Does intellectual capital promote the shift of healthcare organizations towards sustainable development? Evidence from Italy
Introduction
The United Nations Sustainable Development Goals firmly stressed the need to promote healthy lives and wellbeing for all populations (United Nations General Assembly, 2015). In this context, healthcare organizations (HCOs), such as hospitals and local health authorities, are responsible for guiding a shift toward sustainability, which includes a more equitable provision of care and prevention to reduce costs of unnecessary treatments, improving the efficiency of the system, and the reduction of the environmental impact of their structures; indeed, social responsibility should guide the governance of HCOs (Brandao et al., 2013). In other words, hospitals have to: evolve considering the impacts of the healthcare setting and workplace on hospital populations, act as change agents to enforce healthy behaviors, and develop training and research on health promotion while empowering health services (Pelikan et al., 2001). In the Italian healthcare context, it is claimed that intellectual capital (IC) management can have a role in the shift toward sustainability (Botturi et al., 2015, Lavalle et al., 2015). However, when focusing on the literature about the role of IC for sustainable development, research mainly discussed the business sector, and was routed to investigate the effect of green IC on the competitive advantage of these organizations (see for example Chen, 2008, Yahya et al., 2014). Models of green IC, such as the one of Chen (2008), have thus been shaped by the conceptualization of IC that identifies human, relational and structural capital as the main dimensions of intellectual capital. This taxonomy originated with the MERITUM project (2002), a European project aiming at setting general guidelines on intangibles’ measurement and disclosure, and found consistent application in healthcare studies (Habersam and Piber, 2003, Evans et al., 2015). Based on this taxonomy, human capital is defined “as the knowledge that employees take with them when they leave the firm”, including “the knowledge, skills, experiences and abilities of people”; structural capital represents “knowledge that stays within the firm at the end of the working day”, including “the organizational routines, procedures, systems, cultures, databases”, and relational capital defined by “all resources linked to the external relationships of the firm, with customers, suppliers or R&D partners” (MERITUM, 2002, pp.10–11). With reference to the contribution of IC to sustainability of HCOs, at the current state of the art we assist at fragmentary studies that looked at single assets’ role for sustainability successful implementation, while the whole effect of these assets for organizational performance is left unexplored (Evans et al., 2015), despite connectivity has been considered relevant for IC contribution to organizational performance (Habersam and Piber, 2003). In addition, sustainable healthcare has been mainly deployed by the use of the Triple Bottom Line approach, developed by Elkington (1999) for business organizations; this model focuses on social, economic and financial dimensions of sustainable development and in HCOs has been adapted considering the peculiarities of the sector (Jameton and McGuire, 2002). This calls for an extension of IC conceptualization, that should be inclusive of social and environmental capitals within organizations to unlock the potential contribution of these assets for society and ecosystem (Allee, 2000). Studies such as Mertins and Orth (2012)’s paper, although based on private sector organizations, are in this sense pioneering as they focus on an integrated perspective between sustainability (composed by social, economic and environmental dimensions) and IC management. Indeed, the adoption of innovation (which is a component of intellectual capital) in flexible healthcare structures was depicted as fundamental to HCOs’ sustainability strategy planning and implementation (Worley, 2012); nevertheless, studies about the link between IC and strategy and between IC and organizational performance are highly recommended by scholars (Vagnoni and Oppi, 2015, Lev, 2014), as well as research that can deepen the functioning of IC practices within public sector organizations (Dumay and Garanina, 2013, Guthrie and Dumay, 2015). Moreover, IC management for HCOs’ sustainability represents an interesting field of research being HCOs knowledge-intensive organizations that need IC to comply with their mission. For these reasons, the study, based on a quantitative data analysis, aims at investigating sustainability planning in the Italian public healthcare system (PHS), the role of IC in prompting sustainability initiatives and its association with sustainability strategy adoption. IC’s contribution to sustainable healthcare is analyzed espousing the definition of SD in healthcare where the TBL has been conceptualized by goals of health care services’ quality (social dimension), cost control (economic dimension) and environmental impact reduction (environmental dimension) (Jameton and McGuire, 2002). For the purposes of the paper, sustainable intellectual capital is defined as “the sum of knowledge that contribute to implement sustainable development projects in healthcare organizations, where sustainable development is composed by social, economic, and environmental dimensions”. This way, using the MERITUM (2002) conceptualization of IC, a sustainable intellectual capital model for HCOs was defined categorizing IC assets that emerged from the investigated institutional context (the Italian healthcare service) as potential contributors to SD. Then, a stochastic ordering test was conducted to verify if GDs attributing higher importance to IC assets for implemented sustainability projects were also the ones adopting sustainability strategy within their organizations. The contributions of the work are several: first, it aims to analyze the role of IC for sustainability management purposes as recommended by the literature calling for research on the link between IC and strategy (Lev, 2014, Vagnoni and Oppi, 2015). Second, it enables the creation of a Sustainable Intellectual Capital framework that can be used by healthcare practitioners as a reference to think about assets that can contribute to implement sustainability within their structures and processes. Third, the use of the developed framework can be of help to discuss connectivity among different assets, as different combinations of assets can facilitate or hinder the shift of HCOs towards sustainable development.
