This chapter will describe the methodology of this study and how it was applied to examine the cases of Australian and Turkish healthcare systems in terms of their supply chain management practices. At the beginning of this chapter, the methodology of the project will be described, followed by the presentation of findings and analysis of the case study. The first part of this chapter will describe the methodology followed by the presentation of findings. The discussion will focus on how the author applied the chosen methodology to collect information from two hospitals and analyzed it. This study is a combination of quantitative and qualitative research focusing on one hospital located in Australia and Derindere Hospital from Turkey. The study was undertaken in two phases, conducted sequentially, and the findings will be presented for the Australian hospital first, followed by the results of the Turkish facility. The results are presented in two phases sequentially for each of the two hospitals.
This study is conceptually based on demonstrating the connection between the following concepts and fields: the healthcare industry in Australia and Turkey, integrated supply chains (ISC), supply chain management (SCM), green supply chains (GSC), public and private hospitals, green supply chain management (GSCM) practices, ISO 14001-2015, and ISO 9001-2015. This study focuses on comparing what achievements have been reached by public and private hospitals in Australia and Turkey after green practices are integrated into their SCM policies. Furthermore, the focus is also on discussing what challenges can be observed on this path from historical needs as shown by (Maleki & Cruz-Machado 2013; Nassirnia & Robinson 2013). From this point, much attention should be paid to analysing the role of implementing ISO 14001 and ISO 9001 in the healthcare organisations in order to improve hospitals’ focus on the idea of sustainability in terms of its environmental aspect. It is also possible to expect that the hospitals selected for the case study analysis have not implemented the standards in the most appropriate manner or they faced some challenges on this path.
Therefore, for this study, the selected context can be described as the healthcare industries in Australia and Turkey and with paying attention to their similarities and differences. Hospitals with different ownership systems are selected as specific healthcare facilities to be examined within this context. In the selected hospitals, administrators or managers are interested in developing SCM as the approach to improving all types of operations and activities in a facility in terms of cooperating with suppliers and customers. The focus is also on selecting hospitals that concentrated on implementing integrated and GSC through particular green SCM practices (Chakraborty, Bhattacharya & Dobrzykowski 2014). Moreover, the focus is also on the application of ISO 14001 and ISO 9001 standards in the selected hospitals as policies for selecting the most appropriate GSCM practices in order to address certain issues or problems identified in healthcare facilities’ supply chains in different national contexts (Figure 1). The healthcare industry environments of each nation affect their hospitals correspondingly, resulting in the implementation of various new SCM practices, often in accordance with ISO 9001 and ISO 14001 standards.
Green Supply Chain Management in Turkish Hospitals
As it is discussed in the limited literature on SCM in the healthcare industry of Turkey, GSC are widely adopted by leaders in their hospitals in order to improve the quality of proposed care. Those healthcare facilities where sustainable or GSC are adopted are characterised by using ecologically appropriate building materials, the efficient management of hazardous materials, utilising products that do not include mercury or bis (2-ethylhexyl) phthalate, using green cleaners and electronics (Calipinar & Soysal 2012; Özkan, Akyürek & Toygar 2016). In addition, those hospitals that apply GSCs are focused on effective reduction and management of waste, as well as on recycling. These practices are important to contribute to sustainability of all operations in this or that healthcare organisation.
It is important to discuss what particular features of GSCs are viewed as attractive by managers in Turkish hospitals with reference to the fact that they are inclined to follow western patterns adopted in the United States and European countries. According to Özkan, Akyürek, and Toygar (2016), GSCM in hospitals is based on guaranteeing the protection and efficient use of resources in order to eliminate waste. Much attention is also paid to recycling. There are practices when the unnecessary equipment is recycled along with other daily goods typically utilised in hospitals. Another strategy includes the use of only reusable and recyclable products, as well as cleaners and substances for sterilisation and disinfection that can be applied without affecting the environment. Özkan, Akyürek, and Toygar (2016) state that these practices are now followed in such hospitals in Turkey as Istanbul Florence Nightingale Hospital and Medistate Kavacık Hospital in order to shift the focus of management on sustainability and ensure the protection of the environment while making ecologically appropriate choices and decisions.
Green Supply Chain Management and International Standards ISO 14001-2015 and ISO 9001-2015
The mass production of goods and the development of the service-oriented industries have led to the necessity of standardising their activities and measuring the quality of operations in order to guarantee addressing clients’ needs in most cases. The International Standardisation Association (ISA) was established in 1926, and this organisation became the predecessor of the organisation that is widely known today for its focus on providing guidelines and standards for operations in different types of industries. Thus, the International Organisation for Standardisation (ISO) was founded in 1946 in Brussels (Muzaimi, Chew & Hamid 2017; Stoimenova, Stoilova & Petrova 2014; Toprak & Şahin 2013). It began to develop as an international organisation oriented to the standardisation of manufacturing processes that was non-governmental in its character.
Standardisation covered by the ISO is applied in a variety of industries and firms, and exceptions are only related to such fields as electro-technical engineering and electrics which are regulated by other standards and norms (Chege 2012; Toprak & Şahin 2013). From this point, it is important to review the literature on the standards published by the ISO that are directly associated with the implementation of supply chains in different companies. The application of ISO 14001-2015 Environment Management and Occupational Health and Safety Management and ISO 9001-2015 Quality Management Systems – Requirements is discussed in the following sub-sections with reference to the recent literature on the topic within the context of the healthcare industry.
