The sponsor has presented plans to address these impacts to ensure that the proposed project will, upon implementation of the specific agreed measures, comply with host country laws and regulations, IFC’s social and environmental Performance Standards, and relevant environmental, health and safety (EHS) guidelines. The information about how these potential impacts will be addressed by the sponsor/project is summarized in the paragraphs that follow.
PS1: Social and Environmental Assessment and Management Systems:
Social and Environmental Assessment:
To date, all acquisitions APMG has made have been existing hospitals which have already been licensed by the Chinese Health Bureau. In order to obtain the initial license to operate, a hospital must have all the permits and approvals in place. The Chinese Health Bureau inspects facilities regularly. Ongoing compliance with Chinese regulations is required in order to have the hospital license renewed annually. Prior to acquisition, APMG ensures that a target hospital has a clean license. In the future, if the Company plans to undertake greenfield development, it will be subject to a PS1 compliant assessment.
Management Program and Organization:
The Company has established detailed environmental and occupational health and safety (OHS) practices and standard operating procedures (SOPs) that conform to Chinese regulatory requirements. The systems are specific to the regulatory requirements of the city, province and national government and environmental, social, health and safety issues are managed by designated persons in each hospital. The Company has made some progress in moving towards Joint Commission International (JCI) accreditation to demonstrate continuous improvement in quality and safety of health care. The Tiantan Puhua Hospital has started the process of preparing its management systems for JCI accreditation. In addition, two of the JV partners’ hospitals have been accredited: Huashan Hospital in Shanghai since January 2010 and TEDA International Cardiovascular Hospital in June 2009.
The Company intends to modify its partners’ accredited system, to develop one integrated system for APMG internationally. In order to achieve this, APMG will assign a qualified member of the Company management team to take responsibility for developing the management system, rolling it out across all the hospitals and clinics and providing training to staff. This manager will undertake appropriate training to understand the requirements of JCI and will be responsible for managing a team consisting of the HR director and representatives of environmental health and safety management in each hospital. The team will develop a management system that will integrate the HR policies and practices, training, OHS, radiological safety, management of waste and effluent and infection control as well as emergency preparedness and prevention, life and fire safety and community engagement. A full protocol for monitoring and evaluation will be incorporated for all hospitals and clinics in the Company.
As part of the development of the integrated management systems and alignment to JCI, the Company will ensure that there is a common Infection Control Policy and Procedures Manual developed for all the hospitals and clinics that is periodically reviewed by an Infection Control Committee (ICC) made up of the members of various medical departments and including nursing, housekeeping and operating rooms. The ICC’s role will be to serve as both a monitor and a resource in maintaining control standards for nosocomial (hospital-acquired) infection in order to minimize risk to both staff and patients.
APMG’s Puhua Taida Hospital leases dedicated space within TEDA International Cardiovascular Hospital, a public hospital. Once it is open, Puhua Taida Hospital will also lease some of the public hospital equipment such as MRI machines on ‘per use’ basis and may share some specialist doctors. APMG will maintain its environment and social standards through its own management systems, to provide a high level of care to its private patients. The management systems will include procedures for ensuring that the services provided by the public hospital partners, such as specialized doctors, waste water treatment, healthcare waste storage, and fire safety, will meet their standards. The management systems will reference IFC PS and Environmental, Health and Safety General Guidelines and Guidelines for Health Care Facilities and regular reports will be made to IFC on progress with their development and implementation at all sites across the Company.
The management system will also incorporate guidance on site selection for potential new hospitals to include a requirement for seismic hazard assessment in line with the International Building Code as well as L&FS requirements, as described below.
Community Engagement:
It is not the tradition in China for hospitals to have formal local community grievance mechanisms. In some of its hospitals, however, the Company has customer feedback boxes. The Company will train the staff in customer care, ensuring they are able to receive and respond to questions, concerns or grievances raised by the nearby communities or other stakeholders, and keep a register of such inquiries.
At any future construction sites, APMG will have signage with contact details of senior management who are able to respond to the concerns of any stakeholders. The Company will also develop an onsite mechanism to record grievances of the local community on issues related to construction.
