sustainability

Article
The Healthcare Sustainable Supply Chain 4.0:
The Circular Economy Transition Conceptual
Framework with the Corporate Social
Responsibility Mirror
Gláucya Daú 1, * , Annibal Scavarda 2 , Luiz Felipe Scavarda 3 and
Vivianne Julianelli Taveira Portugal 3
1 Health Economic and Technological Evaluation Laboratory, Federal University of the State of Rio de Janeiro,
UNIRIO 22290-180, Brazil
2 Production Engineering School, Federal University of the State of Rio de Janeiro, UNIRIO 22290-240, Brazil;
[email protected]
3 Industrial Engineering Department, Pontifical Catholic University of Rio de Janeiro, PUC-Rio 22451-000,
Brazil; [email protected] (L.F.S.); [email protected] (V.J.T.P.)
* Correspondence: [email protected]; Tel.: +55-21-97202-8136




Received: 2 May 2019; Accepted: 6 June 2019; Published: 13 June 2019


Abstract: Concern regarding the circular economy and Industry 4.0 is starting to increase in the
emerging countries. This research study aims to analyze the healthcare sustainable supply chain
4.0 by proposing the circular economy transition conceptual framework with the corporate social
responsibility mirror. The authors developed an observation guideline to collect empirical data from
a private healthcare institution located in Rio de Janeiro, which has been promoting investment
in new technologies within its operations. The research observation is between January and April
2017. The results show the glass structure can be a channel that provides the lightning resources,
the solar energy with the photovoltaic panels, and the water management. The corporate social
responsibility links the social role in healthcare institutions with sustainable practices and it improves
smart technologies. The applicability of the internet of things and the internet of services adds value
to sustainable practices. The circular economy transition conceptual framework integrates the result
analyses. The research concludes that the union among the triple bottom line, Industry 4.0, and the
corporate social responsibility allows the transition from the linear model to the circular model and
can improve the sustainable healthcare supply chain 4.0.

Keywords: circular economy; industry 4.0; corporate social responsibility; healthcare; sustainable
supply chain; transition conceptual framework

1. Introduction
The circular economy concept, discussed in many studies [1–3], allows the identification of the
opportunities from the fourth industrial revolution and sustainable practices [4,5]. Industry 4.0 inserted
disruptive technologies and it can be present in the circular economy. The Internet of Things (IoT) and
the Internet of Services (IoS) are some of the examples of these disruptive technologies. The triple
bottom line (environment, society, and economy) leads to the 3R concept of the recreate, the recycle,
and the reuse [6]. The aim to transform the linear concept in a circular one is reinforced, allowing a
wider sense of motion to the process by changing it into a cycle. Ranta et al. [7] affirm that sustainable
practices are alternatives for the transition between the two economy concepts. This cycle enables the

Sustainability 2019, 11, 3259; doi:10.3390/su11123259 www.mdpi.com/journal/sustainability

Sustainability 2019, 11, 3259 2 of 19

possibility to have the reverse process, delivering a product that is transformed either to the supplier
as to the consumer. Therefore, it means to affirm that this cycle absorbs and enables reverse logistics.
The Sustainable Development Goals (SDGs) are parts of the commitment that many countries must
keep. In 2015 the United Nations (UN) [8] established the 17 SDGs: No Poverty; Zero Hunger; Good
Health and Well-Being; Quality Education; Gender Equality; Clean Water and Sanitation; Affordable and
Clean Energy; Decent Work and Economic Growth; Industry, Innovation, and Infrastructure; Reduced
Inequalities; Sustainable Cities and Communities; Responsible Consumption and Production; Climate
Action; Life Below Water; Life on Land; Peace, Justice, and Strong Institutions; and Partnership for the
Goals. The SDGs are challenges that promote a positive impact on the countries and their populations.
In 2017 more than half of the world population lived in the urban areas and by 2050 this
number should increase into two thirds. The urbanization is totally connected to social and economic
developments [9]. The International Energy Agency [10] presents on the Energy Efficiency 2018
Analysis and Outlooks to 2040 that the use of the efficient energy impacts on the triple bottom line.
According to UN standards, electric energy is delivered to 13% of the world population, considering it
as a factor for climate changes. The UN affirms that this contribution represents around 60% of gas
emissions and sharing of renewable energy in final energy consumed has reached 17. 5% in 2015.
The global movement brings the insertion of the circular economy and the fourth industrial
revolution to the routine of the global population. The concern towards the world population increases
also the perspectives for the implementation of the circular economy concept. This concept allows
the reuse [11] the repair, and the recondition of the products. Some solutions offered by companies
like the Product Service System (PSS) seek to meet customer satisfaction, the needs presented by
the market, and the concerns about the environmental aspect of sustainability [12], as well as the
social and economic aspects [13]. Among the contributions offered in Ardolino et al. [14] are the
implementation and the role of the IoT, of the Cloud Computing (CC), and of the Predictive Analytics
(PA). This implementation promotes the role of these technologies in the transformation of services.
The implementation of the circular economy in the fourth industrial revolution brings opportunities
and challenges in the economic transformation scenario for many emerging countries like Brazil.
Corporate Social Responsibility (CSR) can help and can accelerate this implementation, allowing the
development of the companies. Some literature gaps are presented as the supply chain and its residues
for biomass production [15]. These authors propose a methodology for the waste biomass projection.
The main objective of this research is to analyze the healthcare sustainable supply chain 4.0 and to
propose the circular economy transition conceptual framework searching for the implementation of the
healthcare sustainable supply chain. Therefore, the authors motivated by the concern that reaches the
whole world establish the following three questions: Does the supply chain from the circular economy
perspective attend the requirements of the sustainable supply chain? How does Industry 4.0 influence
the circular supply chain? What are the expected results with CSR implementation in the sustainable
supply chain?
The research study proposes a way for the adoption of the measures that allow the insertion
of the transition conceptual framework for achieving the healthcare sustainable supply chain 4.0.
The measures result in the alignment with CSR and enhance the image of the healthcare institutional
brand. The ethical principles can be observed, since they must support initiatives in any social segments.
Industry 4.0 and sustainable practices can be integrated and are capable of bringing contributions to the
market through strengthening quality programs. These applications allow competitiveness through
the offer of new products and better services. The natural resource management, as well as the natural
resource use, will be covered in this research study, in addition to the disruptive technologies brought
by Industry 4.0. Moreover, conceptualizing the term sustainability, its broad meaning in healthcare
institutions is related to the environment, society, and the economy. The integration between the
circular economy and Industry 4.0 for creating the sustainable supply chain searches to produce a
model to disseminate these practices through CSR. This research reinforces the circular economy in
Industry 4.0 applied in the healthcare supply chain with CSR use.
Sustainability 2019, 11, 3259 3 of 19

The research study is structured in a way to present the “Theoretical Background” after the
Introduction, aiming to bring the recent publishing related to the items discussed. In the “Materials
and Methods” Section, it is possible to see the data collection development and the study scenario
characterization. The “Results” Section shows through its three subsections the models that compose
the framework basis. These models are also presented in the “Discussion” Section together with “CSR
improving the efficient natural resource use” and “sustainable practices and smart technologies.”
Finally, the Conclusions offer the contributions of the authors of this paper, as well as the limitations
found throughout this research study.

2. Theoretical Background
The Theoretical Background Section is organized into four subsections: “Industry 4.0,” “The Supply
chain sustainability and Corporate social responsibility,” “The Circular economy,” and “The Healthcare
supply chain 4.0.”

2.1. Industry 4.0

Industry 4.0 is a concept that encompasses automation and information technology, besides some
of the main technological innovations of these fields [16]. According to Luthra and Mangla [17],
Industry 4.0 initiatives help industries to incorporate actions for the environmental protection and
control, besides mitigating the risks of the supply chain, turning them into sustainable supply chains.
A sustainable supply chain aims to project, to plan, and to operate supply chains that may guarantee
the market needs, taking into consideration not only the profits, but also the environmental and social
concerns [18]. For instance, the IoT use can bring benefits simultaneously in all dimensions of the triple
bottom line [19].
The sustainable development and the circular economy are parallel issues that may affect the
competitiveness of the companies. However, this systemic transition requires the development of
the Information and Communication Technology (ICT), like the IoT [5], besides the participation and
commitment of those involved in the process. Industry 4.0 provides a robust warehouse, information
and communication systems, assisting management, potentially reducing costs, and increasing
customer satisfaction [20]. According to Stock et al. [21], Industry 4.0 implementation results on the
creation of the potential industrial value focused on sustainable development. Stock et al. [21] highlight
a better integration and inclusion of these contributors, the increased value added to work, and a more
targeted and qualified education of the employees, besides contributing for the harmony between
professional and family life as benefits under the social dimension scope.
The sustainable supply chain, and simultaneously 4.0, can be defined as the supply chain that uses
Industry 4.0 tools in order to close the material and energy cycles, besides helping the information flow
and the activities, turning the operations more efficient, more intelligent, more precise, and quicker.
Kovacs [22] reinforces the educational aspects for human resource development, creating skills, and the
knowledge to deal with the digital economy. These educational aspects promote the fourth industrial
revolution changes on the productions and on the organizations [23]. The positive impact of the digital
technologies, provided by Industry 4.0, is perceived as the digital technologies lead to improve the
supply chain performance.