ISO 14001-2015 and Its Application in Organisations
The problem associated with achieving sustainability in hospitals and developing GSCs is based on the fact that organisations usually have direct and indirect negative influences on the environment, and they need to be overcome. These direct and indirect negative impacts are related to suppliers’ inputs and associated waste at different stages of the cycle that need to be controlled (Chege 2012). ISO 14001-2015 Environment Management and Occupational Health and Safety Management was developed by the International Organisation for Standardisation in the 1990s for the purpose of improving environmental practices in all industries, without exception.
This standard belonging to the family of ISO 14001 controls the environmentally friendly management with reference to supply chain processes, and the current version of the standard was published in 2015 (International Organisation for Standardisation 2015). According to the ISO 14001-2015 norms, the impact on the natural environment is “any change in the environment, whether adverse or beneficial, wholly or partially resulting from an organisation’s activities, products or services,” as it is noted by Olsthoorn et al. (cited in Laari 2016, p. 43). This impact should be minimised while applying ISO 14001 to production and services.
The application of ISO 14000 allows an organisation to follow a certain system in addressing the environmental dimension related to sustainability. When following the norms prescribed by ISO 14001-2015, different types of organisations, including healthcare facilities, can address the international norms regarding the ecological character of their activities, improve their environmental performance, and contribute to achieving sustainability in operations (International Organisation for Standardisation 2015). It is important to note that there are no determined criteria in order to regulate the environmental performance of organisations that allows for applying this standard in different contexts.
From this perspective, ISO 14001-2015 is typically applied by those organisations and firms that plan to improve their operations in terms of their impact on the environment. The ISO14001-2015 certification allows for reconsidering environmental practices followed in the company in order to achieve better outcomes for the environment. What is more important is that accreditation is not a requirement for adopting ISO14001-2015 when companies choose to develop environmental management systems in a holistic manner (International Organisation for Standardisation 2015). Therefore, while focusing on waste management, eliminating air and soil pollution, and guaranteeing the efficient use of sources, organisations follow ISO14001-2015 principles in the most appropriate manner for them, and they become interested in the continual improvement of their environmentally friendly practices, as it is in the case of creating sustainable supply chains.
ISO 9001-2015 and Its Application in Organisations
The quality management in organisations is an additional issue that affects the creation of an effective working supply chain. The International Organisation for Standardisation published the ISO 9000 family of guidelines in order to contribute to developing the most effective quality management strategies in organisations. In this family of standards, ISO 9001-2015 Quality Management Systems – Requirements is applied in order to establish an appropriate working quality management system according to the international principles of quality assurance in different types of organisations (International Organisation for Standardisation n.d.). According to Kovac (2014), ISO 9001-2015 is applied when firms are oriented to implementing a quality management system and proposing specific services and products that can address clients’ needs. However, it is also important to note that, in its nature, the ISO 9001-2015 standard was not developed to assess the quality of offered products, and the key focus is on proposing a set of principles according to which it is possible to organise systematised operations that are of high quality.
From this perspective, ISO 9001-2015 can be viewed as rather generalised because of possibilities to apply it in various organisations which operations and activities differ significantly. This idea is supported by Kovac (2014, p. 670) who states that the ISO 9001-2015 certification should be viewed as “a generic standard that defines certain requirements for the quality management system which are applicable to all organisations, regardless of their type and scope, and consequently to healthcare organisations as well.” This standard in the ISO 9000 family requires certification and accreditation, and this aspect contributes to following its norms by firms in the most accurate manner (International Organisation for Standardisation n.d.). The latest version of this standard is ISO 9001-2015:2015 that is correlated with the recent tendencies in the sphere of measuring the quality management in an organisation (International Organisation for Standardisation n.d.). Thus, this certification is important to be considered while discussing approaches to developing efficient supply chains as successfully working systems.
In spite of the fact that the application of the ISO 9001-2015 certification in organisations is associated with significant positive changes in business processes with the focus on the increased efficiency, researchers still note that many companies face certain challenges when new quality management systems are implemented. The problem is that changes in quality management are associated with alterations in operations and increased workloads, some of the processes are revised, and more innovations are integrated (Muzaimi, Chew & Hamid 2017; Stoimenova, Stoilova & Petrova 2014). Furthermore, the application of these systems according to the ISO 9001-2015 standard also requires the involvement of trained auditors. Earlier researches had identified the lack of these specialists in the sphere (Toprak & Şahin 2013). Still, even if the applied quality management system that operates according to the principles of the ISO 9001-2015 certification is not perfect, and more improvements are required, managers’ report increases in levels of satisfaction with provided services, as it is stated by researchers.
ISO 14001-2015 and ISO 9001-2015 in Healthcare
Researchers agree that the work of supply chains in organisations should be based on the ISO certification system in terms of regulating the impact on the environment in order to guarantee the effective control over a firm’s operations and outputs (Chege 2012; Liu et al. 2017). Moreover, according to Moradi et al. (2016), in hospitals, it is expected that managers adopt different types of ISO standards to address all possible issues associated with the quality of services and products and sustainability of operations. Chege (2012) stated that, in order to implement the ISO 14001-2015 standard in the most efficient manner, it is necessary to apply it in an organisation in the context of the followed environmental policy. As a result, it is possible to expect that a new effective environmental management system will successfully work in a healthcare facility under such conditions to address patients’ needs.
The high quality of delivered care is a priority for healthcare organisations, and governments, authorities, and stakeholders are focused on demanding the provision of superior care while using limited resources, appropriately applying public funding, and demonstrating transparency and accountability in relation to operations in hospitals. In this context, modern hospitals experience the pressure associated with the necessity of guaranteeing quality and realising the principles of accountability (Kovac 2014). Therefore, authorities recommend healthcare facilities to apply innovative and effective quality management systems according to the ISO 9001-2015 standard. Earlier, ISO standards provided recommendations regarding technical specifications of processes in different types of industries, including the service sector (Stoimenova, Stoilova & Petrova 2014). Later, ISO standards became applicable to the healthcare industry to ensure that the quality of provided care and services is high and safety of clients is guaranteed.
