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

This is a category-B project according to IFC’s Environmental and Social Review Procedure because the proposed business activities are considered to involve potentially limited adverse environmental or social risks and impacts that are few in number, generally site-specific, largely reversible, and readily addressed through mitigation measures.

The project''s key environmental and social risks and impacts mainly relate to the following: (a) environmental and social management capacity, (b) compliance with local permits and licenses, including construction and operation permits, (c) labor and working conditions, including occupational health and safety during construction and operation of company facilities, (d) use and conservation of energy and water, (e) protection of community health through adequate building infrastructure and measures to guard against contamination of potable water, sanitation systems, and the like, (f) solid waste management, including transport and disposal of hazardous waste, and (g) emergency preparedness and response, especially life and fire safety.

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.

Policy



While in its day-to-day practices Rede D''Or demonstrates a strong commitment to addressing environmental and social issues proactively and responsibly, the company currently does not have in place a single, comprehensive policy regarding its approach to identifying, mitigating and/or managing its principal risks and impacts across all of its operations. Rather, it has relatively well-developed components of an approach in key operational areas (as described below) that have yet to be fully integrated and communicated explicitly throughout the organization or externally as a visible policy. In accordance with the ESAP, Rede will therefore develop a comprehensive environmental and social policy – to be approved at the board level – and communicate it widely throughout the organization and to key stakeholders by December 31, 2014.



Identification of Risks and Impacts



Brazilian law does not require Environmental Impact Assessments for new hospital development or expansion of existing units. New facilities must obtain a series of construction and operating licenses applicable to hospitals; in certain municipalities, including where Rede D''Or operates, completion of a Neighborhood Impact Assessment (Estudo de Impacto de Vizinhança) is needed for construction projects. These studies typically involve an analysis of basic environmental considerations, impacts from noise and traffic, and effects on local property valuations. All hospitals are also required to have a hospital waste management plan (known by its Portuguese acronym, PGRSS) approved by relevant authorities. Construction of new hospitals wings or greenfield units, much of which is managed intensively by a large in-house team, is underpinned by a strong approach to designing and building structures in ways to minimize risks or impacts and to maximize resource efficiency.



Beyond these regulatory requirements, Rede D''Or has in place robust systems and processes for identifying virtually all of its key risks and impacts. This includes, in particular, its "checklist" system used for diagnosing significant equipment, maintenance, performance, and training gaps for newly-acquired hospitals. This diagnosis then allows for vigorous follow-up and resolution of these gaps to minimize, eliminate, or otherwise manage key risks (see below under "Management Programs" for a more detailed description of this system). In addition, its Integrated Health and Safety System (Gestão Integrada de Saúde e Segurança, or GISS, in Portuguese) – which was first developed within the São Luiz group of hospitals, acquired in 2010, and since rolled out in all Rede D''Or hospitals – is based on a very solid approach to operationalizing the corpus of Brazilian occupational risk, health, and safety norms known as the normas regulamentadoras (see description under Performance Standard 2 for more details). Handling of hazardous hospital waste is also highly regulated in Brazil, and Rede D''Or is both
cognizant of the attendant risks and conscientious in monitoring disposal of such waste by third-parties.



As part of the process of articulating and publicizing an overall policy to environmental and social issues (see ESAP Item above), Rede D''Or will by December 31, 2014, also review the company''s current approach for identifying risks and impacts in light of Brazilian regulatory requirements, good international industry practices, and the World Bank''s Environmental, Health, and Safety (EHS) Guidelines for Health Care Facilities.



Management Programs



Rede D''Or has four interrelated sets of management programs and systems that encompass environmental and social issues. These are (1) an internal quality assurance process for its facilities (known as the "checklist" system), which is described in further detail in this section, (2) its Integrated Health and Safety System (known as Gestão Integrada de Saúde e Segurança, or GISS), which is described below under Performance Standard 2, (3) its integrated human resources system, also described under Performance Standard 2, and (4) performance oversight efforts, both at an operational level and in pursuit of third-party quality certifications, such as Joint Commission International (JCI),



Rede D''Or''s checklist system is led by the infrastructure and services directorate at the corporate level, but it includes personnel from and looks at issues that also relate to other teams'' competences such as occupational health and safety (OHS), emergency preparedness and response, and environmental performance. The highly comprehensive checklist has close to 400 items (across six broader categories) that are first self-scored by the hospital unit in question and then reviewed and discussed on a regular basis between corporate personnel and hospital leadership. These follow-up discussions cover issues ranging from the existence of site-specific operational norms and procedures to management of the hospital''s infrastructure and availability of appropriate technical staff. Pending items are then transformed into a hospital-specific action plan, which is tracked over time.