2.2. The Supply Chain Sustainability and Corporate Social Responsibility

Due to the technological leap coming from the fourth industrial revolution, it is fundamental
for the companies and their contributors to be prepared to deal with the changes imposed on their
daily routines [24]. According to Gruchmann et al. [25], the consumer can be insensitive to sustainable
practices because current communication is insufficient to diffuse them between them. Therefore, CSR
can work as a bridge between the social responsibility goals of the institutions and the implementation
of sustainable practices and smart technologies [26].
Sustainability 2019, 11, 3259 4 of 19

The healthcare institutions have already absorbed CSR favoring the democratizing of sustainable
practices and establishing accessibility to other healthcare institutions. Democratization can be
approached as the universalization of the opportunities [27]. The healthcare institutions can voluntarily
have adopted CSR bringing a positive contribution to society. The regulatory, ethical, and social
responsibility aspects support CSR use [26,28].
CSR use corroborates and strengthens the healthcare institutional brand in project development.
The ethical principles are part of the institution’s philosophy and are currently a reason for great pride
and enormous differential. Many institutions have already established these practices, but it needs
for broadening and showcasing them [29]. The social responsibility of healthcare institutions is also
supported by its commitment to the sustainable global goals. These global goals enable to influence
the common good of the world population. Sustainable practices, when inserted into CSR use, favor
the link with the social responsibilities of healthcare institutions, which choose this path of working.

2.3. The Circular Economy

With the population growth and urbanization, many sectors of the global market are attentive to
a number of challenges, including food security, energy scarcity, and water safety [30]. Many parts of
society that may have its attention focused on sustainable strategies. These applications add value to
the economy and bring some thought over the ethics concepts, the awareness, and the transformation
of the social environment. The transition from the linear to the circular concepts provides opportunities
to manage waste production [5].
The world discussions around climate changes and the need to speed the implementation of
sustainable practices have stimulated the authors of the present research. Maalouf and El-Fadel [31]
propose a framework involving gas emissions (CO2, CH4, and N2O), residue management, and
emission ways (direct and indirect). They also observe that the landfill takes the first position regarding
gas emission and reinforce recycling as an essential practice for the reduction of this emission. Chen and
Xiang [32] approach carbon dioxide emissions by evaluation of the cost reduction. Gallagher et al. [33]
and Balaman et al. [15] present the concern about climate change and greenhouses gas emissions.
Jabbour et al. [34] found out that decision making regarding the management of sustainable
operations implies a connection between the circular economy approach and Industry 4.0 principles.
It based on the conceptual approach of sustainable operations management and to implement
organizational strategies based on the circular economy principles.

2.4. The Healthcare Supply Chain 4.0

The management of the sustainable healthcare supply chain involves information, supply,
suppliers, service providers, internal and external customers, and end users [35]. Economic
sustainability can be perceived by the objective of the cost control, moving and offering goods
and services in a timeline that starts with the supplier and ends with the end user, integrating the
processes [36]. The experiences of the industrial area are welcomed by the healthcare supply chain and,
in addition, disruptive technologies, like those already mentioned, facilitate the work of healthcare
institutions. As a result, healthcare institutions, by bringing the disruptive technologies together in
their supply chains, opens avenues to be paved with the fourth industrial revolution, to be called the
healthcare supply chain 4.0. The healthcare supply chain 4.0 brings together, in addition to Industry
4.0 technologies, sustainable practices. This union presented by Stock [21] brings the SDGs to the fore,
allowing contributions to the implementation of UN Agenda 2030.

3. Materials and Methods

The research is exploratory, consistent with the emerging field of the topic [37,38]. An empirical
study was conducted, consisting of “knowledge based on real world observations or experiment”
used “to describe field-based research which uses data gathered from naturally occurring situations
or experiments” [39] (p. 251). It served as a primary source of the information through filed visits
Sustainability 2019, 11, 3259 5 of 19

for direct observation. There was no direct intervention or participation from the researchers with
the object of study, as would happen with action research [40,41]. The research observation period
was developed from January to April 2017 in the private healthcare institution. The observational
guideline used is provided in Figure 1 and was guided by the research questions provided in the
introduction of this paper and on the theoretical background (with part of it adapted from Thomé
et al. [42]). The healthcare institution is located in the Rio de Janeiro City and counts with around
250 beds and 11 operation rooms (from which one is hybrid). The hybrid room aims to attend the
surgical teams on its procedures that may need the use of the image simultaneously to surgical features.
The sample selection was conducted base on its conceptual representativeness, as opposed to sampling
selection for large populations [42]. The healthcare institution in which the study was developed
promotes investment on the implementation of the new technologies, like the traceability of healthcare
products and the electronic registration of the information about the patients, for example, in order
to bring agility and safety to the processes. The research analyzes the healthcare sustainable supply
chain 4.0 through the circular economy transition conceptual framework with the corporate social
responsibility mirror. The focus is the private healthcare institution building located in countries
called “developing countries.” The authors of this research study understand, through the observation
during working activities in healthcare institutions, that many opportunities are presented. These
opportunities involve: The creation and the implementation of the green structure in the healthcare
building and healthcare institutions can contribute to reaching the UN goals.
The observation period made it possible to rethink the hospital structure and to analyze the
insertion of the new elements into the physical structure and the work environment. The insertion of
the circular economy and the disruptive technologies of the fourth industrial revolution was the object
of this look during the observation period. Based on this observation, three models were selected:
The first model concerns the use of the natural light with the use of the glasses controlled by disruptive
technology; the second model is also related to the reduction of electric energy consumption, but taking
a look at the use of this energy also during the night; and the third model emphasizes the water and
the waste management. Industry 4.0 tools can control these managements.
For each proposed model, four supply chain dimensions are presented: “The time
dimension,” “the infrastructure dimension,” the cost dimension,” and “the institutional dimension.”
These dimensions were structured to draw attention to the research questions. At “the time dimension”
the concern is about: The time impact, the acceleration or the expansion, the products processing, the
well-being of the supply chain professionals, and the economic benefits for healthcare institutions.
“The infrastructure dimension” considers the physical structure influence in the healthcare supply
chain and its impact for each proposed model. “The cost dimension” is reflected in all the other
dimensions. This dimension searches to promote a cost reduction with a positive impact, considering
the maintenance and process quality improvement. Finally, “the institutional dimension” involves the
healthcare institution role and is considered the legal aspects for the implementation. CSR and SDG
contributions are applicable for all the dimensions presented in the observation guideline.
CSR can be a guidance for the implementation of sustainable practices [43]. This green structure
contributes the UN goals, mainly with: The affordable and clean energy; the climate action; the decent
work and economic growth; the good health and well-being; and also with: Industry, innovation, and
infrastructure; partnerships for the goals; and sustainable cities and communities. This green structure
reinforces that the SDGs are not isolated, but are integrated between themselves. This integration,
which establishes a connection with the SDGs, is healthy and independent in many cases. Through
a holistic and positive approach, this connection may be highlighted that this interaction creates an
increasing movement and it raises the level of many goals at the same time. It allows to accelerate the
process for 2030 and to reach the aims established by the UN.
Sustainability2019,
Sustainability 2019,11,
11,3259
x FOR PEER REVIEW 6 of6 19
of 19

Figure 1. The
Figure 1. The observation
observation guideline.
guideline.
Sustainability 2019, 11, 3259 7 of 19

The literature review about the circular economy and Industry 4.0 was without any time restrictions.
The purpose of this literature review can help the authors to establish the correlation between the
circular economy and Industry 4.0 concepts. The selection of these journal papers has also the following
inclusion criteria: Journal papers in English, with Digital Objective Identifier (DOI), and with a
peer-reviewed journal. The choice of only considering peer-reviewed journals is consistent with
many authors of the literature as a strategy to maximize quality papers in the sample (e.g., [44,45]).
The selection searched the terms: “Circular economy AND Industry 4.0,” “circular economy AND
digital,” “circular economy AND smart,” “circular economy AND technology,” “circular economy
AND technologies” in the title. The search included more than two different databases, following the
suggestion offered in Thomé et al. [46] for literature reviews. Therefore, following Science Publishers
where chosen: Cross Mark, Elsevier, Emerald Insight, MDPI, Springer, Taylor and Francis Group, and
Willey Online.