The application of ISO 9001-2015 in the healthcare industry is a challenging process that is widely researched by experts. The ISO 9001-2015 standard prescribes organisations how to arrange, document, integrate, maintain, and assess a specific quality management system applied in this or that firm. However, it is important to note that requirements listed in ISO 9001-2015 are widely applicable in their nature. Therefore, this standard is adopted in the majority of firms regardless of their sphere or activities, including hospitals (International Organisation for Standardisation n.d.). This standard is also reported by Kovac (2014, p. 674) as “the most widely used international standard that sets the requirements for the establishment and maintenance of quality management systems, and is applicable to all types of organisations (profit/non-profit, product/service, small/medium/large).” Thus, if an organisation, and a hospital in particular, starts the process of reforming its supply chain to make it more sustainable and integrated, the application of the 9001-2015 ISO certification is viewed as a reasonable step on this path.
Researchers reported the tendency of implementing quality management systems in hospitals all over the globe because of the necessity to increase the quality of services, address patients’ needs, and prevent medical errors. These tasks should be viewed as critical for healthcare organisations. When quality management systems are adopted in healthcare facilities with reference to ISO 9001-2015, leaders or administrators receive many opportunities to address all possible insufficiencies in processes, improve provided services, regulate controlling and monitoring processes, and prevent or decrease all possible damages while following requirements and guidelines. According to Turkyilmaz, Bulak, and Zaim (2015, p. 1), “to achieve service excellence, hospitals must strive for zero defects and retain every customer that the company can profitably serve.” In order to reach these goals, efficient supply chains based on effective quality management are required.
Researchers support the idea that certification is usually chosen by organisations in the context of their activities oriented to building GSCs because this approach allows for the continuous improvement of operations, determination of certain stages to follow, and customer satisfaction because of the improved quality of services. According to Toprak and Şahin (2013, p. 111), “a health institution accredited with quality assurance certificate not only gains the trust of the public, but also improves the service performance at individual and institutional level thanks to increased cooperation among different units of the institution.” As a result, it is possible to expect that all key operations in a hospital associated with the quality of services and environmental protection are regulated and effectively maintained based on these standards, contributing to the development of a GSC.
ISO 14001-2015 and ISO 9001-2015 in Australian Hospitals
The focus on ISO standards guarantees not only the improvement of quality associated with products and services but also cost savings for companies. Furthermore, the perceived quality of services also increases if clients and other stakeholders know that an organisation follows ISO standards (Chege 2012). Managers oriented to implementing ISO 14001-2015 and ISO 9001-2015 in hospitals expect that they will receive significant benefits associated with improving the quality of products and reducing a negative impact on the environment in the context of creating efficient supply chains. This situation is also typical of Australian hospitals where ISO 14001-2015 and ISO 9001-2015 are followed in the majority of public healthcare facilities (The Royal Australian College of General Practitioners 2015). The reason is that, if a hospital adopts ISO standards, its leaders can expect some benefits, including increases in efficiency, high productivity levels, higher employee satisfaction, improved quality of products and services, reduced costs, and as a result, increased revenues.
In the literature on supply chains in Australia, there are a few mentions of possible applications of ISO 14001-2015 and ISO 9001-2015 in this context. Still, researchers report the importance of following certification in the context of public and private hospitals, as well as other organisations (Australian Government 2016; The Royal Australian College of General Practitioners 2015). As it is mentioned by Stoimenova, Stoilova, and Petrova (2014, p. 373) in their article, the ISO 9001-2015 standard, for instance, “is utilised in a variety of ways as a vehicle for health care organisations to identify systemic breakdowns and close gaps, streamline workflow and maximise resource utilisation,” and moreover, it is used to “focus on patient and provider needs and expectations, facilitate compliance to health care accreditation standards and regulatory requirements, etc.” Therefore, the application of standards oriented to improving environmental and quality management systems in Australian hospitals can be viewed as an appropriate choice for healthcare organisations where the quality of services and protection of a community’s interests, including environmental ones, are the priorities.
To guarantee that a supply chain in an Australian hospital develops as a green one, the application of ISO 14001-2015 is expected in order to determine and follow specific requirements regarding environmentally friendly processes and operations typical of healthcare settings. Researchers also pay attention to the fact that the development of a supply chain is associated with integrating a quality management system, and its work is expected to be regulated by ISO 9001-2015 (Muzaimi, Chew & Hamid 2017; Toprak & Şahin 2013). Focusing on building strong and efficient supply chains in hospitals, leaders need to start the accreditation and certification process. In the context of Australia, the reference to ISO 14001-2015 and ISO 9001-2015 is supported at national, state, and local levels (Australian Government 2016). Researchers also note that the provision of the ISO certificate does not mean stopping the development process, and an organisation is expected to be accredited every three years while having the space for progress and expanding sustainable supply networks (Chege 2012; Kovac 2014). For Australian hospitals, it is important to refer to standards for environmentally friendly operations and improve quality while building supply chains.
