately funded (Bhakoo, Singh & Sohal 2012). Public hospitals remain most popular among Australians because of the high quality of provided care, and about 60% of patient admissions are addressed to public hospitals in Australia (The Royal Australian College of General Practitioners 2015). In spite of an appropriate budget adopted for hospitals in Australia, the quality of the work of a healthcare system depends on effective management. The problem is that healthcare costs increase each year and certain changes to demography have led to developing challenges for managing healthcare facilities successfully and providing high-quality services to implement working management practices.

From this perspective, managers in Australian hospitals work to adopt specific practices to improve, maintain, and effectively monitor healthcare operations, workers’ performance, people management, care delivery, quality management, waste management, and the work of a supply chain. In Australian hospitals, much attention is paid to guaranteeing the high quality of provided services and ensuring that the length of patient stay is appropriate, and spent costs are reasonable (Agarwal et al. 2016). In order to achieve these results, managers improve used protocols, promote the utilization of the most efficient clinical practice guidelines, focus on the most effective organizational practices, and change hospital layouts to address patient flows (The Royal Australian College of General Practitioners 2015). In addition, they introduce advanced technologies to provide care for more patients and exchange knowledge and data, implement practices to reduce expenses, and focus on innovative and cost- and resource-efficient management approaches (Agarwal et al. 2016; Bhakoo, Singh & Sohal 2012).

In order to build accountability in Australian hospitals, managers and administrators focus on implementing new systems for working with material and human resources, evaluating performance and outcomes, ensuring sustainability, and guaranteeing high-quality care. For this purpose, healthcare administrators change their approaches to addressing a community’s needs and patients’ expectations, managing waste, developing supply chains, and monitoring performance (Bhakoo, Singh & Sohal 2012; Rodwell & Gulyas 2013). As a result, levels of employee commitment and the quality of care in Australian hospitals are comparably high according to recent statistics for the industry (The Royal Australian College of General Practitioners 2015). Therefore, it is possible to state that modern healthcare management practices adopted in public and private hospitals of Australia are oriented not only to the improvement of patients’ treatment but also to the use of most cost-efficient approaches in their practice.

However, not all Australian hospitals are managed effectively to address patients’ needs, stakeholders’ interests, and save costs. The adoption and work of management practices in the healthcare industry depend on various factors, including managers’ leadership, the type of implemented practices, management areas covered during change processes, the staff’s response, and specifics of cooperation with suppliers. From this perspective, administrators in the most successful Australian hospitals tend to pay much attention to managing their operations and applying SCM principles (Agarwal et al. 2016; Böhme et al. 2014). The choice of the most effective approaches in this case is based on hospital-specific features that determine paths selected by managers in the healthcare industry to achieve higher outcomes for patients and decrease associated costs.

Large Australian hospitals with more beds and patient flows usually demonstrate more strict management, effective performance, and high-quality care because of the adoption of the most efficient managerial practices appropriate for the healthcare industry. Nevertheless, these hospitals, which often belong to the public sector, also face the most critical challenges and barriers to decreasing costs, balancing expenses, and avoiding the negative impact on the environment and community because of their activities (Böhme et al. 2014; The Royal Australian College of General Practitioners 2015). Moreover, supply chains in the healthcare industry in Australia differ significantly from other sectors. All these aspects influence Australia hospitals’ necessity to revise their policy with the focus on strategies, methods, and SCM improvements in these facilities and contribute to sustainability and corporate responsibility.

Healthcare Management Practices in Hospitals in Turkey

In Turkey, the healthcare industry is accounted for about 6% of the country’s GDP, and it is represented by public and private sectors (Polater, Bektas & Demirdogen 2014). However, in spite of paying much attention to funding this industry, there are still management issues that can be observed in different types of Turkish hospitals. The healthcare industry is constantly growing and developing in order to address national health goals, and as a result, it is oriented to adopting changes and using a variety of efficient healthcare management practices. Technological improvements and enhancements in the quality of provided services are typical of the Turkish healthcare sector (Akdaǧ 2015; Erus & Hatipoglu 2013). Although much attention is paid to innovation and changes, common issues include the reference to ineffective managerial practices and processes, the inappropriate utilization of resources, the use of outdated systems for sharing information, the use of ineffective cost distribution and control strategies, as well as the application of inefficient waste management (Akdaǧ 2015; Erus & Hatipoglu 2013; Polater, Bektas & Demirdogen 2014).

From this perspective, it is possible to state that healthcare management practices applied in Turkey’s hospitals are most effective when they are oriented to change management. With that said, this direction does not resolve the matter entirely, and other measures will also need to be applied to maximize performance. According to Özkan, Akyürek, and Toygar (2016), there are problems with managing healthcare personnel, organizing effective healthcare logistics, and controlling the work of supply chains to reduce costs and address the inefficient use of resources. Camgöz-Akdağ et al. (2016) also agree that healthcare management practices in Turkey require improvement. The focus should be on integrating strategies and techniques that can help healthcare providers and administrators reduce costs and funding and change the approach to using resources, and achieve better outcomes for patients. This aims carter the demands of international standards provisions that requires enhancing organizational operations to carter for management inefficiencies that alters the ability of the hospital to meet higher level of customer satisfaction through effective application of the system including making process improvement to conform to statutory and regulatory requirements Thus, administrators in Turkey’s hospitals have achieved significant positive results in implementing innovation and change in their organizations. However, the basic healthcare management practices still need to be improved and developed.

The healthcare sector’s focus on innovation and change is the adoption of national policies directed towards the promotion of the universal health coverage for all citizens in Turkey among other initiatives (Akdaǧ 2015; Erus & Hatipoglu 2013). From 2002 through 2012, Turkey’s healthcare industry experienced significant changes in the context of realizing the principles of the national health transformation program. On its path to providing universal health coverage, Turkey achieved the improvement of the nation’s health status, decreases in infant mortality rates, and increases in patient satisfaction. The overall access to healthcare increased for different categories of the country’s population, and this aspect created more challenges for organizing the work of healthcare personnel in hospitals (Akdaǧ 2015; Erus & Hatipoglu 2013). Despite the fact that updating health information systems, reorganizing resources in healthcare facilities, redistributing costs, and improving supply chains were tasks required for completing in the context of the Health Transformation Program, there are still barriers to achieving these goals.

Moreover, it is important to note that changes in the country’s healthcare industry have led to attracting more healthcare practitioners to public hospitals because of increased incentives. As a result, approaches to organizing specialists’ work and using resources have been changed as SCM principles were followed inappropriately in many cases (Akdaǧ 2015; Erus & Hatipoglu 2013; Özkan, Akyürek & Toygar 2016). Thus, inefficiency in the work of public hospitals of Turkey can be observed even today in spite of efforts made by healthcare administrators to address the problem. From this perspective, it is possible to state that healthcare management practices used in Turkish hospitals are developed to address the policies associated with health transformation program that have been realizing in the country during a decade. However, there are still problems with integrating practices that can reduce costs and improve the use of resources without compromising the quality of care.

Rationale for Research

The practical application of green SCM approaches in the healthcare industry is still almost unstudied in contemporary literature despite the current interest of researchers in investigating this problem in different sectors, including healthcare. In spite of the fact that many hospitals in different countries choose to transform their SCM into GSCM to reduce waste, focus on recycling, and eliminate a negative impact on the environment, additional research is still required in this field (Chakraborty & Dobrzykowski 2014; Kovac 2014). Moreover, scholars and practitioners have to pay attention to the fact that those practices that are used by managers to make their supply chains green require further investigation in a specific healthcare industry. Furthermore, the national factor is also important in this context because GSC strategies and practices selected by healthcare managers in various countries differ significantly.

As a result, it is assumed that the experience of hospitals in Australia and Turkey on their paths to building GSC is different, with the focus on certain barriers, challenges, advantages, and disadvantages associated with this process. The problem is that more research is required to examine how hospitals can successfully apply green SCM practices to address the idea of sustainability and reduce their environmental influence with reference to specific case studies. Moreover, research is also required in order to understand how the application of ISO 14001 and ISO 9001 can influence the process and lead to developing GSCM in this or that facility (Muzaimi, Chew & Hamid 2017). The ISO application provisions demands for innovative process change on the current organizational operations that carter for the current customer needs and other current environmental demands (Ferreira, Poltronieri & Gerolamo 2019). Although discussing supply chains in the healthcare industry researchers often refer to ISO 14001 and ISO 9001 standards, there is still no appropriate evidence to state that the application of these standards is directly associated in hospitals with their realization of GSCM.

Certain practices are important to be implemented in Australian and Turkish hospitals to improve SCM to overcome challenges associated with high costs, disintegrated processes, and resource-consuming operations. As a result, the rationale for conducting this study is that there is the lack of literature on comparing the experience of hospitals from different contexts regarding the development of GSC. Moreover, there is also the lack of literature on discussing the application of ISO 14001 and ISO 9001 in this area. Finally, more recommendations for practitioners are required to be formulated as a result of this study. It is important to investigate how the application of ISO 14001-2015 and ISO 9001-2015 standards can contribute to building strong integrated GSC based on dyadic relationships in Australian and Turkish hospitals. It is also critical to compare the findings for two national contexts using a mixed-methods case study design.

Aims of the Study

First, this research aims to evaluate and describe the specific connection between the application of green SCM principles and successful compliance with the ISO 14001-2015 and ISO 9001-2015 in certain selected hospitals in Australia and Turkey. Further research should examine how hospitals in Australia and Turkey can apply green SCM and ISO 14001 and ISO 9001 and integrate them into its daily practices because the trend of greening practices is comparably new for the healthcare industry all over the globe (Bhakoo, Singh & Sohal 2012;Camgöz-Akdag et al. 2016). The second aim for this research is to determine and explain the procedures that are necessary for applying effective greening strategies that comply with ISO 14001-2015 and ISO 9001-2015 in the healthcare industry of both countries. Finally, the third aim is to compare and contrast processes of greening supply chains with reference to ISO 14001-2015 and ISO 9001-2015 in the selected hospitals of Australia and Turkey to conclude which approach is more environmentally friendly.

These aims reflect the need for examining GSCM strategies in the selected hospitals to provide the background for additional research on the topic, determining how these case studies are representative of greening practices in some hospitals of Australia and Turkey. The research does not aim at comparing the hospitals’ achievements in greening supply chains based on the type of ownership, and the focus is on comparing practices in different national contexts. The aims address critical issues determined for Australian public and Turkish private hospitals, which have grappled with the problem of increased healthcare expenditures and the negative impact of management on the natural environment due to the growing number of patients, along with the increased volume of waste.

Moreover, these processes may be connected with increasing activities in hospitals over the past decades (World Health Organization 2014). The problem is that, in Australia and Turkey, public and private hospitals only start focusing on GSC initiatives, and the overall process of shifting standard managerial processes to this specific greening practice is rather complex and problematic (Bhakoo, Singh & Sohal 2012; Camgöz-Akdağ et al. 2016). The complexity of health care sector operations continues to intensify in the current period. And as noted in the ISO provisions, hospitals are to ensure that current issues are addressed considerably and more innovative approaches are used to ensure successful implementation of environmental management processes (Noviantoro et al. 2020; Sepetis 2019). Such innovative measure includes the management policies applied by different organization in the implementation of green supply management.

Consequently, at this stage, supply chains in Australian and Turkish hospitals can be viewed as mostly disintegrated. The reason is in faced problems with information sharing, controlling processes, and planning interactions with suppliers and customers. Social costs that are associated with these challenges are high because they affect the quality of proposed services and care (Chakraborty, Bhattacharya & Dobrzykowski 2014). In order to address these problematic questions, the current research will be built on a new framework that is based on the explanation of the influence of innovative greening practices on the traditional organization of business and logistics management processes in the healthcare industry.

This study used a TOE framework to address the main issues with the implementation of GSCM from the organizational perspective. The objective of this research is to address the literature gap on GSCM practices in healthcare, which is the lack of studies that would explore the practice of implementing the GSCM standards aligning with ISO 14001 and 9001 in the healthcare system. The current literature either explores the theory of GSCM or focuses on statistical data. Moreover, only a few studies explore GSCM within the healthcare system, and no study was found that compares the application of GSCM to public and private institutions. Therefore, by analyzing the application of GSCM practices in Australia and Turkey, the researcher aims to create a case study that healthcare institutions’ managers can use to implement GSCM in their facilities effectively.

Moreover, the analysis of the literature shows that the input of stakeholders is essential for the proper implementation of GSCM. The stakeholders, such as the hospital’s patients, community members, policymakers, and international organizations, are the ones pressuring these healthcare facilities to implement greener practices into their operations.

Research Questions

Hence, this case study will serve as a reference point for managers who want to understand the needs of their stakeholders when implementing GSCM. Hence, the research question for this case study analysis is the exploration of the expectations and the effects of implementing GSCM practices on hospitals. The case study is written using data collected from two hospitals, one private and one public, to showcase the management differences of the two approaches. This study examines specific cases related to adopting SCM practices in hospitals of Australia and Turkey and their success in following ISO 14001-2015 and ISO 9001-2015 standards. In order to address the purposes and aims of the study, it is necessary to respond to the following main research question:

Research question: what are the effective strategies for implementing a GSCM management strategy that hospital managers can use, and what potential limitations of GSCM will they face?


  1. What is the significance of greening hospital supply chains in Australian and Turkish hospitals?
  2. How can SCM changes in hospitals, both public and privately owned, of Australia and Turkey be promoted effectively?
  3. Why is the application of ISO 14001-2015 and ISO 9001-2015 in the context of integrated GSCM appropriate for Australian and Turkish hospitals?
  4. What integrated GSCM procedures, corresponding with ISO 14001-2015 and ISO 9001-2015, are applicable to healthcare sectors in Australia and Turkey?

ISO 9001 and ISO 14001

The ISO 9001 and ISO 14001 standards are used by the International Organization for Standardization. The former is the better-known of the two, as it covers the foundations of a quality management system. Most businesses have recognized the utility of such a framework, and it has become standard to create one. The ISO offers certification that confirms an organization’s compliance with the ISO 9001 standard, which has helped establish its reputation. ISO 14001 is a similar standard to ISO 9001 that sets out the basic standards for creating an environmental management system. It can also be certified to, but, since it is a newer development, as indicated by the higher family number, it is not as popular as its quality-related counterpart. With that said, certification in either standard can provide the assurance that the organization’s systems are based on a sound design approach to its employees and stakeholders. Moreover, the basic structure can serve as a foundation for the development of a more advanced green framework that takes the context of the organization into consideration.

Contribution to Knowledge

This study significantly contributes to both theory and practice related to the topic of implementing GSC in the healthcare industry. The reason is that the lack of research is currently observed regarding this issue, and there are many aspects to examine and discuss while referring to the contexts of Australian and Turkish hospitals. Specific theoretical contribution and practical contribution will be considered and discussed below.

Theoretical Contribution

The development of modern healthcare sectors in both Australia and Turkey is rapid due to significant increases in numbers of patients requiring treatment and new functioning hospitals. However, the problem is that such increase in the volume of the healthcare sector operations directly affects the condition of the natural environment in Australia and Turkey (Agarwal et al. 2016; Akdaǧ 2015). Therefore, a specific impact of healthcare operations on the natural environment has become a subject of scientific and management interest that requires its further discussion and analysis. The issue is specifically related to the situation with Australian hospitals because the national government emphasizes the implementation of advanced greening techniques to minimize the negative impact of the healthcare industry on the natural environment (Bhakoo, Singh & Sohal 2012; Böhme et al. 2014).

The similar situation is observed in Turkey, where the government published a series of regulations in order to improve waste management processes in different sectors, including the healthcare sector (Camgöz-Akdağ et al. 2016). To address the negative impact of the absence of recycling procedures and effective waste management techniques, companies and international organizations develop environmentally friendly approaches to management, such as GSCM, that is the transition from traditional supply chains to eco-friendly ones (Özkan, Akyürek & Toygar 2016). As a result, it is essential to understand the role of integrated green SCM in greening healthcare business procedures, along with possible benefits, when considering public and private medical facilities in Australia and Turkey.

From this perspective, this research will add to the scholarly SCM literature in healthcare and GSCM in Australian and Turkish public and privately owned hospitals. It is possible to state that, currently, the identified subject of interest lacks the detailed investigation, discussion, and analysis, especially in terms of comparing adopted green SCM practices in the hospitals of Australia and Turkey. Therefore, the proposed research seems to have theoretical significance as the planned study will also discuss the application of ISO 14001-2015 and ISO 9001- 2015 in the context of the healthcare industry as the framework for developing GSC (Agarwal et al. 2016; Camgöz-Akdağ et al. 2016; Özkan, Akyürek & Toygar 2016). The analysis of potential drawbacks and benefits connected with arranging integrated green SCM based on the requirements set by these two standards in Australian and Turkish hospitals will also add to the theoretical significance of the study.

Practical Contribution

There are many studies on specifics of applying ISO 14001-2015 and ISO 9001-2015 in healthcare organizations of different countries, but the limited research on the situation in Australia and Turkey is present. It is important to focus on how these standards can be used in hospitals over the globe. In the context of adopting the ISO 14001-2015 standard, it is expected that organizations will be able to reduce their waste, contamination of air, water, and soil, eliminate costs, and avoid the use of hazardous materials (International Organisation for Standardisation 2015). Furthermore, the application of the standard in hospitals is associated with decreasing the possibility of environmental accidents and enhancing performance because of decreased numbers of pollutants in the environment (Chege 2012). Therefore, while applying ISO 14001-2015, organizations become able to determine what environmental impact their operations have and how it can be addressed in terms of controlling activities, using resources, and manipulating inputs and outputs.

The problem of organizing efficient GSC in Australian and Turkish hospitals to overcome the issue of polluting the environment and improving waste management is practical in its nature. The analysis of GSC in healthcare industries of these two countries allows for determining the most effective approaches to forming supply chains in order to achieve the highest outcomes for hospitals applying ISO 14001-2015 and ISO 9001-2015 standards, as well as for their communities which involve a move to meeting current community needs and other environmental management demands.(Muzaimi, Chew & Hamid 2017) From this point, the practical contribution of the study is that its results will help managers and administrators in public and private hospitals in Australia and Turkey to identify and overcome possible complexities or challenges that are related to using ISO 14001 and ISO 9001 standards as a foundation for their SCM procedures. The analysis of the hospitals selected depending on their application of the standards, the type of services provided and the approach to managing medical waste will allow for identifying green SCM practices associated with referring to ISO 14001-2015 and ISO 9001-2015 in different national contexts.

The findings will be helpful for administrators in hospitals to choose the optimal ways to apply ISO 14001-2015 and ISO 9001-2015 standards in their country. Moreover, it is critical to pay attention to the focus on the comparison of greening supply chains in Australia and Turkey that allows for determining factors that influence the quality and performance of adopted SCM practices. This approach will help managers from different countries to analyze what techniques are most applicable to their specific contexts following the historical changes and the current advanced demands (Bhakoo, Singh & Sohal 2012; Chakraborty, Bhattacharya & Dobrzykowski 2014; Zainudin et al. 2014). In addition, it is also necessary to consider the fact that the study findings will contribute to improving the healthcare sector of Australia and Turkey while determining the most efficient green SCM procedures with reference to policy evolution in this area.

Statement of Significance

This research has both theoretical and practical significance. The conducted study adds to the existing knowledge and theory on green SCM strategies and practices in different national contexts, especially in the healthcare industry with its specifics. SCM in hospitals and, especially, GSCM are not well covered and discussed in the modern literature on management in hospitals in order to conclude what greening strategies and practices can be discussed as more or less effective in this or that context (Shen 2013; Silvestre 2016; Toke, Gupta & Dandekar 2010). As a result, more research is required in this field. In addition, the study potentially contributes to the generation of new knowledge following the pursuit of the more comprehensive investigation of green SCM strategies per the recommendations of ISO 14001-2015 and ISO 900-2015. Moreover, the study addresses new areas of research, such as the impact of greening and these standards on public and private sector hospitals in Australia and Turkey, along with the challenges connected with implementing such changes.

Furthermore, one of the factors that can maximize the study’s significance is the analysis of the increased impact of the healthcare sector on the natural environment, as well as a rising interest in seeking specific ways to diminish this influence. The reason is that the transition to environmentally friendly management strategies, as well as the focus on the legislation strictly controlling the level of impact on the natural environment, is a common tendency across most developed states (Mbaabu 2016; Min 2014). Still, the existing research in this area related to the contexts of such countries as Australia and Turkey does not cover this topic completely. The Australian and Turkish governments are currently taking their first steps in the direction of applying the principles of GSC in their hospitals, and numerous challenges and complexities are connected with the abovementioned transition due to a lack of appropriate theoretical and practical instruments and recommendations for making the process effective and productive (Böhme et al. 2014; Camgöz-Akdağ et al. 2016). Thus, additional research is required and expected in the field.

It is also important to state that the proposed research is of practical significance, and this aspect can be viewed and explained at several levels. Firstly, this study can be helpful and viewed as relevant for healthcare units in Australia and Turkey because they will receive within the framework required for implementing this challenging transition. Moreover, this study will illustrate the best methods of incorporating a theoretical investigation into the practical experience with the focus on green SCM approaches in hospitals of Australia and Turkey. As a result, recommendations provided in the study can consequently be applied by different healthcare organizations and units from similar contexts in order to avoid the most common problems in SCM, as well as maximize benefits. Moreover, the proposed research can be consulted and utilized by different companies across other industries to modify their practices in addition to learning how to adopt GSC.

Overall, it should be taken into consideration that administrators and managers can use the proposed findings to reduce environmental expenditures and the volume of resources utilized to make supply chains more effective. In addition, they will be able to focus on green management according to the principles and criteria associated with ISO 14001-2015 and ISO 9001-2015. From this perspective, the research demonstrates the significant potential value and connection to modern knowledge and practice.


GSCM is an emerging topic of substantial importance for various organizations. However, it is currently mostly being considered in the context of its utility to various manufacturing companies, where it is relatively simple to discern the patterns of pollution generated throughout the supply chain. On the other hand, in healthcare, the topic remains inadequately explored, and managers are often unaware of it or see little reason to adopt it given their work environment. However, in cases where it has been applied, the potential for substantial improvement has been discovered. Moreover, the ISO 9001 and ISO 14001 frameworks appear to be suitable for application in the healthcare industry through different approaches, notably those of Australia and Turkey. As such, a comparison between the two to determine the viability of green SCM and the approach that generates the most success is warranted for the further development of the relevant theory.

Historical Background

This chapter will address the background of the healthcare systems in the domain of their SCM. The concept of SCM has been used in business for over forty years. Whereas, the notion of sustainable SCM practices has existed thirty years ago. The process of SCM is complex in its nature, and the decision to move towards green practices, considering that this concept has been developed recently and that little literature and recommendations exist on this topic, is a challenge for contemporary healthcare organizations.

To structure this study and the interpretation of the results, the authors have used a research framework. This research has used a Technology Organization Environment framework, which is an approach that allows reviewing a technology-linked phenomenon from an organizational perspective (Chiu et al., 2017). Under TOE, there are three primary factors that determine whether an organization will accept a technology-based change or not, which are: usefulness, internal issues, and business environment (Chiu et al., 2017). This means that for the successful adoption of GSCM frameworks, the organizations have to have a suitable company culture and no internal managerial issues, as well as an established service provision strategy. Additionally, the change in question has to provide an evident benefit for the business, which in part means that the effect on the company’s bottom line has to be positive. Finally, the competitors, business partners, and suppliers have to be prepared to support the change. In the healthcare environment, TOE means that the hospital’s management has to be prepared to implement the changes that are needed to support GSCM and sustainability, for example, address waste management issues or energy consumption problems. Additionally, the suppliers that cooperate with these hospitals have to have the capability to produce the items and materials that align with the sustainability requirements. The TOE framework allows one to look at the GSM from a structured perspective, analyzing the varied factors that impact the success of implementing GSCM.

The more recent studies on GSCM and the implementation of green practices in hospital management produce mixed results. For example, Fahimnia et al. (2018) conclude that hospitals under their investigation experienced negative trade-offs when implementing GSCM since this approach was more costly when compared to the traditional or robust SCM. The authors note that there are industries where GSCM is especially effective, for example, for fresh food companies, GSCM means that the product is delivered in limited quantities and within specific time frames, which helps limit the amount of waste, preserve the environment, and save costs for the businesses. For hospitals, however, there is a need to invest in GSCM and sustainable practices, which does not produce results as effective as for other industries.

The question of balance between sustainable SCM practices, costs, and retention of the SC’s robustness remains an important topic in the literature. Fasan et al. (2021) argue that the main benefit of the traditional supply chains is their robustness, which is the ability of the SC to withstand a disaster, which is not the case with sustainable SC. Haiyun et al. (2021) analyze the efficiency of GSCM strategies using the QFD (quality function deployment) framework and conclude that understanding the customer’s expectations and having a proper customer relationship management system in place is the most important element for managing GSCs. By assessing the expectations of the consumers, the organizations can find a better balance between sustainable practices and the profits they want to retain from their operations. For hospitals, this might mean assessing the needs and expectations of the community members and policymakers to balance the profits with sustainability. Moreover, Haiyun et al. (2021) found that having a research and development department is helpful for organizations that aim to implement green practices since innovation is linked with sustainability, and these departments can help transform the operations of the business in general. Finally, Hayun et al. (2021) report that having an assessment of stakeholders’ opinions from different parties is an effective way to determine the strategies that the management should implement for sustainability. Thus, some studies link sustainability and implementation of GSC and the effectiveness of these strategies with the expectations of the stakeholders.

As was mentioned in the introduction, the notion of GSC management has existed for over thirty years; however, this approach has not gained sufficient attention from researchers and practitioners until recently. Agi et al. (2020) report that only within the past three years has there been an increase in the number of publications regarding GSCM, while before, the number of published articles was limited. However, the authors also note the majority of these papers are statistical models and two-level SCM structures (Agi et al., 2020). This suggests that little attention is given to the practice of implementing SCM strategies, which means that managers have limited access to the information and case study materials that would show them the best practices of GSCM. Agi et al. (2021) suggest that researchers focus on developing stochastic models and complex level GSCM to aid the practical implementation of this approach. Hence, this research paper contributes to the body of knowledge on GSCM in healthcare and addresses a critical gap in the literature, which is the lack of case studies and empirical data that would explore the experience of hospitals that have implemented GSCM strategies.

GSCM can be divided into internal supply chain management practices and external strategies. Stekelorum et al. (2021) argue that contemporary organizations have to embrace both strategies as the stakeholders require changes both in the way a company or institution operates and in how they procure the resources required for operations. Green supply is an external practice that many profit-oriented organizations have already adopted, which prompted the suppliers to change their operations and resort to environmentally friendly practices (Stekelorum et al., 2021). This suggests that currently, it is easier for companies to implement green practices as the infrastructure has evolved to support this approach and many suppliers understand the demand and the need to use sustainable production approaches. However, similarly to other studies explored in this review, Stekelorum et al. (2021) point to the mixed results of the financial performance that these firms show, as in many cases, GSCM leads to a decrease of costs, but only in specific industries. The main issue with GSCM is the high cost of the initial implementation, meaning that firms have to invest substantial financial resources into the initial implementation of GSCM. In many cases, the investment is justified as this practice reduces inventory investment and asset recovery, but the timeframe required for these benefits is also longer when compared to traditional SC. Again, this study points to a need to investigate GSCM further to develop a best practice approach suitable for organizations in terms of business benefits and stakeholders’ expectations.

Another important aspect of GSM is its potential positive impact during crisis or disaster times. An important feature of the traditional SCs is their robustness or their ability to withstand a natural or human-made disaster while retaining the same outputs, which is linked to the well-developed network of these types of supply chains. Fasan et al. (2021) report that US companies that used GSCM networks were able to withstand the negative effects of the COVID-19 pandemic better when compared to those using the traditional SCs. This suggests that GSCM has the potential of being more crisis resilient, which is especially important for the healthcare industry.

Thus, the literature has been critically analyzed to explore the gaps that exist in understanding the GSCM practices and their application in services. The TOE framework provides three critical elements that determine the success of implementing a technology-based innovation into the operations. However, TOE has not been used to explore the specifics of sustainability and GSCM in particular. Moreover, little research exists that addresses TOE and the application of GSCM in the healthcare industry, while the stakeholders, such as policymakers, consumers, and international organizations, pressure healthcare institutions to use sustainable practices.

History of Supply Chain Management in Healthcare in Australia and Turkey

In 1982, the concept of SCM was used to only explain to organizations the specifics of logistic management concerning different types of organizations and providers of resources and services (Asgari et al. 2016). Later, SCM was “integrated with the sustainable development concept to create many new trends in the academic field,” and the idea of “sustainable SCM was proposed by Linton in 2007” (Liu et al. 2017, p. 422). While the realization of SCM principles in the healthcare industry is a challenging task, managers are focused on reaching the goal of developing effective hospital supply chains.

These processes are associated with mitigating increases in expenses, improving resource usage, and patient care quality improvement. Nevertheless, the process of moving to the efficient SCM is complex, and currently, only a few healthcare industries worldwide can be characterized by having strategically efficient and collaborative supply chains including hospitals (Maleki & Cruz-Machado 2013; Rakovska and Stratieva 2018). The problem is that supply chains involving hospitals can be viewed as fragmented because of participants’ independent activities in these chains (Gerwig 2015; Polater, Bektas and Demirdogen 2014). In the healthcare sphere of Australia and Turkey, SCM is related to developing efficient structures and systems of governing hospitals and other facilities, developing productive relationships with suppliers, improving procurement and resource management, and implementing IT systems (Agarwal et al. 2016; Camgöz-Akdağ et al. 2016).

Supply chains are based on a series of interdependent transactions between all participants of the chain, and much attention should be paid to their collaboration. The major participants of healthcare supply chains in Australia and Turkey include different types of manufacturers, such as providers of equipment, specific hospital supply, and pharmaceutical companies, distributors, individual providers of specialized medical services, insurance companies, transport operators, national and state agencies, governmental authorities, employers, and patients (Agarwal et al. 2016; Bhakoo, Singh & Sohal 2012; Böhme et al. 2014; Camgöz-Akdağ et al. 2016). The success of the work in a hospital depends on the cooperation of all these actors because they need to guarantee the on-time delivery of high-quality services for the population. Currently, the authorities in both Australian and Turkish hospitals are oriented to implementing more efficient SCM practices to make hospitals effectively operating systems. However, they have to contend with the novelty of SCM’s application in the healthcare industry, and many modern hospitals have no experience in integrating the required changes effectively and achieve the goal of optimizing supply chains along with thew associated improvements.

The key SCM-related tasks faced by healthcare administrators in hospitals of Australia and Turkey include improving the management of inventory, facilitating public-private collaboration, and predicting the patient mix to guarantee the efficient use of available resources (Agarwal et al. 2016; Özkan, Akyürek & Toygar 2016). At this stage, administrators and managers of hospitals in Australia and Turkey consider opportunities for developing supply chains in the most efficient manner, and the universal response to this issue is the implementation of green SCM principles (Camgöz-Akdağ et al. 2016; Chege 2012). Green supply chains address the idea of sustainability not only in terms of the effective utilization of resources and inventory management but also in terms of minimizing waste and an overall negative impact of hospitals’ operations on the environment.

As was mentioned before, SCM application in hospitals is a comparably modern trend, and scholarly literature and practice within the last twenty years have been divided on the topic of GSC. Thus, the focus in hospitals and other healthcare facilities in Australia and Turkey seems to be moved from guaranteeing the high-quality care while using minimum resources to providing high-quality care while minimizing the complexity of all processes and their negative effects on the environment (Agarwal et al. 2016; Bhakoo, Singh & Sohal 2012; Camgöz-Akdağ et al. 2016). When choosing the path of modernizing SCM and even selecting strategies connected with GSC, hospitals all over the globe begin to save their human and material resources, address a community’s needs more efficiently, protect the environment, and reduce expenses (Agarwal et al. 2016; Maleki& Cruz-Machado 2013). Therefore, one of the major strategic goals usually considered by administrators or managers in hospitals is the realization of effective SCM.

One more characteristic of a hospital supply chain in Australia is its dependence on the aspects of total quality management. There are many international, national, and regional standards and guidelines that determine the quality of provided services in hospitals, thus affecting the work of a supply chain (The Royal Australian College of General Practitioners 2015). Furthermore, the variety of these standards is high because specific norms and rules are followed in different regions of Australia, and the healthcare industry of the country is not interconnected, and cooperation within supply chains in different regions is based on various guidelines.