4. Results
The world concern regarding climate changes enables innovating thoughts for the insertion of
smart and sustainable technologies in healthcare institutions. These insertions may be aligned to the
physical structure and the healthcare supply chain. On the present research study, the authors have
chosen the use of glass as wall structure, the inclusion of the photovoltaic panels, and the water and
waste management. Industry 4.0 applications controlled the insertions mentioned, allow stimulating
the efficient use of energy, the temperature, the lighting, and the reduction of the residues production.
Sun et al. [47] refer to modeling with the approach of the ecological benefits, the circular economy
practices, and the industrial applications. The research provides the development of the eco-industry
in China.

4.1. Lighting Resources: Glass Structures and Solar Energy

The healthcare institutions can have high energy consumption and the possibility of adopting the
use of solar energy is a path. This high energy consumption can be justified by the use of artificial
lighting and of the equipment during the day and the night. The intensive care, surgical center, and
central sterilization sterile supply units are examples of the high energy consumption, due to the
amount and kind of equipment used. This kind of consumption is highlighted and its energy is
directed to the ambiance lighting.
The efficient use of solar energy for the ambiance lighting can be one of the resources used
in order to reduce energy waste. This is one of the concerns of the UN and the subject of the
studies [48,49]. The glass offers a number of the options for the construction business, the possibility
of the efficient use of daylight, as well as visual comfort. It can be used in walls, providing natural
lighting during the day and saving energy of healthcare institutions. Besides natural lighting, glass
provides comfort for the professionals whose responsibility is to deal with complex supply chain and
repetitive actions, especially in institutions located in green areas, and those which visual is comforting
for the healthcare professionals.
Pao and Chen [50] refer to an interdependence character among the environmental, energy, and
the economy for global growth, strengthening the environment protection. Therefore, it would bring
energy conservation policies, the sustainable use of energy, and the dissociation of the environmental
pressure from economic growth.
The glass walls bring thermal balance in the urban areas, where the temperatures are normally
high. Another possibility would be glass walls and green roofs in order to reduce the temperature
inside healthcare institutions. In cities where the violence rates are high, it might be considered to
use armored glass. It allows the healthcare professional staff and the safety of the patients in extreme
situations. For the healthcare buildings vertical and horizontal structures, it is also an option regarding
privacy, in addition to every aspect previously mentioned. This evaluation is also appropriate for the
case of the healthcare institutions that have many buildings around them. Pombo et al. [51] assess
 The glass walls bring thermal balance in the urban areas, where the temperatures are normally
high. Another possibility would be glass walls and green roofs in order to reduce the temperature
inside healthcare institutions. In cities where the violence rates are high, it might be considered to
use armored glass. It allows the healthcare professional staff and the safety of the patients in extreme
situations. For 11,
Sustainability 2019, the3259
healthcare buildings vertical and horizontal structures, it is also an option 8 of 19
regarding privacy, in addition to every aspect previously mentioned. This evaluation is also
appropriate for the case of the healthcare institutions that have many buildings around them. Pombo
the
et al.environmental perspective andperspective
[51] assess the environmental its impactsand
on its
their study.onAmong
impacts theseAmong
their study. impacts, the impacts,
these demand
energy reduction, the increase of the building material, and the potential increase of
the demand energy reduction, the increase of the building material, and the potential increase of global warming
can bewarming
global listed. can be listed.

4.2. Energy
4.2. EnergyResources:
Resources:Photovoltaic
PhotovoltaicPanels
Panelsand
andSolar
SolarEnergy
Energy
The concern
The concerntowards
towardsenergy
energyobtaining through
obtaining renewable
through sources
renewable and theand
sources natural
the means
naturalenables
meansa
discussion
enables around thearound
a discussion physical structure
the physicalof structure
the healthcare
of theunits. A holistic
healthcare view
units. A from the view
holistic administrators,
from the
the engineers, and the architects is a good opportunity to rethink energy obtaining.
administrators, the engineers, and the architects is a good opportunity to rethink energy Theobtaining.
search to
implement
The theimplement
search to use of the the
photovoltaic
use of thepanels guarantees
photovoltaic thatguarantees
panels solar energythatis solar
captured
energyduring the day,
is captured
collecting enough energy to support the night shift and with low sun exposure
during the day, collecting enough energy to support the night shift and with low sun exposure [52,53]. The energy
storage would supply the lighting and cooling systems (Figure 2).
[52,53]. The energy storage would supply the lighting and cooling systems (Figure 2).

Figure
Figure 2.
2. The
Thestructure
structureto
toimplement
implementthe
thephotovoltaic
photovoltaicpanels.
panels.

The Urban
The Urban Agenda
Agenda for for the
the European
European Union
Union [54]
[54] establishes
establishes an an energy
energy transition
transition onon itsits priority
priority
list. This
list. Thispriority
prioritylist
listaims
aimsthe
thelong-term
long-termchange
changefrom
fromthethecurrent
currentenergy
energysupply
supplyto torenewable
renewableenergyenergy
through efficient
through efficientenergy.
energy.The Thestudy made
study by Chen
made and Xiang
by Chen and [32] highlights
Xiang that Chinathat
[32] highlights is responsible
China is
for a huge amount
responsible of energy
for a huge amount useof and carbon
energy use dioxide
and carbonemission.
dioxide This level ofThis
emission. consumption is one of the
level of consumption
concerns
is of the
one of the Chineseofgovernment
concerns the Chinesethat provides athat
government stimulus for the
provides reductionfor
a stimulus of the
the reduction
current rates of and
the
the use rates
current of efficient
and theenergy.
use of efficient energy.
Brazil,
Brazil, an
an emerging
emerging country,
country, still
still moves
moves shyly
shyly through
through the the insertion
insertion of of this
this kind
kind of of energy
energy inin
healthcare
healthcare institutions.
institutions. Martins
Martinsetetal.al.[55]
[55]point
pointonontheir
their study
study that
that Brazil
Brazil has
has plenty
plenty of of the
the potential
potential
to
to apply
apply photovoltaic
photovoltaic energy
energy systems.
systems. ThisThiskind
kindofofenergy
energyisisoneone of
of the
the most
most viable
viable and
and renewable
renewable
technologies
technologies available.
available. They
Theyreinforce
reinforcethatthatBrazil
Brazilisisaa potential
potential country
country to to apply
apply this
this energy
energy useuse
because
because of thethe solar
solarresources
resourcesavailable
available andand worship
worship thethe applicability
applicability of itof
in itthe
inurban
the urban
area. area. For
For Chile,
Chile, the promotion
the promotion of renewable
of renewable energy energy
aims to aims
reach to reach
a 20% a 20%
rate rate of production
of production by 2025. Among by 2025. Among
renewable
renewable energy
energy sources aresources are the photovoltaic,
the photovoltaic, the concentrated
the concentrated solarand
solar power, power,
the and the industrial
industrial heat
heat supply
supply plants [56].
plants [56].
The research led by Zhang et al. [57] presents growth taxes on many kinds of renewable energy
from 2013 to 2016. In order of the growth taxes, it is possible to mention: Hydropower, wind power,
solar photovoltaic, biomass energy, geothermal energy, and solar thermal power. The study made by
Wang and Lin [58] shows the concern with energy consumption and the points out that its use per
capita in China is relatively low, in comparison to other countries. Tziogas et al. [59] make a critical
analysis and reveal that sustainability and energy security are two broadly expanding research areas.
Sustainability 2019, 11, 3259 9 of 19

Rafique et al. [60] affirm that the electrification and the unit rate of the electricity are important points
for social and economic development.
The foreign direct investment in China brings the progress of the technologies and the impacts
on the efficient use of electric energy. This is one of the topics presented in the study developed by
Xin-gang et al. [61]. The same authors analyze the impact of the foreign production by the direct
investment on the host country production factors, like: The capital, the labor, the management
experience and the innovation, the knowledge, and the technology.