ISO 14001-2015 and ISO 9001-2015 in Turkish Hospitals
In Turkish hospitals, the application of ISO 14001-2015 and ISO 9001-2015 is a widely followed modern trend because this approach guarantees positive changes in healthcare operations and processes in order to address clients’ needs and expectations (Özkan, Akyürek & Toygar 2016; Toprak & Şahin 2013). For instance, according to Toprak and Şahin (2013, p. 114), in Turkey, “while in 2006, the number of the Health of Ministry hospitals with ISO 9000:2000 and the ISO 9001-2015:2000 certification was 68, this number increased to 112 in 2008.” Later, positive changes in the tendency were also observed because of identifying obvious benefits in improving quality management systems in correlation with the recommendations provided by ISO 9001-2015.
The similar situation can be noticed with reference to the implementation of the principles of ISO 14001-2015 in Turkish hospitals. This practice is directly associated with the establishment of new principles of creating GSCs. The development of sustainable networks to regulate operations in hospitals depends on the adoption of certain national policies proposed by the Turkish authorities at different levels (Erus & Hatipoglu 2013). However, the application of ISO 14001-2015 as the key standard to regulate the work of environmental management systems is essential for this context because concrete actions of suppliers and partners in hospital chains need to be strictly regulated to achieve higher results and decrease negative influences on the environment.
It is also important to pay attention to the fact that, in Turkey, hospitals became interested in applying the quality certification in the 1990s, but the process was rather slow. Today, the focus of healthcare organisations on using certification is more obvious, and the compliance with requirements promoted according to ISO -2015 and ISO 9001-2015. As identified in the earlier application of the standards, the compliance allows healthcare organisations to respond to clients’ needs, minimise errors, conduct regular assessments, and monitor all possible strengths and weaknesses in processes (Muzaimi, Chew & Hamid 2017; Polater, Bektas & Demirdogen 2014; Vincente et al. 2015). Thus, as it is noted by Toprak and Şahin (2013, p. 112), “the quality certificate, which is the proof of improved performance contributes to the second-party audits and customers’ higher perception of quality.” The level of trust to the hospital that has successfully applied ISO 14001-2015 and ISO 9001-2015 can increase while leading to positive changes in financial gains.
From this perspective, the literature indicates that Turkish hospitals receive many benefits while referring to the ISO standards. As it is noted by Stoimenova, Stoilova, and Petrova (2014) and Muzaimi, Chew, and Hamid (2017), leaders in healthcare organisations become able to plan operations with reference to internal and external environments and ensure controlling all processes associated with caring for patients. They also receive tools in order to decrease the number of medical errors and patient complaints and guarantee the most efficient use of available resources with reference to the principles of reverse logistics among others (De Vries & Huijsman 2011; Stoimenova, Stoilova & Petrova 2014). As a result of applying the ISO standards, hospitals seem to change all processes that were typical of them previously in the context of ensuring high quality of services and sustainability.
Researchers note as a result of their studies and reviews of available literature that immediate positive outcomes can be observed after implementing supply chains with the dependence on ISO 14001-2015 and ISO 9001-2015 (Muzaimi, Chew & Hamid 2017; Polater, Bektas & Demirdogen 2014). A logical consequence associated with this process is the increase in patients’ satisfaction and trust, and revenues in the healthcare industry can also rise significantly. According to Toprak and Şahin (2013, p. 112), in a hospital following the ISO standards, “it is known how the process will be handled, and thanks to monitoring individuals within the process, their strengths and weaknesses are identified and thus, it becomes possible to assign the right task to the right person.” These processes contribute to the active integration of ISO 14001-2015 and ISO 9001-2015 not only into Turkish hospital supply chains but also into healthcare industries all around the world.
Depending on the type of research questions formulated for this study and the researcher’s expectations and assumptions, it is possible to state that pragmatism is a paradigm that is more appropriate for the study. A pragmatist paradigm combines the features of both positivism and interpretivism that allows for using this paradigm when conducting mixed methods studies that include quantitative and qualitative methods (Creswell & Poth 2017). The key quality of a pragmatist philosophy is that its proponents are oriented towards finding direct solutions to practical issues and problems in the world around without focusing on the nature of knowledge or truth, as it is typical of other paradigms (Bryman & Bell 2015; Creswell & Poth 2017). Thus, applying a pragmatist perspective, a researcher is interested in examining practical aspects and consequences of certain studied processes and phenomena.
In this study, the main focus is on identifying and analysing the major practical aspects, as well as benefits and risks, of greening supply chains in the healthcare sector with reference to two different national contexts. As such, pragmatism is more suitable to the purpose than any of ontology, epistemology, realism, or either of positivism and interpretivism alone. Referring to pragmatism, the researcher gets an opportunity to concentrate on collecting both numeric and narrative data for further analysis (Domínguez & Hollstein 2014; Neuman 2014). These advantages of pragmatism allow for selecting this paradigm as suitable for this study.
In this study, the focus on the pragmatist paradigm explains the choice of the approach that can combine the features of both deductive and inductive reasoning. This type of applying both principles to examining the phenomenon is known as abductive reasoning, and it is selected as the key approach for this study (Edmonds & Kennedy 2017). According to Bryman and Bell (2015, p. 27), “Abduction involves the researcher selecting the ‘best’ explanation from competing explanations or interpretations of the data,” and “this is related to the philosophical idea of the ‘hermeneutic circle,’ through which understanding is seen as a continuous dialogue between the data and the researcher’s preunderstandings.” The nature of the formulated research questions and the aim of the research explain the necessity of using the assumptions typical of inductive and deductive approaches in order to use different methods for examining the issue under discussion.
As a result, while referring to the idea of intersubjectivity typical for the combination of inductive and deductive approaches, it is possible to state that abductive reasoning allows for testing certain assumptions from both theoretical and empirical perspectives (Bryman & Bell 2015). Applying the combination of deductive and inductive approaches in the form of abductive reasoning, the researcher in this study receives an opportunity to examine the problem from different sides, without selecting this or that approach. Moreover, the researcher overcomes the limitations associated with using the other discussed approaches.