The checklist is applied most intensively when a hospital has just been acquired, and Rede is seeking to close its most serious performance gaps, primarily within the first 1-2 years after acquisition. Checklist visits are therefore carried out on semi-annual basis for newly-acquired hospitals and on a yearly basis for all hospitals. In addition, Rede D''Or''s audit and compliance team assists the company''s top management in conducting monthly meetings on overall performance at each hospital; this quality control and assurance process encompasses aspects of environmental and social performance as well. This links directly to Rede D''Or''s efforts to achieve third-party quality certifications for each of its hospitals. Its premium or flagship hospitals have been or are being certified under JCI whereas its remaining hospitals h
ave achieved or are seeking certification under a Brazilian standard, Organização Nacional de Acreditação (ONA), which is then in some cases also confirmed by Accreditation Canada. Under the hospital certification schemes, audit and recertification activities are frequent (every 2-3 years) and include the identification of high-risk health and safety conditions applicable to workers and patients as well as investigation of serious occupational accidents or patient injury or death as well as recording of near-misses. If applicable, these events are investigated in depth to develop necessary corrective action plans. Rede D''Or''s third-party certification efforts were noted by staff to have played a highly positive role in improving group-wide standards and encouraging cross-functional working groups and transfer of innovative practices within the company.



Organizational Capacity and Competency



Rede D''Or has both corporate-level teams and hospital-specific staff who are responsible for managing elements of the company''s overall ESMS and for implementing or monitoring specific activities. At the corporate level, four interrelated groups focus on environmental and social issues on a day-to-day basis. These are (1) facilities, maintenance, nutrition, and housekeeping, which reports to the infrastructure and services directorate, (2) human resources, and (3) occupational health and safety (known by the standard Brazilian name, Serviço Especializado em Engenharia de Segurança e em Medicina do Trabalho, or SESMT), which reports to human resources but also handles some environmental issues, and (4) audit and compliance, which handles issues such as licensing and reporting to authorities but also manages Rede''s cross-cutting efforts to achieve quality certifications under JCI, Accreditation Canada, and ONA by developing and applying a comprehensive system of internal controls.



The senior managers and mid-level staff whom the IFC met in these functions are all well-trained, well-seasoned professionals, often with years of experience in their areas. Most of the senior managers have served with Rede D''Or or one of the predecessor hospitals acquired by the chain for a decade or more. These centralized corporate functions ensure that the company''s policies, standards, and procedures are clearly articulated and consistently applied, and corporate staff provide support and oversight for hospital-level processes, procedures, and staff. In addition, they attempt to identify and disseminate good practices developed at one hospital throughout the chain. Each hospital is led by a team of senior managers, including a director-general (often but not always a physician by training), a clinical director (always a medical doctor), and an operational director (often a former physician as well), all of whom are highly experienced and have often worked for decades with Rede D''Or or a predecessor hospital. Hospital-level staff responsible for environmental and
social functions, who can vary in number based on the size and complexity of the unit, report to the operational director but also receive frequent visits and support from corporate-level personnel involved in quality control, occupational health and safety and/or facilities management. (There is an additional layer of regional management, responsible for oversight and support on financial and operational issues for a number of hospitals within a region, but the regional director''s role is not as directly relevant to environmental and social issues as the above-mentioned functions and therefore not discussed here.)



Training



Rede D''Or operates in a heavily competitive market for private healthcare workers where its commitment to training and supporting its staff is a key strategy for ensuring superior performance and for retaining able, well-experienced personnel over time. During its appraisal IFC encountered numerous staff related to environmental and social performance who had served with distinction at one hospital in a junior or mid-level role and were then transferred to a corporate role or to a newly-acquired unit in a mid-level-to-senior role to help with the successful integration of such hospitals according to the group''s corporate standards. In addition to accelerating the uptake of the group''s ethos and practices, this helps with skills transfer. This process involves considerable on-the-job training and support in addition to any formal instruction. As noted elsewhere in this summary, Rede D''Or not only invests in training its personnel responsible for environmental and social management for functional roles, but also supports additional internal capacity-building efforts and formal external training (e.g. fire department trainings for emergency response teams, as described below).



Emergency Preparedness and Response (EPR)



Rede D''Or has a well-developed approach to emergency preparedness and response, given the constraints of a hospital environment (where it is not feasible to perform full-on fire drills during day-to-day operations, for example). Rede D''Or follows all relevant state norms on emergency preparedness and fire safety. The company has a master emergency plan (plano de emergência), which each of its units is also expected to formulate at the local level. These plans are to contain an evacuation plan, a communications plan, training program, drills, fire response plan, and a response plan in the event of a catastrophe or disaster with multiple victims. Specifically, each local emergency plan describes key characteristics of life and fire safety at the site''s building(s), ward by ward, floor by floor, and identifies potential risks in each, particularly those stemming from the potential for accidental fires or similar events. The plan describes escape routes for use during any evacuation and provides guidance on procedures for crisis response, including external contacts, such as for the local fire depa
rtment, and each hospital has clearly designated personnel for a crisis management team. In addition, Rede D''Or has established contingency plans in the event of any critical failure (of drinking water, power supply, or medical gases).



