Emergent climate protection strategies in German hospitals: A cluster analysis

PLOS One | https://doi.org/10.1371/journal.pone.0312661 May 16, 2025 3 / 18 academic research [28]. In recent years, the topic has gained attention, and initial studies have been conducted [29,30]. They indicate that effective hospital administrative leadership not only facilitates compliance with climate-related policies but also enhances employee engagement [30]. Hospital administrative leadership is in a pole position to plan and imple- ment climate actions and create a fundamental change toward an environmentally sustainable corporate culture through communication and employee engagement [31]. This highlights the necessity of a clear strategic approach towards climate protection to address the challenges of climate change [29]. In this context, it is relevant to identify the strate- gies of German hospitals from the perspective of administrative leaders, focusing on the central role of organization and communication. As a global network with more than 1.900 members, GGHH is represented in more than 86 countries [5]. The network includes healthcare organizations from countries such as the United Kingdom, with 38 members, and Australia, with 156 members [32], which are already pursuing national strategies with ambitious targets for climate protection in the health- care sector [11,27,33]. While German healthcare organizations are less present in this network, with a total of 18 mem- bers [32], several national non-profit organizations and networks have been established in Germany to promote climate

protection in healthcare [34]. A prominent example is the German Alliance on Climate Change and Health (KLUG), which aims to strengthen education in planetary health and empower healthcare professionals as key agents of change [35]. The alliance was founded as a network of individuals, organizations, and associations from across the healthcare sector and provides a German-speaking platform for information exchange, networking, and implementing actions on plane- tary health [35]. Since its inception, the network has expanded continuously and now includes numerous institutions and initiatives, such as the Planetary Health Academy and Health for Future, which are supported by various member orga- nizations within the healthcare sector [34]. In addition to these networks and non-profit organizations, there is a growing awareness regarding climate protection within hospitals [36]. This awareness is reflected by health professionals, particu- larly physicians, who are increasingly committed to actively engaging in climate protection in Germany [36,37]. For exam- ple, the 125th German Medical Assembly called for a national strategy to enhance climate-friendly healthcare and achieve a net-zero healthcare system by 2030 [36,38]. The German healthcare system is widely recognized for its strong Universal Health Coverage and cost-sharing mech- anisms, ensuring access to a comprehensive range of services with comparatively low cost-sharing requirements [39,40]. Inpatient care is of great importance, with a dense network of hospitals comprising a mix of public, private non-profit, and

private for-profit institutions [41]. It includes more than 1.800 hospitals with different bed capacities and levels of care [42], caring for around 17 million cases per year [43]. With European regulations such as the Corporate Sustainability Report- ing Directive (CSRD) coming into force [44], the vast majority of German hospitals are obliged to include sustainability as an integral part of their corporate strategy in the future [45]. This study seeks to explore strategic approaches adopted by German hospitals to promote climate protection. The research question is: “How are German hospitals strategically positioned to contribute to climate protection?” Theoretical perspective Companies across various sectors increasingly strive to consider environmental and social aspects within their business activities [46,47]. In this way, they are responding to the social and political pressure exerted by various stakeholders [48], which has particularly increased with the introduction of CSRD in 2023 [44]. Central to this discourse, the Stakeholder Theory [49] is a framework often used to explain a firm´s sustainability-related behavior [50]. Since its inception [49], Stakeholder Theory has developed into a large and diverse branch of research that comprehensively addresses almost all management sub-disciplines [51]. Stakeholder Theory advocates a management approach that emphasizes the need to consider the interests and needs of all stakeholders, including shareholders, employees, customers, and suppliers [52,53], who can affect or be affected

by the organization´s activities [49,54]. It emphasizes the importance of continuous stakeholder engagement to align