This study aims to examine how integrating regenerative principles into a digitalised balanced scorecard (BSC) can support hospital resilience, sustainability and governance in contexts characterised by systemic complexity, recurrent crises and accelerated digital transformation. While sustainability initiatives in healthcare have traditionally emphasised harm reduction and operational efficiency, a regenerative perspective extends beyond mitigation by fostering net-positive environmental, social and organisational (ESG) outcomes. In this study, regenerative governance refers to practices that reinforce ecosystem stewardship, workforce well-being, organisational learning and adaptive capacity, thereby supporting long-term resilience and more integrated strategic decision-making.
A comparative multiple-case study was conducted across three Portuguese public hospitals. Data collection combined semi-structured interviews conducted between April 2024 and January 2025 with senior executives and key functional managers, documentary analysis of strategic and sustainability reports and longitudinal performance indicators covering the period 2018–2023. This comparative and longitudinal design enabled identification of patterns in digitalisation practices, governance approaches and resilience-related capabilities, supporting interpretation of the BSC as a governance framework rather than solely a static performance measurement tool.
Hospitals incorporating regenerative principles within digitalised BSC architectures appeared to exhibit comparatively stronger adaptive capacity, more structured ESG reporting practices and more consistent continuity of care during periods of disruption. Implementation challenges remain evident, including cultural resistance to change, fragmented information systems, resource constraints and uneven levels of digital maturity. Overall, findings indicate that hospital resilience is influenced not only by structural efficiency but also by governance capabilities that integrate sustainability principles, organisational learning and data-informed decision-making processes. The integration of digital data infrastructures with sustainability-oriented governance practices appears to be associated with stronger cross-departmental coordination, enhanced organisational learning and more structured crisis-response mechanisms.
The study focuses on three hospitals operating within the same national healthcare system, which may limit transferability to institutional environments characterised by different regulatory structures, governance arrangements or funding conditions. Although the comparative design provides analytically rich insights, findings should be interpreted as theoretically informative rather than statistically generalisable. Future research may extend the empirical base through cross-country comparative studies, expanded longitudinal datasets and complementary quantitative modelling approaches to further examine the proposed regenerative digital BSC framework.
Aligning BSC architectures with ESG-oriented metrics and digital performance monitoring systems may strengthen transparency, interdepartmental coordination and anticipatory decision-making. In practice, this integration may support earlier identification of operational vulnerabilities, more coherent allocation of resources and closer alignment between sustainability objectives and performance management systems. A digitalised BSC may facilitate continuous organisational monitoring, more timely responses to disruptions and stronger accountability structures. Embedding regenerative principles within governance systems may support a gradual transition from reactive crisis management towards more adaptive and learning-oriented organisational practices.
The study highlights the potential social value of performance management systems that integrate digital intelligence and regenerative governance in healthcare. By embedding ESG indicators and workforce well-being into strategic decision-making, hospitals can enhance transparency, trust and social accountability. The proposed framework supports more inclusive and ethically grounded governance practices, contributing to improved quality of care and institutional legitimacy. However, broader social impacts depend on sustained policy alignment, organisational commitment and meaningful stakeholder participation beyond managerial levels. As patient and community voices were not directly included in the empirical data, the social implications identified here should be interpreted as enabling conditions rather than fully realised outcomes. Nonetheless, the findings suggest that digitally enabled and regenerative performance systems can strengthen the social role of hospitals within their communities over time.
The study develops a governance-oriented perspective integrating regenerative principles with digital performance management within the BSC framework. Moving beyond conventional applications focused primarily on performance measurement, the study conceptualises the BSC as a dynamic governance mechanism linking sustainability, digital intelligence and adaptive organisational capabilities. This integrative perspective contributes to emerging debates on resilient healthcare governance and provides a theoretically grounded basis for future empirical research on sustainable health system transformation.