It is also important to note that a hospital supply chain based on three key actors can be expanded to include government agencies and insurance companies. The necessity of collaborating with these actors also influences the development of supply chains in Australia through affecting direct and indirect paths of spreading resources (Bhakoo, Singh & Sohal 2012; Böhme et al. 2014). As it was noted earlier, the indirect path involving wholesalers and distributors is more typical of the Australian hospital supply chain (Rakovska & Stratieva 2018). In spite of the fact that hospitals in many countries often choose the direct cooperation, researchers noted that the intermediation involving wholesalers and distributors can have positive economic outcomes for hospitals (Bhakoo, Singh & Sohal 2012; Rakovska & Stratieva 2018). From this perspective, it is possible to state that the level of interrelatedness between actors of hospital supply chains in Australia is high, but the overall level of similarity between public and private hospital chains or between supply chains in different regions of the country is comparably low.

Although the authorities in hospitals in Turkey have focused on implementing supply chains, especially GSC, into their healthcare systems, there is still the lack of data regarding this process. Some researchers agree that the shift to GSC observed in the industry is a stable phenomenon that will lead to positive changes in the sphere in the future (Akdaǧ 2015; Özkan, Akyürek & Toygar 2016). Other researchers point at a range of barriers and challenges associated with the process, and they note that overcoming these issues can take years for hospitals in order to understand what type of a supply chain can work best in this or that context (Camgöz-Akdağ et al. 2016; Erus & Hatipoglu 2013; Polater, Bektas & Demirdogen 2014). As a result, more research is required in order to understand what particular tendencies are followed in hospitals in Turkey in terms of developing the effective SCM based on creating green supply chains.

Background of ISO and Sustainability

For any company that operates in the modern-day market, quality standards that regulate the way the employees perform their duties and the types of supplies that this organization utilizes play an essential role in the delivery of the final product. For healthcare organizations, the standards of quality can help the management ensure that the procurements they use are safe and can be used when working with patients. Moreover, these institutions also have to follow the quality standards and regulations set by the government of the state, which is set to ensure that patients get access only to products that are of acceptable quality. Considering this, the use and popularity of the ISO standard are comprehensible because this organization utilizes the opinions and expertise of the individuals who work in different fields to create a set of standards and to monitor whether the organizations aiming to obtain their certifications follow these standards. This chapter will present a review of literature where the background of GSCM, SCM, ISO, and the use of these practices will be discussed.

History of ISO Standard

In general, the ISO is a result of the development of the system of rules and recommendations that would be followed by organizations internationally to address the issue of quality and process efficiency for nonprofit and for-profit organizations. ISO as an organization emerged in 1946 in London, where the delegates from different states (ISO, no date). Currently, the headquarters of ISO is in Geneva, Switzerland, and the standards that this international organization sets can be applied by businesses and nonprofits globally. The purpose of this meeting was to discuss the potential for creating the international standards that would be followed by organizations. Generally, such a uniform approach would allow companies to globally use the standards that will guarantee their effective work. On the other hand, suppliers and business partners would be able to cooperate with one another knowing that their standards of managing the internal processes, for example, each step of manufacturing a product are created following a set of rules and regulations that guarantee the quality of the final product. With GSCM, which is a relatively new practice, especially in the medical field, ISO helps ensure that the organization is conscious of the impact that its operations have on the environment and that it uses methods of production and management of its processes that help reduce this impact.

Although any organization can use the ISO standards, the state’s government where this institution resides has to become the ISO participant in order for the certification to be valid. However, most developed and developing nations have agreements with ISO, and according to Bastas and Liyonage (2018), currently, 163 states are the official partners of ISO. Currently, the ISO 9001 standard is the most popular and widely applied standard used by organizations, which is the quality management and control certification. Moreover, one of the facets of ISO 9001, apart from quality control, process management, stakeholder cooperation, is the practice and docs on the sustainable development of the organization (Bastas and Liyonage, 2018).

The ISO standards for the medical field and for GSC were created by industry experts who work in these fields and have hands-on experience, which suggests that these are the best practices of management. According to ISO (n.d.), their standards are “internationally agreed by experts” (para. 1). They allow nonprofit and private organizations to organize their workflow in an efficient manner. One of the facets of ISO’s work is describing the best ways of managing processes and supplying materials, which is the area of interest for this research study. The basis of the ISO’s developments and recommendations are the opinions of experts, or individuals who work in different fields, such as manufacturers, suppliers, managers, executives, and others (ISO, n.d.). Therefore, the ISO’s main concern is to provide businesses and public institutions with a set of rules and regulations that will allow these organizations to manage their workflows more effectively.

Hospitals routinely use the ISO standards because of the improvements that these allow them to make to the processes and workflow management. In general, this section addresses the history and background of the ISO standard and how companies and nonprofits use it. The historical background allows one to understand the purpose of the ISO standard better and why hospitals in different states use it to enhance their efficiency. Moreover, ISO allows these facilities to select suppliers that are best suited for them based on whether the latter also use ISO to manage their workflows.

Bastas and Liyonage (2018) note that the majority of organizations that implement ISO standards benefit from them either in the short or long term. For example, these standards allow to not only address the issue of quality assurance but also enhance access to markets and increase the competitiveness of an organization. For a healthcare institution, this means that the implementation of ISO will allow this organization to have a system where the main processes have been outlined already. For example, Bastas and Liyonage (2018) state that with the ISO standards that relate to quality, the idea is that if the processes have been appropriately managed, which will result in the delivery of a high-quality final product or service. With the standards that relate to GSCM, the final outcome of the implementation is the idea that the organization’s use of resources and the practices that it employs to manage its supplies, their delivery, and utilization are not harmful to the environment.

One of the most popular standards that organizations across the world use are the ISO 9001. This certification standard allows the companies to organize their processes in a manner that aligns with the total quality control standards concept. Therefore, they can manage their organization in a way that enables them to deliver high-quality output. From an SCM perspective, the ISO 9001 outlines some of the elements of the purchasing process that are helpful for the customer because they ensure that this process is high quality and effective. For example, this standard requires the suppliers to include specific types of quantities of information about the product that the potential customer should have access to if requested. Additionally, the suppliers have to include information on how the products they produce can be checked for quality and verified if the customer wants to do this.

As was discussed, ISO develops the standardization practices that the companies may choose to apply. However, this organization does not certify the organizations willing to implement these practices. Typically, this process is governed by outside organizations that have permission from the ISO to conduct audits and grant certifications. This approach guarantees that both ISO and the companies which received the certification for the standard adhere to the ethical standards, and this international organization does not benefit financially from providing these certificates. Therefore, ISO is currently the most reliable and trusted tool for screening potential suppliers in order to select the ones that use the best practices of delivering care services. These standards allow ensuring that the processes meet the needs of the stakeholders and that the company’s work complies with the regulations that are imposed by the government of the state or international organizations. Some aspects that are a result of using the ISO include the “top management commitment to quality, its customer focus, adequacy of its resources, employee competence, process management (for production, service delivery and relevant administrative and support processes), quality planning, product design, review of incoming orders, purchasing, monitoring and measurement of its processes and products, calibration of measuring equipment, processes to resolve customer complaints, corrective/preventive actions, and a requirement to drive continual improvement of the QMS” (“ISO 9001,” no date, p. 3). Therefore, the application of the ISO standards encompasses a broad range of topics that allow to delivery of a high-quality product.

In terms of supply chain management, the ISO certification is a verification that the suppliers comprehend the expectations that their partners and stakeholders have from them in terms of quality and product delivery. Moreover, the ISO certification does not relate to the specific types of goods or services manufactured and provided through the supply chains; and instead, it highlights the general best practices and metrics that one can use to ensure that the outputs of the process are high quality and meet the requirements. This makes the ISO standard applicable uniformly to the varied fields and industries, including healthcare. Integrated supply chains as a concept are overseen by the Integrated Supply Chain Management Program (ISCM), which is a set of companies that create the set of regulations and best practices for these systems. The concept of integrated supply chains emerged as a result of the need to create a cohesive SCM system.

Why Hospitals Need SCM Systems

SCM systems allow the hospitals to efficiently procure the resources they require for operations and to enable the link between the varied departments involved in the management of these facilities. According to Bastas and Liyonage (2018), SCM “ensures proper linkage of hospitals department, operations, revenue cycle” (p. 4569). This system is necessary to enable the proper linkage between the different processes, which is what enables the proper process management of these institutions. Evidently, healthcare facilities are not the only institutions that require SCM since other facilities, such as businesses or manufacturers, also have to operate in an effective manner that allows producing high-quality goods with the focus on the revenue and bottom line.

Moreover, the nature of the modern-day supply chains implies that these are complex systems with many deliverables and participants, which makes it difficult for the hospital’s managers to adequately select and cooperate with the suppliers if no standards or best practices are used. According to Bastas and Liyanage (2018, p. 4569), “as an outcome of the current globalization, growing competition and tougher market conditions, more and more activities, processes and services are being outsourced, resulting in more complex supply chain networks and inter-organizational interactions.” For example, a supplier can cooperate with manufacturers and businesses from different states to reduce the costs and benefit from the globalization practice. With this, organizations that need supply chains may find it difficult to manage the cooperation with these businesses without an SCM system in place. In general, the SCM can be defined as the “e channel of materials, information, goods, and services, associating the features of supply, transformation, and demand” (Bastas and Liyonage, 2018, p. 4695). Therefore, one reason explaining why hospitals need SCM systems that are created and managed under the ISO standards is the complexity of the contemporary supply chains, which makes it difficult to navigate through the different sets of suppliers and their partners and to ensure that the quality of the goods obtained through these systems is acceptable and addresses the requirements with the stakeholders.

The second reason for applying the ISO standards to the cooperation with supply chains and for the management of these systems is the need to integrate the perspective of stakeholders. Like any other organization, a hospital has to address two goals with its operations; the first one is to deliver the services that the stakeholders need, which are the provision of healthcare services that allow the patients to enhance and maintain their health. This objective arises from the ethical concepts that the healthcare systems are based on, making healthcare one of the central factors in the establishment of public services in states. The second goal is to operate in a way that is effective, addresses the needs of patients, and allows the organization to maintain its profitability. This is the goal regardless of whether the healthcare facility operates in the environment where healthcare is public or private since even with the public healthcare systems, the government has to manage the costs that are needed to deliver the care services to patients, and therefore, even these institutions cannot be subsidized and operate with no profitability.

Moreover, ISO standards regulate the entire cycle of product delivery, from the initial procurement of the raw materials to managing the output or the final deliverable of the manufacturing process. For healthcare organizations, this means that the quality of each element of the supply chain is monitored across all the facets that these products undergo, and therefore, the final deliverables can be safely used when working with patients. Since the goal of this study is to investigate the use of novel SCM practices using the examples of public and private hospitals in Turkey and Australia, the focus on using the ISO standard is justified due to the use of these practices across different states and the ability to determine how these certifications help hospitals manage the delivery of services sustainably from a perspective of a public and private organization.

ISO is not the only set of standards developed for SCM. However, it is currently the best practice. Bastas and Liyanage (2018, p. 2) explain the goals and need for sustainability in the following manner: “meeting the needs of the present without compromising the ability of future generations to meet their own needs” lies at the heart of sustainability and sustainable development.” Therefore, SCM allows addressing the requests for goods and services that the current generation has by providing them with these items at acceptable costs. However, the sustainability element is what allows ensuing that these needs do not compromise the future generations’ ability to address the same requirements and use the resources. Hence, this is a mindful practice, which in the context of healthcare means that the health of the population is maintained over the long term.

Sustainability for an institution that derives profits from its operations can be separated into three elements: business, environment, and society. The business element relates to the profits and the ability of the management to use the inputs and create products or services that the customers will use, which will allow these institutions to obtain profits. The environmental part relates to the impact that the operations have on nature, for example, the levels of pollution, the rates of unrenewable resource use, the utilization of the products after they are no longer needed (Bastas and Liyonage, 2018). The final aspect is the social element of sustainability since the society is the primary stakeholder that either benefits or are harmed by the business practices. The combination of these three elements is what enables sustainable development that is both profitable and not harmful for others.

For hospitals, supply chains continue to play a vital role in the management and delivery of services. One reason for this is the continuously increasing costs associated with the provision of care. Moreover, the aging population that is a global trend currently means that individuals will require even more attention from medical professionals, for instance, to treat chronic diseases. The developments in the technology field that relate to healthcare are also contributing to the increasing costs because, in order to integrate these technological solutions, healthcare facilities have to spend resources upfront to purchase new equipment and train the personnel. All of these factors combine with the social pressure to operate sustainably and to reduce the harm that organizations cause to the environment, which requires the management to look for better strategies.

Although the importance of sustainable practice is recognized by governments and institutions, there is little research that would address this issue in reality. Bastas and Liyonage (2018) state that “future research should move from focusing on whether or not companies need to integrate corporate sustainability into strategic management to how this could be done in practice.” Hence, it is unclear in many instances how sustainability can be integrated effectively in a way that does not disrupt the operations and does not burden the healthcare facility with additional costs that will eventually be covered by either patients or the government.

Suppliers, when promoting their services and goods, often use the certification of ISO as one of the selling points of their companies since these standards are globally recognized and allow to guarantee that the items are manufactured using the best potential practices that there are in the market. As a hospital manager responsible for the supply chain, one has to select an organization that has been certified; however, only in recent years have the suppliers begun to pay attention to the ISO quality standard relating to sustainability. One of the ways in which ISO helps address the issue of sustainability and integration is by showing the specific practices that have an environmental and societal impact today. Still, the issue of how to integrate these effectively remains, and this study is an attempt to answer the following question by examining how hospitals and suppliers use ISO and the gaps in the way these standards are applied and managed.

The Impact of ISO on the Sustainable Practices

The goal of implementing sustainable practices is to ensure that the procurement of the materials needed for operations is done efficiently and with minimal impact on the environment and the stakeholders. Some examples include implementing systems that enable energy efficiency or using raw materials for products that are biodegradable and which cause minimal harm to the environment (Bastas and Liyonage, 2018). Hence, the main goal of these practices is to address the long terms goals and organization’s operations that are operating in the healthcare field and that want to use sustainable practices in their operations.

Currently, mostly theoretical studies explain the nature of GSCM and sustainability in the context of managing these processes and delivering the services at adequate costs, which explains the purpose and aim of the present research. According to the Delphi study by Bastas and Liynage (2018), both stakeholders and the social pressure businesses to turn towards sustainable practices. Hence, modern-day organizations face a set of multidimensional challenges because they have to manage their processes according to the quality standards, ensure that their final output enables the profitability of the business, and also address the issue of sustainability and green practices with their work as this is the requirement of the modern-day.

In this context, the concept of the triple bottom line is applicable to explaining how companies and public organizations manage their processes focusing on the stakeholders’ needs. For instance, in most cases, companies focus on ensuring that they deliver a proper bottom line, which is the profits that this company obtains over the years and through its operations (Bastas and Liynage, 2018). The triple bottom line approach requires companies to also focus on the stakeholders and ensure that their needs and perspective are integrated into the process of the delivery of the final product. Similar to the concept of GSCM, the triple bottom line approach as a business practice has emerged within the past thirty years, but the popularity of this practice has been continuously increasing. Moreover, Bastas and Liynage (2018) note that ISO standards are very helpful in addressing the triple bottom line since, for example, ISO 9001 requires one to both address and exceed the expectations of the stakeholders, which also implies that environmental sustainability must be an integral part of the strategy development as it has become important for the society in general.

The way that ISO helps address the sustainability and the practices that the company uses is in the plethora of tools and regulations that the organization’s standards provide to the businesses. For example, Bastas and Liyanage (2018, p. 4569) state that “a wide scope of activities internal and external to organizations, throughout the lifecycle of products and services, are included, such as externally provided goods, operations, logistics, and after-sales.” Therefore, the benefits that the ISO provides to the organizations are multiple and allow businesses and nonprofits to create highly effective systems and processes.

History of Public and Private Healthcare

Healthcare is an integral element of services that must be delivered to the citizens of any state because it addresses the inherent need of human beings to maintain their health and wellbeing and address the causes of injuries or severe illnesses. However, different states choose to apply varied systems of the delivery of healthcare services, mainly, either a private or public health approach. Historically, the healthcare system globally has been a mix of public, private, and philanthropic interests, which is the case to this day as well (Weindling, 2015). Hence, one of the underlying reasons for integrating sustainability and green practices into the provision of healthcare services is the ethical nature of this industry which is based on the principles of caring and advocating for the wellbeing of the state’s inhabitants. Considering that unsustainable practices harm not only the environment but also the health of the people residing in a particular state, for example, due to pollution or waste that can cause negative long term effects on one’s health, the integration of GSCM is a step towards creating cohesive healthcare delivery systems. Moreover, the use of non-renewable energy sources, which is one element of GSCM, also harms the stakeholders in the long term because these resources will no longer be available if used without limitation. Hence, the use of GSCM systems and sustainable practices in the healthcare delivery is justified by the principles on which the healthcare systems in different states, regardless of the structure of these systems and the approach to managing the costs, have been established, and therefore, it is vital to investigate how these practices are applied in different states and what impact they have on the delivery of care services and sustainability over the long term.

This study has the potential of uncovering new paths for the efficiency and environmentally-conscious delivery of health care services in the future. According to Weindling (2015), the modernization of healthcare has caused a transformation in the social arrangements that are managed both in the public and private healthcare systems. Therefore, the healthcare systems in the future will differ from those that exist today, and potentially, more attention will be given to the provision of services free of charge as opposed to the insurance or out-of-pocket payments systems that exist today. In this context, understanding the differences in how the hospitals that operate under two systems manage their supply chains and remain profitable, which is the goal of this study, can be very helpful in establishing a framework that integrates the best practices of sustainability and management derived from the public and private healthcare.

With universal healthcare systems, the citizens of a particular state are guaranteed access and the provision of care services regardless of their ability to pay for these services as the state covers the expenses and manages the delivery of the care. An alternative version of universal care is the provision of services free of charge only to the citizens who cannot afford to pay for them, while other residents of the state must cover the expenses out of pocket (Weindling, 2015), Hence, despite the implications of the term “universal care,” the variations of this system exist, and it does not imply that all care services will be accessible to all inhabitants of a region without any expenses on their part. For example, some states use the practice of requiring the citizens to purchase mandatory insurance, which will cover the healthcare expenses in case of an adverse event. These systems are also a part of universal care because they guarantee that a person will receive the services they need in case of an illness or injury; however, such an approach does not necessarily mean that all people who reside in a specific region are capable of purchasing the insurance services. This is why mixed types of systems emerged where the government could cover the expenses for those individuals who are incapable of paying themselves.

From the perspective of universal care coverage, the efficiency of the hospitals’ operations becomes essential because, with systems where the government covers the expenses either partially or fully, the funding comes from taxes that the citizens have paid. According to Abiiro et al. (2015), the goal of the universal care system is to provide access and coverage to all at the highest possible quality of service delivery. This statement implies that healthcare services, regardless of the state and the specific delivery system, must be provided using the best potential practices, including the use of green supply chain management.

The modern-day healthcare systems are still transformed by the opinions of stakeholders, the standards set by government officials, and trends in sustainable development. According to Filc et al. (2020, p. 31), “since the late 1970s, healthcare systems all around the world have been undergoing processes of reform, and public and academic discussions on the transformation of healthcare systems have become ubiquitous.” The general trend of the systems and delivery is the move towards privatization of services and delegating the responsibility of care delivery to the public organizations, which is a result of the need to deliver care effectively in terms of costs, quality, and outcomes.

Historically, the healthcare system in Turkey has developed in line with those of the Mideterrenian regime (Filc et al., 2015). The state experienced relatively late industrialization, and its economy is characterized by the significant role of shadow economy and labor market rigidity. The social spending in the states with this regime is slightly lower when compared to those governed under the neoliberal regimes; however, the welfare system is not capable of addressing the socioeconomic gaps. In part, this suggests that states with similar economic systems as Turkey need to pay specific attention to the supply chain management practices that can guarantee sustainability and efficiency because managing costs and quality becomes essential in the context of these systems. This gap is partially covered by the fact that in Turkey, the private care market is flourishing but access to it is available only to the citizens who have the financial capacity to pay for these services.

Apart from the path that the state has selected for delivering the care services, there are differences in the way public and private healthcare is managed and delivered. Filc et al. (2015) note that when studying the healthcare systems of different states, it is difficult to make adequate comparisons since there are many additional factors, apart from the system of care delivery, and define the way the public and private facets of healthcare are managed. For example, the structure of citizenship and differences in the healthcare delivery culture can affect the way these systems function, and these differences can occur even in states that are in close proximity and which have similar care delivery models. Therefore, the results of the studies similar to this one should be considered with regard to the plethora of differences and unaddressed issues that still exist in the evolving system of global healthcare.

As for Australia, its healthcare system originated in 1788 and developed and evolved under the influence of the British and global forces (Healthcare Chanel, 2019). The current public care system in the state is the deliverable of The Colonial Medical Service, which was the first care service that the British Captain Arthur Phillip brought to this territory. The main goal of this system was to provide basic care to the convicts that became the new residents of New South Wales. In part, this explains why the care services were provided free of charge since the convicts had no financial capacity or freedom to pay for the prospective services. However, after the convict’s transportation to the state was seized, the healthcare facilities became private and were no longer controlled by the government, which allowed them to set their own rules and use practices suitable for their profitability and efficiency, which also limited the access to care for others. As a result of this, the government established a public healthcare administration in the 1850s, which would oversee the healthcare facilities in the state and govern the delivery and provision of services. Moreover, during the 1990s, the state has created the Public Health Unites responsible for the delivery of care to citizens, the goal of which was to address the healthcare needs of the population at the local level and monitor the health trends. Currently, the healthcare delivery in the state is managed by the government that oversees the operations of all healthcare facilities and manages the costs. In this context, it is interesting to investigate the way that the standardization practices are applied in the state whether this system is managed by the government in comparison to the one where it is private and managed as a business enterprise.

Supply Chain Management in Public and Private Healthcare

As it is stated in the literature on managerial processes and operations, SCM is a specific field of knowledge that is related to principles and norms of coordinating the work of supply chains to make them highly controlled and effective. There are a plethora of sources and research articles on the topic of developing SCM in different types of organizations because this area of knowledge has become actively applied to practice during recent years (Chakraborty & Dobrzykowski 2014; Maleki & Cruz-Machado 2013; Nassirnia & Robinson 2013). Therefore, it is important to review the existing literature on SCM in general and in the context of the healthcare industry in order to understand the specifics of covering these aspects in scholarly works.

Different types of firms choose to organize their SCM in order to improve the cooperation with suppliers and guarantee a high-quality end product for customers. The organization of SCM involves the firms’ application regulations that governs the supply chain process to realize the end measure of effective operations thus safeguarding any resulting consequence that may implicate the operating efficiency of the firms. In their study based on the review of the recent literature in the field, Chakraborty and Dobrzykowski (2014) found that collaboration within a supply chain is most required in healthcare organizations. However, according to the researchers, the problem is that it is rather difficult to achieve value co-creation in the context of supply chains because of many resources involved in the process. Thus, one can conclude that, in the context of healthcare organizations, SCM works to address the pressure of improving the quality of providing services and reducing costs.

Other researchers also discussed these aspects in their works. Referring to the experience of Brazil and SCM in its healthcare organizations, Machado, Scavarda, and Vaccaro (2014) stated that supply chains in this industry are usually external and internal, and organizations need to cope with coordinating both chains, and the role of effective SCM in this context is important. As a result, Chakraborty and Dobrzykowski (2014) and Machado, Scavarda, and Vaccaro (2014) agreed that supply chains in the healthcare industry are complex and involving combinations of different relations with participants and various products and processes at each stage of a chain. Therefore, SCM is critical to regulate these sophisticated systems to reduce costs and achieve higher outcomes.

Sustainable Supply Chains

In recent years, supply chains have become discussed in the context of the idea of sustainability. Today, researchers and practitioners are inclined to view supply chains through the prism of the effect of their activities on the environment because the rapid growth of businesses and operations in different spheres potentially leads to increasing the amount of waste and costs. In their study devoted to formulating an effective theoretical model for creating supply chains, Liu et al. (2017) proposed a certain framework for sustainable chains with reference to the idea that these networks or systems should be balanced in terms of the flows of resources, costs, and information within them. Moreover, their influence on the environment, including natural and social settings, should also be balanced and positive. The idea of sustainable development became popular in the 1980s, and it influenced the vision of modern supply chains significantly (Liu et al. 2017; Silvestre 2016). However, the concept of sustainable SCM was formulated in detail only in the 2000s.

Currently, it is possible to state that, when researchers speak about SCM, they mean a sustainable character of this management associated with the development of sustainable supply chains. According to the recent literature in the field, sustainability has involved innovation and creativity in management process that solves the current demands of the changing trends in the operation of different firms. In the few years back, the focus on sustainability was typical of researchers’ works in the 2000s and it shifted to managers’ and experts’ interest in GSC (Toke, Gupta & Dandekar 2010; Zainudin et al. 2014).

The current shift has only involved the options of the changing trends which demands for measure that manage effective use of resources and as well as safeguarding options of the current resources for future operational and economic benefits. Therefore, currently, sustainable supply chains are characterized by addressing the economic aspect of the business development, as well as the environmental one and the social one. As a result of this characterization, it is important to mention that this complex or holistic approach is preferred by managers in different types of organizations because of a range of expected positive benefits and advantages for firms in terms of addressing a community’s needs.

Integrated Supply Chains

The widespread development of integrated supply chains can be viewed as a modern tendency in SCM. While there were companies in the past that made efforts to control the entirety of their supply chains, they were considerably less numerous than they are now. Many organizations have become oriented to transforming their fragmented or separate supply chains into integrated ones in order to achieve a certain level of efficiency in operations and processes (Nassirnia & Robinson 2013). As a result, the concept of supply chain integration has recently developed further, and much attention should be paid to discussing specifics of integrated supply chains with reference to the existing literature on this issue.

The purpose of integrated SCM is to achieve control over most or all of its elements. In doing so, the company is able to modify its supply chain and refine to maximize efficiency (Maleki & Cruz-Machado 2013). In particular, one of the advantages of integrated supply chain management is better communication between its different elements, which now work toward a unified goal. This information sharing can also lead to the discovery and development of new synergies between different elements of the chain, reducing waste and improving efficiency. Additionally, the profit motive present in independent suppliers disappears, which can lead to lower costs for manufacturing and transporting supplies. While there are also challenges associated with adopting integration and adjusting systems across the supply chain to achieve the benefits, the advantages have popularised the concept.

Green Supply Chains

As it is stated in many studies on the topic, GSCM is oriented towards redesigning SCM into an effective system for the purpose of minimizing a negative impact of organizations’ activities on the environment. Thus, as it is noted and explained in the review article by Toke, Gupta, and Dandekar (2010, p. 1), GSCM “refers to the way in which innovations in SCM and industrial purchasing may be considered in the context of the environment.” All the issues associated with implementing GSC are widely discussed in the scholarly literature today, and more attention should be paid to identifying tendencies in analyzing these questions.

The conference GSC 2018 that was conducted in Thessaloniki, Greece, on July 2-4, 2018, attracted researchers from all over the globe to discuss these particular issues. The key topics that were covered by experts included the following ones: supply chains and sustainability, the design of supply chains, collaboration within chains, performance measurement, practices of supply chain management, energy and water consumption, eco-design, and many others (Conference topics 2018). These topics are actively analyzed and discussed by experts in order to reflect practitioners’ interest in these spheres. From this point of view, to address changes in managerial perspectives regarding SCM, it is important to focus on the recently published literature on the topic of GSC that have become actively explored by researchers.

ISO-14001-2015 and ISO-9001-2015

The ISO-14001-2015 is the latest revision of the family of standards created by the International Organization for Standardization (ISO). Per the International Organisation for Standardisation (2015), it specifies the requirements which an organization has to satisfy to enhance its environmental performance comprehensively and without omitting critical details. It is designed to be applicable to any organization and scalable regardless of the size. Similarly, the ISO-9001-2015 standard is the current revision of the requirements for an adequate quality management system at an organization. International Organisation for Standardisation (no date) claims that it is the only constituent of the 9000 standard family to which a company can be certified, from which over 1 million organizations worldwide benefit. It is also applicable to any organization, though it should be noted that this quality also means that it necessarily avoids specifics, favouring broad and generic statements wherever possible.

ISO 9001-2015 attempts to set out the basic procedures that an organization needs to take to implement a quality management systems. It sets out a number of basic requirements, such as having a quality policy, distributing organizational responsibilities appropriately, maintaining competence and awareness in the staff, and others. The execution of each of these steps is left entirely to the organization, as the standard aims to be suitable for every industry and therefore cannot provide any specifics. With that said, the ISO provides certification services, in which certified auditors can assess the organization for compliance with the standards (International Organisation for Standardisation, no date). As the adoption of quality management systems grew, these certifications have become increasingly demanded, and thousands of organizations have received them worldwide to date. The standard is now well-known and popular, and it is advisable for any organization to familiarise itself with it and comply with the requirements.

ISO 14001 aims to fulfil the same purpose for environmental management systems that ISO 9001 occupies for quality management frameworks. It sets out many similar requirements in another large checklist that the organization should fill out based on its context and experience. To further reinforce the similarities, the ISO also provides certification to the standard, though it is not yet as widespread as that for ISO 9001 (International Organisation for Standardisation, 2015). With that said, certifying to it may be seen as a way of showing the organization’s stakeholders that it is committed to becoming and remaining environmentally friendly. Both ISO 14001 and ISO 9001 have been revised in 2015 to match the latest developments in their respective fields. They demand continuous improvement from their users and are themselves regularly maintained to remain relevant.


In summary, this chapter presents an overview of the history of the supply chains and the integration of this business practice into the management of healthcare resources. Notably, although the history of SCM dates to the 1980s, the issue of sustainability has only become relevant in 2007. Hence, both the researchers and the practitioners have not had enough time to address the problem of sustainability and introduce methodologies and effective practices. The ISO standards’ revised version from 2015 is a framework for the environmental sustainability and organization of the supply chains. Apart from this, an important event is the 2018 conference in Greece, where the presenters discussed their ideas of sustainable supply chains. Moreover, recently the researchers began to focus on the topic of integrated supply chains as a valid option for addressing the discrepancies in this field, which also presents a challenge for the healthcare industry. Thus, SCM is a new discipline, especially for healthcare managers who want to improve the efficiency of their resource management practices, which is why many challenges arise when integrating this practice.

This chapter focuses on the background and history of fields related to SCM in healthcare and ISO standard in particular. ISO was established in the 1940s by experts who wanted to create a standardized system for companies. Currently, ISO standards are used by not-for-profit and for-profit organizations to manage their workflow and create work processes that are efficient and help address the goals of these organizations. Moreover, this standardization practice is verified in over 163 states, which makes ISO the most meaningful quality standard globally, and therefore, healthcare institutions can rely on the ISO certification as a method of verifying whether their suppliers confront the process management practices that guarantee the high quality of the final outputs. The second sanction of this literature review focuses on the specifics and history of supply chains, integrated supply chains, and green supply chain management practices.

In general, although GSCM has existed for only thirty years, the value of this approach is continuously increasing as the stakeholders demand the companies to use practices that will address not only quality expectations but also will be sustainable over the long term. In the final section, the different aspects of care delivery in the states with public and private care systems are addressed and analyzed to determine how GSCM can be applied there. Hence, this section provides an assessment of the background information relating to ISO standards in healthcare delivery and management in the context of sustainability.

Literature Review

Green initiatives in hospitals, in general, are either reactive or proactive.

The method in reaction to regulatory pressure is based primarily on waste reduction or a voluntary approach confined to a narrow range of environmental practices in the hospital supply chain. One of the primary causes of environmental delays in the healthcare supply chain is that hospitals are evolving in a hazy environment marked by ambiguity in aims and uncertainties in the outcomes of care activities and logistical operations. The green healthcare supply chain management (SCM) serves as a worldwide endeavor to achieve sustainable development through three pillars such as economic, environmental, and social. Moreover, it is critical if the healthcare industry is to be sustainable in the global business world. To be a part of the solution, the healthcare industry must approach this challenge strategically. Moreover, this literature review focuses on the exploration of the supply chain practices in general and in hospitals and the issue involved in employing green practices in supply chains.

There are many definitions of supply chain management and the approaches taken to examining this concept, although in general, it is viewed as the processes associated with the management of resources, it is the use of production and consumption of resources transport with the end goal of moving the resources from goods from production to consumption. This chapter is a review of literature on the topic of SCM that will address the development of SCM, its integration into the healthcare system, and the increasing popularity of green SCM practices. This chapter summarises the information from approximately 60 sources on SCM, including scholarly articles and textbooks and summarises the scholar’s opinion on the practice of SCM, green SCM, and ISO standards.