4.3. Water Resources: Waste Management

The water is a natural resource that enables the generation of electric energy, the urban supply
for daily use, and is also a base element that makes the hard technologies use possible. In healthcare
institutions, it is possible to see it in these three moments, in which the last one can be exemplified by
the water used in the electric stream generators and the boilers.
The water has its official day on March 22nd. This concern is presented by 2017 World Water
Development Report, through the United Nations, Educational, Scientific, and Cultural Organizational
Director-General Irina Bokova report [62]. The Director-General reinforces the management of the
water residues treatment in order to reduce pollution, to remove contaminant agents, allowing its
reuse, as well as to improve the social acceptance for the use of the treated water as a strategic move
towards the future. The water pollution is widely discussed by researchers [63,64], who search for
evidence for the contaminant’s removal.
In healthcare institutions, factors like the size, the equipment, and the specializations attended
might be different, and it influences directly the water consumption. The management of the
water residues might involve rainwater [65,66] for toilets reuse, likewise the possibility of choosing
equipment with low water consumption for example. The reuse must be in accordance with the
technical regulations like the Brazilian Standard National Association 15527 [67]. Other strategies,
like internal campaigns for the correct use of common taps and its replacement by those activated
by sensors are also worthy. In the central sterilization sterile supply unit, the processing of products
management may provide huge water saving with the safe optimization of the sterilizing cycles.
Therefore, the implementation of the new studies and the new technologies that might enhance the
treatment of reused water brings the possibility to reach the proposal of the UN 2030 Agenda, with the
full participation of healthcare institutions.
Another relevant aspect to be considered, besides the conscious use of energy, is the proper
use of the water. A matter of full attention should be supported by the triple bottom line with the
implementation of simple measures. In 2018, the Itaipu Hydroelectric, a Binational power plant
(Brazil and Paraguay) [68], has received the United Nations members for the workshop. The theme
was the 17 goals for sustainable development and among the 17 goals, the aims “the clean water
and sanitization” and “the affordable and clean energy” were highlighted. Tseng et al. [4] reinforce
the academic popularity of the term green supply chain since the beginning of the 20th century.
The authors show the top fifteen countries by publications (China, United States, United Kingdom,
India, Taiwan, Iran, Canada, Brazil, Italy, Malaysia, Denmark, France, Germany, Netherlands, and
Hong Kong).
The traditional model of healthcare institutions has been establishing buildings that use a lot
of brickwork and a few uses of sunlight. Natural resources are underestimated and some units are
located underground healthcare institutions. A transitional framework proposes the exchange of the
traditional model by the rational use of natural resources through the implementation of the circular
economy in Industry 4.0. The use of a green area outside joining the landscaping techniques help the
sustainable structure of the building and blend with the inside area. The presence of the photovoltaic
panels structured for energy storage in amounts enough to supply the lighting systems during the night
and the cooling day and night systems allow a relevant impact both on economic and environmental
Sustainability 2019, 11, x FOR PEER REVIEW 10 of 19

sustainable structure of the building and blend with the inside area. The presence of the photovoltaic
panels structured
Sustainability for energy
2019, 11, 3259 storage in amounts enough to supply the lighting systems during the
10 of 19
night and the cooling day and night systems allow a relevant impact both on economic and
environmental aspects. The water management can be improving in healthcare institutions. The
aspects. The water
holistic view management
and the educationalcanprograms
be improving
wheninimplemented
healthcare institutions. Themanagement
can help this holistic view and the
(Figure
educational
3). programs when implemented can help this management (Figure 3).

Figure 3.
Figure 3. The integration among the glass, the photovoltaic panel, and water management.

5. Discussion
5. Discussion
This
This section
section presents
presents two
two subsections: “CSR improving
subsections: “CSR improving thethe efficient
efficient natural
natural resource
resource use”
use” and
and
“sustainable
“sustainable practices
practices and
and smart
smart technologies.”
technologies.” CSR
CSR insertion
insertion related
related to
to the
the efficient
efficient use
use of
of natural
natural
resources
resources allows
allows the
the establishment
establishment ofof aa connection
connection between
between the
the results
results and
and the
the questions
questions that guided
that guided
the present research study.
the present research study.

5.1. CSR Improving

5.1. CSR Improving thethe Efficient
Efficient Natural
Natural Resource
Resource Use
Use
The
The healthcare institutions should
healthcare institutions should exceed
exceed its
its role
role regarding
regarding primary,
primary, secondary,
secondary, and and tertiary
tertiary
attention
attention towards the population health as a whole. This activity exceeds the common assistance
towards the population health as a whole. This activity exceeds the common assistance
principle
principle andandshould
should embrace
embrace the the
global challenges
global and opportunities
challenges in a holistic
and opportunities in a view. By analyzing
holistic view. By
these topics through a macro vision, they can be brought to the reality of the healthcare
analyzing these topics through a macro vision, they can be brought to the reality of the healthcare institution itself,
by means of the action and sharing experiences that enable the expansion of these
institution itself, by means of the action and sharing experiences that enable the expansion of these actions, its success
and attempts.
actions, its success and attempts.
Bringing
Bringing the the social
social dimension
dimension of of this
this responsibility
responsibility inside
inside healthcare
healthcare institutions
institutions along
along thethe
environmental and economic expectations creates a healthy wave made
environmental and economic expectations creates a healthy wave made by a chain of the actions.by a chain of the actions.
The
The ethical
ethical aspects
aspects that
that surround
surroundthisthistheme
themeallow
allowfor
fora aconscious
consciousawareness
awareness ininorder
orderto to
realize
realizehowhowto
contribute, to participate, and to strength movements in accordance with global
to contribute, to participate, and to strength movements in accordance with global sustainability. sustainability.
In
In order
order to to organize
organize thethe development
development of of “CSR
“CSR improving
improving the the efficient
efficient natural
natural resource
resource use”
use”
subsection, the authors of this research study have divided it into three subsections:
subsection, the authors of this research study have divided it into three subsections: “Glass “Glass resources,”
“photovoltaic panels,” andpanels,”
resources,” “photovoltaic “water management.”
and “water management.”
5.1.1. Glass Resources
5.1.1. Glass Resources
The utilization of glass as a mean to use natural resources, in addition to the comfort of the people
The utilization of glass as a mean to use natural resources, in addition to the comfort of the
and the professional setting should also be considered. Another aspect of the outdoors landscaping
people and the professional setting should also be considered. Another aspect of the outdoors
is the possibility to have pauses in a pleasant site while at work. The integration of the physical
landscaping is the possibility to have pauses in a pleasant site while at work. The integration of the
building and the green areas allows a more kind temperature. The Association for the Advancement
physical building and the green areas allows a more kind temperature. The Association for the
of Medical Instrumentation ST79 [69] affirms that the healthcare products processing unit should
Advancement of Medical Instrumentation ST79 [69] affirms that the healthcare products processing
follow the Engineering Society of North America (IES) guidelines. This association establishes specific
unit should follow the Engineering Society of North America (IES) guidelines. This association
categories for each activity developed on its units, including age range. CSR might influence the
establishes specific categories for each activity developed on its units, including age range. CSR
decision making of healthcare institutions, starting with the architectural project itself. The next
might influence the decision making of healthcare institutions, starting with the architectural project
subsection, “the photovoltaic panels”, explains the photovoltaic panels and it establishes the same
itself. The next subsection, “the photovoltaic panels”, explains the photovoltaic panels and it
approach for the efficient natural resource use.
establishes the same approach for the efficient natural resource use.
Sustainability 2019, 11, 3259 11 of 19

5.1.2. Photovoltaic Panels

The photovoltaic panel is a possible alternative to this study, but there might be other conscious uses
of natural resources, like wind power. Many cities have the potential to apply this technology to energy
storage. By using natural resources, the emission of carbon dioxide might be reduced. This structure
needs to be rethought and structured by healthcare institutions that are under construction and by
those that are being reformed and restructured. The purpose of the corporative awareness should not
be established inside the healthcare institution, but should exceed the corporative boundaries and
create a stimulus chain towards other institutions.
An approach on analysis and reduction of the cumulative energy demand of the product service
system is made on Glatt et al. [70] study identify the relevant changes on product service system for
the cumulative energy demand. These changes were assembled in technical (an increase of machine
performance and efficiency increase by retrofit) and organizational (request provocative maintenance
and training for employee). With the use of natural energy, emissions of the greenhouse gases are
also reduced, thus, promoting possibilities to create a healthier environment and reduce poverty [71].
In addition to the photovoltaic panels, the authors of this research study also have the concern about
the water management.

5.1.3. Water Management

The other application use of sustainable resources are the educational programs for the conscious
use of the water, by establishing intern protocols for hand washing, the setting of the sensors in
toilet taps and on hand washing station of the surgical centers. The establishment of a careful look
towards the possibilities of the water reuse allows opportunities of sustainable conscience and CSR.
CSR promotes responsibilities for the triple bottom line and ethical aspects. The promotion of the
responsibilities enables the healthcare institution to solidify its brand and its image, as well as to the
professional that works in the institution, to promote sustainable practices in personal life.
The third resource is shown in this study, water management, allows the reuse of the pluvial
waters, but also the development of an educational program to control the use of these resources.
The programs bring the healthcare staff and the institution a great help. The involvement enables
conscious awareness and the replication of the practices in the domestic environment and it exceeds to
the community.
At the end of this subsection, the authors propose the following hypotheses. These are a
suggestion for future researches and a contribution to reinforcing new strategies for achieves the
healthcare sustainable supply chain 4.0:
Hypotheses A:

Hypothesis A1. Faced with the opportunities and the challenges associated with implementing the circular
economy guidelines of Industry 4.0, CSR can contribute by integrating people and the environment with the
SDGs of the institutions.