PS2: Labor and Working Conditions:
Working Conditions and Management of Workers Relationship
APMG’s Human Resources policy and procedures vary according to the city in which they apply in order to be consistent with the relevant local statutes and regulations. The Employee Handbook is also aligned to the particular local requirements and is readily available in all departments. All personnel are required to confirm their understanding of the document on their entry to the Company. Together the documents communicate the working conditions and terms of employment of all employees. The Company will develop one corporate HR policy aligned to IFC PS2 which will communicate common corporate principles applicable to all staff. Terms and conditions will be standardized as much as possible. Where specific city regulatory requirements require that terms and conditions should vary, these will be communicated to staff clearly.
APMG currently employs a total of 677 staff (China 588, Singapore 62, Malaysia 5, Hong Kong 22). The contractual arrangements vary. In Tiantan Puhua, staff are either on fixed term, temporary or service contracts. At Shanghai Gamma Knife Hospital, only support staff are employed by the Company while doctors and nurses are employed by the JV partner. The Company proposes to employ 150 staff at the newly acquired hospital in Beijing after its redevelopment. This will include many of the 30 staff who are currently employed there. The Puhua Taida Hospital will employ 35 staff when it opens, which includes a number of doctors who will be seconded from the JV Partner. Currently, HR management is undertaken by a manager in Beijing, responsible for staff at Tiantan Puhua Hospital and Tiantan Puhua Clinic. She will also become responsible for staff at the newly acquired hospital in Beijing and Puhua Taida Hospital as the staff recruitment starts. There are separate HR managers for Shanghai St Michael Hospital, Singapore and Malaysia, and Hong Kong.
In China, the Company has encouraged workers to constitute a union within the hospital to facilitate collective bargaining and grievance redressal. In addition, the Company has a formal grievance mechanism for workers to raise reasonable workplace concerns, either through the Company management and HR department or through the union.
Although the Company bases its employment decisions on the principle of non-discrimination and equal opportunity, the Company will modify the HR policy to reflect these principles.
Protecting the Workforce:
The Company will also modify its HR policy to reflect its employment decisions based on minimum age.
Doctors and nurses are required by the Chinese Health Bureaus to undertake continual professional development. Each Health Bureau provides a number of training courses to enable professional staff to obtain sufficient credits in order to maintain their licenses to practice. In addition, APMG hospitals provide annual training and assessment programs for its entire staff, including induction training, Occupational Health and Safety (OHS), medical waste disposal, quality of care and better hospital management. Records are kept of attendees for all courses.
The Company employs some security and housekeeping staff through a contractor. It verifies that all contract labor enjoy terms of employment that comply with the national law.
Occupational Health and Safety:
The Company undertakes to provide the employees with a safe and healthy work environment. In this respect, the Company has legally compliant radiation safety, infection control, fire safety and hazardous waste management procedures. Fire safety drills are undertaken 6 times a year and fire hydrants and extinguishers are checked regularly. There are SOPs for spills of hazardous materials. The hospital is licensed to use linear accelerator, gamma knife, CT and MRI machines. In order to retain these licenses the hospitals must follow government regulations for equipment maintenance, have detailed event procedures, a training system, monitoring process, radiation quality assurance program, radiation protection and quality guarantee program, and designated roles and responsibilities. At Shanghai Gamma Knife Hospital, practitioners have health checks in the radiation treatment centre of the nearby university, repeat health checks annually and always wear radiation level monitoring badges. In addition, all staff receive immunizations and an annual health check as well as appropriate health and safety training. Injuries are recorded if they involve lost time or insurance claims.
The Company plans to construct an extension to the newly acquired hospital in Beijing. The construction project is being managed by a member of the Company’s senior management. The Company will ensure that for all construction projects, Health and Safety is managed adequately on site by including environmental, social and occupational health and safety requirements in bids and contract documentation, requiring contractors to develop a site safety manual and ensure effective implementation, for example, by regular communication through safety site toolbox talks.
Emergency preparedness and response plans:
In compliance with Chinese regulations APMG hospitals have emergency response plans for radiation exposure, fire, hazardous waste leakages, natural disaster and earthquakes. Relevant staff training is provided.
PS3: Pollution prevention and abatement:
APMG is committed to ensuring its compliance with both local regulatory requirements and IFC guidelines for waste water discharges, emissions to air, hazardous waste, ambient noise and workplace conditions. APMG has confirmed that it has acquired all necessary regulatory permits and authorizations and will continue to ensure all permits are obtained throughout the operation of the hospitals, as well as prior to commencing construction at new developments.
Total consumption of electricity for the whole company in 2010 was 3.6 million kWh. As the Company plans to undertake construction to expand hospitals, it has agreed to consider measures to maximize the energy and water efficiency in the design.
