While all Performance Standards are applicable to this investment, IFCs environmental and social due diligence indicates that the investment will have impacts which must be managed in a manner consistent with the following Performance Standards. If IFCs investment proceeds, IFC will periodically review the the project’s ongoing compliance with the Performance Standards

PS 1 – Assessment and Management of Environmental and Social Risks and Impacts
PS 2 - Labor and working conditions
PS 3 - Resource Efficiency and Pollution Prevention
PS 4 – Community Health, Safety and Security
If IFC’s investment proceeds, IFC will periodically review the the project’s ongoing compliance with the Performance Standards
While all Performance Standards (PSs) are applicable to this investment, IFC’s environmental and social due diligence indicates that the investment will have impacts which must be managed in a manner consistent with the above Performance Standards:

There are no known land acquisition issues associated with any of the hospital portfolio of the group. The hospitals are situated in urban areas, most have been in these locations for decades and, as such, no impact on biodiversity, indigenous people or cultural heritage is expected. Impacts related to PS6: Biodiversity Conservation and Sustainable Natural Resource Management; PS7: Indigenous Peoples; and PS8: Cultural Heritage are therefore not expected in this investment.

Based on the site visit to two operational hospitals in Singapore and two in Malaysia as well as a visit to a new hospital in Singapore due to open in July 2012, IFC’s previous experience in the healthcare sector and with other parts of IHH, and review of client and IFC information by IFC’s Environment and Social Specialist, this project will have limited potential adverse environmental and social impacts. The project has been classified as Category B according to IFC’s Environmental and Social Review Procedure. The key social and environmental aspects associated with the project include: the ability to implement rigorous and systematic management systems such as JCI, management of solid and liquid wastes, particularly biomedical wastes, and life and fire safety.

Potential adverse impacts arising from the issues mentioned above are limited, site specific and can be avoided or mitigated by adhering to generally recognized industry performance standards, guidelines or design criteria.

IFC's appraisal considered the environmental and social management planning process and documentation for the project and gaps, if any, between these and IFCs requirements. Where necessary, corrective measures, intended to close these gaps within a reasonable period of time, are summarized in the paragraphs that follow and (if applicable) in an agreed Environmental and Social Action Plan (ESAP). Through the implementation of these measures, the project is expected to be designed and operated in accordance with Performance Standards objectives.

Environmental and Social Assessment and Management System:
All hospitals in the group are recognized for their best hospital management practices in their respective countries and regions. Many of the hospitals have full Joint Commission International (JCI) accreditation and many laboratories and central sterilization units are accredited by ISO 9001 Quality Management System. Acibadem Labmed, which provides clinical laboratory services, is also accredited according to the ISO 15189 standards. Nuclear Medicine Departments of Acibadem have ISO9001 Quality Management System certification since 2006 and five have European Nuclear Medicine Accreditation by the Board of Nuclear Medicine (EBNM) of European Union of Medical Specialists (UEMS).

There is a decentralized EHS management system in place, with some coordination by regional operational teams. Currently, initiatives are being taken to ensure that management systems across PPL hospitals are continually improved to enhance the quality of care and to benefit from learning from the experiences of the other hospitals in the group. PPL has centralized HR, IT, purchasing functions as well as nurse training and a team has been set up to look at how other subsidiaries can be brought into the centralization process. The aim is to have a corporate system that ensures quality of care and fosters talent management as the group grows into new markets. For example, there is a central Quality Forum which includes all hospitals in Singapore and Malaysia. The group intends to further develop and implement corporate level policies, guidelines, checklists and MIS to ensure that hospitals and laboratories which are not certified by any such accreditations are designed and operated according to the requirements of these systems.

IHH also has a minority investment in Apollo Hospitals in India and Parkway has two joint venture hospitals with Apollo. Apollo has developed and demonstrated its expertise in managing hospitals over the years and is recognized for its best practices in the region, which are in line with international standards. This group has management systems that comply with international certifications such as ISO 9001 and JCI which are integrated in the design and operations of all the hospitals in the group. Corporate level policies, guidelines, checklists and MIS have been developed and implemented for this purpose.

Expansion plans for the IHH group in the next 3-5 years are for approximately 3,300 beds, which will include expansion of existing facilities and opening of new hospitals, which include one in Singapore, three in Malaysia, four in Turkey and one in India. In addition, the group will be operating a new hospital in Vietnam and another new hospital in China under separate hospital management agreements. All these hospitals will involve expansions within countries in which IHH is already established (save for Vietnam) and management systems, including EHS management systems in existing operations will be replicated as far as possible.

All PPL hospitals have an audit risk team that report to the corporate audit risk committee that reviews quality across Singapore and Malaysia. There is a Head of Health and Safety (H&S) in each hospital, with a Director of H&S at the corporate level. Acibadem has environmental engineers based in the Headquarters and has assigned persons in each of the hospitals. There are Health and Safety committees at each site which meet monthly. Most sites implement a health and safety plan and have undertaken risk assessments of the workplaces and prepared Emergency Response Plans. Most sites have performed internal noise, internal air control, electromagnetic wave, nuclear radiation, and noise and vibration measurements and have conducted fire drills.