In order to address the research questions and purpose of this study, it is necessary to apply the research design, according to which it is possible to answer questions requiring the analysis of both qualitative and quantitative data. Therefore, the application of both descriptive and exploratory research designs is reasonable for this study (Edmonds & Kennedy 2017). The causal design is less relevant, as no experiments will be conducted in the course of this study. The principles of the descriptive design are important to be implemented in order to work with quantitative data to explain factual benefits and weaknesses of selecting and integrating GSC in hospitals of Australia and Turkey. The principles of the exploratory research design should be used to collect and evaluate qualitative data in order to examine the problem from the perspective of participants involved in implementing GSC in the healthcare sector (Domínguez & Hollstein 2014). Thus, the rules typical of a convergent parallel design need to be applied to this study (Creswell 2014; Creswell & Poth 2017). In this case, the collection and analysis of quantitative and qualitative data are realised not sequentially but independently.
For this study, mixed methods research is selected as the most appropriate option to address the set research questions. The reason is that the mixed methods methodology provides a researcher with a variety of approaches and techniques to choose from in order to conduct the high-quality research that will not be limited by the approaches typical of only qualitative or only quantitative methods (Domínguez & Hollstein 2014; Edmonds & Kennedy 2017). This study is aimed at determining possible benefits and risks associated with implementing GSC in hospitals of Australia and Turkey with the focus on possible similarities and differences in these countries’ experiences. The complex character of this purpose supports the idea that only the combination of qualitative and quantitative methods can help a researcher to collect appropriate data for analysis to conclude regarding the experience of the Australian and Turkish healthcare systems in greening supply chains.
The provided research questions can be effectively answered only with reference to collecting both quantitative and qualitative data for further analysis. The financial data explaining the establishment of GSC in hospitals can be successfully analysed with reference to the principles of descriptive research and the quantitative method (Jason & Glenwick 2016; Pelto 2015). On the contrary, ideas and views of managers implementing green supply management principles, administrators in hospitals, and the personnel should also be taken into account, and the qualitative methodology allows for collecting this information (Merriam & Tisdell 2016; Pelto 2015). Views regarding possible advantages or challenges associated with greening supply chains in healthcare systems of two different countries can be collected with the help of interviews. As a result, focusing on the mixed methods methodology, the researcher receives more opportunities to examine the situation with greening supply chains in Australia and Turkey from objective and subjective perspectives to make accurate and relevant conclusions.
Sampling: The Selected Case and Setting in Australia
For the purpose of this research, an Australian hospital located in Victoria, was selected as an Australian public hospital to be included in this study. This hospital is one of the largest public healthcare facilities not only in Melbourne, Victoria, but also around Australia. This hospital was established in 1848, and today it belongs to one of the healthcare hospital groups in the region. The Australian hospital has the reputation of a healthcare facility, the leaders of which are oriented towards adopting the latest technologies and applying the most innovative approaches to their practice. Furthermore, the hospital has developed an effective program oriented towards greening their operations and improving waste management and achieved certain successes in designing and IGSC. The examination of the experience of this hospital in implementing SCM is important in the context of this case study research.
The Selected Case and Setting in Turkey
Derindere Hospital (Hastane Derindere) is located in Kagithane province, Turkey, and it is one of the leading private hospitals in the country that has operated in the region since 2015. The hospital is famous for paying attention to clinical research and implementing innovative methods and practices to deliver care. Moreover, the hospital has received ISO 9001 and ISO 14001 certifications, and it has experience in improving its SCM and waste management to address global standards (Derindere Hospital 2020). This particular experience needs to be studied and explained in the context of this selective case study.
This section presents the information on the procedures used to receive the participants’ informed consent and protect their confidentiality and privacy. According to Hancock and Algozzine (2016, p. 47), “the researcher must adhere to legal and ethical requirements for all research involving people. Interviewees should not be deceived and must be protected from any form of mental, physical, or emotional injury.” Thus, the aspects of using an informed consent form are described in detail. Approaches to resolving the issue of confidentiality in this study are discussed in the second sub-section in order to guarantee that all ethical concerns are addressed without violating the interests of the participants involved in the study. The approval of the administration of the hospitals in Australia and Turkey was required for conducting this research to involve the employees as participants in this study. To recruit the participants, the researcher contacted the administrators at both organisations via email using formal letters to request and receive their approval for organising the study based on their data and involving employees as participants.
In order to protect participants’ privacy and guarantee their psychological comfort, it is important to focus on the concept of confidentiality and how it works in the context of this study. Those personal data that are used in this study for collecting qualitative information should be secured and presented in this study only as confidential answers to interview questions (Kumar 2014; Mertens 2014). The researcher ensures that all information that can be used for indicating participants is removed from records, and personal information is concealed. These procedures are required in order to avoid the situation of violating subjects’ confidentiality and disclosing their private information. The participants should be informed that their names and identities are de-identified, and confidentiality is protected in the context of the study.
In the context of this study, the researcher keeps the names of participants and other personal data confidential while preparing records of interview sessions and transcribing them. In order to distinguish between participants, ID numbers are assigned to subjects, and they are used for marking records and narratives. The researcher is the only person who knows the names and contacts of subjects invited to participate in the study that are reflected in informed consent forms. This information is kept secret and secured by the researcher, and the access to the data which can be used for identifying participants is restricted.