GSCM can minimize the environmental effect of industrial operations while maintaining quality, cost, reliability, performance, and energy use efficiency. It entails a paradigm change, from end-of-pipe control to fulfill environmental requirements to reducing ecological harm while simultaneously generating total economic value. The Supply Chain Performance (SCP) measuring approach considers three factors: resource, output, and flexibility (Kumar et al., 2019). Efficient resource management is crucial to profitability; if consumers do not receive acceptable outputs, they will seek other supply chains; and, in an unpredictable world, supply chains must be ready to adjust to change.

The Supply Chain Operations Reference (SCOR) model provides a unique framework for defining and combining performance measurements, processes, best practices, and people into a coherent structure (Kumar et al., 2019). It is the world standard for supply chain management. In measuring supply chain performance and comparing it to internal and external industry goals, the following factors are considered: reliability, achievement of customer demand fulfillment on time, complete, without damage, responsiveness, the time it takes to react to and fulfill customer demand, agility the ability of the supply chain to increase or decrease demand within a given planned period, objective cost assessment of all supply chain costs, assets the assessment of a supply chain The SCOR model can assist supply chain managers in evaluating cost and performance tradeoffs and developing methods for reaching targets.

Environmental practices and performance include both internal and external actions, such as avoiding pollution before it occurs, recycling trash and wasted goods, extracting resources and raw materials, or collecting hazardous pollutants and disposing of them properly. GSCM is defined by Kumar et al. (2019) as “integrating environmental thinking into SCM, encompassing product design, material sourcing and selection, manufacturing processes, delivery of the finished product to the user, and end-of-life management of the product after its useful life” (p. 15). GSCM may alternatively be described as the process of taking environmentally acceptable inputs and converting them into outputs that can be recovered and reused at the end of their lives, resulting in a sustainable SC.

Green supply may be defined as the purchasing organization’s intention to enhance the environmental performance of acquired inputs and the suppliers that offer them. As a result, green supply encompasses a wide range of actions, such as collaboration across organizations to reduce the logistical effect of material flows or information collection about the features of acquired items. Others have offered definitions that are more focused on the purchasing function, implying that green supply activities include the purchasing function’s engagement in assisting internally-driven environmental actions such as recycling, reuse, and source reduction.

Balan and Colon (2016) support the network definition of SCM by seeing enterprises as connections in a networked SC. As a result, a firm’s performance is equally dependent on how effectively and efficiently it collaborates with its direct partners, as well as how well these business partners collaborate with their own partners. Corporate activities such as purchasing, production, marketing, logistics, and information systems must be connected and coordinated. Customer focus, efficiency, quality, responsiveness, and, most recently, environmental sustainability are all strategic imperatives that must be harmonized. With supply chain competition and a focus on changing consumer needs, it is vital to identify and implement techniques that produce a competitive advantage at the supply chain level.

Hospitals are attempting to find greener alternatives to their current supply chain management techniques since the advantages are enormous. Green and healthy hospital efforts, according to Balan and Colon (2016), have been linked to enhanced quality of life for patients and medical personnel, albeit the actual amount of money saved is uncertain. Furthermore, several institutions have already incorporated green practices and seen financial benefits. For example, Kaiser Permanente of California formed an eco-friendly program that takes health-related considerations into account. She concluded that by lowering their environmental impacts, healthcare companies should be able to safeguard the health of their patients, workers, and communities. According to Balan and Colon (2016), Johns Hopkins saved $100,000 by lowering medical waste by 16%. Hence, there is a potential to reduce the costs substantially by using GSCHM practices, although this benefit becomes evident in the long term perspective, as opposed to short term results of GSCHM that can result in additional expenditures.

The popularization of GSCM leads to innovation and the creation of new methods of managing supply chains and manufacturing. According to Colon and Balan (2016), one relatively recent green technique that has received a lot of attention is the recycling of medical equipment. According to the authors, more than 25% of hospitals in the United States are adopting reprocessing to reduce the tons of disposable garbage created. Hence, GSCM serves as a motivation for the suppliers to invest in better practices as well, which can benefit other industries, apart from healthcare.

As was discussed earlier, hospitals often use practices that contaminate the environment and make it dangerous for the people, and one of the goals of GSCHM is to eliminate this threat. Several studies over the last several years have found links between the environment and health. According to the Healthier Hospitals Initiative (HHI), environmental dangers may be partly to blame for the epidemic of chronic illnesses, which accounts for around 75% of all healthcare expenses (Balan and Colon, 2016). The HHI organization was founded on the premise that hospitals have a duty to reduce the harmful environmental consequences of their operations. HHI offers a variety of resources to help achieve these objectives, including hospital mentoring programs and interactive webinars. The HHI offers advice on how healthcare institutions may achieve sustainability through lowering energy usage and waste, as well as choosing safer goods.

Greening the supply chain is vital for healthcare businesses in order to eliminate environmental dangers that may cause chronic illnesses. Due to the fact that healthcare is complicated, numerous companies must collaborate to offer high-quality treatment to patients (Balan and Conlon, 2016). All of these entities must adhere to green supply chain policies. Because of the sheer number of firms involved and the intricacies of healthcare systems, determining whether each firm in the supply chain is adopting green supply chain standards is challenging.

Analyzing organizational records is one technique to determine whether a company is using green supply chain strategies. However, because these reports include a large amount of data, performing the analysis manually is exceedingly time-consuming (Balan and Conlon, 2016). This is another constraint that does not allow for the rapid implementation of GSCHM since it is difficult to evaluate whether the suppliers of raw materials are using green practices across their supply chains and within their organizations. For evaluating vast amounts of data, a computational technique based on data mining technology may be more viable. Text mining and analytics research has been going on for decades with the sole goal of finding a better and more effective way of performing supply chain analysis (Balan and Colon, 2016). Text mining has proven useful in a variety of fields, including business, healthcare, and literature. Text analysis involves several academic fields, including natural language processing (NLP), information retrieval, and computational linguistics (Balan and Colon, 2016). With the vast amounts of data accessible nowadays, it is critical to undertake text analysis using an automated technique.

As the sole purpose of hospitals and healthcare centers is to ensure the good health of their patients, it is appropriate for these institutions to change their practices to the ones that do not indirectly harm the health of the people. According to research, there is a clear link between the environment and the disorders that hospitals treat, such as respiratory diseases, cancer, and diabetes (Balan and Colon, 2016). Since hospitals generally are not obliged to use environmental norms, they often apply the approaches that seem the most efficient or cost-effective, based on the management’s opinion.

Due to a lack of environmentally safe norms, around 90,000 people admitted to hospitals each year die from different illnesses such as sepsis, pneumonia, and other infections (Balan and Colon, 2016). Every year, hospitals create five million tons of solid garbage. Hospitals also require large amounts of water and must continually circulate fresh air, making them the most energy-intensive business after food services. According to recent research on Texas nurses, those who were exposed to disinfectants and cleaning agents had greater incidences of asthma (Balan and Colon, 2016). Hence, the institutions that have the sole purpose of improving health contribute to illnesses of the employees. Furthermore, in 1996, environmentally unsuitable polyvinylchloride (PVC) accounted for 27% of all plastic used in medical products in the United States (Balan and Colon, 2016). Healthcare providers need to adjust the chemical makeup of items in order to reduce the usage of PVC. The examples above support the idea that GSCM is a necessity as the operations of hospitals harm not only the environment and also the health of the employees and community members.

The History and Nature of Supply Chains

The Purpose of Supply Chain Management in Organisations

Currently, there is no unified definition of the SCM that authors would use since the majority of reviewed articles offer a different outlook on this practice and propose a unique definition of this term. For example, Min (2014) and Silvestre (2016) argue that SCM is a cycle of production, where the first stage is a supplier, and the last is a customer. On the other hand, Chakraborty, Bhattacharya and Dobrzykowski (2014) view SC as networks of organisations engaged in the production of goods or services. As a result, SCM is defined by researchers as the management of these networks with reference to logistics and the control over activities and processes (Chakraborty, Bhattacharya & Dobrzykowski 2014; Liu et al. 2017). However, it is also accentuated in the literature that SCM differs from the traditional management of resources, inventory, and operations because of the necessity to focus on a chain as a system or a cycle. The conflicting definitions of SCM explain the wide application of SCM in different organisations plus its related effect in ensuring the success of an organisations and sustainable management of resource usage.

Consequently, it is important to analyse how the purpose and role of SCM in organisations are reflected in its meaning. In the definition provided by Bracci and Tallaki (2015, p. 54) in their review-based article, it is stated that SCM is “the systemic, strategic coordination of the traditional business functions and tactics across these business functions within a particular company and across businesses within the supply chain,” and all this is realised “for the purpose of improving the long-term performance of the individual companies and the supply chain as a whole.” The researchers came to the conclusion regarding the specifics and purpose of SCM as a result of analysing several frameworks for assessing performance in companies with reference to operations in these chains (Bracci &Tallaki 2015). The specifics defines the common process of application of SCM that regards the needs of quality management and environmental provisions. These specifics equally aims at realising the purpose of SCM which involves meeting higher measure of sustenance in resource provision and efficiency levels plus realising the strategic coordination of relations and developing links between all participants of a supply chain in order to use all resources effectively and improve the performance of an organisation.

The analysis of the literature on SCM in organisations indicates that its purpose is in providing opportunities for companies to increase the quality of their operations through the effective management of connections with suppliers and reduction of costs. From this perspective, SCM is most required in hospitals because supply chains in the healthcare industry are complicated, and facilities regularly work with a number of suppliers. As a result, they are interested in decreasing logistics costs and building cooperative relationships with suppliers to improve operations and proposed services (Chakraborty, Bhattacharya & Dobrzykowski 2014). However, in spite of obvious benefits for the healthcare industry and a clear purpose of SCM for organisations, associated practices have actively been adopted in other industries, and “healthcare has not been able to derive benefits from them due to their slow adoption” (Rakovska & Stratieva 2018, p. 4). Therefore, the literature indicates that the healthcare industry is only at its starting point regarding the adoption of SCM with the focus on its purpose in organisations and potential advantages.

The notion of sustainable development began in 1987 with the United Nations Conference on Environment and Development (Kumar et al., 2019). The goal of this conference was to examine the global environment and development till the 2000s and beyond. Previous research has defined sustainable development in a variety of ways (Kumar et al., 2019). The most prevalent description was supplied as “development that fulfills the requirements of the current generation without jeopardizing future generations’ ability to meet their own needs” (as cited in (Kumar et al., 2019). By concentrating on the whole supply chain management process, sustainable development allows managers to integrate their strategies into a holistic approach and balance environmental, social, and economic intentions for the healthcare business. As a result, sustainable development has progressively gained acceptance as evidence of an innovative method to create long-term profitability and growth for the industry.

However, when the historical context of the supply chain is examined, it becomes clear that its emergence goes back to the 1960s. Bowersox was the first to identify the physical distribution process, which is the initial stage of supply chain management (Kumar et al., 2019). Following the introduction of material needs planning in the 1970s, managers recognized the relevance of cost, quality, and on-time delivery of the product, and they adopted an integrated strategy. With increased global competitiveness, corporations shift to the second stage of supply chain management, which is logistics. Houlian was the first person to adopt the word “supply chain” for this system by integrating the company’s strategic choices and logistic facilities (Kumar et al., 2019). Supply chain management has been more relevant in both academic and corporate settings, particularly since the late 1990s. In the early 2000s, large corporations established supply chain units.

Since GSCM is a relatively new domain in supply chain management and especially in the field of healthcare, there are not many studies and empirical evidence that would allow practitioners to develop best practices on their basis. There have not been a lot of studies done on GSCM strategies in the healthcare industry that contribute to the long-term development of this practice (Tumpa et al., 2019). In today’s globalized world, a disproportionate environment, a booming economy, and an increasing worldwide population all have a significant influence on long-term growth, particularly in healthcare. As a result, the significance of sustainable development in the healthcare business has received significant emphasis. However, there are some substantial barriers to implementing the GSCM practices in the management of organizations.

The expansion of international supply chains has led to companies relocating their production facilities to developing economies, which may not be sustainable in the long term if industrial manufacturers do not embrace green practices. This is because purchasers in affluent nations are increasingly concerned about the environment and impose rigorous environmental criteria on suppliers in developing countries (Tumpa et al., 2019). Some of these purchasers are even willing to pay more and relocate production units from low-cost nations to substantially higher-cost countries in order to preserve sustainable sourcing practices.

Government policies have a significant impact on the effectiveness of fostering green projects in industrial sectors. Government policies have a significant impact on the effectiveness of fostering green projects in industrial sectors. Furthermore, the increasing cost of making green products has been regarded as the most significant impediment to GSCMP adoption. The acquisition of green and eco-friendly materials incurs an additional cost in the textile business, increasing overall expenditure (Tumpa et al., 2019). When an organization uses GSCMP in its early phases, it incurs additional costs due to a lack of knowledge of new materials and implementation of new technology, design, and construction procedures (Tumpa et al., 2019). As a result, the perception that adopting green materials may jeopardize their financial success inhibits practitioners from embarking on GSCMP efforts.

Aside from financial risk, green supply chain projects may face operational risks such as incompatibility with other materials, increased material handling needs, altering infrastructure, and coping with incompetent staff. Among all green activities, improving organizational environmental performance through green supply chain initiatives is critical for industry experts (Tumpa et al., 2019). However, it appears that practitioners are not yet ready to deploy GSCMP throughout their organizations. Tumpa et al. (2019) report that extensive and simple instruments for assessing the environmental performance of green materials are not available to industry professionals, posing a significant barrier to GSCMP projects. The lack of experience among industry practitioners in implementing GSCMP might increase the initial cost of green supply chain initiatives.

Sustainable development in the healthcare business raises complicated difficulties that necessitate an innovative environment approach in the healthcare industry via the supply chain. As a result, GHSCM techniques, as an innovative strategy, might contribute to the healthcare industry’s long-term development (Kumar et al., 2019). However, there are substantial barriers to overcome in order to implement GHSCM procedures. To fully realize the contribution potential of GHSCM practices, the healthcare sector must integrate internal practices emphasizing functional coordination with external practices, such as collaboration with suppliers and customers (Rezali, Ali, and Idris, 2018). Hence, both internal and external factors play a role in the management of a successful GSC.

Some previous studies, for example, by Rezali, Ali, and Idris (2018), indicate that boosting overall performance as a holistic strategy necessitates synchronization of both internal and external GHSCM procedures. Moreover, internal considerations are a priority and have an impact on the company’s supply chain. Employees, strategic concerns, and functional challenges inside the organization are examples of internal factors (Rezali, Ali, and Idris, 2018). Currently, the industry’s adoption of GHSCM practices has been moderate despite GHSCM’s contribution to sustainable growth from an internal standpoint.

Internal aspects, which relate to the organization’s strengths, cannot be overlooked when considering the transition to sustainable practices. Furthermore, internal factors exploration is an expanding idea in the current philosophy of environmental management that extends to the whole supply chain. In today’s globalization period and economic instability, the most difficult challenges for the organization will come from both internal and external sources. Similar to other businesses, the healthcare industry faces internal and external challenges. Internal factors refer to organizational behavior within the company that has a significant impact on the firm’s vision and goal (Rezali, Ali, and Idris, 2018). Internal factors can become the organization’s strength and have a positive influence on a firm.

However, in order to succeed, the company should prioritize these internal factors. As a result, the healthcare industry is under growing pressure to continue its operations while taking into account the human and environmental consequences. Meanwhile, if the healthcare business fails to address internal difficulties, it will have a negative impact not only on the potential of implementing GSCM but also on the overall development of the organization (Rezali, Ali, and Idris, 2018). GHSCM practices are a relatively proactive strategy that healthcare institutions may take in order to contribute to sustainable development.

Although supply chain management provides numerous benefits when done correctly, there are many difficulties and impediments to overcome in practice. Obstacles encountered in supply chain activity, as well as the benefits. Despite the benefits of sustainable development, considering the financial context of the healthcare business, sustainable growth is difficult since finances play a crucial role. The finances are essential for supporting quality of care and the use of best practices, and some of these practices have an environmental impact or contribute to the economy. Moreover, in many cases, poor management of the healthcare supply chain may result in medical waste and contamination, endangering both human health and the environment (Kumar et al., 2019). Due to the rapid growth in environmental contamination levels, the healthcare business has been driven to embrace GHSCM procedures as an innovative method and a basic necessity to no longer endanger people and the environment.

Purpose of GSCM

As a result of globalization, corporations use reformist techniques at all stages of their operations in order to obtain a competitive and sustainable advantage. Approaches for environmental awareness, which have been increasingly prevalent as environmental contamination has increased, are now being mirrored in corporate operations, particularly in the last several years (Koberg and Longoni, 2019; Migdadi, 2018). Companies that practice green management with an environmentalist mindset not only contribute to green management but also fulfill their social responsibilities. Hence, sustainability has become both a necessity and a part of the company’s brand image that reflects the management’s willingness or unwillingness to make improvements that would minimize the environmental harm of the operations.

Elements of GSCM

Green management methodologies guided businesses toward green supply chain management practices by integrating them into their supply management procedures. GSCM is characterized as a process that includes green procurement, green manufacturing or material management, green distribution or marketing, and reverse logistics (Migdadi, 2018). Another definition is a technique of building out a supply chain that integrates the manufacturing process with recycling and remanufacturing. Hence, there are different ways of defining the GSCM practices, which can lead to confusion and misunderstanding.

Green supply chain management is also defined as including an environmentalist approach to supply chain management in the areas of product design, material supply and selection, manufacturing processes, delivering the product to the consumer and product life cycle management (Kumar et al., 2019). Green purchasing decisions are the acts of purchasing recyclable, reused, or simply recycled products. Green Production entails a variety of operations, including green production, reuse, replication, and recycling. Green Distribution means selecting a distribution chain and storage stations, managing routes, determining which mode of transportation will be utilized, coordinating prospective and retroactive actions, and managing them in this context. Green Packaging is using environmentally friendly and recyclable materials and being environmentally conscious in packaging activities. Exchange, return, repair, maintenance, remarketing, and placement are all examples of new activity in reverse logistics. It is the act of transporting a product from the consumer to a reprocessing or recycling facility.

The Need for GSCM

Social and environmental issues that occur as a result of economic and technological growth may occasionally create havoc, particularly in the healthcare business. The contemporary complexity of healthcare services has developed in tandem with the rise in environmental consciousness and the lack of healthcare resources (Kumar et al., 2019). Green supply chain management is a process that includes green buying, green manufacturing/material management, green marketing, and reverse logistics (Kumar et al., 2019). When one looks throughout the world, one sees that green supply chain management strategies are primarily prevalent in the United States (Kumar et al., 2019). In Turkey, on the other hand, one can argue that the green management method has just lately begun to be acknowledged and utilized. So far, two hospitals in Turkey have concentrated on this topic: “Istanbul Florence Nightingale Hospital” and “Meditate Kavack Hospital” (Kumar et al., 2019). This shows that the empirical data on GSCM is scarce as not many institutions have implemented this approach. Parallel to the spread of the green hospital idea, there may be a rise in green supply chain management methods in Turkey.

As globalization has accelerated, social and environmental issues have evolved following the economic and technical growth. This rapid expansion may sometimes cause havoc, particularly in the healthcare business. As a result, management techniques for environmental health have been established in conjunction with the increased environmental consciousness in many sectors. Companies that use this method, known as green management, place a strong emphasis on developing environmental principles and doing their business in accordance with them (Kumar et al., 2019). Supply chain management, the integration of cash, information, and material flow that allows the right product to go through at the right time and place at the right price, has become a sector in which environmental practices are carried out.

As part of the environmental awareness approach, “Green Supply Chain Management” is described as the process of minimizing the negative environmental consequences of supply chain management and determining the actions to utilize the best source and decrease complexity (Kumar et al., 2019). In hospitals, it is well recognized that energy and water consumption are high, chemical and nonchemical waste amounts are excessive, potentially hazardous substance output is high, and materials purchased are diverse and numerous. As a result, in order to deliver an efficient and beneficial health service, they must effectively complete the supply activities. Adopting an ecologically friendly and environmentally conscious strategy when executing supply operations is only achievable if one has a grasp of green supply chain management.

Global climate change, growing technology, a more conscious society, acts of sustainable development, social responsibility programs, economic shifts, and legal duties all play a significant part in the development of environmental methods. This is achieved by both manufacturing and service firms. It also motivates managers to strive toward green management. As environmental consciousness has grown, institutional environmentalism or green management knowledge has become a popular notion and an important technique to deal with complexity and turmoil in this field (Kumar et al., 2019). Thus, one of the reasons for the growing popularity of GSCM is the dissemination of knowledge on the environmental impact of supply chains, making studies in this field important for the further improvement of SCM practices.

Green management is a process that involves planning, organizing, directing, and managing organizational operations from an environmental standpoint in order to safeguard the environment and build an ecologically friendly organization (Kumar et al., 2019). In other words, green management entails purchasing materials that are recyclable, reusable, or have recently been recycled; selecting a supplier that adheres to environmental goals; providing savings in using all types of sources; supplying products that make sourcing fruitful; making environmentalist decisions by management; using materials, equipment, and devices that do not contain hazardous materials; reducing waste materials; and creating reuse or recycling opportunities.

Green management practices aim to make the society to which they provide services more sustainable by providing activities that promote health and a healthy lifestyle. Green management, a new approach to environmental management, is a process that includes environmental health improvement (Kumar et al., 2019). Green enterprises that have implemented green management practices want to be the creators of environmental living quality. With this goal in mind, the first stage is to prevent environmental contamination generally, and the second step is to give savings in all types of sourcing while gravitating toward renewable sources (Kumar et al., 2019). When businesses seek to increase their productivity, profitability, and market share, as well as strengthen their competitive position and reduce costs, they also seek to raise awareness and create a green image in society in order to protect sustainable development and ecosystems by minimizing their negative impact on the environment.

Sustainable Supply Chains

On the contrary, GSCs are mainly focused on the environmental aspect, which becomes the priority when improving the work of a supply chain in any organisation. In this case, green SCM and improvised approach on SCM options that work to meet the current environmental management demands. The recent approaches links to the change social context, which can be discussed in the context of the impact of a supply chain on the environment in this situation as noted in the recent past (Camgöz-Akdağ et al. 2016; Chege 2012).

Still, even with the change and inclusion of GSCM options by different firms it is possible to observe a certain trend in research articles on the topic, as well as in practice, according to which supply chains are interpreted as sustainable when they only focus on an environmental dimension while ignoring the other ones (Chiarini 2015). Therefore, the review of application of SCM relies on a wide regulatory provisions that master the needs in the larger business environment. The exclusivity of some of the key consideration in the older supply management options has led to many researchers disagreeing with this position that GSCM can on own meet all environmental concerns.

Like in the past, where supply chains were focused on addressing a specific issue the only current change in GSCM has only opened up wide to manage critical issue in the environment bus still it can be limited in solving all other related concerns. Therefore, current researchers accentuate in their articles on the problem that, in order to be viewed as sustainable, supply chains need to operate as a network of providers of different services and resources, supporting actors, and customers, and all realised transactions should be cost- and time-efficient. These demands stretches far more from specific environmental concerns to defining firm operational processes. New concerns should ensure that the negative impact on the nature should be minimal, and the overall work of this chain should be successful (Chiarini 2015; Maleki & Cruz-Machado 2013; Silvestre 2016). And above all it should focus to other specific innovative approaches that will handle the drastic changes within the business environment.

Referring to the importance of these processes and their analysis in the existing literature, it is possible to agree with Silvestre (2016, p. 235) who stated that “one of the most promising areas within the supply chain literature is the intersection between SCM and sustainability.” If managers focus on the simultaneous assessment of all three aspects related to sustainability while evaluating the work of a supply chain, it is possible to expect improvements in business operations. The focus of managers on sustainable supply chains is explained by researchers with reference to intentions to eliminate costs and resolve all possible supply chain problems associated with the ineffective distribution of resources, cooperation with actors in a chain, and inappropriate waste management.

In consequence, in the article on current debates in the area of SCM, Silvestre (2016) explained the increase in the interest in this topic and managers’ focus on sustainable supply chains with the help of discussing supply chain risks that can be addressed when shifting to the principles of sustainability in operating interactions with suppliers and customers. From this perspective, the idea of sustainability linked to supply chains seems to influence managers’ actions and practices associated with developing the most effective form of a supply chain for their unique organisation (Correia et al. 2017; Liu et al. 2017). Still, the next step in developing supply chains is related to building integrated chains.

Characteristics of Integrated Supply Chains

The supply chain is characterized as a group of components that includes suppliers, logistic service providers, manufacturers, distributors, and retailers, as well as aspects such as material, product, and information flow (Koberg and Longoni, 2019). Another definition of the supply chain is an integrated process composed of many organizations such as suppliers, manufacturers, distributors, retailers, and so on, with the goal of delivering raw materials, converting them into goods, and distributing these products to retailers and end consumers (Koberg and Longoni, 2019). Supply chain management, on the other hand, is the management of materials or products, money, and information between suppliers, producers, distributors, retailers, and customers. All of these elements are involved in the value chain to ensure that goods can be delivered to customers, from raw material supply to production and distribution. The integration of the primary work activities that provide product, service, and information from the supplier to the end consumer is also characterized as supply chain management.

Essentially, the supply chain consists of the firm, its suppliers, and its consumers. In addition to this structure, in an extended supply chain, there is a supplier of the supplier or an ultimate supplier at the beginning and a customer of the customer or an ultimate customer at the end of the chain (Koberg and Longoni, 2019). Finally, certain service providers give services to all of the enterprises in the supply chain.

In a business environment, “integration” means the coordinated and mutually dependent process of cooperation and interaction, the result of which is an expected and acceptable positive outcome (Maleki & Cruz-Machado 2013). Thus, integrated supply chains are characterised by such type of collaboration when each process and operation depends on one another, and these activities can be viewed as inseparable (Mindur 2017). In the research article on specific port-dependent supply chains, Robinson (2013, p. 2) argued that, in the context of supply chains, integration can be referred to the “essential integrity of the system as a set of interdependent functions performed by a single, vertically integrated firm or many firms and agencies that link the production or supply of a good to the buyer or customer of that good.” It is important to note that this holistic approach to organising supply chains in the industry allows companies to control their processes in cooperation with their partners and other stakeholders (Maleki & Cruz-Machado 2013; Robinson 2015). Thus, the holistic approach means paying attention to developing cross-functional integration and relationships within a chain.

The key dimensions of supply chain integration include such aspects as coordination, information sharing, resource sharing, and the organisation of relationships and connections between participants of a chain. Studies demonstrate that these key factors also cover technology integration, forecasting, planning, and evaluation, and they determine the level of integration in a certain supply chain (Maleki & Cruz-Machado 2013; Mindur 2017). Thus, the major characteristics of integrated supply chains are directly associated with the work of the listed dimensions. According to Maleki and Cruz-Machado (2013), who were focused on the idea of supply chain integration in their research, while referring to these key characteristics, it is possible to state that integrated chains work effectively only when managers concentrate their efforts on optimising the work of the whole chain, not just its separate components. Therefore, optimisation should be related to enhancing information and resource sharing between all actors from a chain and building effective relationships between partners in this chain as a system.

The review of the literature indicates that there are several types of supply chain integration that can be applied by managers in order to achieve higher results in their firms’ performance and productivity. According to the findings in recent studies, they include vertical integration that is associated with the direction of integration for dyadic relationships, functional integration based on performance and cooperation, and models of integration that allow for customising practices (Chiarini 2015; Robinson 2015). Therefore, it is important to note that, when it is necessary for companies to move from one approach to organising the work of supply chains to the idea of integration, they usually choose a model to apply from the listed ones.

In order to work efficiently, the following aspects of an integrated supply chain need to be addressed: the utilisation of costs and resources in a chain should be reconsidered, collaboration with suppliers and other actors should be planned and regulated, and the focus on a linear supply chain should be avoided (Mindur 2017). Thus, according to Mindur (2017)and his interest in qualitative determinants of connected and interdependent supply chains, the idea of supply chain integration does not support a traditional linear transfer of data, resources, and information from one actor of a chain to another. Integration can be associated with collaboration at different levels and in various directions. From this point, according to Maleki and Cruz-Machado (2013), the performance of organisations and their relationships with customers improve oftener in those companies where the focus is on supply chain integration. According to Calipinar and Soysal (2013), the goal of integration is to minimise the waste and contribute to the performance, which is achieved through improved productivity. SCM practices allow companies to achieve these benefits through the collaborative efforts since all actors contribute to the end result. In the end, the goods that the consumer received can be of high quality while the organisations have spent less money and effort on creating them.

Referring to the reviewed literature on the topic, it is possible to pay attention to the fact that, in the context of the healthcare industry, integrated supply chains are characterised by the improved cooperation between manufacturers, governmental agencies, suppliers, and hospitals among other actors. Hospitals usually apply schemes related to functional integration in order to improve performance, decrease waiting times, promote innovation and the use of technology, and offer high-quality on-time care (Mindur 2017; Polater, Bektas & Demirdogen 2014). Still, the results of examined studies demonstrate that the implementation of integrated supply chains in the healthcare industry can be viewed as a challenge. The reason for this statement is in a large number of actors who participate in this system, and on the other hand, the development of an integrated network is an effective approach to improving collaboration in the healthcare sector.

Dyadic Relationships in Integrated Supply Chains

In the context of focusing on characteristic features of integrated supply chains, researchers also refer to the notion of “dyadic relationships.” Thus, in their research, Nassirnia and Robinson (2013) stated that integration, which is typical of dyadic relationships, is also characteristic of the most efficient supply chains, and these concepts need to be discussed in connection to each other. From this perspective, dyadic relationships can be defined as specific supplier-buyer interactions that are characterised by a high level of dependence of their components on one another (Rakovska & Stratieva 2018). Moreover, in dyadic relationships, much attention is paid to analysing the specifics of collaboration between dyadic partners because their successful cooperation influences achieving profits and outcomes for the work of the whole system. These aspects were mainly discussed by researchers in their studies on the specifics of different types of supply chains that are typically organised in various firms.

Depending on the nature of a supply chain and its purpose, it is important to note with reference to the existing literature on the topic that relationships between dyadic partners can be short-term and long-term. Researchers also focus on explaining these details and state that a short-term dyadic partnership allows for developing immediate effective cooperation for completing certain operations and addressing a task as part of a series of assignments (Maleki & Cruz-Machado 2013). According to Robinson (2015) SCM requires establishing long time partnerships, which allow for long-term cooperation between different parties with the goal of creating goods or services. In this case, it is possible to expect higher outcomes for a company because each step in these relationships is based on a single strategic goal set for a prolonged period in an organisation.

The discussion of dyadic relationships is active in the literature on SCM with a focus on supply chain integration because these interactions form the core of an interdependent chain. As a result, in addition to optimising the work of the whole integrated supply chain, it is also possible to focus on improving cooperation in dyadic relationships within the chain perceived as a system (Laari 2016; Robinson 2015). The reason is that the operational performance of participants of a chain increases when they efficiently cooperate with their dyadic partners within a system in order to achieve the set strategic goal. Individual efforts of participants of a chain do not guarantee similar results (De Vries & Huijsman 2011). The principle of dyadic relationships also works in the healthcare industry because the participants of integrated chains more directly cooperate with their adjacent partners, for example, providers of medical suppliers and inventory managers, and the quality of these relationships determines the quality of the whole system in most cases.

Efficiency of Integrated Supply Chains

It is mentioned in the scholarly literature that any integrated supply chain can be viewed as more efficient in comparison to other types of supply chains because it allows participants to decrease their regular operational costs, achieve higher results due to intensive cooperation, improve controlling and monitoring systems, and maximise profits. Organisations receive opportunities to improve their services, focus on profits, control costs, and monitor the quality (Mindur 2017). Apart from this, Akdaǧ (2015) argues that integrated supply chains have disadvantages as well because integrated supply chains are complex and difficult to manage. As a result, most businesses chose to have partially integrated supply chains or have fully disintegrated supply chains. Hence, one can conclude that there is no single and best-suited approach to SCM since different organisations select methods that suit their needs best, and although the theory suggests that integrated supply chains are the most effective, the ways of integrating them in practice still have to be studied to create strategies that can be applied in real life.

The powerful principle of an integrated supply chain is that each component in this chain works to maximise the outcome from the whole chain perceived as a controlled system. As a result, in contrast to a simple supply chain, actors of an integrated chain work to support the products and results of activities of each other, as it is stated by Maleki and Cruz-Machado (2013) in their review of articles on the problem of integration. Thus, actors are not concentrated on providing high-quality services or products at each step, but they are concentrated on achieving the most effective result from the work of the whole chain. This approach that is based on interdependence of an integrated chain’s components contributes to its efficiency. According to Maleki and Cruz-Machado (2013) and Mindur (2017), in order to guarantee the efficiency of integrated supply chains, it is important to avoid conflicts in goals, tasks, and activities of all participants of a chain. The focus should be on cooperation in the context of the same goals, values, and expectations regarding outcomes.