Hypothesis A2. CSR can contribute to healthcare institutions with implementing the social and ethical aspects
in order to bring the ergonomic ambiance for the employees.

Hypothesis A3. The healthcare institutions role can allow other healthcare institutions to implement sustainable
practices based on sharing experiences.

Hypothesis A4. Sustainable practices can modify the actual healthcare institutional physical structure.

Hypothesis A5. The healthcare institutions can improve their budgets with sustainable practice implementation.
Sustainability 2019, 11, 3259 12 of 19

5.2. Sustainable Practices and Smart Technologies

On the fourth industrial revolution era, the IoT enables the integration and the use of some
technologies, like glasses with sensors. The decrease on energy consumerism, the visual and thermic
comfort for healthcare staff, patients, and their families, allows the use and the storage of natural
resources and to inform and copy these actions in the social context. Opoku [72] concludes that
biodiversity is enhanced through sustainable practice applications. The promotion of biodiversity can
create possibilities to reinforce some points: The planet adaptation to climate change, the improving of
the air quality, and the well-being of the population.
In order to organize the development of “sustainable practices and smart technologies” subsection,
the authors of this research study have divided it into three subsections: “Glass resources and
smart technologies,” “photovoltaic and smart technologies,” and “water management and smart
technologies.”

5.2.1. Glass Resources and Smart Technologies

The integration between the IoT and the IoS creates value through the disruption, providing a new
paradigm, and supports the conceptual change of the production chain, that is, through the insertion
of the digital technologies in the supply chain [73]. This conceptual change can be extrapolated,
reflected, and adapted to the healthcare supply chain, especially in those areas where the production
of healthcare products is adopted at healthcare institutions.
Through this integration between IoT and IoS, the adoption of glass as a resource has a relevant
aspect to be considered. The incidence of the daylight straight on the glass walls, which would demand
a very efficient air conditioning system. The cities like Rio de Janeiro, where the temperature can
easily reach 104◦ Fahrenheit, in these circumstances, the use of smart and sustainable technologies
would be a solution. Lighting and temperature control make through the sensors. These sensors
capture the light and temperature intensity over glassy materials and automatically send a message for
the structures to adjust heat and lighting. The lighting control of the glasses by sensors that inform
how much lighting can be reduced and how much heat should be blocked. Regarding environmental
lighting, as previously mentioned, intensity control devices located on the walls of each unit allow for
the control the amount of light needed.
The lighting adjustment should base its structure on the kind of activity to be performed in
each building of healthcare institutions. The hospitalization area with patients resting is a good
example. It would be feasible to have a panel with some basic commands like “rest,” “ambulation,”
and “assistance.” These commands would apply respectively when the patient is resting (dim lights),
when it is necessary to go to the toilet and walk around the room (moderate lights), and when the staff
is performing any kind of assistance (full lights on). The next subsection, “the photovoltaic and smart
technologies,” shows the photovoltaic opportunities in addition to glass resources.

5.2.2. Photovoltaic and Smart Technologies

In addition to this concern, the proper use of natural resources and the use of disruptive
technologies inserted by the fourth industrial revolution enable to implement sustainable projects
and the cost reduction. Jannati and Nazarpour [74] approach a model to attempt the environmental
and economic dimensions for electric vehicles parking lots on a recent study. The photovoltaic
panels are presented as one of the alternatives for these parking spaces. Comparing the parking
spaces to healthcare institutions, the use of these panels brings benefits for environmental, social, and
economic aspects.
The IoT brings development for the healthcare institution daily routine, since it is integrated into
the construction process, as well as the restructuring of the projects and the processes. In this sense,
the IoT helps to lead sustainable practices, endorsing the connection with the triple bottom line and
disruptive technologies [75]. It is important to highlight that both concepts allow the circular economy
Sustainability 2019, 11, 3259 13 of 19

to perform its goals on this supply chain, allowing the transformation, the recycling [76], and the
reusing [11]. Bradley et al. [77] propose a model that determines the placement of the resources in a
closed recovering system, which is, recycling, reducing, and reusing on its study. They also mention
the innovation and the green decision making on this process. In order to stimulate the green decision
making, “water management and smart technologies” presents the water concern.

5.2.3. Water Management and Smart Technologies

On healthcare institutions day by day, some actions have a significant impact on the economy with
the implementation of simple measures. These measures, as closing the taps during some processes
and the maintenance of those activated by the sensors, represent a significant change. The reuse of the
water, in case of the toilets, is applied and tends to increase even more, by getting new users of this
practice. The water resource and the wastewater treatment are some aspects discussed in Abu-Ghunmi
et al. research [78].
The use of the sensors is another resource widely used in many buildings around the city, and
which can be implemented on a larger scale, in possible the healthcare institution sites. Likewise,
healthcare institutions management of the water use integrated into the IoT (the sensors, the software,
and the people). This integration allows the opening of the pluvial water reservoirs, placed in safe
locations with the aim of capturing and storing rainwater. In this case, the water from this reservoir
would not pass by the roofs and the floor. The sensors might help the opening of slots in wells to receive
pluvial water. The reuse of the wastewater in the urban areas is discussed by Marteleira et al. [79].
The implementation of the new work routines and proposals requires a cultural and behavioral
change. As an example, it is common, in the surgical center unit, the professionals to leave the tap
open while washing hands before surgical procedures when the device is a common tap, forgetting to
close it by the end of the hygiene process. It is estimated that this procedure lasts from two to five
minutes using common taps. On the other hand, when the sensors system is placed, the tap is open
only while necessary, reducing water waste.
The authors bring as a contribution to further research study the following hypotheses. These
hypotheses are a way to future researches and provide a reflection about sustainable practices together
with disruptive technologies:
Hypotheses B:

Hypothesis B1. Sustainable practices, strengthened by the circular economy, together with disruptive
technologies, can help healthcare institutions to contribute to enhancing the SDGs.

Hypothesis B2. Smart technologies, when implemented with sustainable practices, can allow the time and cost
reductions and can enhance CSR and the healthcare institutional brand.

Hypothesis B3. The healthcare institutions can positively impact society by influencing and sharing their
practices in order to achieve the SDGs.

Hypothesis B4. The healthcare institutions can offer educational support to their employees in order for the
employees to be able to use smart technologies.

Hypothesis B5. The employees of healthcare institutions can try to adapt and to understand smart technologies
in order to improve their careers.

The circular economy transitions conceptual framework with the corporate social
responsibility mirror.
The integration between the circular economy and Industry 4.0 allows the management and the
implementation of the actions. This integration aims the optimization of natural energy use, sustainable
resources, and water management inside the healthcare institution. The IoT, inserted on the healthcare
Sustainability 2019, 11, 3259 14 of 19

unit project, establishes the connection for adjustments and better use of natural resources. As an
example, the use of the sensors in glass walls to control the daylight incidence, being previously
programed to receive and control the intensity of solar energy, enabling the smart use and the comfort
of it. The pellicles put on glasses could perform the same function, but its main goal would be to
Sustainability 2019, 11, x FOR PEER REVIEW 14 of 19
reduce the temperature inside the rooms with lower heat absorption. The IoT also has the role to
spread
on howsustainable
to use natural practices. The wisely,
resources apps that guide
like free employees
flow of theand thewhile
water local community
showering and on how to use
doing the
natural resources wisely, like free flow of the water while showering and doing
dishes, collecting of rainwater to be used as toilet flushing. These are a stimulus to make and to the dishes, collecting of
rainwater
spread these to be used as in
practices toilet
theflushing.
community. These Thearesites
a stimulus to make
and social and toprofiles
network spread these practices
may also informin
the community. The sites and social network profiles may also inform about
about new practices done by the healthcare institution. It allows the elevation of the brand and the new practices done by
the healthcare
ethical pattern,institution.
enabling theItcommunity
allows the elevation
to see, andofrealize
the brand andhealthcare
that the the ethicalinstitution
pattern, enabling the
as an acting
community
partner on the to contexts
see, and in realize
which that
theytheare
healthcare
located. institution as an acting partner on the contexts in
which they are located.
Regarding the staff, online games and training sessions can be elaborated in order to provide
betterRegarding
connectivity theon staff, online games
sustainability andand training
Industry 4.0.sessions can be
The internal elaborated
disclosure in order
of the actionstocreates
provide a
better
sense of value and pride from the professionals, since they are part of a company with ethicala
connectivity on sustainability and Industry 4.0. The internal disclosure of the actions creates
sense of value
concepts and pride
and global from
vision. the is
This professionals,
some of CSRsince role they are
and it part
can of a company
create withreflects
a mirror that ethical the
concepts
good
and global for
examples vision.
otherThishealthcare
is some of CSR role and itFigure
institutions. can create a mirror the
4 presents that circular
reflects the good examples
economy for
transition
other healthcare institutions. Figure 4 presents the circular economy
conceptual framework, which highlights how CSR and smart technologies implement the transition conceptual framework,
which highlights
responsible natural how CSR and
resource use.smart technologies implement the responsible natural resource use.