The paper is structured as follows. Section 2 discusses the challenge of sustainability in the Italian public healthcare context, and the role of intangibles in addressing the challenge. Section 3 presents an overview of the scarce research on the relation between IC and SD in the private and public sectors. Section 4 presents findings from a review of the literature on the contribution of IC to the sustainability of healthcare and then proposes a framework: Sustainable Intellectual Capital for Healthcare Organizations. Section 5 presents the research methodology of the study. The results are presented in Section 6 and some conclusions are drawn in Section 7.
Section snippets
The challenge of sustainability in the Italian healthcare context: a role for intangibles
In 2015, the Italian Senate produced a document titled “Consultation on the sustainability of the healthcare system” (“Indagine conoscitiva sulla sostenibilità del Sistema Sanitario”) in which the sustainability of the PHS was presented. In the report, the Senate outlined the main criticalities the Italian PHS should address to achieve sustainability. The containment of healthcare spending, the deficit of some Regions’ balance sheets for which repayment plans were issued (De Belvis et al., 2012
The relationship between IC and SD: an overview
The literature discussing the link between IC and SD is mainly related to the private sector. For example, scholars have started to focus on integrated reporting as a means to combine IC and sustainability information. Indeed, the overlap existing between IC and SD in social and environmental reports and sustainability reports (Cordazzo, 2005, Del Bello, 2006, Polo and Vázquez, 2008, Cinquini et al., 2012) and the use of international sustainability guidelines (such as Global Reporting
Corporate culture, competences and clinical possibilities
Bontis (1999, p. 450) stated that culture “constitutes the beliefs, values and attitudes pervasive in the organization and results in a language, symbols, and habits of behavior and thought”. With reference to culture, many studies showed the relevance of an HCO’s sensitivity to SD topics (Ball et al., 2014, Pinzone et al., 2012) as a condition to enact positive engagement of management and employees with sustainability. Ramirez et al. (2013) pointed out the need to train professionals at
Material and methods
The literature review revealed that IC (human, structural and relational capital) can help the implementation of sustainability projects in HCOs. For this reason the paper aimed at investigating strategy planning for sustainability within the Italian PHS and to examine the incidence of IC in the adoption of sustainability projects. Another objective was to determine whether HCOs that adopted formalized sustainability strategies were also the ones that attributed higher value to IC assets in the
Results
The number of GDs answering the questionnaires was 31, which was a response rate of 15%; of these, 16 GDs responded to the first round of postal delivery, while 15 responded to the second cycle of recall and mailing. Of the 31 completed questionnaires, 14 declared they had adopted a SD plan, 7 were waiting for approval/implementation and 10 GDs affirmed they had not have yet adopted a sustainability plan. However, all the respondents stated they had adopted projects or actions to increase their
Conclusions
The aim of the present paper was to investigate strategic planning and implementation of sustainability in the Italian PHS and, in particular, to analyze the role of IC in sustainability development. The results showed that the majority of GDs had adopted or were planning to adopt a formalized strategy for sustainability. In addition, except for three organizations that did not set dedicated internal positions for SD, the managerial approaches to deal with sustainability were various and mainly
Acknowledgements
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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