The participants’ agreement to join the study with the focus on its specific conditions and purpose is known as informed consent. Potential participants selected with the help of purposive sampling can be viewed as voluntarily deciding on being involved in the study, and informed consent forms reflect this decision (Bryman & Bell 2015). The selected respondents agreed to participate in interviews after receiving all the required information about the nature and purpose of this study by email from the administrators cooperating with the researcher in the two hospitals. They reviewed and signed the prepared informed consent form before being invited to participate in interview sessions and answer questions. In order to guarantee that the informed consent form can be effectively used for protecting participants’ interests, some type of information should be added to this form.
Thus, the provided informed consent forms had the following details: the study’s purpose and type, the description of collecting the information with the help of interviews and associated procedures, and the information about options for withdrawing at any stage of research. Additional details include the information about protecting participants’ confidentiality and anonymity and the statement indicating the voluntary participation in the study (Creswell & Poth 2017). It is important to note that the researcher started to conduct interviews with the invited participants only after receiving the signed informed consent forms from all subjects. As a result of applying the informed consent form, it is possible to address ethical questions while conducting the study and guarantee the protection of participants’ interests.
Quantitative Research Design
The purpose of this sub-section is to discuss how the quantitative methodology has been applied in this study. The focus of this sub-section is on presenting the specific variables to measure as well as data collection tools that have been selected for the research (Bryman & Bell 2015). Furthermore, much attention is paid to describing the data analysis procedure with the focus on the specific information collected with the help of quantitative techniques.
Constructs to Measure
The constructs to measure with the help of tools of the quantitative methodology are derived from the research questions formulated for the study. In order to understand what benefits and challenges are associated with implementing integrated GSCM in Australian and Turkish hospitals, it is necessary to evaluate these hospitals’ changes in financing supply chains, waste management, recycling, and the application of ISO 14001 and ISO 9001 certificates among other initiatives (Dadhich et al. 2015; Feng et al. 2017; Jayaram, Dixit & Motwani 2014). It is significant to collect numerical data and financial figures on changes in costs and revenues related to implementing GSC and changing waste management procedures and after the implementation, related to applying ISO 14001 and ISO 9001 standards, and related to the overall performance of the selected hospitals in terms of their sustainability. From this perspective, for the purpose of this study, it is necessary to empirically test how the implementation of integrated GSC and associated changes in waste management can affect the value related to the chosen hospitals.
Collection of Quantitative Data
The two hospitals have been contacted and provided the permission for including them in the study. For the purpose of this study, annual financial reports, financial documentation, documentation on the ISO standards and GSCM practices, and non-¬confidential documentation provided by the administration of the Australian hospital and Derindere Hospital and available in the hospital websites have been examined to retrieve the numerical data, figures, and charts on these healthcare facilities in terms of applying GSC. The key focus was on retrieving data on the expenses associated with implementing GSC (integrated chains) in the discussed hospitals, possible unexpected costs, and expenditures directly related to waste management practices. These quantitative data were collected with the help of reviewing hospitals’ annual reports and other financial documentation (electronic copies) provided by the managers in the selected Australian and Turkish hospitals, who are responsible for greening supply chains in their organisations.
The quantitative data collected with the help of reviewing hospitals’ financial documents have been analysed not in connection with the analysis of qualitative data, but simultaneously (Creswell 2014; Treiman 2014). The determined changes in the financial performance of hospitals before and after the implementation of IGSC have been compared and analysed for both hospitals located in different contexts of Australia and Turkey. Some types of financial performance have been evaluated with the focus on the operating performance, the accounts performance with the focus on actual financial data, and the environmental performance.
It was important to determine any changes in figures indicating hospitals’ financial performance in order to speak about possible advantages and disadvantages of integrating green supply chains in the healthcare sectors of two different national contexts. The comparison of financial performance indicators before and after implementing supply chains, as well as for Australian and Turkish hospitals, is important to address the set research questions. It is significant to note that the application of statistical analysis is also required for this research in order to present descriptive statistics regarding the findings associated with the numerical data provided in hospitals’ reports (Bryman & Bell 2015; Creswell 2014; Hamad et al. 2016).
In this study, it was important to compare financial performance figures before and after implementing GSC for hospitals in Australia and Turkey with a focus on changes in waste management. Moreover, it was necessary to compare changes in determined financial indicators for different healthcare settings in these two countries. Therefore, the analysis of quantitative data retrieved from the hospitals’ documentation was performed with reference to presenting descriptive statistics and charts regarding the observed changes in figures and ratios (Leavy 2017; Neuman 2014). These steps were important to conclude about the efficiency of developing IGSC in the healthcare sector.
While analysing the financial, operating, and environmental performance of the selected hospitals associated with the implementation of the principles of GSCM, it was important to calculate certain financial ratios as indicators. The following types of ratios were calculated: profitability ratios, liquidity ratios, debt management ratios, and asset management ratios (Feng et al. 2017; Jin, Jeong & Kim 2017). Profitability ratios include the profit margin (Net income/Sales), the return on equity (Net income/Common equity), and the return on assets (Net income/Total assets). These ratios help to estimate the profitability of hospitals as entities in spite of the fact that one of these hospitals belongs to the public sector.
Liquidity ratios calculated for this study include the current ratio (Current asset/Current liabilities), the cash ratio (Cash and equivalents/Current liabilities), and the quick ratio (Current asset + inventory/Current liabilities). Debt management ratios are the following ones: the total debt ratio (Total Debts/Total assets), the long-term debt ratio (Long-term liabilities/Long-term liabilities + Common equity), and the debt to equity (Debt/Common equity) (Feng et al. 2017; Jin, Jeong & Kim 2017). These ratios estimate an organisation’s debt.