Figure 4.4.The
Figure circular
The economy
circular transition
economy conceptual
transition framework
conceptual with the corporate
framework with thesocial responsibility
corporate social
mirror.
responsibility mirror.
6. Conclusions
6. Conclusions
This research study has presented the importance of the social responsibility for the sustainability
in theThis research
healthcare study
supply has aspresented
chain, well as has the importance
shown of the technologies
how disruptive social responsibility for the
can contribute to
sustainability in the healthcare supply chain, as well as has shown how disruptive
the achievement of the SDGs in the triple bottom line. The linear concept goes through changes that technologies can
contribute
allow to theof
the reach achievement
the circularofconcept.
the SDGs in the
What triplenext
comes bottomis aline. The of
concept linear
the concept
resource’sgoes through
extraction,
changes that allow the reach of the circular concept. What comes next is a concept
as previously shown here by natural resources, like solar energy and water. The integration between the of the resource’s
extraction,
triple bottomasline previously
and Industry shown here by
4.0 allows natural resources,
the transition like concept
from the linear solar energy and water.
to the circular economyThe
integration between the triple bottom line and Industry 4.0 allows the
concept. The production and the generation of the material used, its use, its return to the residue transition from the linear
concept to and
condition, the circular economy concept.
its transformation into anotherThe stage,
production and that
are cycles the generation
enable theirofreproductions
the material used,
as manyits
use, its return to the residue condition, and its transformation into another
times as possible. Because they are cycles, they might be transformed, reproduced, and recyclable. stage, are cycles that
enable
The their that
practices reproductions as many
are established times by
and shared asCSRpossible. Because
complete they are
the purposes forcycles, they might
the acceleration be
of the
transformed,
global movement reproduced,
towards the andreach
recyclable.
of the 17TheSDGspractices that are
established established
by the UN in 2015 and
forshared
the yearby2030.
CSR
complete the purposes for the acceleration of the global movement towards
The authors of this study established questions that guided the present research study, from thethe reach of the 17 SDGs
established
common by the
world UN in about
concern 2015 for the year 2030.
sustainable development. Does the supply chain from the circular
The authors of this study established questions
economy perspective attend the requirements of the sustainable that guidedsupply
the present
chain?research
How does study, from the
Industry 4.0
common world concern about sustainable development. Does the supply chain from the circular
economy perspective attend the requirements of the sustainable supply chain? How does Industry
4.0 influence the circular supply chain? What are the expected results with CSR implementation in
the sustainable supply chain?
In order to answer these questions, the authors propose the circular economy transition
Sustainability 2019, 11, 3259 15 of 19

influence the circular supply chain? What are the expected results with CSR implementation in the
sustainable supply chain?
In order to answer these questions, the authors propose the circular economy transition conceptual
framework with the corporate social responsibility mirror. The term transition was incorporated as a
way to characterize the change from the linear to the circular economy.
The rational use of natural resources by the putting of glass instead of brickwork enhances the use
of sunlight for environmental lighting. The fourth industrial revolution integrates this framework with
the sensors that allow the environmental lighting and heat control, to which pellicles could be used
in addition to the sensors. The triple bottom line brings up the environmental issues, as well as the
cost reduction and the staff comfort while at work on healthcare institutions. The social concern can
also be observed and attended, by the shielding of the hospital glasses, besides the privacy character
it brings to patients, its family members, and the healthcare staff. The solar energy stored in the
photovoltaic panels allows the reduction of the artificial lights through its storage for the day and night
use. The other point is the reuse of the pluvial water and the educational programs for the conscious
use of the water. The IoT and the IoS help by corroborating one more stage.
CSR allows the circularity of the healthcare supply chain. It enables sharing and replicability of the
practices so that other healthcare institutions may have it as a corporative example. After that, a new
supply chain takes place, the so-called healthcare sustainable supply chain 4.0, bringing circularity to the
process and contributing to reaching the global goals. New studies about the topic should be developed
and stimulated, especially due to the tendency that is already present on the current publishing.
The authors of this study seek to encourage new research involving the healthcare supply chains
with the insertion of sustainable practices and disruptive technologies. Additionally, a systematic
search in the literature of good practices of the social sustainability in the sustainable healthcare supply
chain is also recommended, as well as the positive effect analyses of these practices on the stakeholders’
quality of life. This study has limitations regarding the analysis of a single healthcare institution, which
also opens avenues for additional future research. More empirical studies should be conducted to
analyze the replicability of the proposed conceptual model in other healthcare real-life settings aiming
generalization of the research findings.

Author Contributions: Conceptualization, G.D., A.S., L.F.S., and V.J.T.P.; Methodology, G.D., A.S., L.F.S., and
V.J.T.P.; Project administration, G.D., A.S., L.F.S., and V.J.T.P.; Supervision, G.D., A.S., L.F.S., and V.J.T.P.; Validation,
G.D., A.S., L.F.S., and V.J.T.P.; Visualization, G.D., A.S., L.F.S., and V.J.T.P.; Writing—Original Draft, G.D., A.S.,
L.F.S., and V.J.T.P.; Writing—Review & Editing, G.D., A.S., L.F.S., and V.J.T.P.
Funding: This work was supported by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior—
Brazil—CAPES (Finance Code 001) and the Brazilian National Council for Scientific and Technological
Development—CNPq (Grant Number 311757/2018-9).
Acknowledgments: The authors would like to acknowledge the Health Economic and Technological Evaluation
Laboratory (HETEL) of the Federal University of the State of Rio de Janeiro, where they have developed
this research study. This work was supported by the Coordenação de Aperfeiçoamento de Pessoal de Nível
Superior—Brazil—CAPES (Finance Code 001) and the Brazilian National Council for Scientific and Technological
Development—CNPq (Grant Number 311757/2018-9).
Conflicts of Interest: The authors declare no conflict of interest.

References
1. Domenech, T.; Bleischwitz, R.; Doranova, A.; Panayotopoulos, D.; Roman, L. Mapping Industrial Symbiosis
Development in Europe: typologies of networks, characteristics, performance and contribution to the
Circular Economy. Resour. Conserv. Recycl. 2019, 141, 76–98. [CrossRef]
2. Favot, M.; Veit, R.; Massarutto, A. The ratio of EPR compliance fees on sales revenues of electrical and
electronic equipment in Italy. A circular economy perspective. Resour. Conserv. Recycl. 2018, 135, 34–37.
[CrossRef]
3. Martin- Gómez, A.M.; González, F.A.; Bárcena, M.M. Smart eco-industrial parks: A circular economy
implementation based on industrial metabolism. Resour. Conserv. Recycl. 2018, 135, 58–69. [CrossRef]
Sustainability 2019, 11, 3259 16 of 19