It is possible to state that supply chain integration is used by many organisations as a competitive approach to build cooperation between suppliers and other actors of a chain in order to guarantee the improvement of interactions and make collaborations continuous and productive. Robinson (2013, p. 19) argued that chains are usually presented as sets of interdependent firms, and their integration depends on the “mutual adjustment” as a constant in this case. The researcher was also focused on the whole-of-chain perspective while discussing the efficiency of supply chains in the context of integration. Therefore, according to the researcher, the integration of chains should be viewed as a strategic imperative for organisations because this process contributes to increasing supply chains’ efficiency (Robinson 2013; Robinson 2015). This idea is also shared by other experts who conducted their studies and reviews of the literature on the topic.

An important aspect of supply chain management is the reduction of costs, and there is a need to ensure that GSCM does not impact the bottom line negatively. When discussing the creation of a Green Supply Chain, it may be helpful first to define what the researchers mean by the term. It is the incorporation of environmentally friendly practices into the traditional supply chain in order to reduce waste and carbon footprints while increasing efficiency. A company may also change its standard supply chain into a green one by including the “environment” aspect in every stage of the supply chain, from product creation to production to distribution to end customers (Kumar et al., 2019). This can be accomplished through digital transformation or by simply enacting applicable policies. Moreover, companies may save money by employing digital technologies that aid in the transition to a greener environment (Kumar et al., 2019). IT solutions that aid in power consumption reduction, energy substitution, and recycling can have a favorable influence on a company’s financial statements.

Businesses that embrace green initiatives focus on lowering greenhouse gas emissions, which leads to shorter journeys and fewer shipments. As a consequence, expenditures are reduced since cars consume less fuel and have less wear and tear.

If a company has implemented green practices in its supply chain, there should be a procedure or policy in place that allows them to reproduce and recycle its product at the same rate as it is consumed.

The enforcement of green practices remains low among organizations. According to the second annual CDP Supply Chain Report, which aggregated climate change data from 710 suppliers, 6% of large corporations currently reject suppliers that fail to control carbon (Kumar et al., 2019). According to current forecasts, this figure will climb to 56% in the future (Kumar et al., 2019). Businesses are finding reasons to become green, whether it is to comply with government laws or to fulfill the expectations of their consumers or clients. However, as the recognition of these approaches grows, it is evident that more and more suppliers will implement GSCM.

Characteristics of Green Supply Chains

The review of the recent literature on SCM indicates that the organisation of supply chains reflects modern tendencies in industries, and the focus on overcoming environmental issues and addressing sustainability principles makes companies move to developing specific GSC. The reason is that corporate leaders have become aware of environmental problems and concerns associated with activities and practices followed by their firms (Chege 2012). According to Laari (2016), the key characteristic of a GSC is its association with the idea of sustainability that is based on addressing a firm’s economic, social, and environmental goals. In this context, the development of a sustainable GSC is usually related to concentrating on environmental issues and goals. Thus, green supply management is the process of “integrating environmental thinking into SCM, including product design, material sourcing and selection, manufacturing processes, delivery of the final product to consumers as well as the end-of-life management of the product after its useful life” (Laari 2016, p. 46). Researchers agree that GSC should be discussed as firms’ approaches to realising the idea of sustainability to address environmental concerns.

Another characteristic of a GSC is associated with adopting and following certain practices and activities that are viewed as green in order to protect the environment from the negative impact of organisations’ operations. Chiarini (2015) claimed that modern organisations understand their responsibilities regarding their impact on the environment and regulate these processes with the help of GSCM systems. Camgöz-Akdag et al. (2016) also noted that GSC are typically focused on redesigning operations, reducing wastes and costs, and reusing materials and resources to eliminate negative effects on the environment. Thus, green practices are incorporated into the production process at all stages of a product’s life cycle. Furthermore, organisations also often choose to use green materials and remanufacture processes to minimise waste with the help of sustainable designs (Zainudin et al. 2014). From this point, the transition to GSCM along with other techniques and strategies aimed at reducing the negative impact of industries on the natural environment is a topic of scientific interest and research.

It is also important to note that some researchers are inclined to view the concept of GSCM as a modern approach to presenting a holistic view regarding sustainability in organisations’ activities. Thus, according to Mbaabu (2016), GSC are perceived today as unique systems, the use of which can guarantee the reduction of waste, the effective distribution of resources, the high quality of products, and economic profits for companies. From this perspective, GSC can be characterised by not only their environmentally friendly nature but also their sustainable fundament (Özkan, Akyürek & Toygar 2016). In spite of the fact that different researchers are inclined to accentuate various definitions of GSCM, they seem to agree on the key characteristics of GSC: a sustainable character, the focus on reducing waste and minimising a negative impact on the environment, and the realisation through the adoption of green supply management practices that need to be discussed in detail.

Green Supply Chain Management Practices

GSCM is realised with the help of implementing certain green practices. Referring to the findings of his descriptive survey-based research, Chege (2012) stated that there are four dimensions that are associated with GSCM practices: eco-design, internal environmental management, investment recovery, and external environmental management. This dimensioned widened up in the most recent research findings to involve the changing trends in SCM technological improvement as a result of increased innovation and creativity in management practices. The change has enhanced active application of SCM and as a result, GSC practices are currently related to many dimensions adjustable within other considerable factors. The adjustment has involve the integration of technological inventions in the production process thus redefining the issue of eco- design as identified in past dimensional classification of GSCM.

Moreover, the issue of Internal environmental management has increased to involve alternative practices applied to improve firms’ operations, including recycling, waste management, and reusing resources among others and the improvement of this practices efficiency as a way to ensure realisation of GSCM objective. The current effective distribution of resources and funds is discussed in the context of investment recovery which , based on the current investment options, involves wide consideration of investment options that implicates the GSCM decisions of different firms Notably, Unlike in the 1990s when external environmental management was based on national and international environmental regulations and policies adopted to protect the environment (Shen 2013; Toke, Gupta & Dandekar 2010).The current application of the policies involves expert evaluations in improvising new external guidelines that management firm decisions in GSCM. These change of this policies and norms need to be reflected in corporate regulations to avoid affecting the nature.

Eqaully, the key GSCM practices identified by researchers and practitioners in the recent past as influencing sustainability in an organisation are green manufacturing, reverse logistics, eco-design, green purchasing, and green distribution (Chege 2012; Zainudin et al. 2014). The practices have only maintained to involve other major technologies to ensure they meet the demanding and changing needs in the current application of green supply management. Green manufacturing is a practice oriented to improving operations and using resources efficiently without making hazardous waste and producing contamination. According to Zainudin et al. (2014), green manufacturing was perceived as a necessity for firms which try to minimise the use of raw materials and orient to innovation. D’Eusanio, Zamagni and Petti (2019) identifies the same perception to include the current firms’ ideologies in the application of GSCM The practice is also meant by current researcher who have focused in new inventions in green procurement and green operations. However, it is also important to focus on the description of other major practices associated with the development and implementation of GSC.

The current application of reverse logistics has increased a lot of concerns among different researchers. Currently, the core of this practice involves controlling a specific cost-effective use of raw materials and organising inventory through reversing the typical logistics based on a chain with suppliers and customers. The same approach was stated by Chege (2012) research on the earlier application of green logistics As a result of using reverse logistics, inappropriate materials or products can be returned to suppliers by customers (Mbaabu 2016). This return becomes a result of recycling and reusing materials that allows for reducing resource consumption and waste as identified in the past research findings. (Toke, Gupta & Dandekar 2010). In the past, Toke, Gupta, and Dandekar (2010, p. 5) identified reverse logistics to be based on completing such important steps as “collection, separation, densification or disassembly, transitional processing, delivery and integration.” This changes improves as Zainudin et al. (2014) also added remanufacturing, developing modifications, recycling, and packaging to the list of techniques typically used in reverse logistics.

Currently, there are more other options which are related to use of technology aimed at efficiency and changing current operational needs.Nevertheless, the findings shows that the result of reverse logistics is the transformation of products can currently be used one many times in order to minimise waste and consumption of materials while leading to returning resources to Suppliers. Moreover Eco-design is also mentioned in academic literature as one of the GSCM practices.

The focus is on addressing design issues in order to respond to the requirements of the environmental safety and make products and services ecologically appropriate for using (Mbaabu 2016). Researchers noted that organisations follow the principles of eco-design when they systematically focus on the safety of their products and services for the environment and people (Mbaabu 2016; Shen 2013). There should not be issues associated with the impossibility to recycle packaging or reuse products while leading to producing hazardous waste (Zainudin et al. 2014). As a result, a company’s focus on eco-design guarantees minimising the consumption of energy and raw materials and maximising possibilities for recycling.

Equally, the recent findings have ranked green purchasing as one of the key practices in green supple management that has improved to incorporate the changing concern in GSCM (Seman et al. 2019). In the past, this GSC approach was defined as an activity that makes sure that all bought products address the requirements regarding the environmental protection, and they can be discussed as environmentally friendly (Toke, Gupta & Dandekar 2010). In the most recent definition, according to Zainudin et al. (2014), this approach focuses on analysing how the content of a purchased product meets environmentally-conscious standards, whether the required certification is provided, whether labelling is provided to inform customers, and whether product content restrictions can be observed (Standards: ISO standards are internationally agreed by experts 2020). As a result, the decision-making process of customers regarding the choice of this or that product or service can be viewed as influencing the realisation of the practice of green purchasing by organisations.

In addition to specifics of green purchasing, researchers also identified such practice as green distribution. As it is stated by Zainudin et al. (2014) in the article on supply chains in the Malaysian healthcare industry, this practice is directly associated with ensuring that green packaging is used along with green transportation and green logistics in order to reduce negative effects on the environment. It is also important to state that researchers and managers are inclined to add such practices as outbound logistics, inbound logistics, and waste management as separate ones (Mbaabu 2016; Toke, Gupta & Dandekar 2010; Zainudin et al. 2014). However, these practices can also be discussed as included into green manufacturing and reverse logistics.

Green Supply Chain Performance

In order to understand how the applied GSC practices influence the activities of a firm in terms of eliminating negative impacts on the environment, it is necessary to measure the performance of GSCM. Therefore, one more concept has been introduced by theorists and practitioners in order to be able to state how effective GSC are. To measure performance of a supply chain, it is appropriate to focus on such categories as the use of resources, received outputs, and the flexibility of a system (Laari 2016; Mbaabu 2016).

From the above perspective, Chege (2012) research on SCM in Kenya states that GSC are assessed in terms of the efficiency of observed resource management, the effectiveness of energy utilisation, the acceptability of outputs, and the flexibility of all operations and processes involved in production and distribution. It is possible to conclude that, evaluating the performance of GSC, managers decide on the appropriateness of performance metrics, the effectiveness of the whole system, and changes to implement in order to achieve higher results.

It is also important to state that some researchers also discuss performance of GSC separately, with reference to such aspects as environmental performance, economic performance, innovation performance, and operational performance. Environmental performance is associated with organisations’ readiness and ability to eliminate waste and hazardous emissions (Toke, Gupta & Dandekar 2010). Economic performance is connected with firms’ capacity to minimise costs related to producing goods and providing services in order to ensure appropriate energy consumption and waste management (Zainudin et al. 2014). When researchers speak about innovation performance, they mean the ability of GSC to utilise innovative technologies and strategies in order to eliminate negative effects on the environment and save resources. Operational performance is directly associated with a firm’s ability to improve practices and activities in order to make operations environmentally friendly and cost-efficient (Mbaabu 2016; Zainudin et al. 2014). From this point, the process of evaluating the performance of GSC is a strategy of controlling the distribution of resources and funds, addressing costs, applying technologies, and minimising effects on the environment.

Green Supply Chain Management in Healthcare

Green supply chain management (GSCM) in the healthcare system extends beyond traditional supply chain management based on traditional physical flows and other flows, such as patient waiting time, usage of medical resources, and other aspects (Badi & Murtagh, 2019). Based on this literature review, many studies focus on the issue of green practices in hospital supply chain management and attempt to establish a framework to integrate the green healthcare environment with supply chain management. Connecting environmental information, such as environmental costs, will prompt consumers to consider the healthcare system’s responsibility. The treatment of GSCM in the healthcare system might be divided into two components. The internal supply chain, which includes patients or customers, the patient care unit, and hospital process units, is one example (Badi & Murtagh, 2019). The external supply chain, which includes vendors, manufacturers, and distribution hubs, is the other.

As a result, a good GSCM framework in the healthcare system will combine the activities and operations of internal and external units in order to increase long-term competitive advantages. Furthermore, GSCM can help with information sharing and exchange in environmental challenges, as well as continuous material flow in the healthcare process (Badi & Murtagh, 2019). As a result, using GSCM, the healthcare system may strengthen its resources and operations to satisfy individual and public health demands. Badi and Murtagh (2019) completed a thorough evaluation of the literature on the investigation of GSCM and proposed a direction for future study. Green purchasing and procurement, for example, are GSCM activities, as are green design, green manufacturing, green logistics, waste management, green operation, and end-of-life management.

Furthermore, from the start to the conclusion of a product’s life cycle in order to improve the long-term performance of individual enterprises and the supply chain. The public has been increasingly conscious of environmental concerns and global warming over the last two decades, and businesses constantly expect queries about how green their production methods are, their carbon impact, and how they recycle final items after use (Badi and Murtagh, 2019). As a result, both manufacturing and service firms must assess the influence of environmental approaches on company success, economic viability, and environmental performance. Success in the supply chain leads to success in the organization. Since customers and governmental bodies have begun to expect environmentally friendly processes, goods, and services, it is critical that managers identify and execute the environment.

GSCM is the incorporation of a green component into SCM, and it entails addressing the influences and interactions between SCM and the natural environment. GSCM methods, according to Badi and Murtagh (2019), extend beyond green buying to incorporating green SC, moving from suppliers to manufacturers and eventually to customers. Based on the literature, GSCM techniques are divided into four categories: internal environmental management, external environmental management, investment recovery, and eco-design. In terms of quality management, Badi and Murtagh (2019) state that GSCM implementation falls under quality control and that firms may enhance their environmental practices by learning from the experiences of their quality management programs. Organizations can build organized procedures for continual improvement in environmental performance by getting the ISO 14001 environmental management system (EMS) standard certificate. Environmental sustainability strategies that extend across the supply chain.

Companies are being compelled to adopt environmental management by two pressures in particular. The first is international environmental protection legislation, such as the Montreal Convention and the Kyoto Protocol (Badi and Murtagh, 2019). Next, the second is consumer environmental awareness. Companies recognize that if they provide products and services that address their consumers’ environmental concerns, those customers are more likely to choose their products or services. For hospitals whose operations are rooted in ethics, it is essential to use practices that are not harmful or that can help minimize the negative impact of operations.

The highly regulated healthcare business has been slower than other sectors of the building industry to include sustainability in the creation of its buildings. According to the Washington, DC-based US Green Building Council, healthcare buildings account for fewer than 1% of all Leadership in Energy, and Environmental Design (LEED) certified projects in the United States (as cited in Johnson, 2010). A healthcare institution, according to the Environmental Protection Agency (EPA), is the second most energy-intensive commercial building category, trailing only the foodservice business. Given the demands imposed on hospitals—round-the-clock operation needing light, heat, and considerable energy for ventilation, equipment, sterilization, washing, and food preparation—the high level of energy usage is understandable.

Hospitals produce five million tons of solid waste each year, require massive amounts of water, must pump in fresh air rather than recirculate to avoid infection, and work 24 hours a day, seven days a week, making them the nation’s second most energy-intensive business behind food services (Johnson, 2010). Concerns have also been raised that environmentally-friendly measures may make it more difficult to achieve demanding regulatory requirements for infection control and construction standards. Despite the fact that certain hospitals around the country are attempting to improve efficiency, it is not surprising that just 36 healthcare institutions of all sorts have qualified for any level of LEED certification. Another 350 people have signed up to pursue LEED certification, accounting for only 2% of projects in the LEED pipeline (Johnson, 2010).

Hospitals produce five million tons of solid waste each year, require massive amounts of water, must pump in fresh air rather than recirculate to avoid infection, and work 24 hours a day, seven days a week, making them the nation’s second most energy-intensive business behind food services (Johnson, 2010). Concerns have also been raised that environmentally-friendly measures may make it more difficult to achieve demanding regulatory requirements for infection control and construction standards. Despite the fact that certain hospitals around the country are attempting to improve efficiency, it is not surprising that just 36 healthcare institutions of all sorts have qualified for any level of LEED certification. Another 350 people have signed up to pursue LEED certification, accounting for only 2% of projects in the LEED pipeline (Johnson, 2010). Hence, some hospitals in the United States have already implemented the green practices necessary for the full-scale implementation of green supply chain management.

The green movement has contended with other difficulties weighing on the hospital and healthcare business, such as capital shortages, growing prices, regulatory compliance, maintaining operational margins, an aging population, staff retention, and outmoded buildings (Johnson, 2010). Because healthcare accounts for at least 80% of the country’s emissions, Health Care Without Harm, a nationwide coalition of healthcare and community organizations, is collaborating with the healthcare care industry to decrease the impact of hospital pollution on the environment. Some hospitals around the country are seeking to strike a balance by becoming green in order to lessen their environmental effect. Many supporters hope that enough hospitals have joined the green movement to ignite a wave of change that will eventually make green hospitals the norm.

Roof gardens, solar panels, and exposure to natural light are among its features. Practice Greenhealth, the nation’s premier sustainability group, comprises more than 700 institutions (Johnson, 2010). Green practices among its member hospitals have increased, according to the group. According to the American Hospital Association, there were roughly 6,248 hospitals of various sorts in the United States in 2007 (Johnson, 2010). As a result, according to environmental experts, the medical business in the United States generates more than two million tons of garbage every year. Plastic bandages and cotton swabs are among the waste items, as are hospital gowns after a single usage. Some trash is disposed of in incinerators, which emit dioxin, mercury, and poisons when burned. There is a growing consensus that the environment has a vital role.

As a result, the healthcare industry is impacted by a number of significant environmental legislation and regulations. Compliance Assistance: Healthcare, Hospital, Medical, Infectious Waste Incinerators, Medical Waste; The Memorandum of Understanding Between the United States Environmental Protection Agency and the American Hospital Association; Profile of the Healthcare Industry; and State Medical Waste Programs and Regulations are among the documents that include the regulations (Kumar et al., 2019). On September 16, 2009, the EPA imposed new limitations on medical and infectious waste incinerators at the majority of current hospitals (Johnson, 2007). Each year, the efforts aid in decreasing approximately 390,000 pounds of various pollutants such as acid gases, nitrogen oxides, and metals such as lead, cadmium, and mercury. Hence, the current practices of GSCM appear to help reduce the environmental effect of the production.

In addition, the EPA is completing monitoring and inspection standards. The EPA has a technical five-stage approach for hospitals considering how to become more Energy Star-rated: retro commission operations by maximizing the efficiency of existing equipment, conducting a lighting evaluation, achieving supplemental load reduction, using Energy Star products, upgrading the air handling system, and right side the building chiller (Johnson, 2007). The EPA will include elder healthcare and assisted living establishments in the process in the future when the Institute of Medicine published its 2001 report labeling the United States’ healthcare system as hazardous, inefficient, and lacking a patient-centered emphasis (Johnson, 2007). Moreover, it sparked a patient safety and quality revolution that resulted in the change in healthcare environments across the country.

This is now referred to as the healthy hospital movement. Cleveland Clinic, Massachusetts General Hospital, and East Carolina Heart Institute at Pitt County Memorial Hospital are among the national leaders in this program (Johnson, 2007). The healthy hospital movement comprises surroundings that encourage healing while aiming to minimize environmental toxins to ensure that the healthcare setting does not negatively affect a patient’s health. Some of the steps include phasing out mercury-based thermometers, phasing out PVCs in hospital equipment, phasing out incinerators that emit toxic dioxin, and introducing more healthy and organic options in hospital food—all while using green building practices to save energy and resources while eliminating pollutants.

In summary, American hospitals use the GSCM practices; however, the level of use and standardization of practices remains low. Despite the American Hospital Association’s strong interest in green policy, its monthly membership surveys have focused on other healthcare concerns, such as management methods (Johnson, 2010). The American Hospital Association has conducted no particular research on green initiatives. Therefore, this lack of support from the organizations and not sufficient research to support the real-life implementation of green supply chain management practices further supports the idea that more attention should be provided to GSCM.

One of the GSCM case application in different health hospitals has involved management practices to ensure better consumptions of water and energy resources. The consumption of water and energy in hospitals is known to have increased risks or specific hazardous chemical and non-chemical waste are high (Bhakoo, Singh & Sohal 2012). This aspects is considered as one of the critical issue that involves sustainable resources usage by hospitals and as well as affects the safety of the environment within which different hospitals operates (D’Eusanio Zamagni & Petti 2019; Abdel-Baset, Chang & Gamal 2019). Notably, the issue of water and energy consumptions is linked to the necessity of focusing on GSCM. Different researchers agree that healthcare industries in many countries are concentrated on greening operations and activities in hospitals (Böhme et al. 2014; Dobrzykowski et al. 2014). The findings by the researchers are based on the concentrated efforts in health care industry identified by different health care facilities in ensuring safety of the hospital operations policies that relates to environmental safeguarding and increased economic benefits of the hospitals operations.

The identified efforts or actions of green operation have involved the process of application of critical development strategy outstand that emphasises on the effect of environmental degradation that relate to decreased level of operations performance level of different hospitals (Tumpa et al. 2019; Seman et al. 2019). These relationship of the environmental degradation to the firm performance levels is attributed to creating effectual economic effects that turns to affect the industry performance levels and as well inhibits the Hospital efforts in meeting different customer demands. Ferreira, Poltronieri and Gerolamo (2019) argue that the involvement of ISO standards in this approach includes the reuse of ISO 14001- 2015 and ISO 9001-2015 standards that have catered for the stretched effect of hospital operations to both the environment and the stakeholders.

Based on the provision of this standards, the hospitals are demanded to ensure the management system meet the quality requirements that demonstrates the ability of the firm to offer hospital services that will meet the customer preferences as deemed in the regulatory requirement of the ISO standards (Ferreira, Poltronieri & Gerolamo 2015). These demands are consequently demanded to meet the environmental needs which require reduced environmental degradation levels through creation of a better environmental management system that enhances the hospital environmental performance levels. As stated by Noviantoro et al. (2020),these approaches should ensure that hospitals achieve the required outcome of the developed environmental management system plus providing the required value out of the system that benefit the organisations itself and the interested parties. However, ensuring the implementation of the ISO standards plus integrating the demands of green supply management is challenging too many Hospital entities.

Note that, the application of Green supply management policies is based on the need for applying the environmentally conscious approach to minimising waste and utilising resources in the healthcare industry. This approach should seek to involve other considerable action of the organisation in ensuring that the needs of the hospital are kept intact even after the implementation of the policies is established by the management. Different Hospitals believes that employment of more investments options are necessary for upgrading technologies and retraining staff in order to adopt GSC in hospitals (Tönnissen & Teuteberg 2020). However, the exercise of this plans comes along with other aspects that that implicates the effective implementation of the demands started in ISO14001-2015 and ISO- 9001-2015 provisions (ISO. 2020; ISO 9001-2015 2020; ISO 14001-2015 2020). Another problem is also identified with the issue of investment of significant resources identified with transition to green supply management. The action to invest more resources leads to increased hospital exposure levels or other operational actions that implicate the environment and as well as effect the effecting levels of the hospitals thus not realising the effective implementation of the ISO standards.

Moreover, the authorities of hospitals and other healthcare facilities in different countries are inclined to interpret existing environmental regulations and recommendations regarding GSC in specific ways. According to Toke, Gupta, and Dandekar (2010), the perception of GSCM and the necessity to adhere to the recommendations developed in ISO 14001-2015 and ISO 9001-2015 are ambiguous because of constant changes in their understanding. However, the changes in the underdoing the provisions involve an constant integration of the new concerns in the management process and environmental aspects that should be included in firm operations to ensure realisation of high levels of quality (Tumpa et al. 2019). Nonetheless, the issue of ambiguity can be explained with reference to the fact that the level of perception of related responsibilities is different. Authorities in hospitals can be either oriented to investing in developing practices and going green or ignore the criticality of their influence on the natural environment (Kovac 2014; Muzaimi, Chew & Hamid 2017). As a result, many hospitals all over the globe remain uninvolved into the process of going green.

Thus, in the context of GSC in the healthcare industry, managers usually focus on such critical factors as the efficient use of water, energy consumption, the distribution of products or food, the focus on a well-organised eco-design of a building, efficient transportation, waste management, and possible recycling. Those hospitals that are on the path of transitioning from traditional SCM to sustainable or GSCM pay attention to measuring how they use resources, how they can reduce costs, and what greening practices they can implement in their settings (Gerwig 2015; Machado, Scavarda & Vaccaro 2014). As a result of such evaluations, the most appropriate practices are selected to refocus on the idea of green supply management. Nevertheless, in spite of all efforts of administrators in the healthcare industry to go green, they can experience difficulties associated with costs and the necessity of changing many processes and operations, as it is noted by Gerwig (2015). Therefore, the process of developing the principles of GSCM in the healthcare industry cannot be viewed as easy to realise.

Current State of Supply Chains in Australia and Turkey

Hospitals’ Supply Chains in Australia

In this section of the chapter, it is important to review specific features of hospital supply chains in Australia that depend on the national legal environment, as well as on particular features of the market and industry. Therefore, it is necessary to pay attention to specifics of supply chains in Australian hospitals and to the principles of their work. Moreover, this section also presents the analysis of researchers’ ideas regarding the importance of supply chains in the country and regarding the unique features of GSC in the context of Australian hospitals.

Specifics of Supply Chains in Australian Hospitals

In hospital supply chains, much attention is paid to such components as supply, labour, and purchasing activities that directly influence the quality of provided care and expenses. In Australia, these components of a supply chain also play key roles because hospitals spend many financial resources on ensuring the provision of high-quality supply, improving care, and guaranteeing the attraction of the most qualified staff (Böhme et al. 2014). As it is noted by Bhakoo, Singh, and Sohal (2012, p. 218), “the Australian hospital supply chain has a three-tiered structure including the manufacturer, wholesaler/distributor and a hospital.” The role of wholesalers or distributors in this context is important because products do not come directly from suppliers to hospitals, and this specific feature influences the work of a chain.

Supply Chains in Hospitals in Australia

In this sub-section, it is important to focus on the literature that explains how a three-tiered structure of Australian hospital supply chains works in detail. According to Bhakoo, Singh, and Sohal (2012), it is critical for hospital supply chains to develop the distribution function in order to spread resources more efficiently on other operations, processes, and activities. As a result, the pressure on the staff also decreases. In addition, according to Agarwal et al. (2016), specific roles of participants in hospital supply chains can be shifted when it comes to persons responsible for making purchasing decisions, spreading resources, planning costs, contacting with manufacturers and distributors, and buying products and services. Thus, researchers note that supply chains in Australian hospitals develop in order to optimise the work of all actors and achieve the highest results.

Furthermore, hospital supply chains in Australia can be discussed as rather flexible, and they can adapt to changes in government regulations and markets. This idea was proposed and discussed by Bhakoo, Singh, and Sohal (2012) and Budgett, Gopalakrishnan, and Schneller (2017) in their studies. However, in spite of flexibility in the work of supply chains and effectively organised interactions with distributors, hospitals can face some issues that are reported in the literature. For example, collaboration can be affected by the lack of trust between hospitals and distributors or between hospitals and manufacturers. Moreover, there are often situations when goal incongruence is observed between hospitals, distributors, and manufacturers (Böhme et al. 2014). This problem appears when distributors or manufacturers try to maximise their profits or when hospitals are oriented towards decreasing their costs significantly.

Supply chains in Australia should also be viewed as not only flexible but also dynamic, and this aspect influences the choice of SCM practices to adopt in this or that situation. In order to apply these practices effectively, managers in hospitals need to address a series of purchasing decisions, focus on specifics of cooperation, and select appropriate distributors. In addition, researchers also identified such risks for developing working supply chains as decentralisation, the lack of appropriate information sharing, and the lack of effectively used information technologies (Böhme et al. 2014; Budgett, Gopalakrishnan & Schneller 2017). These issues are also typical of Australian hospital supply chains, and they need to be addressed by managers.

The human aspect of sustainability is addressed by social sustainability. According to the literature, there is a growing movement toward adopting social practices in the supply chain, and despite the topic’s widespread adoption, it appears that social sustainability is still a relatively new concept in the service sector in general and in the healthcare sector in particular. Today’s business climate is more competitive than ever before. While such competition is found in SCM practices, the issue of sustainability has emerged as a prominent topic over the last decade. Sustainability is defined as the strategic, transparent integration and achievement of “social, environmental, and economic goals in the systemic coordination of key inter-organizational business” operations for enhancing the long-term economic performance of the company and its suppliers (Hussain et al., 2018, p. 15). This might be seen as actual sustainability occurring at the junction of three interconnected cornerstones: economic, environmental, and social. These pillars, however, are not given the same degree of attention. A heavy emphasis on the economic and environmental pillars has resulted in a scarcity of research on social sustainability.

As a result, while treating patients is the primary goal of healthcare service supply chains, offering access to and teaching opportunities about preventative behavior and wellbeing are equally vital. The sector covers services that need collaboration among actors in order to connect with clients and the community. To achieve better patient outcomes, healthcare institutions should shift their focus from illness treatment to prevention and wellness, which is an important component of societal sustainability. The key to doing this is the efficient integration of corporate activities and channel members. While the current literature indicates that the social element of sustainability has recently been brought into the study, theoretical and empirical investigations are still lacking. This feature has been extensively addressed only in relation to legislative difficulties, legal obligations, or human safety. It should be mentioned that greater attention should be paid to the expectations and views of all stakeholders who impact or are affected by the business. In this regard, it is critical to shedding light on stakeholders’ perceptions of what makes companies socially viable. Despite the demand for enterprises to adopt socially sustainable practices, the motivators and constraints of diverse stakeholders have not been well investigated.

Due to long-term corporate sustainability being contingent on fulfilling stakeholders’ expectations, managing organizational connections with them has been viewed as a manner of connecting organizational strategy to social and ethical concerns. This has resulted in greater awareness when dealing with stakeholders, indicating effective management of both positive and negative consequences on individuals and communities. As a result, social development has been a focal point in supply chain operations, and there has lately been an increase in interest in the social pillar of sustainability, driven by the political agenda and commercial objectives focused on community development.

In comparison to the other two pillars, social sustainability has often been regarded as the most ambiguous and elusive term. Much little research has been conducted on social sustainability. This demonstrates a vacuum in the present research about how social sustainability might be integrated into modern decision-making processes.

Furthermore, most logistics and supply chain management research has looked at concerns like the environment, safety, and human rights in isolation, without considering the possible interrelationships between these and other facets of social responsibility.

Furthermore, while stakeholders’ ties with the focus organization vary, the nature and distinctiveness of those interactions determine how an organization reacts to stakeholders’ interests and influence how stakeholders relate to the supply chain. The literature, on the other hand, falls short in recognizing the intersections between stakeholders’ interests and aspirations of social sustainability. According to Hussain et al. (2018), a wider variety of players with a web of interests and relative tradeoffs must be evaluated and integrated. Furthermore, the significance of stakeholders’ roles and duties in assessing company social performance should be highlighted in connection to their respective stakes. It is critical to have a thorough awareness of the actors (stakeholder groups), their roles, and their relationships with other stakeholders.

The social dimension is well-known, yet it receives less attention than may be expected in supply networks. Social issues in the supply chain are defined as three levels of stakeholders, focusing on the evolving set of social concerns for which the organization has influence in the supply chain and including management capabilities that respond to these concerns by mitigating risk or improving customer value. Equity, safety, health and welfare, philanthropy, ethics, and human rights are some of the basic components of supply chain social sustainability (Hussain et al., 2018). Competitive pressure, followed by customer requirements, financial liquidity, social concern, and social sustainability awareness, are the primary driving forces for supply chain social sustainability (Hussain et al., 2018). Not only does social sustainability play an important role in allowing other sustainability projects.

As a result of this fact, supply chain managers are under increasing pressure to integrate sustainability principles throughout the whole supply chain. A focus on supply networks is an important step toward greater adoption and development of sustainability. Hussain et al. (2018) define supply chain management as “the integration of important business activities from end-user to original suppliers that produce products, services, and information that provide value for customers and other stakeholders” (p. 977). This implies that supply networks are comprised of numerous enterprises, and the chain’s sustainability is dependent on the sustainability of each of those companies. Sustainable supply chain management must include a wider variety of concerns and, as a result, must examine a larger portion of the supply chain.

