Healthcare sustainability-driven innovation: balancing institutional pressures with internal resources and competencies

Healthcare systems are challenged to balance high-quality care with growing demands for green transition. Within the Italian context, PNRR encourages targeted investments and reforms promoting sustainability, resilience, and innovation in healthcare, while hospitals encounter barriers such as regulatory constraints, cultural resistance, and limited resources. This paper investigates how Italian hospitals are integrating environmental sustainability practices in response to increasing institutional pressures on environmental issues and green objectives achievement. Adopting a qualitative multiple case study approach, the paper examines four healthcare organizations varying in size, location, and sustainability degree. Results identify three organizational profiles: pioneers, regulatory responders and fragmented adopters. Sustainable practices mainly involve energy efficiency, waste management, and green mobility, but their implementation is influenced by internal resources, cross-functional competencies, and external incentives. The preliminary results show that sustainability in healthcare requires more than technological solutions, demanding organizational adaptation, skill development, and institutional alignment supporting a systemic and long-term transformation.