4. Tseng, M.M.; Islam, S.M.; Karia, N.; Fauzi, F.A.; Afrin, S. A literature review on green supply chain
management: Trends and future Challenges. Resour. Conserv. Recycl. 2019, 141, 145–162. [CrossRef]
5. Garcia-Muiña, F.E.; González-Sánchez, R.; Ferrari, A.M.; Settembre-Blund, D. The Paradigms of Industry 4.0
and Circular Economy as Enabling Drivers for the Competitiveness of Businesses and Territories: The Case
of an Italian Ceramic Tiles Manufacturing Company. Soc. Sci. 2018, 7, 255. [CrossRef]
6. Tseng, M.L.; Tan, R.R.; Chiu, A.S.F.; Chien, C.F.; Kuo, T.C. Circular economy meets industry 4.0: Can big data
drive industrial symbiosis? Resour. Conserv. Recycl. 2018, 131, 146–147. [CrossRef]
7. Ranta, V.; Stenroos, L.A.; Ritala, P.; Mäkinen, S.J. Exploring institutional drivers and barriers of the circular
economy: A cross-regional comparison of China, the US, and Europe. Resour. Conserv. Recycl. 2018,
135, 70–82. [CrossRef]
8. United Nations—Sustainable Development Goals. 2016. Available online: https://www.un.org/
sustainabledevelopment/sustainable-development-goals/ (accessed on 19 May 2019).
9. United Nations—Department of Economic and Social Affairs. World Urbanization Prospects Highlights.
2014. Available online: https://esa.un.org/unpd/wup/publications/files/wup2014-highlights.pdf (accessed on
30 November 2018).
10. International Energy Efficiency—Energy Efficiency. Analysis and Outlooks to 2040. 2018. Available online:
https://www.iea.org/efficiency2018 (accessed on 19 May 2019).
11. Nascimento, D.L.M.; Alencastro, V.; Quelhas, O.L.G.; Caiado, R.G.G.; Garza-Reyes, J.A.; Rocha-Lona, L.;
Tortorella, G. Exploring Industry 4.0 technologies to enable circular economy practices in a manufacturing
context: A business model proposal. J. Manuf. Technol. Manag. 2019, 30, 607–627. [CrossRef]
12. Fargnoli, M.; Costantino, F.; Di Gravio, G.; Tronci, M. Product service-systems implementation: A customized
framework to enhance sustainability and customer satisfaction. J. Clean. Prod. 2018, 188, 387–401. [CrossRef]
13. Fargnoli, M.; Haber, N.; Sakao, T. PSS modularisation: A customer-driven integrated approach. Int. J.
Prod. Res. 2018. [CrossRef]
14. Ardolino, M.; Rapaccini, M.; Saccani, N.; Gaiardelli, P.; Crespi, G.; Ruggeri, C. The role of digital technologies
for the service transformation of industrial companies. Int. J. Prod. Res. 2018, 56, 2116–2132. [CrossRef]
15. Balaman, S.Y.; Wright, D.G.; Scott, J.; Matopoulos, A. Network design and technology management for waste
to energy production: An integrated optimization framework under the principles of circular economy.
Energy 2018, 143, 911–933. [CrossRef]
16. Birkel, H.S.; Veile, J.W.; Müller, J.M.; Hartmann, E.; Voigt, K.I. Development of a Risk Framework for Industry
4.0 in the Context of Sustainability for Established Manufacturers. Sustainability 2019, 11, 384. [CrossRef]
17. Luthra, S.; Mangla, S.K. Evaluating challenges to Industry 4.0 initiatives for supply chain sustainability in
emerging economies. Process. Saf. Environ. 2018, 117, 168–179. [CrossRef]
18. Barbosa-Póvoa, A.P.; Silva, C.; Carvalho, A. Opportunities and challenges in sustainable supply chain:
An operations research perspective. Eur. J. Oper. Res. 2018, 268, 399–431. [CrossRef]
19. Müller, J.M.; Voigt, K.I. Sustainable Industrial Value Creation in SMEs: A Comparison between Industry 4.0
and Made in China 2025. Int. J. Precis. Eng. Manuf. Green Technol. 2018, 5, 659–670. [CrossRef]
20. Mostafa, N.; Hamdy, W.; Alawady, H. Impacts of Internet of Things on Supply Chains: A Framework for
Warehousing. Soc. Sci. 2019, 8, 84. [CrossRef]
21. Stock, T.; Obenaus, M.; Kunz, S.; Kohl, H. Industry 4.0 as enabler for a sustainable development: A qualitative
assessment of its ecological and social potential. Process. Saf. Environ. 2018, 118, 254–267. [CrossRef]
22. Kovacs, O. Big IFs in Productivity-Enhancing Industry 4.0. Soc. Sci. 2019, 8, 37. [CrossRef]
23. Hamada, T. Determinants of Decision-Makers’ Attitudes toward Industry 4.0 Adaptation. Soc. Sci. 2019,
8, 140. [CrossRef]
24. Tjahjono, B.; Esplugues, C.; Ares, E.; Pelaez, G. What does Industry 4.0 mean to Supply Chain. Procedia
Manuf. 2017, 13, 1175–1182. [CrossRef]
25. Gruchmann, T.; Schmidt, I.; Lubjuhn, S.; Seuring, S.; Bouman, M. Informing logistics social responsibility
from a consumer-choice-centered perspective. Int. J. Logist. Manag. 2019, 30, 96–116. [CrossRef]
26. Hah, K.; Freeman, S. Multinational Enterprise Subsidiaries and their CSR: A Conceptual Framework of the
Management of CSR in Smaller Emerging. J. Bus. Ethics 2011, 98, 281–295. [CrossRef]
27. Carvalho, J.S.F. “Democratização do ensino” revisitado. Educação e Pesquisa, 2004, São Paulo. 30, n2, 327 -334,
mai/ago 2004. Available online: http://www.scielo.br/pdf/ep/v30n2/v30n2a11.pdf (accessed on 8 June 2019).
Sustainability 2019, 11, 3259 17 of 19

28. Torugsa, A.; O’Donohue, W.; Hecker, R. Capabilities, proactive CSR and financial performance in SMEs:
Empirical evidence from an Australian manufacturing industry sector. J. Bus. Ethics 2012, 109, 483–500.
[CrossRef]
29. Cruz, L.B.; Boehe, D.M. How do Leading Retail MNCs leverage CSR Globally? Insights from Brazil. J. Bus.
Ethics 2010, 91, 243–263. [CrossRef]
30. Xue, J.; Liu, G.; Casazza, M.; Ulgiati, S. Development of an urban FEW nexus online analyzer to support
urban circular economy strategy planning. Energy 2018, 164, 475–495. [CrossRef]
31. Maalouf, A.; El-Fadel, M. Towards improving emissions accounting methods in waste management:
A proposed framework. J. Clean. Prod. 2019, 206, 197–210. [CrossRef]
32. Chen, J.; Xiang, D. Carbon efficiency and carbon abatement costs of coal-fired power enterprises: A case of
Shanghai, China. J. Clean. Prod. 2019, 206, 452–459. [CrossRef]
33. Gallagher, J.; Basu, B.; Browne, M.; Kenna, A.; McCormack, S.; Pilla, F.; Styles, D. Adapting Stand-Alone
Renewable Energy Technologies for the Circular Economy through Eco-Design and Recycling. J. Ind. Ecol.
2017, 23. [CrossRef]
34. Jabbour, A.B.L.S.; Jabbour, C.J.C.; Godinho Filho, M.; Roubaud, D. Industry 4.0 and the circular economy:
a proposed research agenda and original roadmap for sustainable operations. Ann. Oper. Res. 2018, 270,
273–286. [CrossRef]
35. Scavarda, A.; Daú, G.L.; Scavarda, L.F.; Korzenowski, A.L. A proposed healthcare supply chain management
framework in the emerging economies with the sustainable lenses: The theory, the practice, and the policy.
Resour. Conserv. Recycl. 2019, 141, 418–430. [CrossRef]
36. de Vries, J.; Huijsman, R. Supply chain management in health services: an overview. Int. J. Supply
Chain Manag. 2011, 16, 159–165. [CrossRef]
37. Yin, R. Case Study Research: Designs and Methods, 3rd ed.; Sage Publications: London, UK, 2018.
38. Carvalho, A.; Scavarda, L.F.; Lustosa, L.J. Implementing finite capacity production scheduling: lessons from
a practical case. International. J. Prod. Res. 2014, 52, 1215–1230. [CrossRef]
39. Flynn, B.B.; Sakakibara, S.; Schroeder, R.G.; Bates, K.A.; Flynn, E.J. Empirical research methods in operations
management. J. Oper. Manag. 1990, 9, 250–284. [CrossRef]
40. Carvalho, A.N.; Oliveira, F.; Scavarda, L.F. Tactical capacity planning in a real-world ETO industry case:
An action research. International. Int. J. Prod. Econ. 2015, 167, 187–203. [CrossRef]
41. Carvalho, A.N.; Oliveira, F.; Scavarda, L.F. Tactical capacity planning in a real-world ETO industry case:
A robust optimization approach. Int. J. Prod. Econ. 2016, 180, 158–171. [CrossRef]
42. Thomé, A.M.T.; Scavarda, L.F.; Pires, S.R.I.; Ceryno, P.; Klingebiel, K. A multi-tier study on supply chain
flexibility in the automotive industry. Int. J. Prod. Econ. 2014, 158, 91–105. [CrossRef]
43. Oncioiu, I.; Căpus¸neanu, S.; Türkes, M.C.; Topor, D.I.; Constantin, D.M.O.; Marin-Pantelescu, A.; Hint, M.S.
The Sustainability of Romanian SMEs and Their Involvement in the Circular Economy. Sustainability 2018,
10, 2761. [CrossRef]
44. Egbunike, O.; Purvis, L.; Naim, M.M. A systematic review of research into the management of manufacturing
capabilities. Prod. Plan Control. 2018, 29, 1349–1366. [CrossRef]
45. Magon, R.B.; Thomé, A.M.T.; Ferrer, A.L.C.; Scavarda, L.F. Sustainability and performance in operations
management research. J. Clean. Prod. 2018, 190, 104–117. [CrossRef]
46. Thomé, A.M.T.; Scavarda, L.F.S.; Scavarda, A.J. Conducting systematic literature review in operations
management. Prod. Plan Control. 2016, 27, 408–420. [CrossRef]
47. Sun, L.; Li, H.; Dong, L.; Fang, K.; Ren, J.; Geng, Y.; Fuji, M.J.; Zhang, W.; Zhang, N.; Liu, L. Eco-benefits
assessment on urban industrial symbiosis based on material flows analysis and emergy evaluation approach:
A case of Liuzhou city, China. Resour. Conserv. Recycl. 2017, 119, 78–88. [CrossRef]
48. Chou, C.; Chiang, C.T.; Wu, P.Y.; Chu, C.P.; Lin, C.Y. Spatiotemporal analysis and visualization of power
consumption data integrated with building information models for energy savings. Resour. Conserv. Recycl.
2017, 123, 219–229. [CrossRef]
49. Domínguez, A.; Geyer, R. Photovoltaic waste assessment in Mexico. Resour. Conserv. Recycl. 2017, 127, 29–41.
[CrossRef]
50. Pao, H.T.; Chen, C.C. Decoupling strategies: CO2 emissions, energy resources, and economic growth in the
Group of Twenty. J. Clean. Prod. 2019, 206, 907–919. [CrossRef]
Sustainability 2019, 11, 3259 18 of 19

