Isomorphism and Resource-Orchestration for enhancing Sustainability-Oriented Innovation: insights from the Hospital Setting

Environmental sustainability is increasingly acknowledged as a fundamental pillar across all sectors—most notably within healthcare one—driven by the principles of the United Nations Sustainable Development Goals (SDGs), the European Union’s reporting requirements, and, within the Italian context, the National Recovery and Resilience Plan (Piano Nazionale di Ripresa e Resilienza, PNRR) investment programs. Hospitals face the challenge of embedding process-level green innovations—such as digital monitoring, green procurement, and waste segregation—into continuous clinical operations without compromising care, recognizing their role as significant generators of emissions and waste, notably of special or hazardous categories. This study explores which sustainability-oriented innovations and practices are adopted by the hospitals, how coercive, normative and mimetic pressures shape their uptake, and which resources and competences enable implementation. To achieve this objective, basing on the Sustainability-Oriented Innovation (SOI) perspective and leveraging on different theoretical lenses such as Institutional Theory, Isomorphism and Resource-Based View (RBV) Theory, a multiple case study, based on interviews, is defined, involving five Italian healthcare organisations. Three different adoption archetypes emerge: “pioneers” with formal sustainability boards, dedicated roles and KPI platforms; “regulatory responders” focused on compliance-driven energy efficiency; and “fragmented adopters” relying on isolated, bottom-up pilots. Moreover, Institutional Theory explains how PNRR funding and accreditation standards drive or limit change, while RBV highlights the need to orchestrate tangible assets (renewables, waste-management systems) and intangible competences (project management, life-cycle assessment). By integrating two different theoretical lenses – Institutional Theory and RBV Theory – under the SOI perspective, this paper offers a multilevel model of healthcare sustainability and a practical roadmap for hospital leaders to scale process-oriented environmental innovations.