The group employs more than 24,000 people worldwide. All hospitals have HR policies and working conditions that are compliant with host country labor laws in Singapore, Malaysia, Turkey and India which meet the requirements of IFC Performance standards.

Occupational Health and Safety:
IFC visits to a sample of hospitals indicated that there is evidence of adequate OHS management. In PPL hospitals, six H&S goals are set and progress towards achieving the goals reported to the board quarterly. There is a set of Standard Operating Procedures that are applied for sharps injuries, including treatment of the wound, medical follow up and testing as well as counseling. Acibadem hospitals undertake worker health and safety risk assessments, hazardous chemical substances risk assessments, chemical exposure monitoring and the applicable medical surveillance as required by the local legislation have been conducted. Employees’ radiation exposure is monitored. Work place monitoring systems are extensive and appropriate to the nature and scale of operations.

Resource Efficiency:
During IFC’s 2009 visit to four of Acibadem’s hospitals energy conservation programs were observed to be systematically rolled out across all the facilities and reductions were actively sought. All facilities were LNG-fired and several had co-generation and CHP capabilities.

In response to government incentives, Mount Elizabeth Novena, PPL’s new flagship hospital in Singapore which is due to open in July 2012 has been designed and has been awarded a Green Mark Platinum Award. The Singapore Buildings and Construction Authority Green Mark Scheme differentiates energy efficient buildings. This Platinum award is given for buildings that achieve a minimum 30% energy saving as well as water efficiency and other sustainability initiatives. Although other PPL buildings and renovations are not being designed to such high efficiencies, lessons from designing this efficient building are being transferred to other buildings. Energy efficiencies are achieved through optimum orientation of the building, energy efficient double glazing, glare control and indirect lighting, use of energy efficient ceramic tiles on the façade, heat exchange for climate control, intelligent lighting and generation of renewable energy from photovoltaic cells on the roof to heat water. Other sustainability measures include a toilet flushing system that uses recycled water waste water piped from the municipal treatment facilities and water efficient fittings.

The design of hospitals in PPL is undertaken by a central Project Management department. This team is currently preparing a standard Design Brief for its future hospitals to maintain the quality of the brand internationally.


Pollution Prevention:
At all the hospitals in the group, medical waste management procedures are well established with attention to minimization, segregation and appropriate disposal. Medical waste is removed by contractor to a licenced facility. Radioactive waste generated at a number of hospitals is disposed of by the regulated authority.

The 2009 IFC visit to Acibadem hospitals established that, from available records and procedures on effluent discharge and solid/hazardous waste disposition that Turkish and IFC requirements are being met. Regulatory inspections also indicate compliance. General hospital hygiene and operations have been accredited by JCI which also requires compliance with local EHS laws and regulations.

At PPL, medical effluents from the operating theatres, laboratories and pharmaceuticals are separated, treated as specialty waste and removed by a licensed contractor. Radioactive waste water is handled and discharged according to Standard Operating Procedures that are compliant with regulatory requirements. There is a spill kit and procedures for breakages of thermometers. The hospitals are phasing out use of mercury thermometers.

At the new Mount Elizabeth Novena Hospital in Singapore, decay tanks have been installed to allow the radioactive content of any waste water to decay according to its half-life before removal by a licensed operator. Bio-infectious waste is disinfected and laboratory waste diluted. Periodic samples of the discharges are taken and tested in the laboratory to ensure compliance with the regulatory standards.

The hospitals in Acibadem, PPL and Apollo have all been audited by the local fire authorities, conduct fire drills and have Emergency Preparedness and Response Plans. IFC visits to Acibadem hospitals in 2009 and PPL hospitals in 2012 indicated adequate LFS. The new Novena hospital has lateral evacuation and compartmentalization and each floor has a fire lift and rescue bed lift.

None of the PPL hospitals are in seismically active zones. 8 of the hospitals in Acibadem are located in Istanbul, which is in a seismically active zone.

There is a customer satisfaction system for all facilities. In PPL, public suggestion boxes located around the hospitals and the customer service team talks to patients about their experience. Any complaints are recorded, reported to the senior management of the hospital and responses are given to the patient within 14 days. In addition, an independent company is commissioned quarterly to undertake telephone interviews of discharged patients to obtain feedback. Satisfaction levels are included in the hospital KPIs that are reported to the board.

In terms of social responsibility, Apollo is providing leadership in improving patients’ rights and customer services. Patent and Family Rights policies are in close accordance with the European Patient Rights Reports (Amsterdam, 1994), World Physicians Association Report on Patient’s Rights (Bali, 1995), Turkish Ministry of Health patient Rights Regulations, and Joint Commission International Standards for Hospitals.

Acibadem has been providing in-kind support to many public oriented programs.

PPL hospitals undertake CSR initiatives. At Pantai Hospital in KL, for example, the staff work with an NGO to raise awareness of breast cancer and give around 300 low income women free mammograms and basic health screening.

Broad Community Support is not applicable for this project

Current client performance is aligned with applicable Performance Standards and EHS Guideline requirements. No ESAP is required.