51. Pombo, O.; Rivela, B.; Neila, J. Life cycle thinking toward sustainable development policy-making: The case
of energy retrofits. J. Clean. Prod. 2019, 206. [CrossRef]
52. Charles, R.G.; Davies, M.L.; Douglas, P.; Hallin, I.L.; Mabbett, I. Sustainable energy storage for solar home
systems in rural Sub-Saharan Africa e A comparative examination of lifecycle aspects of battery technologies
for circular economy, with emphasis on the South African contexto. Energy 2019, 166, 1207–1215. [CrossRef]
53. Dominguez, S.; Laso, J.; Margallo, M.; Aldaco, R.; Rivero, M.J.; Irabien, A.; Ortiz, I. LCA of greywater
management within a water circular economy restorative thinking framework. Sci. Total Environ. 2018,
621, 1047–1056. [CrossRef]
54. European Commission—The Urban Agenda for the, EU. 2016. Available online: https://ec.europa.eu/
regional_policy/en/policy/themes/urban-development/agenda/ (accessed on 18 May 2019).
55. Martins, F.R.; Rüther, R.; Pereira, E.B.; Abreu, S.L. Solar energy scenarios in Brazil. Part two: Photovoltaics
applications. Energy Policy 2008, 36, 2865–2877. [CrossRef]
56. Escobar, R.A.; Cortes, C.; Pino, A.; Pereira, E.B.; Martins, F.R.; Cardemil, J.M. Solar energy resource assessment
in Chile: Satellite estimation and ground station measurements. Renew. Energy 2014, 71, 324–332. [CrossRef]
57. Zhang, L.; Xin, H.; Yong, H.; Kan, Z. Renewable energy project performance evaluation using a hybrid
multi-criteria decision-making approach: Case study in Fujian, China. J. Clean. Prod. 2019, 206, 1123–1137.
[CrossRef]
58. Wang, T.; Lin, B. Fuel consumption in road transport: A comparative study of China and OECD countries.
J. Clean. Prod. 2019, 206, 156–170. [CrossRef]
59. Tziogas, C.; Georgiadis, P.; Papadopoulos, A. Fostering the transition to sustainable electricity systems:
A hierarchical analysis framework. J. Clean. Prod. 2019, 206, 51–65. [CrossRef]
60. Rafique, M.M.; Bahaidarah, H.M.S.; Anwar, M.K. Enabling private sector investment in off-grid electrification
for cleaner production: Optimum designing and achievable rate of unit electricity. J. Clean. Prod. 2019,
206, 508–523. [CrossRef]
61. Xin-gang, Z.; Yuan-feng, Z.; Yan-bin, L. The spillovers of foreign direct investment and the convergence of
energy intensity. J. Clean. Prod. 2019, 206, 611–621. [CrossRef]
62. United Nations. United Nations, Educational, Scientific, and Cultural Organizational. 2017. Available
online: http://www.unesco.org/new/en/unesco/events/prizes-and-celebrations/celebrations/international-
days/world-water-day-2017/ (accessed on 30 November 2018).
63. Gong, H.; Jin, Z.; Xu, H.; Yuan, Q.; Zuo, J.; Wu, J.; Wang, K. Enhanced membrane-based pre-concentration
improves wastewater organic matter recovery: Pilot-scale performance and membrane fouling. J. Clean. Prod.
2019, 206, 307–314. [CrossRef]
64. Youssef, A.M.; El-Naggar, M.E.; Malhat, F.M.; El Sharkawi, H.M. Efficient removal of pesticides and heavy
metals from wastewater and the antimicrobial activity of f-MWCNTs/PVA nanocomposite film. J. Clean. Prod.
2019, 206, 315–325. [CrossRef]
65. Espíndola, J.A.C.; Cordova, F.; Flores, C.C. The importance of urban rainwater harvesting in circular economy:
The case of Guadalajara city. Manag. Res. Rev. 2018, 41, 533–553. [CrossRef]
66. Gómez, Y.D.; Teixeira, L.G. Residential rainwater harvesting: Effects of incentive policies and water
consumption over economic feasibility. Resour. Conserv. Recycl. 2017, 127, 56–67. [CrossRef]
67. Brazilian Standard National Association. Água de chuva—Aproveitamento de coberturas em áreas urbanas
para fins não potáveis—Requisitos 15527. 2007. Available online: https://www.abntcatalogo.com.br/curs.
aspx?ID=34 (accessed on 25 April 2019).
68. Itaipu Binacional, ONU e Itaipu debatem a divulgação dos objetivos para o desenvolvimento sustentável e
de projetos sustentáveis. 2018. Available online: https://www.itaipu.gov.br (accessed on 19 May 2019).
69. Association for the Advancement of Medical Instrumentation. ANSI/AAMI: ST 79 2017 Comprehensive
Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities. Available online: http:
//my.aami.org/aamiresources/previewfiles/1709_ST79Preview.pdf (accessed on 12 June 2019).
70. Glatt, M.F.; Yi, L.; Mert, G.; Linke, B.S.; Aurich, J.C. Technical Product-Service Systems: Analysis and
reduction of the Cumulative Energy Demand. J. Clean. Prod. 2019, 206, 727–740. [CrossRef]
71. Zhang, H.; Xu, Z.; Zhou, D.; Qiu, Y.; Shen, D. Targeted poverty alleviation using photovoltaic power in China:
Identifying financial options through a dynamic game analysis. Resour. Conserv. Recycl. 2018, 139, 333–337.
[CrossRef]
Sustainability 2019, 11, 3259 19 of 19

72. Opoku, A. Biodiversity and the built environment: Implications for the Sustainable Development Goals
(SDGs). Resour. Conserv. Recycl. 2019, 141, 1–7. [CrossRef]
73. Müller, J.M.; Kiel, D.; Voigt, K.I. What Drives the Implementation of Industry 4.0? The Role of Opportunities
and Challenges in the Context of Sustainability. Sustainability 2018, 10, 247. [CrossRef]
74. Jannati, J.; Nazarpour, D. Optimal performance of electric vehicles parking lot considering environmental
issue. J. Clean. Prod. 2019, 206, 1073–1088. [CrossRef]
75. Veleva, V.; Bodkin, G. Corporate-entrepreneur collaborations to advance a circular economy. J. Clean. Prod.
2018, 188, 20–37. [CrossRef]
76. Lin, K.Y. User experience-based product design for smart production to empower industry 4.0 in the glass
recycling circular economy. Comput. Ind. Eng. 2018, 125, 729–738. [CrossRef]
77. Bradley, R.; Jawahir, I.S.; Badurdeen, F.; Rouch, K. A total life cycle cost model (TLCCM) for the circular
economy and its application to post-recovery resource allocation. Resour. Conserv. Recycl. 2018, 135, 141–149.
[CrossRef]
78. Abu-Ghunmi, D.; Abu-Ghunmi, L.; Kayal, B.; Bino, A. Circular economy and the opportunity cost of not
‘closing the loop’ of water industry: the case of Jordan. J. Clean. Prod. 2016, 131, 228–236. [CrossRef]
79. Marteleira, R.; Pinto, G.; Niza, S. Regional water flows – Assessing opportunities for sustainable management.
Resour. Conserv. Recycl. 2014, 82, 63–74. [CrossRef]

© 2019 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access
article distributed under the terms and conditions of the Creative Commons Attribution
(CC BY) license (http://creativecommons.org/licenses/by/4.0/).