Emergent climate protection strategies in German hospitals: A cluster analysis

PLOS One | https://doi.org/10.1371/journal.pone.0312661 May 16, 2025 12 / 18 CSRD, might be a driver in disclosing the social and environmental risks hospitals face [44]. The anticipated transparent description of GHG emissions will reveal the extent of hospitals´ climate impact and the average contributions to climate protection [45,80]. The resulting regulatory pressure may drive hospitals to take a more proactive role in climate protec- tion, enhancing their engagement with sustainable practices [84]. Climate action implementation Although most administrative leaders reported implementing climate actions, there are marked differences in scope. Operations and facility management emerge as common focal points across Clusters 2, 3, and 4 highlighting energy as a central area of operations among respondents. This result is also reflected in the survey of key performance indi- cators for climate protection. While all hospitals collect data on energy consumption, data collection for chemical dis- posal, anesthesia suction, and food disposal seems to be of secondary importance. The marginal report of actions in hospital-specific domains such as chemicals or pharmaceuticals illustrates hospital administrative leaders´ underestima- tion of specific GHG sources as reported by previous studies [85]. A significant part of hospital emissions are generated by hospital-specific emission sources. For example, medical supplies and pharmaceuticals alone are responsible for

up to 50% of overall emissions [86]. In addition, the disposal of pharmaceutical waste is critical, as improper disposal practices can contribute to environmental pollution [87]. Although the bulk of GHG emissions generated during patients´ healthcare delivery is indispensable [88], the potential for climate actions in medical departments of German hospitals can be further exploited. Climate protection initiatives and projects Distinct variations in allocating responsibilities and human resources for climate action efforts across clusters were observed. Clusters 1 and 2 do not allocate additional human resources for implementing climate actions, whereas Clusters 3 and 4 do. However, existing research suggests that climate actions can be implemented despite limited resources by employing innovative strategies and strengthening employee engagement and motivation [89–91]. In hospitals without additional human resources, initiatives predominantly originate from technical employees (Cluster 1) and, to a lesser extent, administrative employees (Cluster 2). Hospital medical employees contribute to climate protection, where additional human resources are created, and clear responsibilities exist (Cluster 3 and 4). Assigning overarching responsibility, for example, by creating a sustainability committee, can support the involvement of various employee groups in climate protection efforts [90,91]. Integrating employees from different departments within the hospital promotes a comprehensive approach to climate protection, considering various perspectives and expertise

[90]. Previous studies emphasize that employee engagement is crucial in developing and promoting environmental responsibility [92]. Organization. The clusters show considerable differences in the hospitals´ organization regarding climate protection efforts. The implementation of climate actions across various hospital areas and departments critically hinges on the strategic planning undertaken by hospitals´ administrative leadership, which is engaged for climate targets in a pioneering role (Cluster 1, 2, 3). Due to challenges such as the shortage of skilled employees and financial performance [93], climate protection is not a strategic priority in many hospitals, except those in Cluster 4. While the Act on Corporate Due Diligence Obligations in Supply Chains was introduced in Germany in 2023 [94], hospitals in Cluster 1 and 2 do not have established sustainability requirements for suppliers. The Act obliges organizations to ensure complete transparency along their supply chain and is intended to ascertain compliance with human rights and environmental obligations. Hospitals are obliged to fulfill their due diligence obligations and to transparently document these in an annual report [94]. Additionally, all respondents reported the pioneering role of hospital administrative leadership as pivotal (except in Cluster 1). The present study extends previous research [92] by identifying emergent strategy stages.