Asset management ratios are important to be measured in the context of understanding how changes in supply chains could influence the organisation of assets and resources in the studied hospitals. These ratios include the receivables turnover ratio (Sales/Receivables) and the fixed assets turnover ratio (Sales/Fixed assets) (Feng et al. 2017; Jin, Jeong & Kim 2017). The focus on these financial indicators was important to determine possible changes in the selected hospitals’ profits depending on their experience in implementing supply chains with a particular interest in integrated supply chains.
Qualitative Research Design
This section represents the details of organising the qualitative component of the case study analysis. The focus is on describing the aspects of data collection and data analysis by means of specific qualitative tools. Moreover, in this section, much attention is paid to discussing protocols for semi-structured interviews that are adopted for this study in order to collect the required narrative information from the sample appropriate for this research.
While using the qualitative methodology, researchers collect data using such techniques as interviews, observations, and focus groups. These strategies are used with reference to the purpose of investigating a phenomenon or a situation from the perspective of participants who are directly involved in the studied processes. The participants’ perspective can be learned and reported when researchers conduct interviews and communicate with individuals having the specific experience regarding the problem under analysis (Miles, Huberman & Saldana 2014). The insider’s perspective can also be learned with the help of organising focus groups where several participants discuss their personal experiences in contrast to individual interview sessions (Creswell 2014; Leavy 2017). In addition, important data regarding the studied issue can be collected with the help observations that are conducted in a specially selected setting in order to provide a researcher with as much information as possible (Creswell & Poth 2017).
This section explains the choice of instruments and tools for collecting qualitative data with reference to conducting interviews. The first sub-section provides the justification for conducting interviews with the participants of the study in order to gather narratives regarding their experiences in implementing supply chains. The second sub-section presents the information on designing a specific interview protocol that has been used in this study in order to guide interview sessions and collect all the required information for analysing and responding to the research questions (Bryman & Bell 2015; Creswell & Poth 2017).
Justification for Conducting Interviews
While applying the qualitative methodology as the component of mixed methods research, the author of the study is oriented towards investigating, understanding, and explaining a certain phenomenon. As a result, the focus of a researcher is on collecting as much data on a certain issue as possible in order to develop in-depth meanings regarding the studied problem (Castillo-Montoya 2016). For this purpose, interviews are selected as a tool that allows a researcher to gather information on participants’ ideas, views, experiences, and beliefs associated with the studied phenomenon. These interviews are usually conducted in the form of one-to-one sessions (Alshenqeeti 2014). In order to address the purposes of their studies, researchers can choose from structured, semi-structured, and unstructured interviews that differ in terms of protocols that are used for organising interview sessions (Creswell & Poth 2017; Neuman 2014).
Structured interviews are based on preparing a list of questions to ask without focusing on differences in interviewees. These interviews are standardised, and they do not allow for collecting much information about respondents’ experiences. As a result, this type of interviews is not appropriate for this study. Unstructured interviews are not based on a certain framework or a set of questions, and interviewers ask questions following interviewees’ responses (Taylor, Bogdan & DeVault 2015). This type of an interview can provide a researcher with a lot of data that are not suitable to address a research question, and this aspect does not allow for using it in this particular study.
Semi-structured interviews are based on using the questions prepared in advance, but these questions are open-ended, reflecting the topic of the interview, and playing the role of probing questions that are used for developing an interview in a conversation on the studied topic. Thus, semi-structured variants of interviews “are carefully prepared lists of questions that stimulate each informant in a comparable way,” and the answers of respondents are unanticipated in this case (Domínguez & Hollstein 2014, p. 186). This type of interviews is selected for this study because the researcher received an opportunity to get answers to the prompts that can help in addressing the research questions, but he or she can remain flexible and ask additional questions if necessary (Edmonds & Kennedy 2017). Furthermore, the gathered information can be classified as valid in this case.
Designing an Interview Protocol
The process of designing a semi-structured interview protocol for this study included the following stages: the review of the literature and questionnaires used in other studies to select questions that are aligned with the research ones; the adaptation of the selected questions to this research and the formulation of original open-ended questions; editing and proofreading. At the first stage, it was important to review the literature on the topic to understand what models for formulating effective questions were used by other researchers (Cosimato & Troisi 2015; Dadhich et al. 2015). At the second stage, it was necessary to adapt the selected questions and formulate additional ones in order to guarantee that these questions are valid and can contribute to collecting data required for answering the set research questions. Open-ended questions written in English were proposed to receive full and descriptive answers regarding the issues mentioned in these inquiries. As a result, ten probing questions were formulated:
- What is your role or position in the hospital?
- What differences have you noticed regarding the implementation of GSCM? What management practices were changed?
- How are ISO 14001 and ISO 9001 standards applied in your organisation? How has the application of ISO 14001 and ISO 9001 changed the organisation’s performance?
- What policies provide the grounds for waste management strategies and practices followed in your organisation? Discuss their possible link with ISO 14001 and ISO 9001 standards.
- What waste management segregation and elimination procedures are applied in your organisation in the context of GSCM? Is there specific recycling, reusing or waste disposal practices used in the organisation?
- How is general, clinical, and recycled waste managed in your organisation according to the principles of GSCM? What differences in procedures and associated sustainability effects can you name and discuss?
- What can you tell about the possible correlation between waste generation, waste management, and the number of patients in your organisation? What trends have you noticed?
- How have waste management costs changed in your organisation after it focused on green and ISCM strategies and practices? Are there associated waste cost reductions or increases?