Importance of Supply Chains in Australian Hospitals

In Australian hospitals, supply chains play the significant role in ensuring the provision of on-time and high-quality care for patients. To support this idea, researchers indicate that effectively arranged supply chains involving hospitals work to cope with such types of waste in activities and operations of healthcare facilities as reworking, overproduction, ineffective processing, increased waiting time, weaknesses in transportation, and inappropriate management of inventory (Machado, Scavarda & Vaccaro 2014; Rodwell & Gulyas 2013). It is important to note that these common types of waste are identified for different forms of supply chains, including hospital ones among others.

The importance of supply chains and interactions between partners within these systems is accentuated in many research articles on the topic. Different studies provide evidence to support the idea that collaboration within supply chains is necessary for eliminating waste, avoiding procurement hazards, using resources appropriately, improving logistics, and decreasing a negative impact on the environment and community (Bhakoo, Singh & Sohal 2012; Machado, Scavarda & Vaccaro 2014; Rodwell & Gulyas 2013). As a result, performance, productivity, and competitive advantage of private and public healthcare organisations improve due to efficient and properly coordinated collaboration. In order to operate effectively, hospitals in Australia need to plan their activities and interactions with suppliers and distributors with much attention on information sharing, spending financial resources, and protecting the environment (Chakraborty & Dobrzykowski 2014). When a supply chain including this or that hospital does not work efficiently, the balance in the system is affected, and there appear threats to the life and health of patients.

Therefore, researchers agree on the fact that supply chains in the healthcare industry are important for improving the quality of care, implementing innovation, as well as reducing costs, waiting time, and used resources. According to De Vries and Huijsman (2011), the integration of flows of resources and information associated with collaboration is important for organisations to enhance processes in their specific internal and external environments that involve different actors. In spite of the fact that the coordination of the work of all partners in a system, the elimination of waste, and the appropriate distribution of resources are viewed as the key ideas and principles associated with SCM, researchers also put emphasis on the strategic nature of effectively arranged supply chains (Min 2014; Polater, Bektas & Demirdogen 2014). The reason is that the strategic goals of any organisation can be successfully addressed only in those cases when all partners in a chain work in cooperation.

The other group of researchers accentuated the importance of supply chains in the healthcare industry with the focus on perspectives for predicting or coping with possible threats and barriers in the market. Thus, if SCM relationships are not efficient or not based on trust between all actors, there are risks that operations and activities in hospitals can be negatively affected involving more outside actors to resolve a problematic situation (Böhme et al. 2014; Rakovska & Stratieva 2018). In addition to that, referring to building strong supply chains, leaders in hospitals not only improve the inventory management and logistics in their organisations, but they mainly focus on creating prolonged positive relationships with suppliers and distributors in order to rely on these partners in any situation (Bhakoo, Singh & Sohal 2012; Budgett, Gopalakrishnan & Schneller 2017). From this perspective, developing supply chains, leaders in Australian hospitals and globally focus on minimising risks associated with the fact that hospital supply chains are based on the issue of availability of resources, interconnectedness, and collaboration.

It is also possible to find several stages of maturity identified for supply chains in the literature that can be discussed in the context of supply chains in Australian hospitals. At the first stage, new hospitals only start developing their supply chains by finding partners in order to address the needs in terms of materials, resources, and different types of supplies. At the next stage, hospitals build their supply chains according to the principle of collaboration in order to improve the delivery of care and patient outcomes. At the most advanced stage, managers in the healthcare industry become interested in building sustainable and integrated supply chains in order to guarantee the progress of an organisation with the focus on economic, social, and environmental dimensions (Bhakoo, Singh & Sohal 2012; Correia et al. 2017; Rodwell & Gulyas 2013). These stages are described in the recent literature on the problem, and they illustrate the idea that the development of effective supply chains is an important step for Australian hospitals to improve their performance.

Green Supply Chain Management in Australian Hospitals

In spite of the fact that GSCM is actively discussed today in scholarly literature in relation to the idea of sustainability, there are no recent reports or studies on applying the principles of GSC in the Australian healthcare sector. In their study, Bhakoo, Singh, and Sohal (2012) focused on examining the nature of interactions between actors of hospital supply chains in Australia, but they did not refer to the case of greening supply chains. Furthermore, Mitchell et al. (2017) concentrated their cross-sectional study on analysing effective cleaning practices in Australian hospitals in the context of minimising waste, increasing productivity, and improving patient outcomes, and some of the proposed approaches can be viewed in the context of greening, but they did not discuss the role of supply chains. Thus, it is possible to state that the information on sustainable or GSC in the healthcare industry of Australia is rather limited.

The review of the literature has indicated that available reports also do not provide appropriate statistics or facts regarding the issue. In the report by Global Access Partners (2016), the researchers analysed the most effective approaches to arranging supply chains in the Australian healthcare industry, but they did not mention possible variants of greening those chains that are used currently. Therefore, it is almost impossible to retrieve the relevant information on GSC in Australian hospitals from available sources and research articles.

However, there are still some studies that can be viewed as helpful for understanding the trends in the Australian healthcare regarding the implementation of sustainable and GSC.

As a result of their multi-method research, Böhme et al. (2014) found that supply chains in Australian hospitals are often inefficient because working systems are inappropriate, and functions and roles of all participants are not stated or followed clearly. The researchers proposed a series of improvements for current supply chains in the Australian healthcare industry, and they concentrated on enhancing flows of resources and people within a chain. Some implications for developing a sustainable network with the elements of greening were also proposed (Böhme et al. 2014; Silvestre 2016; Zainudin et al. 2014). These steps are critical in order to make hospital supply chains in Australia as efficient as it is in other countries of the world, according to the data reported by Toke, Gupta, and Dandekar (2010) and Mbaabu (2016).

There are also other authors who proposed some ideas on the issue of creating sustainable or GSC in the country. According to Budgett, Gopalakrishnan, and Schneller (2017), hospitals in Australia are on the path of developing sustainable and GSC with the focus on the idea of building integrated supply chains to guarantee the strategic collaboration of all partners within a network. In this context, leaders in the healthcare industry contribute to using IT for sharing information and making strategic decisions. In addition, the focus on modernised supply chains is associated with “aggregating purchasing data enabled procurement to better understand trends and possible areas for cost-reduction projects in a public hospital in Australia” (Budgett, Gopalakrishnan & Schneller 2017, p. 64). It is important to note that all these steps to improving supply chains lead to developing strong working systems that are rather sustainable and corresponding with strategic goals of an organisation that also include the environmental stability. Thus, GSC are implemented in Australian hospitals, but more research is required in this field in order to cover this gap in the existing literature on the topic.

Hospitals’ Supply Chains in Turkey

Supply chains in hospitals of Turkey also have particular features in comparison to those chains adopted in healthcare industries of other countries. In Turkey, supply chains typical of hospitals are discussed as rather fragmented, and this aspect influences operations of all involved actors, as well as their communication (Polater, Bektas & Demirdogen 2014). Therefore, it is important to focus attention on the literature that describes the elements of SCM in Turkey.

Specifics of Supply Chains in Turkish Hospitals

As it is presented in the literature, supply chains that are adopted in Turkish hospitals are characterised by the great number of involved actors. According to Polater, Bektas, and Demirdogen (2014, p. 115), the major participants in these chains include “manufacturers (drugs, medical equipment, and hospital medical supplies), distributors, medical service providers, medical groups, insurance companies, government agencies (such as, Social Security Services), employers, government regulators, and users of healthcare services.” As a result, the level of fragmentation in this network is high, and this factor influences the quality of interactions and expenses associated with maintaining the whole chain.

It is also discussed in the literature on supply chains in Turkey that this field is highly regulated by national directives and norms oriented to protecting the environment. As a consequence, following different types of directives, organisations in Turkey pay much attention to reducing waste in their operations. According to the results of Camgöz-Akdağ et al.’s (2016, p. 469) study, Turkish organisations in the healthcare industry are oriented to preventing waste “at source, otherwise reduce waste and finally if waste is unavoidable recycle it.” From this perspective, the variety of relationships between participants in supply chains is based on the idea that the limited amount of waste can be produced at each stage of interactions within a chain (Erus & Hatipoglu 2013). Researchers agree that authorities in Turkish hospitals pay much attention to following directives and norms as well as to eliminating waste in operations.

Supply chains in Turkey are also characterised by the emphasis on the role of leaders or managers in the process of regulating and monitoring interactions within a developed network, as it is in the case of hospital supply chains. According to Akdaǧ (2015), the authorities in the Turkish healthcare industry concentrated on bringing change to administration and operations in hospitals in order to improve the quality of care and address clients’ needs. In this context, they shifted to the idea of transformational leadership and the adoption of the most efficient practices to enhance all types of interactions between healthcare providers, suppliers, and clients. From this perspective, leaders in supply chains of Turkish hospitals are oriented to implementing change in business processes and moving to the principles of sustainable SCM with the focus on greening techniques.

Supply Chains in Hospitals in Turkey

In Turkey, supply chains in hospitals work to ensure that patients receive care and treatment in time with reference to all required medications, equipment, and services. In this context, all actors of a chain discussed by researchers are expected to provide “a synchronised decision” in order to achieve the highest result (Polater, Bektas & Demirdogen 2014, p. 116). Thus, the whole process of the cooperation in a chain is based on all participants in order “to produce and distribute the products or services at the right quantities, to the right locations, and at the right time, in order to minimise system-wide costs while meeting customer expectations” (Polater, Bektas & Demirdogen 2014, p. 116). According to these researchers, if these tasks are addressed efficiently, it is possible to expect significant achievements in patient outcomes.

As it was stated earlier, hospital supply chains in Turkey are considered to be fragmented because operations associated with different stages of these chains are usually completed independently, and the whole chain does not work as a system. The support for this idea is provided in research-based articles by Erus and Hatipoglu (2013), Polater, Bektas, and Demirdogen (2014), and Turkyilmaz, Bulak, and Zaim (2015). As a result, different types of leaders in healthcare facilities in Turkey are oriented to developing the most effective supply chains, the components of which can work interdependently, as it is in the case of popular integrated supply chains (Özkan, Akyürek & Toygar 2016). It is also important to state that the development of the greening concept is also a task for managers because sustainability is viewed as the requirement in the healthcare industry of Turkey.

Importance of Supply Chains in Turkish Hospitals

In spite of the fact that the limited number of studies exists on specifics of supply chains in the Turkish healthcare industry, the importance of choosing the most innovative variants of networks and types of cooperation with suppliers, distributors, and clients is accentuated in current articles. The reason is that researchers note that the focus on SCM is the priority for the majority of modern healthcare organisations (Polater, Bektas & Demirdogen 2014; Turkyilmaz, Bulak & Zaim 2015). The application of supply chains in Turkish hospitals is discussed in the literature because the adoption of sustainable systems will potentially lead to improving the quality of the provided care and the quality of life in communities because of decreasing a negative effect on the environment.

Currently, expenses associated with supporting operations in the healthcare industry in Turkey are high. According to Camgöz-Akdağ et al. (2016), in order to reduce these costs, it is necessary to change the approach to SCM in both public and private hospitals. The refocus on GSC is efficient in this case because the use of green materials and goods and the choice of recycling guarantee the reduction of waste and negative effects on the environment (Bracci&Tallaki 2015; Chakraborty, Bhattacharya & Dobrzykowski 2014). In addition, such sustainable choices can potentially lead to saving all types of resources for an organisation, involving not only material but also financial ones.

Referring to the available literature on supply chains in Turkey, it is possible to note that the healthcare industry in the country is on the path to altering its operations in order to make them greener according to the standards that have been adopted at the national and local levels, as well as according to European and global trends. In this context, much attention is paid to imitating patterns that are used by US hospitals because of their orientation to environmentally friendly supply chains, and this practice is followed in the United States during about two decades (Chiarini 2015; Dobrzykowski et al. 2014; Gerwig 2015). The experience of the United States and European countries is widely discussed in the literature as important in order to accentuate the role of moving to GSC for saving all types of resources and improving performance and productivity.

Gaps in Research

The review of the literature has helped to indicate specific areas in research that need to be further studied in order to understand how SCM has evolved during the past decades and what types of supply chains are now implemented in organisations. In spite of the fact that SCM is an actively discussed topic in managerial and business literature, there are still gaps in the existing research on this issue (Bracci & Tallaki 2015; Chakraborty & Dobrzykowski 2014). These gaps are identified even in the most recent research and they are related to implicate the inappropriate application GSCM by different firm including firms identified in health industry.

The identified gaps are primarily related to the contexts in which different types of modern supply chains are developed or implemented. Thus, although many studies cover diverse dimensions and aspects of SCM with the focus on sustainable, integrated, and GSCs, there is still the lack of research on SCM in the healthcare industry in terms of advantages and disadvantages of applying these chains in hospitals. The problem is identified widely as no currently researcher who has focused on identifying the current alteration of GSC that have affected different industries and as well as increased the wide application of GSC. This deficiency has therefore limited research on the integration of GSCM on the current provisions of ISO standards. Researchers have provided various findings on benefits of referring to GSCs in organisations, but only a few of them relate to the context of the healthcare industry.

In addition, more data and research are required on barriers that organisations can face when they choose to integrate modernised variants of supply chains. Thus, the existing literature presents the extensive review of theoretical principles of developing GSCs and a general review of the role of SCM in firms (Shen 2013; Toke, Gupta & Dandekar 2010; Shabbir et al. 2019; Zainudin et al. 2014). However, there is the limited number of studies that refer to concrete cases in different industries. Few current researchers are focusing in this issues although the increased environmental concerns has led to a wide view of the application of green supply management approaches thus widening the scope of study making it difficult to have a focused research approach as detailed in the past studies. From this perspective, it is necessary to focus on researching supply chains not only in the context of the healthcare industry but also with reference to concrete case studies, similarly to the approach used by Chege (2012), Zainudin et al. (2014), and Laari (2016) among other experts. More research is needed in order to discover the key benefits and challenges of implementing integrated GSCs in healthcare facilities with the focus on concrete cases in order to propose a list of recommendations to improve the implementation of these practices.

It is also important to note that additional research is also required for the context of Australian and Turkish hospitals in order to understand what practices are used by healthcare authorities to improve SCM in the industry. The topic of applying green and integrated supply chains in hospitals has received little attention from researchers who preferred to focus on general strengths of applying GSCs without referring to the industry or to the context. However, there are many aspects that are associated with the implementation of green and integrated supply chains in the healthcare environments that need to be discussed and analysed in detail in order to improve the theoretical knowledge in this field. The reviewed literature demonstrates that a few details and little analysis are available regarding the role of integrated and GSCs in hospitals in spite of researchers’ and practitioners’ interest in this topic (Gerwig 2015; Shen 2013). Therefore, the current study is oriented to addressing the determined gaps in research and contributing to the existing knowledge regarding the implementation of GSCs in Australian and Turkish hospitals.

Big Data and GSCM in Other Industries

Before delving into the application of Big Data in green supply management methods, it is necessary first to define data and big data. The numbers, letters, or symbols on which a computer performs operations can be stored and transferred as electrical impulses and recorded on magnetic, optical, or mechanical media (Kumar et al., 2019). Big Data is a massive collection of data that is expanding exponentially over time. It is a data set that is so huge and complicated that typical data management systems cannot store or analyze it efficiently. Big data is a type of data that is extremely large in size.

Given BDA’s recent popularity and the breadth of its applications, it is difficult to agree on a definition. BDA is described broadly as “a new generation of technologies and architectures designed to cheaply extract value from very large quantities of a wide range of data by allowing high-velocity collection, discovery, and analysis” (Benzidia et al., 2021, 12055). It necessitates novel technical forms of information processing for improved comprehension and decision-making (Benzidia et al., 2021). Allowing businesses to gain a competitive advantage, these benefits include skill management, supply chain management, and corporate performance.

Big data analytics has grown in popularity due to its ability to employ strategies that allow managers to make better decisions using evidence as opposed to human judgment or intuition (Benzidia et al., 2021). It necessitates the establishment of particular technologies to handle the possible data volume and, as a consequence, discover patterns, recognize models, and gather important findings (Benzidia et al., 2021). Technological advancement has substantially raised the importance of big data in the decision-making process of businesses (Benzidia et al., 2021). Technologies such as smartphones and RFID, cloud computing, and the internet of things (IoT) provide considerable advantages in terms of integration and real-time data processing and analysis for obtaining useful information.

One of the difficulties that businesses confront when using BDA technology is the subjectivity and unpredictability of the findings, which may have originated from the wrong sources (Wang et al., 2019). Another issue that may arise is the confidentiality and security of shared data, which is still a major concern in industries such as healthcare. This circumstance necessitates not only the mobilization of technology in line with standards but also the development of human skills capable of grasping the technical aspects associated with BDA (Benzidia et al., 2021). By integrating tools, methodologies, and procedures, big data analytics helps firms to make effective decisions about green operations in the supply chain (Benzidia et al., 2021). The influence of big data on decision-making processes related to green supply chain integration and environmental performance, on the other hand, remains to be seen.

Big data analytics and artificial intelligence (BDA-AI) technologies have piqued the interest of academics and practitioners in recent years. Few empirical research, however, has looked at the benefits of BDA-AI in the supply chain integration process and their influence on environmental performance (Benzidia et al., 2021). In recent years, the healthcare industry in many countries has experienced a surge in digitization and adoption of BDA technology. In France, the government appears to recognize the technology opportunity and is implementing a new plan called “My Health 2020,” which intends to transform the hospital into a linked organization (Benzidia et al., 2021). The government, for example, is investing in large big data projects like ConSoRe and Health Data Hub (Benzidia et al., 2021). In hospitals, big data sources might rely on a range of technology devices, including electronic patient records, cloud computing, smartphones, tablets, and wearables. These technology sources are critical to enhancing clinical treatment.

Big data is often studied using artificial intelligence (AI) systems capable of processing massive amounts of data for medical research purposes. Despite the fact that medical research on the relationship between BDA and AI is numerous, it is seldom mobilized in the development of hospital supply chain procedures, particularly green practices (Benzidia et al., 2021). The research by Benzidia et al. (2021) focuses on the impact of BDA in conjunction with AI (BDA-AI) in improving EP in hospitals, a topic that, based on current research, has received little attention. The relationship between BDA and supply chain process integration as a technique for developing organizational performance has also been studied in the literature. This entails both external integration and internal integration depending on the collaborative capabilities of supply chain partners.

As a result, this is a crucial topic to investigate because poor supply chain integration has a detrimental influence on performance (Benzidia et al., 2021). However, the interaction of these three processes, namely BDA-AI, internal and external integration, and the influence on EP, has received little attention. This was the first research to look at this link in the setting of hospitals. In addition, the research on BDA capacity has tended to focus on the technical side and computing capability to enhance the supply chain process. Some studies’ empirical findings also highlight the need to invest in other complementary and intangible resources, such as human resource skills.

The organizational information processing theory (OIPT) has been widely applied in the analysis of the manufacturing supply chain, according to Benzidia et al. (2021), and, in a few rare circumstances, the hospital supply chain. This idea, however, has yet to be practically applied to the specific issue of hospital green supply chain. Due to the complexity of the hospital supply chain, the uncertainty of managing several flows, for example, “patients, drugs, laundry, catering, and waste,” and the coordination of various interdependent processes, for example, “medical units, pharmacy, supply, transport, and production,” OIPT was an appropriate theoretical framework to use (Benzidia et al. 2021, p. 12077).

Our work, which is based on OIPT and a survey of 168 hospitals, adds to a deeper understanding of the mechanisms through which BDA-AI technologies affect EP in a complex setting. The study by Benzidia et al. (2021) research developed and empirically verified a conceptual model that demonstrates how BDA-AI technologies increase internal and external environmental integration in supply chain operations, contributing to EP. The study by Benzidia et al. (2021) expanded the OIPT model beyond traditional technical infrastructure and organizational mechanisms by including BDA-AI as a cutting-edge technology that enables decision-making in GSC procedures. Another expansion was the presentation of digital learning as a GSC process moderator.

Other Industries

Climate change has prompted businesses to widen their reporting of environmental performance during the previous few decades (Migdadi, 2018). Many factors, including government legislation, consumers, and other stakeholders, have pushed firms to embrace more environmentally friendly practices. Firms of diverse sizes and industries have begun to act more responsibly toward the natural environment (Benzidia et al., 2021). Some of them have begun to implement more environmentally friendly competitive tactics in order to boost their competitiveness, which has also improved performance. Since the mid-1990s, green supply chain management strategies have been extensively researched in the literature (Migdadi, 2018). Migdadi (2018) develops the best green strategy patterns explicitly and in-depth in his study, documenting the practices of six prominent mobile phone companies; however, his suggestive models are addressed with relatively rudimentary statistical approaches. Furthermore, Migdadi’s study, due to its small sample size, does not report on regional strategic tendencies or compare one region to another.

Migdadi (2018) conducted a study that reports on the strategic patterns of green manufacturing by ISO 14001 certificate holders in a single nation and examines the green strategies used in-depth. Indeed, when it comes to manufacturing green initiatives, all past research has concentrated on one nation or a limited number of countries. This suggests that further studies are needed in the service sector, and cross-regional studies may give more insight into effective strategy patterns. Green airline practices have been investigated from a variety of viewpoints, including marketing, information technology, operational issues, and technical standards.

From a marketing standpoint, the studies have concentrated on measuring customers’ readiness to pay for green airline operations and their propensity to acquire green aviation products. The operational studies focus on reporting the influence of certain operational methods on green indicators. Green strategic patterns represent success milestones in green practices, as these activities are part of the broader competitive advantage that firms strive for in order to increase market share (Migdadi, 2018). The environmental effect of aviation is caused by heat, noise, and, in particular, greenhouse gas emissions (GHGs) released by aircraft engines, such as carbon dioxide, water vapor, hydrocarbons, and carbon monoxide, and aviation accounts for around 2% of total global CO2 emissions (Migdadi, 2018).

Because of the rising demand for airlines, the environmental effect of aviation has grown dramatically during the last 25 years; the environmental impact of this sector has, in turn, increased significantly (Migdadi, 2018). CO2 emissions surged by 80% between 1990 and 2014 and are expected to climb by another 45% between 2014 and 2035 (Migdadi, 2018). Nitrogen oxide (NOx) emissions more than doubled between 1999 and 2014, and they are anticipated to rise by another 43% between 2014 and 2035. The airlines have pledged to half their overall CO2 emissions from 2005 by 2050, and they are working hard to minimize the environmental effect of their operations (Migdadi, 2018). This begs the issue of what are the best operational activities for airlines to take in order to lessen their negative environmental effect. Although this section is primarily focused on the use of green practices, this research shows the increasing amount of waste, pollution, and inefficient practices across different industries.


Although it is evident that there is a need for the use of green practices in the healthcare industry, as well as others, to reduce the harmful impact that these facilities have on the environment, there are also risks associated with the adoption of these practices. The pharmaceutical industry plays a critical role in providing society with life-saving products and services. There are several methods for pharmaceutical materials and services to impact the environment, including inappropriate pill or tablet disposal by patients, expired and unused medications, improper drug release by pharmacies, and home sewage combined with surplus drugs (Kumar et al., 2019). Managers must assess the risks associated with implementing GSC initiatives in order to ensure operational sustainability.

Drugs are manufactured, distributed, and consumed in the pharmaceutical industry. As a result of its importance, storage, transit, and laws, it must be treated differently than other physical products supply chains. By recycling unused/unwanted medications and disposing of items in an environmentally sustainable manner, GSC activities assist in enhancing the pharmaceutical industry’s ecological and economic advantages. GSC activities in the pharmaceutical business may be characterized holistically as the incorporation of green practices at each step of the supply chain, such as green sourcing, eco-friendly design, green manufacturing, green distribution, reverse logistics, and others.

Green sourcing is recognized as an essential feature in the pharmaceutical industry, guaranteeing the purchase of materials/products/services with the least detrimental impact on the environment and society (Kumar et al., 2019). Risk in GSC efforts may jeopardize the pharmaceutical industry’s operational stability. As a result, GSC risk may have a substantial influence on pharmaceutical sector green sourcing decisions, such as interruption in material supply, quality issues, higher environmental consequences, diminished competitive gains, and others (Kumar et al., 2019). In order to acquire a perspective on this task, improve performance, and manage GSC activities, considering a holistic view of GSC, the idea of GSC risks must be addressed.

Due to the risks involved in operations, forecasting future policy is exceedingly challenging. The risk may be defined as the likelihood of anything happening that interrupts routine operations/activities (Mangla et al., 2015b). Consider the failure of a new product or initiative, for example. The risk may also be defined as a deviation from an expected mean that can have an impact on supply chain operations and procedures (Kumar et al., 2019). In accordance with this, risks in the context of GSC are defined as “the occurrence of unanticipated events that may affect the green material movement and even disrupt the proposed flow of eco-friendly materials and finished green products from their point of origin to the point of consumption in business” (Kumar et al., 2019, p. 11).

As a result, the supply chain is critical in supplying medications or resources to pharmaceutical sector stakeholders. Introducing GSC initiatives has the potential to convert the industry into one that is more environmentally conscious and accountable to the community (Kumar et al., 2019). In contrast to typical supply chain techniques, GSC approaches in the pharmaceutical sector entail optimal resource usage. However, the inclusion of risks may squander resources and impact the acceptance of GSC concepts (Kumar et al., 2019). GSC hazards can have a detrimental impact on quality, supply failures, and workflow interruptions, disrupting ecological equilibrium and triggering a drop in business sales (Kumar et al., 2019). If managers are unable to recognize and manage these risks in a timely way, the consequences might be disastrous.

To develop or maintain a green supply chain (GSC) that produces products and services ethically and sustainably, supply chain managers should employ methods that enable the effective detection, quantification, and mitigation of ever-present hazards. Hence, there are several risk variables connected with the procedures involved in GSC management (Zou et al., 2021). For managers, GSCM deployment is beneficial to a supply chain, resulting in a higher competitive advantage. For example, it may assist a corporation in identifying its brand or building a positive corporate image and credibility in order to gain consumers’ confidence. GSCM can also have the added benefit of assisting in cost reduction. Green logistics, which makes use of fewer resources and more efficient logistics modes, may reduce operational costs while increasing firm earnings (Zou et al., 2021). It may also assist businesses in overcoming current hurdles to green operations and taking advantage of foreign markets.

Several empirical studies on GSCs have been undertaken in recent years. More specifically, the advantages and disadvantages connected with the practical implementation of a GSC have been investigated. Zou et al. (2021) examined the three key influencing aspects of GSCM principles: practice, performance, and external pressure from stakeholders. Zou et al. (2021) evaluated the influence of GSCM on the environmental, economic, and intangible performance of organizations as a consequence of GSCM activities. A structural model for determining the causal link between specified criteria was developed utilizing fuzzy set theory, choice test, and assessment laboratory methodologies.

Another relevant topic of research would be the risk criteria that influence GSCM procedures. Behzadi (2018) performed a thorough analysis of the relevant literature on quantitative risk management modeling of agricultural supply chains, taking into account the robustness and elasticity of essential risk management components. The application of material performance analysis (IPA) tools has also been demonstrated to give strategic suggestions for improving the performance of industrial supply chains (Kumar et al., 2019). A methodology for assessing risk management and the sustainability of supply chains has also been devised (Kumar et al., 2019). Wang (2018) divided and analyzed risk variables impacting a supply chain into three categories: external factors, internal factors, and overall factors.

External elements were further classified as political considerations, economic factors, natural aspects, legal issues, and consumer factors, while internal factors were enlarged to include corporate decision-making, managerial control, and logistics-related hazards. The general factors group was further subdivided by the risks taken in a variety of fields, ranging from the pursuit of profit aims to contracts, information systems, and capital flows. Furthermore, potential solutions to these risk factors were proposed, assisting firms in managing and avoiding hazards.

The identification of risk variables is critical since some of them can impede the implementation of GSCM. The identification of the amount of risk in a supply chain is critical to the effective implementation of a GSC, which includes the development of risk evaluation criteria and the development of a risk evaluation model. Improving an enterprise’s capacity to manage supply chain risk is a critical component of ensuring its long-term viability. In order to optimize a company’s profit, it needs to have a certain level of risk awareness, the capacity to prevent hazards in advance, and the ability to limit the risk of loss. This model described in this study can be beneficial for managers in predicting the risks detected in their firms’ GSC and allowing the design of relevant countermeasures and plans to prevent hazards and decrease associated expenses.

A crucial topic to investigate because poor supply chain integration has a detrimental influence on performance (Benzidia et al., 2021). However, the interaction of these three processes, namely BDA-AI, internal and external integration, and the influence on EP, has received little attention. This was the first research to look at this link in the setting of hospitals. In addition, the research on BDA capacity has tended to focus on the technical side and computing capability to enhance the supply chain process. Some studies’ empirical findings also highlight the need to invest in other complementary and intangible resources, such as human resource skills.

The organizational information processing theory (OIPT) has been widely applied in the analysis of the manufacturing supply chain, according to Benzidia et al. (2021), and, in a few rare circumstances, the hospital supply chain. This idea, however, has yet to be practically applied to the speAs a result, this iscific issue of hospital green supply chain. Due to the complexity of the hospital supply chain, the uncertainty of managing several flows, for example, “patients, drugs, laundry, catering, and waste,” and the coordination of various interdependent processes, for example, “medical units, pharmacy, supply, transport, and production,” OIPT was an appropriate theoretical framework to use (Benzidia et al. 2021, p. 12077).

Our work, which is based on OIPT and a survey of 168 hospitals, adds to a deeper understanding of the mechanisms through which BDA-AI technologies affect EP in a complex setting. The study by Benzidia et al. (2021) research developed and empirically verified a conceptual model that demonstrates how BDA-AI technologies increase internal and external environmental integration in supply chain operations, contributing to EP. The study by Benzidia et al. (2021) expanded the OIPT model beyond traditional technical infrastructure and organizational mechanisms by including BDA-AI as a cutting-edge technology that enables decision-making in GSC procedures. Another expansion was the presentation of digital learning as a GSC process moderator.


In summary, this chapter is an analysis of literature on the topic of SCM and its application by hospitals in Australia and Turkey. Some of the reviewed definitions for the SCM include viewing it as a stage by stage process that begins with suppliers and ends with the customer who receives the product. For hospitals, these customers are the patients; hence the SCM theory requires the managers to adjust supply chains to deliver a combination of quality and cost. The literature analysis shows that the Australian hospitals have advanced SCM systems when compared to the Turkish ones, which may be attributed to the form of ownership. However, the findings do not point to the widespread adaptation of the green SCM practices nor address the reasons explaining why sustainability has not become common in hospital management.



This chapter will describe the methodology of this study and how it was applied to examine the cases of Australian and Turkish healthcare systems in terms of their supply chain management practices. At the beginning of this chapter, the methodology of the project will be described, followed by the presentation of findings and analysis of the case study. The first part of this chapter will describe the methodology followed by the presentation of findings. The discussion will focus on how the author applied the chosen methodology to collect information from two hospitals and analyzed it. This study is a combination of quantitative and qualitative research focusing on one hospital located in Australia and Derindere Hospital from Turkey. The study was undertaken in two phases, conducted sequentially, and the findings will be presented for the Australian hospital first, followed by the results of the Turkish facility. The results are presented in two phases sequentially for each of the two hospitals.

Conceptual Framework

This study is conceptually based on demonstrating the connection between the following concepts and fields: the healthcare industry in Australia and Turkey, integrated supply chains (ISC), supply chain management (SCM), green supply chains (GSC), public and private hospitals, green supply chain management (GSCM) practices, ISO 14001-2015, and ISO 9001-2015. This study focuses on comparing what achievements have been reached by public and private hospitals in Australia and Turkey after green practices are integrated into their SCM policies. Furthermore, the focus is also on discussing what challenges can be observed on this path from historical needs as shown by (Maleki & Cruz-Machado 2013; Nassirnia & Robinson 2013). From this point, much attention should be paid to analysing the role of implementing ISO 14001 and ISO 9001 in the healthcare organisations in order to improve hospitals’ focus on the idea of sustainability in terms of its environmental aspect. It is also possible to expect that the hospitals selected for the case study analysis have not implemented the standards in the most appropriate manner or they faced some challenges on this path.

The reliability and validity of case studies are perhaps the biggest issues in this research because this method implies some difficulties with the generalization of data. Case studies entail the investigation of tiny data sets, such as one or two firms, which may lead to the researcher gaining some insights into patterns in relevant industries. A case study of an American hospital, for example, might be used to generalize about comparable firms in the healthcare market. The data is real life, meaning that it was collected from a firm or company (Methods of collecting data, no date). However, because the investigations include limited data, typical empirical approaches cannot be employed, or if they are used, they may have restricted relevance because there may not be enough data to fulfill statistical significance requirements.