Waste Management:
All hospitals and clinics follow local regulatory requirements with respect to segregation, storage and disposal of solid and hazardous waste. The SOPs conform to Chinese regulations, and industry good practices. At each site, waste is segregated by category and stored temporarily as per internationally and locally accepted procedures. For its operations in China, APMG enters into a formal arrangement with a larger neighboring state hospital to hold all segregated hazardous and municipal waste in its temporary storage facility. Hazardous waste is removed every 24 hours by the authorized contractor designated by the local authority and taken to the permitted facility. APMG has a formal agreement directly with the authorized vendor and all paperwork for transfer of waste to the authorized vendor is held by the respective APMG hospitals. Domestic waste is disposed according to municipal regulations. The Environmental Protection Agency and Chinese Health Bureau inspect the waste storage facilities every two months. The medical administrator in each APMG hospital inspects the facilities daily.
The hospitals produce radioactive waste from the gamma knife. Radioactive cobalt is replaced approximately every 7 years, or whenever the machine is upgraded. The 201 sources of radioactive cobalt are removed by the manufacturer’s representative and returned to Sweden. The replacement process is regulated by the Environmental Protection Agency, with a police escort to and from the hospital. Other sources of waste are also disposed of according to Environmental Protection Agency regulations. Out dated drugs are returned to the drug companies, and used drug and chemical containers are treated as medical waste which is collected by the city licensed medical waste management company. APMG does not produce any mercury waste.
Emissions to air:
The primary source of air emissions is from the ventilation and air conditioning systems. All air conditioning for patient rooms are independently operated and ventilate through the windows. Operating theatres have an independent filtered ventilation system.
Waste water:
Waste water at each hospital is treated according to local requirements. The most common model in the Company is for effluent from APMG hospitals to be treated by the neighboring state hospitals, under formal contractual agreement. Commonly, effluent is dosed with chlorine to disinfect it and chlorine levels in the effluent are monitored prior to discharge into the municipal sewerage system. At St Michael Hospital, however, the waste water is biologically digested. At all hospitals, after this pre-treatment, effluent enters the city sewerage system and is treated again in the municipal waste water treatment system. On a monthly basis, the Chinese Environmental Bureau measures the faecal bacteria in the effluent before it enters the municipal sewage treatment system for further treatment. Each APMG hospital receives the Environmental Bureau monitoring results to confirm that the effluent treatment is compliant with local regulations. Neither the monitoring undertaken by the treatment facility nor the monitoring undertaken by the Chinese Environment Bureau measures sufficient parameters to establish if the treated effluent is within IFC limits. The Company will agree with IFC, and implement an appropriate monitoring program for the effluent from each of its hospitals and clinics in order to establish if the method of treatment is sufficient to ensure that IFC limits can be met.
PS4: Community health, safety and security:
All hospitals provide bottled drinking water to staff and a mixture of bottled and boiled water for patients.
Infection Control is standard practice for nurses and the government requires that each nurse obtains a minimum number of credits at their initial training and participates in annual training to maintain their license. Training is undertaken both externally as well as internally. The Head Nurse maintains the training records for all nursing staff.
Life and Fire Safety:
APMG hospitals have been designed in compliance with the local and national fire codes. They are regularly inspected by the local Fire Department and any corrective actions identified are implemented as required. The Company has agreed to take the necessary measures to ensure that the existing and new hospitals and clinics also meet IFC’s Life and Fire Safety (L&FS) guidelines. For all existing hospitals and clinics in China, whether leased or owned by APMG, the Company will contract a competent professional to conduct a L&FS audit against an international L&FS standard and implement any recommendations. For future hospitals and clinics that lease space within existing public hospitals, the audit will be undertaken prior to signing a lease for the premises. For new construction projects, the Company will ensure the hospitals are designed to comply with an international fire safety code. APMG will provide to IFC certification from a suitably qualified professional that all the facilities are in compliance with an international L&FS code.
Emergency preparedness and response:
APMG has in place detailed standard operating procedures (SOPs) for a number of possible disaster situations, such as radiation exposure, fire, hazardous waste leakages, natural disaster and earthquakes. The Company has formed emergency response teams in every facility, which act as first responders in the event of any security or disaster situation. As part of its integrated management system, APMG will ensure integration of the SOPs, consistency across all hospitals and regular monitoring and review.
APMG security personnel do not carry fire arms.
