Abstract
BACKGROUND: Environmental sustainability is an increasingly critical priority for healthcare systems due to their substantial environmental impact and vulnerability to climate-related challenges. Yet, its integration within healthcare organizations remains inconsistent and poorly documented. This study investigates the level of awareness, the degree of implementation, and the extent of operationalization of environmental sustainability activities in healthcare organizations. It also identifies the main barriers and drivers influencing this process. METHODS: A semi-structured survey was developed based on Rogers' Diffusion of Innovations framework and the NHS England Green Plan model. It was administered to Italian healthcare organizations affiliated with the Italian Federation of Healthcare and Hospital Organizations. The survey was complemented by a desk analysis of strategic documents. The lack of explicit national policy on environmental sustainability in healthcare offered a neutral context to examine organizational approaches, motivations, and challenges in the absence of centralized guidance. RESULTS: The survey achieved a 23% response rate, with 39 organizations from 14 regions participating. A high level of awareness among healthcare leadership was observed, with 97% of respondents reporting that environmental sustainability was recognized as a strategic concern. However, only 41% of organizations had formalized sustainability commitments in strategic documents. Despite this, 90% reported having undertaken at least one concrete action, indicating that operational engagement often precedes formal strategic planning. The analysis also revealed a positive association between the number of sustainability domains addressed and the number of actions implemented, suggesting that broader engagement supports more structured implementation. CONCLUSIONS: The findings suggest that organizations do not necessarily follow a linear or formalized pathway in adopting environmental sustainability practices. Instead, implementation often emerges from pragmatic and context-driven processes, even in the absence of strategic codification. This behavior reflects both the adaptability and the limitations of decentralized action, with risks of fragmentation and uneven progress. A national strategy-supported by standardized indicators, reporting systems, and financial incentives-could strengthen alignment, enhance scalability, and support healthcare organizations in embedding sustainability more systematically, while preserving flexibility for local innovation.