The case study approach entails a thorough assessment of all elements of a corporation, for example, and can employ a variety of various measuring techniques; the case study researcher is not bound to any one methodological instrument. Data may be collected over time and is contextual or related to a certain industry (Methods of collecting data, no date). The histories and case study stories that can be told about the firm may also be evaluated and documented—not only empirical facts but also stories and anecdotes about how the company interacts with the marketplace.

To increase validity, good case studies employ a variety of research tools. For example, the researcher can employ both qualitative and quantitative methodologies, as well as a variety of data gathering tools such as surveys, interviews, documentation review, and artifact collection. It is best to “triangulate” your research tools or methodologies so that they present multiple perspectives on the issue (Methods of collecting data, no date). This eliminates the issue of observer bias, such as selecting an instrument that measures what you want to see rather than what is actually there. Hence, this research paper utilizes the method of case study to collect and analyze the data. The researcher has considered the potential issues and biases that are related to the case study method.

Therefore, for this study, the selected context can be described as the healthcare industries in Australia and Turkey and with paying attention to their similarities and differences. Hospitals with different ownership systems are selected as specific healthcare facilities to be examined within this context. In the selected hospitals, administrators or managers are interested in developing SCM as the approach to improving all types of operations and activities in a facility in terms of cooperating with suppliers and customers. The focus is also on selecting hospitals that concentrated on implementing integrated and GSC through particular green SCM practices (Chakraborty, Bhattacharya & Dobrzykowski 2014). Moreover, the focus is also on the application of ISO 14001 and ISO 9001 standards in the selected hospitals as policies for selecting the most appropriate GSCM practices in order to address certain issues or problems identified in healthcare facilities’ supply chains in different national contexts (Figure 1). The healthcare industry environments of each nation affect their hospitals correspondingly, resulting in the implementation of various new SCM practices, often in accordance with ISO 9001 and ISO 14001 standards.

The conceptual framework of the study
Figure 1: The conceptual framework of the study

Green Supply Chain Management in Turkish Hospitals

As it is discussed in the limited literature on SCM in the healthcare industry of Turkey, GSC are widely adopted by leaders in their hospitals in order to improve the quality of proposed care. Those healthcare facilities where sustainable or GSC are adopted are characterised by using ecologically appropriate building materials, the efficient management of hazardous materials, utilising products that do not include mercury or bis (2-ethylhexyl) phthalate, using green cleaners and electronics (Calipinar & Soysal 2012; Özkan, Akyürek & Toygar 2016). In addition, those hospitals that apply GSCs are focused on effective reduction and management of waste, as well as on recycling. These practices are important to contribute to sustainability of all operations in this or that healthcare organisation.

It is important to discuss what particular features of GSCs are viewed as attractive by managers in Turkish hospitals with reference to the fact that they are inclined to follow western patterns adopted in the United States and European countries. According to Özkan, Akyürek, and Toygar (2016), GSCM in hospitals is based on guaranteeing the protection and efficient use of resources in order to eliminate waste. Much attention is also paid to recycling. There are practices when the unnecessary equipment is recycled along with other daily goods typically utilised in hospitals. Another strategy includes the use of only reusable and recyclable products, as well as cleaners and substances for sterilisation and disinfection that can be applied without affecting the environment. Özkan, Akyürek, and Toygar (2016) state that these practices are now followed in such hospitals in Turkey as Istanbul Florence Nightingale Hospital and Medistate Kavacık Hospital in order to shift the focus of management on sustainability and ensure the protection of the environment while making ecologically appropriate choices and decisions.

Green Supply Chain Management and International Standards ISO 14001-2015 and ISO 9001-2015

The mass production of goods and the development of the service-oriented industries have led to the necessity of standardising their activities and measuring the quality of operations in order to guarantee addressing clients’ needs in most cases. The International Standardisation Association (ISA) was established in 1926, and this organisation became the predecessor of the organisation that is widely known today for its focus on providing guidelines and standards for operations in different types of industries. Thus, the International Organisation for Standardisation (ISO) was founded in 1946 in Brussels (Muzaimi, Chew & Hamid 2017; Stoimenova, Stoilova & Petrova 2014; Toprak & Şahin 2013). It began to develop as an international organisation oriented to the standardisation of manufacturing processes that was non-governmental in its character.

Standardisation covered by the ISO is applied in a variety of industries and firms, and exceptions are only related to such fields as electro-technical engineering and electrics which are regulated by other standards and norms (Chege 2012; Toprak & Şahin 2013). From this point, it is important to review the literature on the standards published by the ISO that are directly associated with the implementation of supply chains in different companies. The application of ISO 14001-2015 Environment Management and Occupational Health and Safety Management and ISO 9001-2015 Quality Management Systems – Requirements is discussed in the following sub-sections with reference to the recent literature on the topic within the context of the healthcare industry.

ISO 14001-2015 and Its Application in Organisations

The problem associated with achieving sustainability in hospitals and developing GSCs is based on the fact that organisations usually have direct and indirect negative influences on the environment, and they need to be overcome. These direct and indirect negative impacts are related to suppliers’ inputs and associated waste at different stages of the cycle that need to be controlled (Chege 2012). ISO 14001-2015 Environment Management and Occupational Health and Safety Management was developed by the International Organisation for Standardisation in the 1990s for the purpose of improving environmental practices in all industries, without exception.

This standard belonging to the family of ISO 14001 controls the environmentally friendly management with reference to supply chain processes, and the current version of the standard was published in 2015 (International Organisation for Standardisation 2015). According to the ISO 14001-2015 norms, the impact on the natural environment is “any change in the environment, whether adverse or beneficial, wholly or partially resulting from an organisation’s activities, products or services,” as it is noted by Olsthoorn et al. (cited in Laari 2016, p. 43). This impact should be minimised while applying ISO 14001 to production and services.

The application of ISO 14000 allows an organisation to follow a certain system in addressing the environmental dimension related to sustainability. When following the norms prescribed by ISO 14001-2015, different types of organisations, including healthcare facilities, can address the international norms regarding the ecological character of their activities, improve their environmental performance, and contribute to achieving sustainability in operations (International Organisation for Standardisation 2015). It is important to note that there are no determined criteria in order to regulate the environmental performance of organisations that allows for applying this standard in different contexts.

From this perspective, ISO 14001-2015 is typically applied by those organisations and firms that plan to improve their operations in terms of their impact on the environment. The ISO14001-2015 certification allows for reconsidering environmental practices followed in the company in order to achieve better outcomes for the environment. What is more important is that accreditation is not a requirement for adopting ISO14001-2015 when companies choose to develop environmental management systems in a holistic manner (International Organisation for Standardisation 2015). Therefore, while focusing on waste management, eliminating air and soil pollution, and guaranteeing the efficient use of sources, organisations follow ISO14001-2015 principles in the most appropriate manner for them, and they become interested in the continual improvement of their environmentally friendly practices, as it is in the case of creating sustainable supply chains.

ISO 9001-2015 and Its Application in Organisations

The quality management in organisations is an additional issue that affects the creation of an effective working supply chain. The International Organisation for Standardisation published the ISO 9000 family of guidelines in order to contribute to developing the most effective quality management strategies in organisations. In this family of standards, ISO 9001-2015 Quality Management Systems – Requirements is applied in order to establish an appropriate working quality management system according to the international principles of quality assurance in different types of organisations (International Organisation for Standardisation n.d.). According to Kovac (2014), ISO 9001-2015 is applied when firms are oriented to implementing a quality management system and proposing specific services and products that can address clients’ needs. However, it is also important to note that, in its nature, the ISO 9001-2015 standard was not developed to assess the quality of offered products, and the key focus is on proposing a set of principles according to which it is possible to organise systematised operations that are of high quality.

From this perspective, ISO 9001-2015 can be viewed as rather generalised because of possibilities to apply it in various organisations which operations and activities differ significantly. This idea is supported by Kovac (2014, p. 670) who states that the ISO 9001-2015 certification should be viewed as “a generic standard that defines certain requirements for the quality management system which are applicable to all organisations, regardless of their type and scope, and consequently to healthcare organisations as well.” This standard in the ISO 9000 family requires certification and accreditation, and this aspect contributes to following its norms by firms in the most accurate manner (International Organisation for Standardisation n.d.). The latest version of this standard is ISO 9001-2015:2015 that is correlated with the recent tendencies in the sphere of measuring the quality management in an organisation (International Organisation for Standardisation n.d.). Thus, this certification is important to be considered while discussing approaches to developing efficient supply chains as successfully working systems.

In spite of the fact that the application of the ISO 9001-2015 certification in organisations is associated with significant positive changes in business processes with the focus on the increased efficiency, researchers still note that many companies face certain challenges when new quality management systems are implemented. The problem is that changes in quality management are associated with alterations in operations and increased workloads, some of the processes are revised, and more innovations are integrated (Muzaimi, Chew & Hamid 2017; Stoimenova, Stoilova & Petrova 2014). Furthermore, the application of these systems according to the ISO 9001-2015 standard also requires the involvement of trained auditors. Earlier researches had identified the lack of these specialists in the sphere (Toprak & Şahin 2013). Still, even if the applied quality management system that operates according to the principles of the ISO 9001-2015 certification is not perfect, and more improvements are required, managers’ report increases in levels of satisfaction with provided services, as it is stated by researchers.

ISO 14001-2015 and ISO 9001-2015 in Healthcare

Researchers agree that the work of supply chains in organisations should be based on the ISO certification system in terms of regulating the impact on the environment in order to guarantee the effective control over a firm’s operations and outputs (Chege 2012; Liu et al. 2017). Moreover, according to Moradi et al. (2016), in hospitals, it is expected that managers adopt different types of ISO standards to address all possible issues associated with the quality of services and products and sustainability of operations. Chege (2012) stated that, in order to implement the ISO 14001-2015 standard in the most efficient manner, it is necessary to apply it in an organisation in the context of the followed environmental policy. As a result, it is possible to expect that a new effective environmental management system will successfully work in a healthcare facility under such conditions to address patients’ needs.

The high quality of delivered care is a priority for healthcare organisations, and governments, authorities, and stakeholders are focused on demanding the provision of superior care while using limited resources, appropriately applying public funding, and demonstrating transparency and accountability in relation to operations in hospitals. In this context, modern hospitals experience the pressure associated with the necessity of guaranteeing quality and realising the principles of accountability (Kovac 2014). Therefore, authorities recommend healthcare facilities to apply innovative and effective quality management systems according to the ISO 9001-2015 standard. Earlier, ISO standards provided recommendations regarding technical specifications of processes in different types of industries, including the service sector (Stoimenova, Stoilova & Petrova 2014). Later, ISO standards became applicable to the healthcare industry to ensure that the quality of provided care and services is high and safety of clients is guaranteed.

The application of ISO 9001-2015 in the healthcare industry is a challenging process that is widely researched by experts. The ISO 9001-2015 standard prescribes organisations how to arrange, document, integrate, maintain, and assess a specific quality management system applied in this or that firm. However, it is important to note that requirements listed in ISO 9001-2015 are widely applicable in their nature. Therefore, this standard is adopted in the majority of firms regardless of their sphere or activities, including hospitals (International Organisation for Standardisation n.d.). This standard is also reported by Kovac (2014, p. 674) as “the most widely used international standard that sets the requirements for the establishment and maintenance of quality management systems, and is applicable to all types of organisations (profit/non-profit, product/service, small/medium/large).” Thus, if an organisation, and a hospital in particular, starts the process of reforming its supply chain to make it more sustainable and integrated, the application of the 9001-2015 ISO certification is viewed as a reasonable step on this path.

Researchers reported the tendency of implementing quality management systems in hospitals all over the globe because of the necessity to increase the quality of services, address patients’ needs, and prevent medical errors. These tasks should be viewed as critical for healthcare organisations. When quality management systems are adopted in healthcare facilities with reference to ISO 9001-2015, leaders or administrators receive many opportunities to address all possible insufficiencies in processes, improve provided services, regulate controlling and monitoring processes, and prevent or decrease all possible damages while following requirements and guidelines. According to Turkyilmaz, Bulak, and Zaim (2015, p. 1), “to achieve service excellence, hospitals must strive for zero defects and retain every customer that the company can profitably serve.” In order to reach these goals, efficient supply chains based on effective quality management are required.

Researchers support the idea that certification is usually chosen by organisations in the context of their activities oriented to building GSCs because this approach allows for the continuous improvement of operations, determination of certain stages to follow, and customer satisfaction because of the improved quality of services. According to Toprak and Şahin (2013, p. 111), “a health institution accredited with quality assurance certificate not only gains the trust of the public, but also improves the service performance at individual and institutional level thanks to increased cooperation among different units of the institution.” As a result, it is possible to expect that all key operations in a hospital associated with the quality of services and environmental protection are regulated and effectively maintained based on these standards, contributing to the development of a GSC.

ISO 14001-2015 and ISO 9001-2015 in Australian Hospitals

The focus on ISO standards guarantees not only the improvement of quality associated with products and services but also cost savings for companies. Furthermore, the perceived quality of services also increases if clients and other stakeholders know that an organisation follows ISO standards (Chege 2012). Managers oriented to implementing ISO 14001-2015 and ISO 9001-2015 in hospitals expect that they will receive significant benefits associated with improving the quality of products and reducing a negative impact on the environment in the context of creating efficient supply chains. This situation is also typical of Australian hospitals where ISO 14001-2015 and ISO 9001-2015 are followed in the majority of public healthcare facilities (The Royal Australian College of General Practitioners 2015). The reason is that, if a hospital adopts ISO standards, its leaders can expect some benefits, including increases in efficiency, high productivity levels, higher employee satisfaction, improved quality of products and services, reduced costs, and as a result, increased revenues.

In the literature on supply chains in Australia, there are a few mentions of possible applications of ISO 14001-2015 and ISO 9001-2015 in this context. Still, researchers report the importance of following certification in the context of public and private hospitals, as well as other organisations (Australian Government 2016; The Royal Australian College of General Practitioners 2015). As it is mentioned by Stoimenova, Stoilova, and Petrova (2014, p. 373) in their article, the ISO 9001-2015 standard, for instance, “is utilised in a variety of ways as a vehicle for health care organisations to identify systemic breakdowns and close gaps, streamline workflow and maximise resource utilisation,” and moreover, it is used to “focus on patient and provider needs and expectations, facilitate compliance to health care accreditation standards and regulatory requirements, etc.” Therefore, the application of standards oriented to improving environmental and quality management systems in Australian hospitals can be viewed as an appropriate choice for healthcare organisations where the quality of services and protection of a community’s interests, including environmental ones, are the priorities.

To guarantee that a supply chain in an Australian hospital develops as a green one, the application of ISO 14001-2015 is expected in order to determine and follow specific requirements regarding environmentally friendly processes and operations typical of healthcare settings. Researchers also pay attention to the fact that the development of a supply chain is associated with integrating a quality management system, and its work is expected to be regulated by ISO 9001-2015 (Muzaimi, Chew & Hamid 2017; Toprak & Şahin 2013). Focusing on building strong and efficient supply chains in hospitals, leaders need to start the accreditation and certification process. In the context of Australia, the reference to ISO 14001-2015 and ISO 9001-2015 is supported at national, state, and local levels (Australian Government 2016). Researchers also note that the provision of the ISO certificate does not mean stopping the development process, and an organisation is expected to be accredited every three years while having the space for progress and expanding sustainable supply networks (Chege 2012; Kovac 2014). For Australian hospitals, it is important to refer to standards for environmentally friendly operations and improve quality while building supply chains.

ISO 14001-2015 and ISO 9001-2015 in Turkish Hospitals

In Turkish hospitals, the application of ISO 14001-2015 and ISO 9001-2015 is a widely followed modern trend because this approach guarantees positive changes in healthcare operations and processes in order to address clients’ needs and expectations (Özkan, Akyürek & Toygar 2016; Toprak & Şahin 2013). For instance, according to Toprak and Şahin (2013, p. 114), in Turkey, “while in 2006, the number of the Health of Ministry hospitals with ISO 9000:2000 and the ISO 9001-2015:2000 certification was 68, this number increased to 112 in 2008.” Later, positive changes in the tendency were also observed because of identifying obvious benefits in improving quality management systems in correlation with the recommendations provided by ISO 9001-2015.

The similar situation can be noticed with reference to the implementation of the principles of ISO 14001-2015 in Turkish hospitals. This practice is directly associated with the establishment of new principles of creating GSCs. The development of sustainable networks to regulate operations in hospitals depends on the adoption of certain national policies proposed by the Turkish authorities at different levels (Erus & Hatipoglu 2013). However, the application of ISO 14001-2015 as the key standard to regulate the work of environmental management systems is essential for this context because concrete actions of suppliers and partners in hospital chains need to be strictly regulated to achieve higher results and decrease negative influences on the environment.

It is also important to pay attention to the fact that, in Turkey, hospitals became interested in applying the quality certification in the 1990s, but the process was rather slow. Today, the focus of healthcare organisations on using certification is more obvious, and the compliance with requirements promoted according to ISO -2015 and ISO 9001-2015. As identified in the earlier application of the standards, the compliance allows healthcare organisations to respond to clients’ needs, minimise errors, conduct regular assessments, and monitor all possible strengths and weaknesses in processes (Muzaimi, Chew & Hamid 2017; Polater, Bektas & Demirdogen 2014; Vincente et al. 2015). Thus, as it is noted by Toprak and Şahin (2013, p. 112), “the quality certificate, which is the proof of improved performance contributes to the second-party audits and customers’ higher perception of quality.” The level of trust to the hospital that has successfully applied ISO 14001-2015 and ISO 9001-2015 can increase while leading to positive changes in financial gains.

From this perspective, the literature indicates that Turkish hospitals receive many benefits while referring to the ISO standards. As it is noted by Stoimenova, Stoilova, and Petrova (2014) and Muzaimi, Chew, and Hamid (2017), leaders in healthcare organisations become able to plan operations with reference to internal and external environments and ensure controlling all processes associated with caring for patients. They also receive tools in order to decrease the number of medical errors and patient complaints and guarantee the most efficient use of available resources with reference to the principles of reverse logistics among others (De Vries & Huijsman 2011; Stoimenova, Stoilova & Petrova 2014). As a result of applying the ISO standards, hospitals seem to change all processes that were typical of them previously in the context of ensuring high quality of services and sustainability.

Researchers note as a result of their studies and reviews of available literature that immediate positive outcomes can be observed after implementing supply chains with the dependence on ISO 14001-2015 and ISO 9001-2015 (Muzaimi, Chew & Hamid 2017; Polater, Bektas & Demirdogen 2014). A logical consequence associated with this process is the increase in patients’ satisfaction and trust, and revenues in the healthcare industry can also rise significantly. According to Toprak and Şahin (2013, p. 112), in a hospital following the ISO standards, “it is known how the process will be handled, and thanks to monitoring individuals within the process, their strengths and weaknesses are identified and thus, it becomes possible to assign the right task to the right person.” These processes contribute to the active integration of ISO 14001-2015 and ISO 9001-2015 not only into Turkish hospital supply chains but also into healthcare industries all around the world.

Research Paradigm

Depending on the type of research questions formulated for this study and the researcher’s expectations and assumptions, it is possible to state that pragmatism is a paradigm that is more appropriate for the study. A pragmatist paradigm combines the features of both positivism and interpretivism that allows for using this paradigm when conducting mixed methods studies that include quantitative and qualitative methods (Creswell & Poth 2017). The key quality of a pragmatist philosophy is that its proponents are oriented towards finding direct solutions to practical issues and problems in the world around without focusing on the nature of knowledge or truth, as it is typical of other paradigms (Bryman & Bell 2015; Creswell & Poth 2017). Thus, applying a pragmatist perspective, a researcher is interested in examining practical aspects and consequences of certain studied processes and phenomena.

In this study, the main focus is on identifying and analysing the major practical aspects, as well as benefits and risks, of greening supply chains in the healthcare sector with reference to two different national contexts. As such, pragmatism is more suitable to the purpose than any of ontology, epistemology, realism, or either of positivism and interpretivism alone. Referring to pragmatism, the researcher gets an opportunity to concentrate on collecting both numeric and narrative data for further analysis (Domínguez & Hollstein 2014; Neuman 2014). These advantages of pragmatism allow for selecting this paradigm as suitable for this study.

Research Approach

In this study, the focus on the pragmatist paradigm explains the choice of the approach that can combine the features of both deductive and inductive reasoning. This type of applying both principles to examining the phenomenon is known as abductive reasoning, and it is selected as the key approach for this study (Edmonds & Kennedy 2017). According to Bryman and Bell (2015, p. 27), “Abduction involves the researcher selecting the ‘best’ explanation from competing explanations or interpretations of the data,” and “this is related to the philosophical idea of the ‘hermeneutic circle,’ through which understanding is seen as a continuous dialogue between the data and the researcher’s preunderstandings.” The nature of the formulated research questions and the aim of the research explain the necessity of using the assumptions typical of inductive and deductive approaches in order to use different methods for examining the issue under discussion.

As a result, while referring to the idea of intersubjectivity typical for the combination of inductive and deductive approaches, it is possible to state that abductive reasoning allows for testing certain assumptions from both theoretical and empirical perspectives (Bryman & Bell 2015). Applying the combination of deductive and inductive approaches in the form of abductive reasoning, the researcher in this study receives an opportunity to examine the problem from different sides, without selecting this or that approach. Moreover, the researcher overcomes the limitations associated with using the other discussed approaches.

Research Design

In order to address the research questions and purpose of this study, it is necessary to apply the research design, according to which it is possible to answer questions requiring the analysis of both qualitative and quantitative data. Therefore, the application of both descriptive and exploratory research designs is reasonable for this study (Edmonds & Kennedy 2017). The causal design is less relevant, as no experiments will be conducted in the course of this study. The principles of the descriptive design are important to be implemented in order to work with quantitative data to explain factual benefits and weaknesses of selecting and integrating GSC in hospitals of Australia and Turkey. The principles of the exploratory research design should be used to collect and evaluate qualitative data in order to examine the problem from the perspective of participants involved in implementing GSC in the healthcare sector (Domínguez & Hollstein 2014). Thus, the rules typical of a convergent parallel design need to be applied to this study (Creswell 2014; Creswell & Poth 2017). In this case, the collection and analysis of quantitative and qualitative data are realised not sequentially but independently.

Research Methodology

For this study, mixed methods research is selected as the most appropriate option to address the set research questions. The reason is that the mixed methods methodology provides a researcher with a variety of approaches and techniques to choose from in order to conduct the high-quality research that will not be limited by the approaches typical of only qualitative or only quantitative methods (Domínguez & Hollstein 2014; Edmonds & Kennedy 2017). This study is aimed at determining possible benefits and risks associated with implementing GSC in hospitals of Australia and Turkey with the focus on possible similarities and differences in these countries’ experiences. The complex character of this purpose supports the idea that only the combination of qualitative and quantitative methods can help a researcher to collect appropriate data for analysis to conclude regarding the experience of the Australian and Turkish healthcare systems in greening supply chains.

The provided research questions can be effectively answered only with reference to collecting both quantitative and qualitative data for further analysis. The financial data explaining the establishment of GSC in hospitals can be successfully analysed with reference to the principles of descriptive research and the quantitative method (Jason & Glenwick 2016; Pelto 2015). On the contrary, ideas and views of managers implementing green supply management principles, administrators in hospitals, and the personnel should also be taken into account, and the qualitative methodology allows for collecting this information (Merriam & Tisdell 2016; Pelto 2015). Views regarding possible advantages or challenges associated with greening supply chains in healthcare systems of two different countries can be collected with the help of interviews. As a result, focusing on the mixed methods methodology, the researcher receives more opportunities to examine the situation with greening supply chains in Australia and Turkey from objective and subjective perspectives to make accurate and relevant conclusions.


The Selected Case and Setting in Australia

For the purpose of this research, an Australian hospital located in Victoria, was selected as an Australian public hospital to be included in this study. This hospital is one of the largest public healthcare facilities not only in Melbourne, Victoria, but also around Australia. This hospital was established in 1848, and today it belongs to one of the healthcare hospital groups in the region. The Australian hospital has the reputation of a healthcare facility, the leaders of which are oriented towards adopting the latest technologies and applying the most innovative approaches to their practice. Furthermore, the hospital has developed an effective program oriented towards greening their operations and improving waste management and achieved certain successes in designing and IGSC. The examination of the experience of this hospital in implementing SCM is important in the context of this case study research.

The Selected Case and Setting in Turkey

Derindere Hospital (Hastane Derindere) is located in Kagithane province, Turkey, and it is one of the leading private hospitals in the country that has operated in the region since 2015. The hospital is famous for paying attention to clinical research and implementing innovative methods and practices to deliver care. Moreover, the hospital has received ISO 9001 and ISO 14001 certifications, and it has experience in improving its SCM and waste management to address global standards (Derindere Hospital 2020). This particular experience needs to be studied and explained in the context of this selective case study.

Ethical Considerations

This section presents the information on the procedures used to receive the participants’ informed consent and protect their confidentiality and privacy. According to Hancock and Algozzine (2016, p. 47), “the researcher must adhere to legal and ethical requirements for all research involving people. Interviewees should not be deceived and must be protected from any form of mental, physical, or emotional injury.” Thus, the aspects of using an informed consent form are described in detail. Approaches to resolving the issue of confidentiality in this study are discussed in the second sub-section in order to guarantee that all ethical concerns are addressed without violating the interests of the participants involved in the study. The approval of the administration of the hospitals in Australia and Turkey was required for conducting this research to involve the employees as participants in this study. To recruit the participants, the researcher contacted the administrators at both organisations via email using formal letters to request and receive their approval for organising the study based on their data and involving employees as participants.


In order to protect participants’ privacy and guarantee their psychological comfort, it is important to focus on the concept of confidentiality and how it works in the context of this study. Those personal data that are used in this study for collecting qualitative information should be secured and presented in this study only as confidential answers to interview questions (Kumar 2014; Mertens 2014). The researcher ensures that all information that can be used for indicating participants is removed from records, and personal information is concealed. These procedures are required in order to avoid the situation of violating subjects’ confidentiality and disclosing their private information. The participants should be informed that their names and identities are de-identified, and confidentiality is protected in the context of the study.

In the context of this study, the researcher keeps the names of participants and other personal data confidential while preparing records of interview sessions and transcribing them. In order to distinguish between participants, ID numbers are assigned to subjects, and they are used for marking records and narratives. The researcher is the only person who knows the names and contacts of subjects invited to participate in the study that are reflected in informed consent forms. This information is kept secret and secured by the researcher, and the access to the data which can be used for identifying participants is restricted.

Informed Consent

The participants’ agreement to join the study with the focus on its specific conditions and purpose is known as informed consent. Potential participants selected with the help of purposive sampling can be viewed as voluntarily deciding on being involved in the study, and informed consent forms reflect this decision (Bryman & Bell 2015). The selected respondents agreed to participate in interviews after receiving all the required information about the nature and purpose of this study by email from the administrators cooperating with the researcher in the two hospitals. They reviewed and signed the prepared informed consent form before being invited to participate in interview sessions and answer questions. In order to guarantee that the informed consent form can be effectively used for protecting participants’ interests, some type of information should be added to this form.

Thus, the provided informed consent forms had the following details: the study’s purpose and type, the description of collecting the information with the help of interviews and associated procedures, and the information about options for withdrawing at any stage of research. Additional details include the information about protecting participants’ confidentiality and anonymity and the statement indicating the voluntary participation in the study (Creswell & Poth 2017). It is important to note that the researcher started to conduct interviews with the invited participants only after receiving the signed informed consent forms from all subjects. As a result of applying the informed consent form, it is possible to address ethical questions while conducting the study and guarantee the protection of participants’ interests.

Quantitative Research Design

The purpose of this sub-section is to discuss how the quantitative methodology has been applied in this study. The focus of this sub-section is on presenting the specific variables to measure as well as data collection tools that have been selected for the research (Bryman & Bell 2015). Furthermore, much attention is paid to describing the data analysis procedure with the focus on the specific information collected with the help of quantitative techniques.

Constructs to Measure

The constructs to measure with the help of tools of the quantitative methodology are derived from the research questions formulated for the study. In order to understand what benefits and challenges are associated with implementing integrated GSCM in Australian and Turkish hospitals, it is necessary to evaluate these hospitals’ changes in financing supply chains, waste management, recycling, and the application of ISO 14001 and ISO 9001 certificates among other initiatives (Dadhich et al. 2015; Feng et al. 2017; Jayaram, Dixit & Motwani 2014). It is significant to collect numerical data and financial figures on changes in costs and revenues related to implementing GSC and changing waste management procedures and after the implementation, related to applying ISO 14001 and ISO 9001 standards, and related to the overall performance of the selected hospitals in terms of their sustainability. From this perspective, for the purpose of this study, it is necessary to empirically test how the implementation of integrated GSC and associated changes in waste management can affect the value related to the chosen hospitals.

Collection of Quantitative Data

The two hospitals have been contacted and provided the permission for including them in the study. For the purpose of this study, annual financial reports, financial documentation, documentation on the ISO standards and GSCM practices, and non-¬confidential documentation provided by the administration of the Australian hospital and Derindere Hospital and available in the hospital websites have been examined to retrieve the numerical data, figures, and charts on these healthcare facilities in terms of applying GSC. The key focus was on retrieving data on the expenses associated with implementing GSC (integrated chains) in the discussed hospitals, possible unexpected costs, and expenditures directly related to waste management practices. These quantitative data were collected with the help of reviewing hospitals’ annual reports and other financial documentation (electronic copies) provided by the managers in the selected Australian and Turkish hospitals, who are responsible for greening supply chains in their organisations.

Data Analysis

The quantitative data collected with the help of reviewing hospitals’ financial documents have been analysed not in connection with the analysis of qualitative data, but simultaneously (Creswell 2014; Treiman 2014). The determined changes in the financial performance of hospitals before and after the implementation of IGSC have been compared and analysed for both hospitals located in different contexts of Australia and Turkey. Some types of financial performance have been evaluated with the focus on the operating performance, the accounts performance with the focus on actual financial data, and the environmental performance.

It was important to determine any changes in figures indicating hospitals’ financial performance in order to speak about possible advantages and disadvantages of integrating green supply chains in the healthcare sectors of two different national contexts. The comparison of financial performance indicators before and after implementing supply chains, as well as for Australian and Turkish hospitals, is important to address the set research questions. It is significant to note that the application of statistical analysis is also required for this research in order to present descriptive statistics regarding the findings associated with the numerical data provided in hospitals’ reports (Bryman & Bell 2015; Creswell 2014; Hamad et al. 2016).

Descriptive Statistics

In this study, it was important to compare financial performance figures before and after implementing GSC for hospitals in Australia and Turkey with a focus on changes in waste management. Moreover, it was necessary to compare changes in determined financial indicators for different healthcare settings in these two countries. Therefore, the analysis of quantitative data retrieved from the hospitals’ documentation was performed with reference to presenting descriptive statistics and charts regarding the observed changes in figures and ratios (Leavy 2017; Neuman 2014). These steps were important to conclude about the efficiency of developing IGSC in the healthcare sector.

Financial Ratios

While analysing the financial, operating, and environmental performance of the selected hospitals associated with the implementation of the principles of GSCM, it was important to calculate certain financial ratios as indicators. The following types of ratios were calculated: profitability ratios, liquidity ratios, debt management ratios, and asset management ratios (Feng et al. 2017; Jin, Jeong & Kim 2017). Profitability ratios include the profit margin (Net income/Sales), the return on equity (Net income/Common equity), and the return on assets (Net income/Total assets). These ratios help to estimate the profitability of hospitals as entities in spite of the fact that one of these hospitals belongs to the public sector.

Liquidity ratios calculated for this study include the current ratio (Current asset/Current liabilities), the cash ratio (Cash and equivalents/Current liabilities), and the quick ratio (Current asset + inventory/Current liabilities). Debt management ratios are the following ones: the total debt ratio (Total Debts/Total assets), the long-term debt ratio (Long-term liabilities/Long-term liabilities + Common equity), and the debt to equity (Debt/Common equity) (Feng et al. 2017; Jin, Jeong & Kim 2017). These ratios estimate an organisation’s debt.

Asset management ratios are important to be measured in the context of understanding how changes in supply chains could influence the organisation of assets and resources in the studied hospitals. These ratios include the receivables turnover ratio (Sales/Receivables) and the fixed assets turnover ratio (Sales/Fixed assets) (Feng et al. 2017; Jin, Jeong & Kim 2017). The focus on these financial indicators was important to determine possible changes in the selected hospitals’ profits depending on their experience in implementing supply chains with a particular interest in integrated supply chains.

Qualitative Research Design

This section represents the details of organising the qualitative component of the case study analysis. The focus is on describing the aspects of data collection and data analysis by means of specific qualitative tools. Moreover, in this section, much attention is paid to discussing protocols for semi-structured interviews that are adopted for this study in order to collect the required narrative information from the sample appropriate for this research.