- How has operational and environmental performance changed after your organisation’s focus on modifying waste management procedures in the context of GSCM?
- What benefits and challenges are directly related to waste management strategies and procedures?
- Does the government have a position on greening in general? Does it have a position on GSC?
- Does it encourage adopting the UN conventions? Is it a central government, a regional or is it an individual hospital decision?
At the final stage of designing a protocol for a semi-structured interview, it was important to edit and proofread the questions to ensure that they are accurate. These questions need to be written in the language that can be easily understood by respondents. Furthermore, they should include details that can be discussed wider during a conversation with the focus on other additional questions. As a result, the proposed interview probing questions have the potential to be expanded during interview sessions depending on the participants’ answers.
Data Collection Procedure
In this study, the collection of qualitative data was based on conducting a series of interviews with six participants who are the representatives of two hospitals in Australia and Turkey selected as cases for this research. The invited participants work at different positions in hospitals (senior managers, administrators, medical workers), and they were directly involved in the process of integrating green supply chains in their healthcare facilities. As a result, these selected persons are able to describe their experiences in greening supply chains in the chosen hospitals in order to compare these narratives during the analysis. For the purpose of this study, the researcher prepared the protocols for semi-structured interviews and contacted the selected participants using their e-mail in order to discuss the date and time for conducting interviews.
To contact participants in different countries, it is appropriate to use online tools and mobile applications that allow for calling the participant. In this study, the researcher used Skype for making calls and conducting time-consuming interviews. Each interview was scheduled in advance and conducted separately, and interviews lasted from 45 to 60 minutes. It is advantageous for the researcher to conduct phone interviews using modern technologies and audio recording because of avoiding limitations regarding distance and time and receiving an opportunity to clarify different aspects in provided answers with respondents. The participants of the study were asked to answer several questions prepared in advance, and the researcher added more questions during an interview in order to get more details regarding the aspects mentioned by the participants. Interviews were recorded using technologies for making records of Skype calls, and these audio files were marked with certain ID numbers to avoid identifying participants’ personal information. The completed records were transcribed for the further analysis.
Data analysis in this study included such steps as the preparation of data for further examination with the help of transcribing records, the process of coding and theme identification with the help of NVivo software, and the analysis of determined themes to answer the research questions (Chowdhury 2015; Zamawe 2015). All the records were transcribed to get narratives appropriate for uploading to NVivo. This software allows researchers to import qualitative data into the platform and provide their analysis based on the principle of coding narrative information for identifying themes in collected in-depth answers to the proposed interview questions (Edwards-Jones 2014; Sotiriadou, Brouwers & Le 2014; Zamawe 2015).
Therefore, it is necessary to state that coding as a technique integrated for data analysis in NVivo software is important for studying and evaluating qualitative data. The reason is that codes that are assigned to data components are automatically examined and combined in larger clusters or themes (Edwards-Jones 2014; Sotiriadou, Brouwers & Le 2014). After conducting the automatic analysis, all the data are represented in the form of themes that should be organised by the researcher in concept maps or tables, as well as other illustrative materials (Saldaña 2016; Yin 2015). The purpose of this action is to understand what concepts are associated with participants’ views regarding the process of greening supply chains and improving waste management approaches and techniques in the selected hospitals of Australia and Turkey.
Validity and Reliability
In this mixed methods research, the questions of validity and reliability of the study are discussed from the perspectives of both qualitative and quantitative methodologies. Referring to the qualitative component of the study, the focus is on trustworthiness as the representation of validity (Neuman 2014). Thus, it is important to guarantee that the collected findings are worth discussing, and they can contribute to the existing research on the problem because of their accuracy. The organisation of the collection and analysis of qualitative data is realised according to the principles of dependability, credibility, transferability, and confirmability (Creswell & Poth 2017). As a result, much attention should be paid to the quality of interview protocols as an instrument for collecting data (Darawsheh 2014; Mann 2016). It is possible to speak about content validity in the case when collecting quantitative data and about credibility when focusing on gathering qualitative information.
Internal validity of the quantitative component of the study is guaranteed through the provision of the accurate analysis of collected financial data with the focus on calculating ratios and making relevant conclusions. In the context of the qualitative component, this aspect is associated with transferability of the received findings because of their accuracy (Leavy 2017). In addition, in this study, validity is also based on triangulation as an approach to improve the credibility of findings with the help of collecting and analysing both qualitative and quantitative data which is typical of the mixed methods research (Archibald 2016; Leavy 2017).
Reliability in the mixed methods research is applied to discussing the quantitative component, and the term “dependability” is associated with reliability of the qualitative component. Referring to these concepts, it is important to guarantee that this study can be replicated with the same results because of depending on the analysis of stable financial data (Domínguez & Hollstein 2014). Still, while focusing on the qualitative component, it is necessary to state that identical results cannot be expected and achieved, and it is necessary to guarantee the dependability of data (Neuman 2014; Reio & Werner 2017). Thus, it means that the collected findings remain unchanged and stable without depending on changes in conditions on when and how the participants’ narratives were gathered.
Overall, the study aims to address questions of both the reasons for the adoption of GSCM practices and ISO 9001-2015 and ISO 14001-2015 compliance and their effectiveness. As such, a mixed design in terms of both the research paradigm and the research methodology appears to be the most appropriate. With that said, it is important to note the drawbacks of the design chosen, particularly in terms of the specifics. The sample size is relatively small at only one hospital for each nation, which can exclude critical context such as the situation on the national level. Moreover, the study is characterised by its high complexity with a number of mixed approaches, which introduces the potential for bias. As such, they will be taken into consideration and addressed in later sections.
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