Data Collection

While using the qualitative methodology, researchers collect data using such techniques as interviews, observations, and focus groups. These strategies are used with reference to the purpose of investigating a phenomenon or a situation from the perspective of participants who are directly involved in the studied processes. The participants’ perspective can be learned and reported when researchers conduct interviews and communicate with individuals having the specific experience regarding the problem under analysis (Miles, Huberman & Saldana 2014). The insider’s perspective can also be learned with the help of organising focus groups where several participants discuss their personal experiences in contrast to individual interview sessions (Creswell 2014; Leavy 2017). In addition, important data regarding the studied issue can be collected with the help observations that are conducted in a specially selected setting in order to provide a researcher with as much information as possible (Creswell & Poth 2017).


This section explains the choice of instruments and tools for collecting qualitative data with reference to conducting interviews. The first sub-section provides the justification for conducting interviews with the participants of the study in order to gather narratives regarding their experiences in implementing supply chains. The second sub-section presents the information on designing a specific interview protocol that has been used in this study in order to guide interview sessions and collect all the required information for analysing and responding to the research questions (Bryman & Bell 2015; Creswell & Poth 2017).

Justification for Conducting Interviews

While applying the qualitative methodology as the component of mixed methods research, the author of the study is oriented towards investigating, understanding, and explaining a certain phenomenon. As a result, the focus of a researcher is on collecting as much data on a certain issue as possible in order to develop in-depth meanings regarding the studied problem (Castillo-Montoya 2016). For this purpose, interviews are selected as a tool that allows a researcher to gather information on participants’ ideas, views, experiences, and beliefs associated with the studied phenomenon. These interviews are usually conducted in the form of one-to-one sessions (Alshenqeeti 2014). In order to address the purposes of their studies, researchers can choose from structured, semi-structured, and unstructured interviews that differ in terms of protocols that are used for organising interview sessions (Creswell & Poth 2017; Neuman 2014).

Structured interviews are based on preparing a list of questions to ask without focusing on differences in interviewees. These interviews are standardised, and they do not allow for collecting much information about respondents’ experiences. As a result, this type of interviews is not appropriate for this study. Unstructured interviews are not based on a certain framework or a set of questions, and interviewers ask questions following interviewees’ responses (Taylor, Bogdan & DeVault 2015). This type of an interview can provide a researcher with a lot of data that are not suitable to address a research question, and this aspect does not allow for using it in this particular study.

Semi-structured interviews are based on using the questions prepared in advance, but these questions are open-ended, reflecting the topic of the interview, and playing the role of probing questions that are used for developing an interview in a conversation on the studied topic. Thus, semi-structured variants of interviews “are carefully prepared lists of questions that stimulate each informant in a comparable way,” and the answers of respondents are unanticipated in this case (Domínguez & Hollstein 2014, p. 186). This type of interviews is selected for this study because the researcher received an opportunity to get answers to the prompts that can help in addressing the research questions, but he or she can remain flexible and ask additional questions if necessary (Edmonds & Kennedy 2017). Furthermore, the gathered information can be classified as valid in this case.

Designing an Interview Protocol

The process of designing a semi-structured interview protocol for this study included the following stages: the review of the literature and questionnaires used in other studies to select questions that are aligned with the research ones; the adaptation of the selected questions to this research and the formulation of original open-ended questions; editing and proofreading. At the first stage, it was important to review the literature on the topic to understand what models for formulating effective questions were used by other researchers (Cosimato & Troisi 2015; Dadhich et al. 2015). At the second stage, it was necessary to adapt the selected questions and formulate additional ones in order to guarantee that these questions are valid and can contribute to collecting data required for answering the set research questions. Open-ended questions written in English were proposed to receive full and descriptive answers regarding the issues mentioned in these inquiries. As a result, ten probing questions were formulated:

What is your role or position in the hospital?

  1. What differences have you noticed regarding the implementation of GSCM? What management practices were changed?
  2. How are ISO 14001 and ISO 9001 standards applied in your organisation? How has the application of ISO 14001 and ISO 9001 changed the organisation’s performance?
  3. What policies provide the grounds for waste management strategies and practices followed in your organisation? Discuss their possible link with ISO 14001 and ISO 9001 standards.
  4. What waste management segregation and elimination procedures are applied in your organisation in the context of GSCM? Is there specific recycling, reusing or waste disposal practices used in the organisation?
  5. How is general, clinical, and recycled waste managed in your organisation according to the principles of GSCM? What differences in procedures and associated sustainability effects can you name and discuss?
  6. What can you tell about the possible correlation between waste generation, waste management, and the number of patients in your organisation? What trends have you noticed?
  7. How have waste management costs changed in your organisation after it focused on green and ISCM strategies and practices? Are there associated waste cost reductions or increases?
  8. How has operational and environmental performance changed after your organisation’s focus on modifying waste management procedures in the context of GSCM?
  9. What benefits and challenges are directly related to waste management strategies and procedures?
  10. Does the government have a position on greening in general? Does it have a position on GSC?
  11. Does it encourage adopting the UN conventions? Is it a central government, a regional or is it an individual hospital decision?

At the final stage of designing a protocol for a semi-structured interview, it was important to edit and proofread the questions to ensure that they are accurate. These questions need to be written in the language that can be easily understood by respondents. Furthermore, they should include details that can be discussed wider during a conversation with the focus on other additional questions. As a result, the proposed interview probing questions have the potential to be expanded during interview sessions depending on the participants’ answers.

Data Collection Procedure

In this study, the collection of qualitative data was based on conducting a series of interviews with six participants who are the representatives of two hospitals in Australia and Turkey selected as cases for this research. The invited participants work at different positions in hospitals (senior managers, administrators, medical workers), and they were directly involved in the process of integrating green supply chains in their healthcare facilities. As a result, these selected persons are able to describe their experiences in greening supply chains in the chosen hospitals in order to compare these narratives during the analysis. For the purpose of this study, the researcher prepared the protocols for semi-structured interviews and contacted the selected participants using their e-mail in order to discuss the date and time for conducting interviews.

To contact participants in different countries, it is appropriate to use online tools and mobile applications that allow for calling the participant. In this study, the researcher used Skype for making calls and conducting time-consuming interviews. Each interview was scheduled in advance and conducted separately, and interviews lasted from 45 to 60 minutes. It is advantageous for the researcher to conduct phone interviews using modern technologies and audio recording because of avoiding limitations regarding distance and time and receiving an opportunity to clarify different aspects in provided answers with respondents. The participants of the study were asked to answer several questions prepared in advance, and the researcher added more questions during an interview in order to get more details regarding the aspects mentioned by the participants. Interviews were recorded using technologies for making records of Skype calls, and these audio files were marked with certain ID numbers to avoid identifying participants’ personal information. The completed records were transcribed for the further analysis.

Data Analysis

Data analysis in this study included such steps as the preparation of data for further examination with the help of transcribing records, the process of coding and theme identification with the help of NVivo software, and the analysis of determined themes to answer the research questions (Chowdhury 2015; Zamawe 2015). All the records were transcribed to get narratives appropriate for uploading to NVivo. This software allows researchers to import qualitative data into the platform and provide their analysis based on the principle of coding narrative information for identifying themes in collected in-depth answers to the proposed interview questions (Edwards-Jones 2014; Sotiriadou, Brouwers & Le 2014; Zamawe 2015).

Therefore, it is necessary to state that coding as a technique integrated for data analysis in NVivo software is important for studying and evaluating qualitative data. The reason is that codes that are assigned to data components are automatically examined and combined in larger clusters or themes (Edwards-Jones 2014; Sotiriadou, Brouwers & Le 2014). After conducting the automatic analysis, all the data are represented in the form of themes that should be organised by the researcher in concept maps or tables, as well as other illustrative materials (Saldaña 2016; Yin 2015). The purpose of this action is to understand what concepts are associated with participants’ views regarding the process of greening supply chains and improving waste management approaches and techniques in the selected hospitals of Australia and Turkey.

Validity and Reliability

In this mixed methods research, the questions of validity and reliability of the study are discussed from the perspectives of both qualitative and quantitative methodologies. Referring to the qualitative component of the study, the focus is on trustworthiness as the representation of validity (Neuman 2014). Thus, it is important to guarantee that the collected findings are worth discussing, and they can contribute to the existing research on the problem because of their accuracy. The organisation of the collection and analysis of qualitative data is realised according to the principles of dependability, credibility, transferability, and confirmability (Creswell & Poth 2017). As a result, much attention should be paid to the quality of interview protocols as an instrument for collecting data (Darawsheh 2014; Mann 2016). It is possible to speak about content validity in the case when collecting quantitative data and about credibility when focusing on gathering qualitative information.

Internal validity of the quantitative component of the study is guaranteed through the provision of the accurate analysis of collected financial data with the focus on calculating ratios and making relevant conclusions. In the context of the qualitative component, this aspect is associated with transferability of the received findings because of their accuracy (Leavy 2017). In addition, in this study, validity is also based on triangulation as an approach to improve the credibility of findings with the help of collecting and analysing both qualitative and quantitative data which is typical of the mixed methods research (Archibald 2016; Leavy 2017).

Reliability in the mixed methods research is applied to discussing the quantitative component, and the term “dependability” is associated with reliability of the qualitative component. Referring to these concepts, it is important to guarantee that this study can be replicated with the same results because of depending on the analysis of stable financial data (Domínguez & Hollstein 2014). Still, while focusing on the qualitative component, it is necessary to state that identical results cannot be expected and achieved, and it is necessary to guarantee the dependability of data (Neuman 2014; Reio & Werner 2017). Thus, it means that the collected findings remain unchanged and stable without depending on changes in conditions on when and how the participants’ narratives were gathered.


Overall, the study aims to address questions of both the reasons for the adoption of GSCM practices and ISO 9001-2015 and ISO 14001-2015 compliance and their effectiveness. As such, a mixed design in terms of both the research paradigm and the research methodology appears to be the most appropriate. With that said, it is important to note the drawbacks of the design chosen, particularly in terms of the specifics. The sample size is relatively small at only one hospital for each nation, which can exclude critical context such as the situation on the national level. Moreover, the study is characterised by its high complexity with a number of mixed approaches, which introduces the potential for bias. As such, they will be taken into consideration and addressed in later sections.

Case Study


This chapter presents the results of the mixed methods research based on the application of the selective case study approach. The purpose of the chapter is to provide quantitative and qualitative data analysis related to the chosen hospital in Australia and Derindere Hospital (Turkey) that are helpful to answer the major research question on the main benefits and challenges of implementing integrated GSCM in Australian and Turkish hospitals and associated sub-questions. The chapter starts with discussing background information related to the hospitals, and then the results of two phases of the selective case study are described in detail.

Background Information

The specifics of the selective case study approach allowed for concentrating on studying how two hospitals, the public Australian hospital and private Derindere Hospital in Turkey, applied integrated GSCM procedures with a focus on waste management according to ISO 14001-2015 and ISO 9001-2015. The International Organisation for Standardisation (ISO) was founded in Brussels in 1946 to provide standards and conventions regulating the work of different industries (Muzaimi, Chew & Hamid 2017). ISO 14001-2015 – Environment Management and Occupational Health and Safety Management was developed by the ISO in the 1990s and then revised in 2015 to improve a range of environmental practices in industries and control all processes in the production cycle (International Organisation for Standardisation, 2015). The selected hospitals in Australia and Turkey applied ISO 14001-2015 for ensuring environment-friendly SCM to minimise negative impacts on the environment. The two hospitals follow ISO 14001-2015 to address their specific needs regarding waste management and the efficient use of resources. Addressing ISO 14001-2015 allowed the hospitals to organise waste administration procedures and avoid polluting the environment with clinical hazardous and non-hazardous waste.

ISO 9001-2015 Quality Management Systems – Requirements was also revised in 2015, and today this standard guarantees the establishment of an appropriate quality management system. In the analysed hospitals, the standard is used for providing requirements to organising high-quality systematised operations (International Organisation for Standardisation, no date). For the public Australian hospital and Derindere Hospital, the focus on ISO 9001-2015 means that they were certified and accredited to follow this standard. The application of ISO 9001-2015 is the guarantee for the patients of these hospitals that they receive quality services in the context of green and sustainable operations. The following analysis of selected cases demonstrates how these hospitals grounded their integrated green supply chain procedures in ISO 14001-2015 and ISO 9001-2015 norms.


Phase 1: Quantitative Data Analysis for the Case in Australia

This subsection represents the financial ratio result analysis of the public hospital located in Melbourne, Australia.

Case Characteristics and Descriptive Statistics

The Australian hospital is one of the oldest public hospitals in Australia. The plan to start the Hospital was put in place in 1846 and fully actualized in 1848 to a fully operating hospital that offered different treatment services. The foundational intent to start the Hospital was to meet the rising medical needs in the suburbs of Melbourne and the larger Parkville community in Victoria. The Hospital’s mission is founded on this intent that included ensuring that the health and wellbeing of the community is secured through innovation, research, and quality care services. The Hospital designed its environmental sustainability approach in 2011 by introducing the “Think Green Strategy.” The plan was again restructured to include a more detailed reporting and waste management reinvention planning yearly after the year 2015 based in line with APA and DHHS regulations. Table 1 below provides general description data of this hospital.

Table 1: The Details for the Public Australian Hospital

Factor The Public Australian Hospital
Number of Beds 571 beds
Number of Patients. Patient Services (2018-2019) Over 550 000 patients with over 79 000 emergence cases and more than 270 outpatient appointments.
Adoption of Green Supply Chain Management The Hospital Environmental Sustainability Plans
– Drive a Think Green Culture in 2011
– Embed Sustainability in B/s Culture 2015
Restructuring ESP, latest model 2018/2019 based on APA and DHHS regulations
Current Green Policy The RMH Environmental Sustainability Strategy 2020-25
Thinking green strategy
Waste Management APA Guidelines for disposal by incineration/shredding and disinfecting process
DHHS guidelines
Energy Resources Electricity (Cogenerated and Grid)
natural gas and LPG and
other alternatives such as Stream diesel
Impact on the Environment Reduced waste disposal by 40% in 2019 to keep reducing the waste disposal level.
APA and DHHS standards Works in line with the Hospital Think Green strategy that aims
– Reducing waste disposal ratio/ less plastic
– Effective recycling of wastes
Reinvention – the Hospital celebrates Green Commune Day
Thinking Green Strategy Involves the overall hospital plan on quality management
– The Telehealth Program
Financial Ratios

For the purpose of conducting a quantitative analysis of hospitals’ performance with reference to revenues and costs associated with the implementation of green supply chains, the financial ratio analysis was completed. The following ratios were calculated as indicators of the selected hospitals’ financial performance: profitability ratios, liquidity ratios, debt management ratios, and asset management ratios (Sharma 2020). The analysis of a hospital’s profitability is important to show how profitable it is, and ratios include the profit margin and the return on assets (ROA):

  • For 2018, Profit Margin was equal to $19,810/1,230, 259= 1.6%.
  • For 2019, Profit Margin was$11,281/1,352,713= 0.8%.
  • For 2018, the ROA was equal to $19,810/623,919= 3.2%.
  • For 2019, the ROA was $11,281/845,732= 1.3%.

Liquidity ratios demonstrate how effectively a hospital can pay off possible current debt obligations. Related ratios include the current ratio, cash ratio and quick ratio:

  • In 2018, Current Ratio was $194,487/343,185= 0.6
  • In 2019, Current Ratio was $179,854/382,099= 0.5.
  • Derindere Hospital’s Cash Ratio in 2018 was $107,695/343,185= 0.31.
  • In 2019, this ratio was equal to $ 74,342/382,099= 0.2.
  • Quick Ratio in 2018 was equal to $186,258/343,185= 0.5
  • Quick Ratio in 2019 was $170,907/382,099= 0.4

Debt management ratios represent an important group of liquidity ratios to estimate a hospital’s debt and analyse an organisation’s capital structure. They are the following ones: the total debt ratio, long-term debt ratio, and debt to equity. For such organisations as hospitals, Total Debt Ratio should be calculated.

  • For 2018, Total Debt Ratio was $380,747/623,919= 0.6
  • For 2019, Total Debt Ratio was $431,642/845,732= 0.5

Asset management ratios are important to measure a hospital’s operating efficiency to conclude how effectively an organisation can use its resources to decrease potential costs. In this context, the focus is on the potential to decrease costs of implementing GSCM and waste management. The related ratios include the receivables turnover ratio and the fixed assets turnover ratio.

  • In 2018, Receivables Turnover Ratio was equal to $ 1,230,259/26,903= 45.8
  • In 2019, Receivables Turnover Ratio was equal to $1,352,713/37,364= 34.2
  • Fixed Assets Turnover Ratio for 2018 was $1,230,259/810,182= 1.5
  • Fixed Assets Turnover Ratio for 2019 was $1,352,713/1,097,520= 1.2

Phase 1: Quantitative Data Analysis for the Case in Turkey

In this sub-section, the results of the financial ratio analysis for Derindere Hospital are presented.

Case Characteristics and Descriptive Statistics

Derindere Hospital (Hastane Derindere) in Turkey started its operations in 2015. The hospital’s mission is to “provide patient safety-based service with international quality standards in the healthcare” (Derindere Hospital, 2016, para. 2). The hospital was applying greening practices based on ISO 9001-2015 and ISO 14001-2015 certifications in 2015-2018, and in 2019, its waste management procedure also became addressing global standards (Derindere Hospital, 2020). Table 2 presents the general descriptive data regarding Derindere Hospital.

Table 2. Derindere Hospital Details

Factor Derindere Hospital
Number of Beds 386 beds
Number of Patients (2018-2019) 10,000 patients
Adoption of Green Supply Chain Management 2015-2019, since the establishment of Derindere Hospital
Current Green Policy Derindere Hospital sustainability-oriented program
Waste Management Efficient waste handling and recycling
Energy Resources Electricity, gas, alternatives
Impact on the Environment Controlling waste disposal and greenhouse emissions
ISO 14001-2015 – adopted to minimise a negative impact on the environment/improve using resources;
– controls the medical waste control and recycling system;
– contributes to reducing resource consumption (energy and paper consumption);
– supports the establishment of productive partnerships with suppliers.
ISO 9001-2015 – guarantees the effective quality management in the facility;
– provides criteria on specific conditions to follow to propose high-quality and safe patient services.
Financial Ratios

The financial ratio analysis for Derindere Hospital was completed after reviewing the hospital’s financial information from the balance sheet, statement of operations, and the cash-flow statement for the years of 2018-2019. During the first step of the ratio analysis, profitability ratios were calculated for two years ($ in thousands):

  • For 2018, Profit Margin was equal to $10,075.6/173,027.7= 6%.
  • For 2019, Profit Margin was $8,522.7/179,189.9= 5%.
  • For 2018, the ROA was equal to $10,075.6/257,130= 4%.
  • For 2019, the ROA was $8,522.7/276,984.8= 3%.

The second step was to examine the tendencies in the hospital’s revenues depending on the intensive application of the GSCM in 2019 in comparison to 2018 by calculating liquidity ratios ($ in thousands):

  • In 2018, Current Ratio was $44,922.3/41,774.7= 1.07.
  • In 2019, Current Ratio was $36,178.1/49,978.3= 0.72.
  • Derindere Hospital’s Cash Ratio in 2018 was $15,338.8/41,774.7= 0.37.
  • In 2019, this ratio was equal to $4,107.4/49,978.3= 0.08.
  • Quick Ratio in 2018 was equal to $48,550.4/41,774.7= 1.14.
  • Quick Ratio in 2019 was $40,705.3/49,978.3= 0.81.

The third step of financial analysis included the calculation of debt management ratios ($ in thousands):

  • For 2018, Total Debt Ratio was $64,325.2/257,130= 0.25.
  • For 2019, Total Debt Ratio was $70,819.8/276,984.8= 0.24.

The fourth step was the calculation of asset management ratios to determine the hospital’s operating efficiency ($ in thousands):

  • In 2018, Receivables Turnover Ratio was equal to $173,027.7/16,757.3= 10.3.
  • In 2019, Receivables Turnover Ratio was equal to $179,189.9/21,041.3= 8.5.
  • Fixed Assets Turnover Ratio for 2018 was $173,027.7/185,054.9= 0.94.
  • Fixed Assets Turnover Ratio for 2019 was $179,189.9/207,284.4= 0.84.

Phase 2: Qualitative Data Analysis for the Cases in Australia

Results of Coding Data

The process of coding qualitative data was composed of three steps that were completed by the researcher manually (the preliminary stage of reviewing data) and with the help of NVivo software. At the first stage, open coding was applied as a strategy of the close reading of narratives for the purpose of identifying all interesting ideas and opinions related to the topic and research questions. At the stage of axial coding, recurrent ideas from the participants’ narratives were labelled as invariant constituents forming specific clusters of codes. At the final stage of the coding procedure, selective coding was used to organise the codes labelled and selected as most significant to address research questions and form clusters.

The table below shows the invariant constituents and the major themes in the Interviewees Responses.

Table 3: Themes and Invariant Responses

Thematic Category Invariant Constituents Number of Invariant Constituents
Green Supply Chain Management in Australia
Changed performance
Other Regulations. APA AND DHHS
Application of APA Regulations
Implementation of ISO Standards
Waste management / Waste Reduction procedures
Waste disposal Ratio
Clinical Waste reduction
Less plastic
Thinking Green Strategy
Waste Management Costs
Cost Minimization
Cost reduction
Cost change
Green Supply Chain management benefits, the company implementation challenges
Thematic Analysis and Interpretation

Six key themes were identified from the three interviewee responses:

  1. GSCM in Australia, Victoria
  2. APA and DHHHS Regulations
  3. Waste Minimization and Management Procedures
  4. Waste Management Costs
  5. GSCM Implementation Challenges

The above themes are discussed in details as below.

Phase 2: Qualitative Data Analysis for the Cases in Turkey

In this sub-section, the data collected with the help of interviewing the employees of Derindere Hospital is presented and analysed to address the set research questions.

Results of Coding Data

The narratives of interviewees from Derindere Hospital (Turkey) were transcribed and re-read several times to determine specific patterns or codes in data. NVivo software was used to organise the process of coding data, as it was earlier utilised for the analysis of qualitative data related to the public Australian hospital. The same steps of coding data (open coding, axial coding, and selective coding) were completed to organise codes in thematic categories. Table 4 presents the identified invariant constituents (codes determined with the help of NVivo) and major themes in the interviewees’ narratives.

Table 4. Themes and Invariant Constituents

Thematic Category Invariant Constituents Number of Invariant Constituents
1 Green Supply Chain Management in Turkey
Sustainability 6
Beginning Stage 3
Changes 4
2 ISO Standards and Other Regulations
Application of ISO 14001-2015 6
Application of ISO 9001-2015 6
Turkish Medical Wastes Control Regulation 4
3 Waste Management and Minimisation Procedures
Eco-friendliness 5
Waste Minimisation 5
Green Procedures 8
Digitalisation 6
4 Waste Management Costs
Costs 6
Cost Reduction 3
Increases in Costs 3
5 Benefits and Challenges of Implementing Green Supply Chain Management
Benefits 5
Challenges 5
Prospects 3
Thematic Analysis and Interpretation

Five broad thematic categories were determined after coding qualitative data provided in the interview narratives of three employees in Derindere Hospital. The following themes were identified to be analysed and interpreted in detail:

  1. GSCM in Turkey.
  2. ISO Standards and Other Regulations.
  3. Waste Management and Minimisation Procedures.
  4. Waste Management Costs.
  5. Benefits and Challenges of Implementing GSCM.


In summary, this chapter outlines the methodology undertaken to study the supply chains of the Australian and Turkish hospitals using the example of two institutions. The concept of this research is the ability to find a connection between the ISC, SCM, GSC, and ISO standards. The author used both quantitative methods, primarily to collect data on the hospitals’ performance indicators and capacity and qualitative methods, such as their goals and environmental targets. The mixed design of this research allows the author to study the connection between these concepts in depth by backing the qualitative findings with empirical ones. However, it is important to acknowledge the limitations of this study design, particularly the limited sample size, since only two hospitals were included in this study. There is a potential for bias when interpreting the results since the methodology is complex and requires the author to review and answer multiple questions, although this limitation will be addressed in the subsequent parts of this paper. The following chapter will analyze the presented findings. Additionally, this study allows addressing the adoption of GSCM methods and ISO standards, such as ISO 9001 from 2015 and ISO 14001 from 2015.

Data Analysis and Findings


This chapter presents the results of the analysis of data obtained by mixed methods research based on the application of the selective case study approach. The purpose of the chapter is to provide interpretation of quantitative and qualitative findings related to the public hospital in Australia and Derindere Hospital (Turkey) that are helpful to answer the major research question on the main benefits and challenges of implementing integrated GSCM in Australian and Turkish hospitals and associated sub-questions. The chapter interprets the research findings described in the previous chapter and identifies differences in operations of the two hospitals. Following the case study presentation in Chapter 4, this chapter will address the author’s analysis of the findings. The author segregated the interpretation of the results for the two hospitals and based on the application of the qualitative and quantitative methods.

Interpreting Quantitative Findings for Australia

The 2018-2019 profit margin of the Australian hospital was 1.6 and 1.5, indicating that the Hospital had an overwhelmingly better performance in 2018. The degradation of the industrial level of performance in 2019 reduced almost all mega hospitals’ profit margin. Nonetheless, compared with other hospitals in the industry, the Australian hospital’s performance was average, showing that RMH takes a leading influence in the industry. The ROA ratio of the Hospital was average, and it shows the same tendency on Hospital performance. The Hospital unit return on assets was high showing better performance in 2019, but in 2018, the unit value on return of the Hospital assets was better. The decreased performance in 2019 needs improvement.

The Hospital’s ability to meet its debt obligation gradually decreased. In 2018, the Hospital recorded a CA of 0.6, which decreased in 2019 to 0.5. The same change trends were recorded on the measure for the cash ratio, which increased from 0.3 to 0.2, showing that the value of cash and equivalents the Hospital had in 2019 could not meet its current liabilities at the time. The value on quick ratio also reduced from 0.5 in 2018 to 0.4 in 2019, showing that the Hospital’s current liabilities had either increased compared to its current asset’s value less inventories. The difference shows that the RMH was struggling to meet its obligations in 2019 as compared to 2018. The reduced performance puts in question the 2019 strategies, including the effectiveness of green environmental programs employed by the management

Moreover, on measuring the Hospital debt management ability, the RMH value of total debts may have increased compared to the increase or change value of its total assets in 2019. The total debt ratio is 2019 was 0.5 from 0.6 in 2018. The decrease showed a reduced hospital ability to meet all its debt obligation in 2019 compared to 2018. However, the measure on the two-year ratio showed that the Hospital was better managing its debts and assets since it had more assets than its total debts ( 0.25 and 0.26 were all<1)

In assessing the Hospital’s operating efficiency, the Hospital’s account receivables group was efficient in 2018 compared to 2019. The receivable turnover ratio was reduced from 10.3 in 2018 to 8.5 in 2019. The change showed that the hospital had many quality customers who were willing to pay up their hospital debts in 2018 compared to 2019. Notably, the fixed asset ratio in 2019 was 0.86, a drop from 0.94 in 2018. The decrease showed poor performance in managing fixed assets in 2019. However, the overall change is identified to result from the impact of the drastic economic changes that were identified in the industry in the year 2019.

In reference to the above ration analysis, the Hospitals efforts in building green supply chain in 2019 were not very effective. However, the change is minimal, considering that the Hospital’s improved abilities in 2018 were slightly higher than in 2019. However, the overall indication, especially with reduced Hospital management efficiency, raises questions on the effectiveness of the green supply chain policies and their long-term application. The suggestion is that the Hospital should consider restructuring its management policies to improve performance level in all areas and ensure that greening procedures are effective for a better improvement. This is, however, identified in the Hospital’s current Environmental Sustainability Strategy 2020-25.

Interpreting Quantitative Findings for Turkey

In 2018 and 2019, Profit Margin of Derindere Hospital was low (6% and 5% accordingly), comparing to the industry average of 10-11% in 2018 (Garanti Securities, 2018). This ratio indicated that Derindere Hospital handled available finances ineffectively, while comparing their revenues and sales of services. The ROA demonstrated how profitable the hospital was in relation to generating revenues with reference to the organisation’s assets, and it was 4% in 2018, and 3% in 2019. The indicated ROA was below 5%, and it should be improved.

Current Ratio was 1.07 and 0.72 and Cash Ratio was 0.37 and 0.08 (<0.5-1) for 2018 and 2019 respectively. These numbers indicate that Derindere Hospital had no enough current assets to cover debts. Quick Ratio was 1.16 and 0.81 for 2018 and 2019, which means that, in 2018, the situation was better (1.16>1), and more short-term assets were available to address short-term liabilities. Total Debt Ratio was 0.25-0.26 for the two years that is considered an appropriate debt ratio as the hospital generated enough cash to cover debts. These figures show that Derindere Hospital had no assets to address obligations, but the generation of cash to cover debts was appropriate.

The hospital’s operating efficiency was calculated with reference to Receivables Turnover Ratio (10.3 for 2018 and 8.5 for 2019), as well as Fixed Assets Turnover Ratio (0.94 and 0.86 for 2018 and 2019 accordingly). Receivables Turnover Ratio was rather high, but Fixed Assets Turnover Ratio was low, meaning that Derindere Hospital generated net sales from fixed-asset investments inefficiently. Referring to the ratio analysis, it is possible to find out that the hospital’s focus on implementing waste management procedures in the context of building green supply chains led to the ineffective use of assets. However, the process of greening procedures and a supply chain made Derindere Hospital eco-friendly and more attractive to patients that also contributed to generating more cash to cover obligations.

Interpreting Qualitative Findings for Australia

All three interviewees agreed that the Victorian government was making a progressive approach to implementing green sustainable procedures. According to participant two, the Victorian government progressive approach included the developed new legislation that governs public entities’ operations. The other two participants named the Department of Health and Human Services (DHHS) to perform a critical role in ensuring different public entities, including hospitals, employ effective, sustainable measures.

According to participant 2, Victoria’s state government targeted zero carbon levels by 2050 under the new obligations set in 2019 and 2020+ plan. The government had employed effectual measures to ensure efficient green environmental procedures that include e-waste landfill bans, social procurement strategies, and PVC recycling procedures in different hospitals (Edokpolo et al., 2019). The 2020+ plan had included emission reductions and subsequently provided the reporting and monitoring measures that ensured the strategies of environmental safety are well implemented (Beckett, 2019). The obligations under the new registration are summarized in figure 2 below.

DHHS 2020 New Regime obligations
Figure 2: DHHS 2020 New Regime obligations

As started by Interviewee 2, all Victorian public hospitals are needed to report on their public environmental performance. Ensuring green environmental approaches are developed was relied on individual hospitals to employ effective measures that ensure sustainable operations. The state government of Victoria was tasked to monitor the employed sustainable procedure’s performance in each public entity. If such approaches are not in line with DHHS’s new obligations and the 2020+ environmental safety plan, the hospitals were tasked to restructure their new green operation approaches (Beaufoy, 2017). Notably, the three participants disagreed that the state government of Victoria adopts UN conventions. Instead, they stated that the DHHHS offers proper guidelines on each public entity based on its GSCM regulations.

Participant 2 provided a figure to illustrate the current and future reporting of RMH developed in line with DHHS regulations. Figure 3 below shows the current and future reporting guidelines of the hospitals.

Reporting guidelines of the hospitals
Figure 3: Reporting guidelines of the hospitals
APA and DHHS Regulations

All the three participants did not have enough knowledge on the application of ISO 9001-2015 and ISO 14001-2015 standards. According to the review by the different Australian governments on the application of ISO 9001-2015 and ISO 14001-2015 standards, the adoption of these standards is assumed to incorporate the provisions of APA regulations. Contextually, the Victorian government appeared to believe in its local environmental sustenance plans (Werdiningtyas, Wei and Western, 2020). As a result, the participants responded to APA regulations as the key guidelines that govern different public entities applying green environmental plans. In the same context, the participants agreed that the DHHS set regulations govern the reporting procedures and sustainable measures employed by different public entities.

In reference to this regulation, Participant 3 cited the company adoption of the Thinking Green strategy, which has included effective measures that ensure sustainable procurement and transportation of the company products. Likewise, participant 3 cited the Tele-Health service approach to ensure meeting client/patient needs at their convenience as one of the company measures involved in ensuring sustenance approaches in Line with APA regulation. The company’s provision in implementing sustainable operational procedures shows that the company was a long-term frontier in building sustainable approaches by regarding APA guidelines and sustainable management needs. The common stands of Australian organizations were measured against the APA regulations and DHHS. ISIS (2018) guidelines state that the identified standards of sustainable development in different countries’ public health facilities operations have comparable features of APA regulations and DHHS provisions which were identified as meeting the ISO 9001-2015 and ISO 14001-2015 standards.

Waste Minimization and Management Procedures

The participants discussed a reinvented approach by the RMH that involved a waste management plan applied in line with APA standards. According to participant 2, the Australian hospital has developed a plan that includes continuous waste education and awareness raised through in-service, websites, and posters, among other communication methods. The Hospital has also ensured it engages grassroots sustainability green champions that incorporate waste segregation and recycling procedures in different hospital operations areas. As a result of such an approach, the three interviewees agreed to reduce or minimize the Hospital’s waste levels.

Two participants also provided a graph on the Hospital’s clinical waste reduction based on the Hospital’s waste management plan (Figure 3). According to Interviewee 3, the RMH has managed to reduce its clinical waste by employing better segregation and staff education to reduce environmental impacts of poor waste management and the costs incurred by the waste management team. Participant 3 provided an example of ICU Theatres and Emergence Departs of the Australian hospital’s effective approaches in reducing the clinical waste by over 45% per patient. The management segregation and elimination procedures named by the participants included multiple waste streams and recycling approaches. Examples of recyclables wastes included metals, plastic, food waste, Flouro tubes, PVC, and mattresses.

Clinical waste
Figure 4: Clinical waste

Moreover, the interviewees discussed the general, clinical, and recyclable waste managed by the Hospital in line with an environmentally friendly context. Participants 3 named reusable blood baskets to reduce plastics wastes and incinerations of landfills after shredding and disinfecting processes. The discussion also proved that the above approaches had increased the number of patients served. As a result of great awareness of sustainable disposal of waste among staff members, the waste generation level has reduced. The discussion showed that the effective waste management plan of the Australian hospital affected the amount of waste generated in the Hospital and the number of patients receiving hospital services.

Ultimately, the hospital waste management plan was integrated into its Environmental Sustainability Policy that involved and outlined correct waste disposal methods for the hospital’s various waste types. According to participant two, the Environmental Sustainable Policy included different categorizations of waste type. As discussed before, other participants had named different waste types that, according to participant 3, are included in the Hospital’s larger waste management plan. As indicated in the environmental sustainability policy provided by participant two, the categorization of the wastes involved three waste groups: clinical and related wastes, General waste, and recyclables—each of the waste categories involved in a disposal plan. The plan involved the depreciation of the waste quantities. Also, it involved the correct disposal of all waste types, which involved the recycling of type of waste for reuse to minimize the overall waste level.

Waste Management Costs

The three participants discussed the effect of a waste management plan on waste management costs intensely. According to the respondents, the Hospital’s waste management plan has a serious implication in waste management cost. Participant two cited that the original waste management plan intended to relatively reduce the waste management cost in the Hospital. Although not certain on the reduction level and the decreased value per patient, the three participants agreed that the waste management cost had decreased. An example cited by participant two was the reduction in clinical waste by 40% per patient. The reduction implied a corresponding reduced waste management costs per patient.

Also, participant two argued that the cost is valued greatly between different waste streams. Participant Two agreed that Australian hospital had saved at least $500 000 in clinical costs, a corresponding value of the 40% reduced waste disposal in the clinical and ICU department per patient. According to Participant 2 statement, the reduction in waste cost was a cumulative value for the last seven years. Also, as stated by participant 2, by using a food dehydrator, the Hospital managed to remove 170 tons of organic food wastes from the general waste per annum, thus saving a total of $ 20,000 in disposal costs and a total of $ 50,000 in trade waste costs per annum. This reduction was as a result of the hospital policy to avoid macerating its food but instead sewer them.

The figure below shows the waste level, as discussed by participant 2.

Incorrect disposal cost per kilogram
Figure 5: Incorrect disposal cost per kilogram

As shown from the figure, the disposal cost per kg had a different value dollar effect on the costs.

The data’s assumption equally provided that other optional disposal techniques saved the hospital costs on disposal valued by a given margin. The incorrect figures were measured against per unit and weight. The Hospital cost measures on filling the P22s as identified in the above figure were identifiable with a significant valuation on cost reduction, implying that the hospital measures on waste management plan impacted the waste disposal costs.

As also discussed by participant three, the effectual measure employed in waste management was to ensure an average reduction in total waste management costs. However, there were associated costs on implementing the waste management plan, which were not reflective of the total costs reduced after implementing the the initiative. Nonetheless, the “Think Green” program that was employed by the company was an approach that aimed at reducing waste management as well as reducing the effect of increased waste products such as higher costs due to wastes and disposals and environmental impact costs. The Hospital’s overall costs are reduced at large in significant areas attributed to improved and better measures of the Hospital in ensuring that wastes are reduced. Nonetheless, Fareeduddin et al. (2015) argue that the cost of ensuring environmental sustenance by employing green environmental measures such as waste management plans that include recycling comes along with higher costs in some instances. For instance, the recycling cost of non-biodegradable wastes involves a process with a cost. The case of RMH involved measures that were not expensive. The interviewees supported that the employment of such measures led to an overall reduction in waste management costs.

Green Supply Chain Management Implementation Benefits and Challenges

The overall environmental sustainability plan of RMH resulted in different types of benefits. The key benefit, as stated by participant two, involved reduced GHG emission. As Zissis et al. (2018) argue, the emission is a boost to a safe environment. As indicated by data reference provided by different participants, RMH spearheaded the introduction of a green sustainability program in 2011 by introducing the “Think Green Initiative” that changed its operation to the involvement of GSCM procedure. Based on “The Think Big Initiative,” Interviewee 3 stated that the company improved procedures that ensured sustainable purchase and transportation procedures. Participants 2 named some of the benefits: better environmental performance, improved staff happiness, and cost savings. These benefits were all linked to Hospital health performance.

According to Rojek et al.’s (2020) research report on RMH performance and its long-term effect in the industry, the effective measure of RMH is the key reason for its leadership in the Victorian state in safeguarding the environment. Participant 3 noted that the long effort of RMH spearheading the green supply management plan is the reasons for its effectual performance’ sustainability move lead in the industry. The resulting benefits of its green sustainability approach are the improved work environment and improved workers’ participation in ensuring the Hospital has performed better than other existing public entities in the industry (Waltho 2019; Waltho, Elhedhli and Gzara, 2019). The Hospital level recommendation on good performance includes the rewards the Hospital has received in line with its efforts, as defined with its culture in implementing green environmental plans.

Likewise, the benefits of Green supply managements plan are identified with the Hospital’s reduced costs on operations following effective procedures in RMH management practice. The reduced cost are as a result of the hospital’s 2018 efforts to improve performance level. The efforts supported its environmental campaigning strategiess. As participant 3 stated, the Hospital’s performance level was evident in the company’s approaches in ensuring employment of effective procedures of the green supply management plan (Cowley and Oldaker, 2011). These procedures includes sustainable transportation of hospital products, wastes and supplies through improved transportation logistics to minimize the cost of transportation of different hospital supplies. The other aspects of the procedures included the sustainable approaches that were employed to ensure full and effective utilization of hospital purchases and products.

Contrary, the three participants also identified different challenges in implementing the green supply management approach. Participant one started some of the challenges to include unavailability of recycling opportunities and infectious consideration in some areas. These disadvantages involved the difficulties with attaining full efficiency in the implementation of a green supply management plan. According to participant two, the challenge of recycling opportunities was still a big drawback on some wastes. The participant named some waste such as Styrofoam and Soft plastic to lack provider for recycling streams. Notably, two participants cited the need to monitor performance and also the process of constant education as a key reverse challenge.

Based on interviewee discussions, RMH culture incorporated an approach that ensured all processes were in line with the Hospital’s sustainable needs. The changes in green supply management are adjustable to the change of environmental demands. As a result, they require effectual measures that ensure all needs are frequently included in the green management plan. Thus, the Hospital kept the processes intact and ensured all sustainable needs were met. This check on tasks on the processes was to ensure effective implementation of the green supply management plan. The RMH hospital’s actions were cultured as adopting a “think green” mindset. Participant 3 supported this culture to involve regard of environmental needs subject to APA regulations. The checks on the hospital processes’ application altered the reporting structure of RHM, thus the need, as stated in Australian hospital’s 2018-2019 reports, for the continual restructuring of reporting processes due to changes in policy implementation structures.

Interpreting Qualitative Findings for Turkey

Answering the interview questions, the participants claimed that the focus on sustainability and the development of sustainable or green supply chains in Turkish organisations, including hospitals, were only at the beginning stage. According to Participant 1, “Turkish businesses’ results in global sustainability ratings leave much to be desired“, and it was added regarding the situation at Derindere Hospital that “the hospital is at the beginning of its green supply chain journey“. Participant 2 also shared the same idea, stating that “Turkey is not the most advanced country in terms of GSCM, especially if we are talking about the healthcare sector“. Assessing the situation at Derindere Hospital, it was noted that “We have not reached outstanding results yet, but improved waste reduction and equipment selection practices are already in place” (Participant 2). Participant 3 expressed similar ideas: “we are still in the process of planning the full-scale transition to this new paradigm“. Thus, the participants claimed that, in Turkey, there is an interest in greening hospitals, but most organisations, including Derindere Hospital, are only at the initial stage of this complex process of implementing green supply chains.

It was also mentioned by the interviewees that the Turkish government seems to promote sustainable and green initiatives implemented in organisations, but today there are no strict requirements, except for environmental regulations. Discussing this topic, Participant 2 noted that, “Questions about environmental issues are quite sensitive in Turkey, so I think that our government should be positive towards greening and sustainable businesses”. Furthermore, Participant 3 claimed: “I am sure that the authorities understand the promising nature of green supply chains because Turkey has a huge problem with waste“. These opinions are in line with researchers’ conclusions regarding the current state of the application of sustainable and green policies in the health care sector of Turkey. According to Camgöz-Akdağ et al. (2016), national directives and norms promoted by the authorities in Turkey actively influence the process of greening hospitals. The healthcare sector is highly regulated in terms of supporting environmental initiatives (Akdaǧ 2015). Thus, the Turkish authorities are interested in promoting GSCM and related practices in hospitals, and these ideas are presented by healthcare workers.

ISO Standards and Other Regulations

The participants also actively discussed the topic of applying ISO standards at Derindere Hospital, as well as the regulations influencing the adoption of greening policies. Participant 1 explained that the hospital applied ISO 9001-2015:2015 and ISO 14001-2015, and these practices have led to the optimisation of hospital processes and focusing on environmental objectives. As a result, “a tangible difference” was noticed in the work of the hospital because of the possibilities to apply more eco-friendly practices and promote “medical tourism” (Participant 1). In addition to ISO standards, Derindere Hospital also follows “the official requirements of the Ministry of Environment of Turkey” and “most recent version of the Medical Waste Regulation” (or Turkish Medical Wastes Control Regulation (TMWCR)), which are linked to ISO standards (Participant 1).

Participant 2 stated that the application of the ISO standards “have improved the facility’s performance if we compare patient complaint rates, patient flow, and the hospital’s environmental reputation before and after implementing the standards“. Furthermore, it was declared that “ISO 14001-2015, ISO 9001-2015, and the TMWCR work properly when implemented simultaneously” (Participant 2). Similar ideas were also shared by Participant 3: “I have been told about the standards’ large-scale effects on performance … better patient safety outcomes and an influx of foreign patients“. In the academic literature, related topics were discussed by Toprak and Şahin (2013) and Özkan, Akyürek and Toygar (2016), who discussed the application of ISO standards in their studies. According to researchers, there were several steps in ISO implementation in the healthcare industry in Turkey, and recently, much attention has been paid to making all the practices greener and grounded in ISO norms (Muzaimi, Chew & Hamid, 2017; Polater, Bektas and Demirdogen, 2014). The guarantee that practices in the healthcare sector are ecological and services are of high quality is a priority for the Turkish authorities today.

Waste Management and Minimisation Procedures

When answering interview questions, the participants provided much information about waste management and waste minimisation procedures adopted at Derindere Hospital in the context of applying GSCM. The interviewees stated that the system of waste segregation was used in the hospital: “colour-coded containers and bags of specific types” were applied for the immediate segregation of waste (Participant 1) and “all professionals at Hospital Derindere strictly follow the segregation procedure outlined in the TMWCR” (Participant 2). Furthermore, for clinical waste, “there are such practices as incineration and landfilling” (Participant 1). Much attention is also paid to educating the medical staff regarding to the types of waste and the approaches to waste segregation and reduction followed at the hospital. They also learn what types of waste can be recycled and what procedures should be followed to collect this material. According to Participant 2:

[We] pay close attention to staff education in this regard and make sure that every staff member is well-informed on how to distinguish between healthcare, hazardous, and municipal waste and their subtypes. (Participant 2)

The following areas were determined as critical for waste management and waste minimisation at Derindere Hospital: recycling, the reduced use of paper, and the efficient management of clinical and hazardous waste. According to the interviewees, plastic waste used in the hospital was collected by the staff for recycling, as it was mentioned by Participant 2: “Similar to other hospitals, we recycle plastics from the office and dining areas and wish to expand these initiatives in the future“. Moreover, Participant 3 stated that “Some plastic non-infectious waste gets recycled at local facilities, but we are still to increase the use of such methods“. Medical workers are also educated regarding reusable equipment and how it should be sterilised to be used more than one time. Still, according to Participant 2, “for reusing and waste disposal, there are specific practices to follow, but we are not that different from other hospitals yet“. More time is required to make reusing and recycling stable procedures at the hospital to assess their effect related to sustainability.

In addition to waste management using segregation, recycling, reusing, and disposal, the participants also focused on waste minimisation procedures. According to Participant 2, “our digitisation initiatives have helped us to reduce paper usage”. Participant 3 added “we have focused mainly on ways to reduce waste”, and moreover: “we have digitised data pertaining to patients to reduce general waste, such as paper, and use the segregated waste collection for medical waste“. Additionally, the hospital also used the procedure of minimising the unnecessary transportation of patients when it is possible to reduce pollution. Participant 1 also named Derindere Hospital a “digital hospital” oriented towards eliminating the production of waste.

The realisation of the listed practices is possible through the “collaboration with both metropolitan municipality teams and private waste management organisations” (Participant 3). The focus is on making the existing and followed procedures and policies more eco-friendly. The interviewees also agreed that the intensive growth of the number of patients caused the necessity of adopting greening procedures and implementing a range of waste management procedures, but the key focus is not on waste management in itself but on waste minimisation and the production of less non-hazardous waste. Participant 2 declared “our improved approach to waste management already brings results in the form of decreased paper and plastic waste generation“. Participant 3 also accentuated the positive steps made by Derindere Hospital on the path towards the improved ecological profile of the organisation.

While interpreting these statements with reference to the academic literature, it is important to state that waste elimination and management were the most popular practices mentioned by researchers examining the situation in Turkey. Calipinar and Soysal (2012) and Özkan, Akyürek and Toygar (2016) focused on the idea that, applying green supply chains, hospitals usually aim at reducing and managing waste. The efficient use of resources becomes guaranteed through eliminating waste, recycling, and using mainly reusable goods and tools.

Waste Management Costs

When answering questions related to waste management costs and possible changes in expenses associated with greening supply chains at the hospital, the participants hesitated to express their opinions strictly. Participant 1 accentuated the fact that the hospital is only at the preliminary or beginning stage of applying GSCM strategies, but “there is a slight decrease in waste management costs due to less paper and plastic waste”. Participant 2 and Participant 3 explained some changes in costs associated with waste management with reference to innovation and digitisation. As the interviewees had no direct access to data on waste management costs, they made conclusions depending on the data available in their areas. Participant 3 stated that “innovations that facilitate going green should be costly at first. I think that we will have to devote much more funds to waste management”. Participants 2 provided more details regarding the innovation application to reduce costs and manage waste:

there are changes [in costs] since reliance on digitised medical data has reduced the amount of non-toxic recyclable waste (X-ray films, patient reports, etc.) to be disposed of … our digitisation initiative caused slight reductions in waste costs, but the effects on electricity consumption also require consideration. (Participant 2)

The interviewees agreed that waste management requires many financial resources, and electricity consumption can increase at the first stages of moving to green procedures. However, further digitisation of processes and the elimination of paper waste can lead to slight decreases in waste management costs. At the current stage, it is rather problematic to conclude regarding the results of Derindere Hospital in this area because of the lack of data related to several years of following new waste management principles and the overall system of GSCM. According to Camgöz-Akdağ et al. (2016), the expenses related to implementing green practices at hospitals are extremely high in Turkey. Therefore, hospitals are interested in finding different ways of reducing costs.

Benefits and Challenges of Implementing Green Supply Chain Management

After discussing the application of GSCM practices at Derindere Hospital, the interviewees focused on the benefits and challenges of greening supply chains. According to Participant 1, benefits include the waste minimisation and “contributions to local people’s health, new reputational victories”. Participant 2 focused on “reductions in costs and being able to win customers’ trust”. Participant 3 determined such benefits as “new job opportunities, patient and staff safety, cleaner environments … customers’ trust can be another direct benefit”. These benefits are in line with the findings of such researchers as Erus and Hatipoglu (2013) and Akdaǧ (2015).

Challenges were also identified by the participants, and they include financial and operational issues. Thus, challenges related to financial expenditures can be observed, as it was stated by Participant 1:

[Because] progressive waste management or reduction may require expensive technology … and particular organisations’ aspirations in terms of the best possible waste management are sometimes different from what a country can offer. I mean access to alternatives to landfills. (Participant 1)

Participant 3 also mentioned extra costs and the necessity of education for employees among issues. Furthermore, Participant 2 claimed that “waste management strategies can be non-durable, and their effectiveness often depends on the state of research and the country’s resources”. The academic literature on the costs of greening supply chains and waste management in the healthcare sector of Turkey supports these ideas presented by the interviewees (Bracci and Tallaki, 2015; Turkyilmaz, Bulak, and Zaim, 2015).

Data Analysis

Some of the themes that arise in this section are a result of the researcher’s own analysis of data rather than directly from the case study. The coding process was used to find the correlation between the practices and management approaches of the two hospitals.

Cross-section analysis of the two hospitals shows that the two institutions manage their supply chains in a very similar manner. The quantitative analysis has shown a decrease in profit margins between the years 2018 and 2019 for both hospitals, which suggests that the implementation of GSCM has had a negative effect on the financial performance of these institutions. The qualitative findings suggest that the support of the policymakers is important during the implementation of the GSCM, which was the main highlight of the interviews with the three employees of the Australian hospital and with the interviewees from Turkey. However, it appears that the Australian government has put pressure on the hospital’s management to reduce the levels of CO2 emissions and implement recycling procedures, which is also consistent with the findings from the literature. The Turkish hospital’s management does not appear to face the same pressure from the policymakers, which may be linked to the ownership type of this healthcare facility. The public hospital, as opposed to the privately owned one, has to report to the community members and address their concerns and needs, which are currently based on the environmental sustainability of this facility. The private hospital in Turkey does not face the same pressure, and its environmental and sustainability strategy is linked with the need to comply with the ISO standards. In contrast, to the Turkish hospital, the employees of the Australian facility had little knowledge of the ISO standards and implementation process, suggesting that the management is more focused on complying with the government’s regulations rather than with the international quality standards. Moreover, the main focus of the Australian hospital’s management SCM was on the reduction of GHG emissions. This hospital was also able to achieve some positive results in terms of reducing the costs as part of the GSCM implementation. The participants from the Turkish hospital could not cite any significant effects of the GSCM on the operations of their facility, as it was in the initial stages at the time of the interview. Another issue is the lack of government-led regulations in this state that would promote the development of sustainable supply chains. This issue also explains why the hospital’s main focus is the ISO standard and not the legislations and initiatives created by policymakers.

Main Take-Outs

This section will detail the main takeouts from this research. The financial performance of the Australian hospital has decreased over the observed period, which may be linked to the investment required to facilitate the transition towards a GSCM. Although this implication aligns with the literature review’s findings regarding the initial investment required to facilitate the implementation of GSCM practices, one can conclude that in the short-term perspective, this approach has harmed the business performance of this entity. Moreover, the analysis shows that the lack of governmental support, which is evident in the case of the Turkish hospital, is a substantial barrier that limits the implementation of GSCM practices, as opposed to Australia, where the government requires hospitals to implement sustainable management practices and GSCM.


Based on the results of this study, there are several theoretical and practical implications. The study is limited by the timeframe of data collection, which was between 2018 and 2019, and does not allow to determine the long-term effects of sustainable practices on the operation of the hospitals. However, the short-term financial performance of both facilities decreased in association with implementing ISO standards and sustainability management approaches. Additionally, the government’s input into the development and management of sustainable practices and GSCM has had a substantial impact since the management of the hospital in Turkey has faced many barriers associated with sustainable practices, unlike the management of the Australian hospital.


In summary, Chapter 5 is a summary of the case study based on the Derindere Hospital in Turkey and the Australian public hospital. The two institutions differ in their ownership models since the former is private and the latter is public; however, the ownership approaches are not the focus of this research, which is why this factor was omitted during the analysis. However, the results highlight the difference in financial targets and outcomes of the two institutions. Moreover, the Australian hospital is required to adopt green measures due to the government’s policies, while the Turkish hospital has no such incentive, which affects the spending and profit ratios of the two.


Research Problem Description

As the number and capabilities of healthcare facilities continue to grow, so does the risk of negative environmental impacts from their operations. Thus, addressing relevant concerns from a managerial practice perspective is a priority, which is at the same time ISO compliant. Currently, there is not enough research on the practical application of green SCM approaches in the healthcare industry. While many hospitals around the world are actively moving from SCM to GSCM to reduce waste and negative environmental impact, more research is needed in this area. Moreover, the strategies used by managers to transform supply chains require additional investigation in a healthcare setting. Many hospitals are currently choosing the GSCM practice to meet international requirements 4001-2015 and ISO 9001-2015. Since the implementation of these principles is at an early stage, it is necessary to consider which strategies have already been applied and what results have been achieved. Consideration of these aspects will make it possible to assess the effectiveness of adopting international standards and the difficulties that healthcare facilities may encounter.

Particular attention should be paid to international standards and the extent to which they help promote environmental management practices in hospitals. Many healthcare facilities around the world are unable to effectively optimise their supply chains. The cause of this problem is reliance on the outdated principles of total quality management and little knowledge about optimisation techniques. These factors hinder the construction of green supply chains that could meet modern standards. In this regard, the basis of this study is the operations of two hospitals in Australia and Turkey. The results of the assessment further allow identifying to what extent the supply chain management practices in the two healthcare facilities comply with ISO standards. Additionally, it is possible to define procedures that can be applied to implement the relevant strategies.

Research Methodology

This study aims to compare the two healthcare systems, the one in Australia and the one in Turkey and the supply chain management systems that the two states employ. Hence, there is a need to look at the historical data, such as the statistics, the government reports, legislations, research papers, and reviews that focus on this topic. The goal is to find data that would help understand how green practices following the ISO standards can be implemented into the healthcare supply chains. Based on the data the needs to be collected, this study is a collection of the history of the two systems.

The literature review design addresses the needs of this study because it allows collecting descriptive data that will allow the researchers to define the characteristics of the supply chains of the two healthcare systems. In addition, the researchers aim to collect historical data on this topic because the application of green SCM practices has not been a matter of concern for a long time. However, in recent years this topic has become more important, and both researchers and policymakers have dedicated efforts towards studying the potential ways of improving the SCM of the healthcare facilities. Hence, this study will help understand how the SCM systems of Australia and Turkey developed and how GSCM has become a topic of discussion in recent years.

During this study, the researchers will collect both quantitative and qualitative data by analysing papers that use descriptive design and studies that employ statistical data analysis methods. A literature review will help identify existing practices that both hospitals are using to implement GSC and meet international standards. Hence, this study was conducted using the desk research methodology where literature on the topic was collected and analysed, focusing primarily on the history of the healthcare systems’ SCM practices in both states. the obtained empirical data was based on the analysis of both qualitative and quantitative information. To achieve this goal, both descriptive and explanatory research was used. The choice of mixed methods research is justified by the need to produce high-quality research that addresses the risks and benefits, as well as differences and similarities in the experiences of the two hospitals. Thus, a combination of qualitative and quantitative research is necessary to deal with such a complex task.

For quantitative analysis, we used annual financial reports, financial documentation, documentation on the ISO standards and GSCM practices, and non-¬confidential documentation. In particular, the focus was on collecting information directly related to the costs associated with the implementation of the GSC. Further analysis and comparison of the data revealed any changes in the financial performance of the two hospitals before and after the practice. Techniques such as interviews, observations, and focus groups were used to collect qualitative data. This strategy allows collecting more in-depth information about the studied phenomenon for a detailed answer to the research questions posed. The received answers were later analysed using NVivo software, which allowed identifying the topics presented in the answers and determining the concepts that are associated with the participants with the implementation of GSC. In summary, the approach to examining the hypothesis of this study is the comparison of the histories of the two SCM systems, the Australian and Turkish.

Results of the Study

The purpose of this research was to evaluate the relationship between green SCM application, ISO 9001-2015 and ISO 14001-2015 compliance, and overall performance. The topic of green supply chain management is still somewhat new to hospitals, though it has been applied extensively in other industries. However, there have been efforts to implement it in some nations, particularly Turkey and Australia. They served as excellent examples from which implications for best practice in applying the principles of green SCM can be drawn. Moreover, the two countries are sufficiently different in their approaches that a comparison between the two is warranted, with Australia setting out requirements with which hospitals have to comply and Turkey applying a more laissez-faire approach. To that end, this study selected two different hospitals in the two nations and evaluated their success in applying green SCM.

Overall, both facilities discussed in this study have been able to improve their environmental performance substantially following their application of green SCM principles. The Australian hospital implemented environmental education for its employees and increased its usage of recycling practices and material separation, ultimately reducing its clinical waste production by nearly half. Meanwhile, though the Derindere Hospital applied several similar practices to those of its counterparts, it also focused on reducing paper usage and had to rely more on incineration and landfilling. Both hospitals’ management agreed that, by becoming more sustainable, they could serve higher numbers of patients more efficiently. As such, the measures taken by both facilities coincide substantially and generate similar results, which indicates that the approach is effective overall.

Derindere Hospital is private, while the one in Australia is public, and this distinction manifests itself in several different ways. One of these is the motivation for their choice to implement green SCM practices. Derindere Hospital’s reason for adopting them was the sensitivity of the environmental question in Turkey. As such, in doing so, it aimed to improve its reputation in the community and win the trust of its visitors. On the other hand, the reasoning of the Australian hospital’s management was less direct, and it adopted green SCM to improve the environmental performance of the facility. While the goal is valid, achieving it does not necessarily provide any tangible benefits for the hospital. Instead, Victoria’s government provides negative reinforcement by requiring non-compliant organisations to review their standards. In the long term, this approach may not be sustainable, as, instead of genuine improvements, hospitals may be motivated to only comply with the statistics without regard for side effects.

Ultimately, the study found substantial differences between the application of the practice in the two nations. In the absence of government regulation, Derindere Hospital relied heavily on ISO 9001-2015 and 14001-2015 standards, using them to inform its operations. On the other hand, the management of Australian hospital was largely unaware of the guidelines, instead relying on government-mandated requirements and trusting them to incorporate all of the components necessary for success. As such, its compliance with ISO standards was difficult to evaluate objectively without further research into the matter. With that said, since the guidelines are substantially broad, the assumption can be made that the Victoria government’s green strategy was designed with them in mind. As such, so long as the government designs its green strategies responsibly, both the centralised approach and the decentralised one used in Turkey should be viable.

With that said, the challenges involved in implementing green SCM should be taken into consideration before attempting to replicate the measures. Interview participants from the Australian hospital noted how they could not find providers that could help them deal with specific types of waste, such as Styrofoam. Considering Australia’s overall high level of technological advancement and the government’s promotion of green practices, it is likely challenging to find such recyclers in other parts of the world, as well. The Turkish participants agreed that a nation’s level of technological sophistication would affect the success of green measures strongly, as well. Another problem identified in both nations was the need for continuous education of staff to comply with the latest green standards as they evolve continuously. Until a conclusive set of guidelines can be established, this issue is unlikely to be resolved.

Cost is the last matter that needs to be discussed, as it is the reason cited most often for why businesses do not implement green SCM practices. The implementation of new, more complicated waste management practices is typically expected to result in additional expenses that are not necessarily offset by tangible benefits. However, the participants from the Australian hospital make the opposite claim, stating that their costs were lowered as a result of green SCM application. The stated reason for this change was that, through more mindful waste management practices, the amounts of it that were produced dropped substantially, requiring smaller utilisation efforts. On the other hand, while Derindere Hospital also partially experienced the same phenomenon, its costs increased instead. The stated reason was that it was still in an early stage of an environmentally-friendly transition, and the expenses were expected to go down later on. With that said, it should be noted that the financial performance of both hospitals was worse in 2019, when they started implementing green SCM, than in 2018.

Implications of the Research

The study has found that overall, green SCM is viable for hospitals, effectively reducing their waste production and the associated costs. There are also incentives for private hospitals to adopt it, such as improved reputation and patient trust. Moreover, it confirms that ISO 9001-2015 and ISO 14001-2015 compliance can effectively enable a hospital to follow environmentally friendly practices. With that said, implementing green SCM is associated with increased costs in the short term as the facility adapts to the new standards. Moreover, the long-term implications of the constantly-evolving environmental science and the adaptations it requires can incur additional expenses. Lastly, the technological capabilities of the hospital’s region need to be considered, as they can inform the degree to which it can be environmentally friendly. After considering the short-term viability of the move and the overall potential for savings, hospitals should have substantial reason to consider adapting their practices.

Moreover, the results of this study provide some implications for future research on the topic of GSCM in hospitals. A cross-sectional comparison of the two institutions reveals that their supply chains are managed in very similar ways. This implies that GSCM principles can be used across different settings, and no specific adaptation is needed to the local environment. However, the government’s involvement plays a crucial role in the rate of implementation of the GSCM. According to the findings of the literature, the Australian government has put pressure on the Turkish hospital’s management to minimize CO2 emissions and establish recycling processes. The primary goal of the Australian hospital’s management SCM was to reduce GHG emissions. As part of the GSCM deployment, this hospital was able to obtain some favorable outcomes in terms of cost reduction. The Turkish hospital participants could not identify any substantial influence on their facility’s operations. Hence, the outcomes in terms of financial benefits from using GSCM differ based on the state in which these practices are used.

Another implication of this study is the difficulties that the management faces when implementing and employing GSCM. The respondents agreed that waste management necessitates significant financial resources and that power usage may increase in the early phases of implementing green practices. However, greater digitalization of operations and the removal of paper waste might result in minor cost savings in waste management. At this point, it is difficult to draw conclusions about the outcomes of Turkish hospitals in this area due to a lack of data from multiple years of adhering to new waste management principles and the entire GSCM system. However, the benefit for the environment due to the reduction of waste and emissions remains undeniable.

Limitations of the Research

The most significant limitation of this research lies in the fact that it has only analysed two hospitals. As such, the possibility that they are not representative of the overall hospital industry is substantial. Moreover, Derindere Hospital is private while the Australian facility is public, which means that the two’s objectives and incentive structures are entirely different. As such, a direct comparison between the two may not necessarily be valid, as it will likely be complicated by a variety of confounding factors. Lastly, as mentioned in Chapter 6, the individuals the researcher has interviewed did not have access to all of the information regarding strategy and financial performance. As such, some of the statements they made may be inaccurate or misleading, though the possibility of this happening is low. Overall, a more extensive investigation is required to determine whether the results of this study are accurate.

Future Research Directions

Future research will need to determine whether the results of the study are valid and applicable across the broader hospital industry. It will need to evaluate more facilities, both public and private, that apply green SCM principles for performance changes. An experimental-design study that would oversee the implementation of the approach at a hospital would be of particular interest, as, throughout the process, it would be able to determine specific issues and improvement opportunities. Additional investigations into the green SCM standards that are applied worldwide and their compliance with ISO 9001-2015 and ISO 14001-2015 are also warranted. Research into efficient continued medical worker education regarding changing environmental guidelines can help address the problem identified in this research. Lastly, a consolidation of environmental friendliness research that improves the overall understanding of best practices in the field would be beneficial.

Closing Remarks

Though green SCM and its application to hospitals have not been studied excessively, there appears to be substantial potential for their implementation and usage. While medical facilities do not have many opportunities to affect their upstream supply chains, they can optimise their operations and minimise their waste production. Moreover, there are incentives for both public and private hospitals to do so, such as reduced costs in the long term. With that said, this study demonstrates that green SCM adoption is a process that cannot be effectively performed in an isolated facility. The environment in which it operates needs to be suitable for the purpose, which implies the existence and availability of diverse waste recycling facilities, among other factors. As long as supporting factors exist for the transition, most hospitals will likely make the choice to transition to green practices due to the benefits the practices create.

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