For most of its units around the country Rede D''Or has established emergency response teams covering all wards/floors and shifts at a given location, to ensure at least a minimum emergency response capacity at all times. Rede D''Or sends staff appointed to emergency response functions (known in Brazil as brigadistas) to structured trainings offered by state-level fire departments. Given the constraints of hospital operations, the company is not able to conduct fire drills for its ongoing hospital operations on a comprehensive basis, but it does seek to run drills with personnel outside of operational areas. For example, the company took advantage of the recent remodeling of a ward to conduct a sophisticated simulation with a significant number of personnel in a vacant area in one of its hospitals. The company also seeks to develop and maintain a proactive relationship with local fire departments (whose personnel rotates often) so that first responders are familiar with Rede D''Or''s buildings, staff, and operational challenges.



In the course of the appraisal it came to light that the company does not have emergency response plans and emergency response teams in place for all of its units. As a condition of disbursement under the ESAP, Rede D''Or will therefore provide the IFC with an up-to-date summary of the status, by hospital, for (1) its fire safety certificate (Auto de Vistoria do Corpo de Bombeiros, AVCB, or equivalent), (2) the completeness of the unit''s emergency response plans, (3) designation of crisis management and emergency response teams, and (4) the status of yearly trainings (both internal and external) for emergency response staff. The company will address any gaps in these arrangements through an internal action plan.



Monitoring and Review



Rede D''Or has a company-wide commitment to continuous improvement of the medical care and patient experience that it offers. Given the threat of hospital-related infections, quality of care and patient experience are therefore closely related to underlying systems for managing hospital wastes and minimizing or mitigating other risks. Together with financial performance, the quality of medical care and patient experience is the subject of monthly monitoring and review meetings with the management team at each hospital, and performance-based bonuses for senior operational managers are tied directly to these elements – and not just financial results – at a given hospital. This more inclusive monitoring and review process also seeks to identify and address gaps or shortcomings in environmental and social performance that can affect overall hospital performance, particularly on issues of environmental safety and health.



External Communications a
nd Grievance Mechanisms



Rede D''Or has established a number of mechanisms for stakeholders to raise concerns or lodge grievances with the company regarding its services or practices. These include a telephone line (ouvidoria) for complaints from patients or their families, principally related to the quality of care and/or patient experience, and the internal Canal da Ética described below, under PS2, for worker grievances. The company has no external complaint system as such, for example receiving grievances from residents next to its facilities, suppliers, or other stakeholders (although they could presumably use the toll-free ouvidoria telephone number to register such complaints). The company is currently reviewing the set-up and functioning of the ouvidoria system. As part of this review and under the ESAP, Rede D''Or will explore ways to redesign the ouvidoria system by December 31, 2014, to make it clear that issues, questions, and grievances unrelated to quality of medical services or patient care are also possible to raise through this channel, including for example complaints from communities adjacent to Rede D''Or construction projects related to noise, dust and/or traffic. These changes to the ouvidoria system will be communicated internally and externally through various means, by March 31, 2015.



Ongoing Reporting to Affected Communities



Ongoing reporting to Rede D''Or''s stakeholders is one area of apparent weakness in the company''s approach to managing environmental and social risks. The group currently has no consolidated external report on environmental and social performance, whether as part of its annual report, as a stand-alone publication, or as a detailed area of its public website. The ESAP therefore urges Rede D''Or to begin reporting publicly on an annual basis regarding the key risks, impacts, indicators, and other aspects of environmental and social performance by June 30, 2016 (to cover calendar year 2015), and it will seek to use this public reporting as a means for engaging with and informing its principal stakeholders of its approach and activities in this realm.

Working Conditions and Management of Worker Relationship



Rede D''Or has established a highly professional approach to attracting, training, and retaining a well-qualified workforce. In a very competitive market for skilled healthcare personnel, the company maintains a sizeable workforce of approximately 30,000 employees and 900 contractors, with a turnover rate of 3.5 percent, which is considered excellent by industry standards. Female workers constitute approximately 74% of the company''s workforce, which is located across operational activities in Rio de Janeiro, São Paulo, Recife, and Brasilia (Federal District). The company''s operations have grown significantly over recent years and are expected to continue to grow given its ongoing acquisition and expansion activities.



The company has a code for workplace conduct applicable to all the employees, which includes statements regarding non-discrimination, equal opportunities, and protection of the workforce. In addition, its human resources department has documented procedures including hiring, selection, disciplinary measures, transfer of employees, payment of benefits, and the like. Its HR strategy seeks to create a structured approach to human resource management, career development, and professional advancement, including by posting all of its human resources policies and procedures on the company intranet, and the company has developed its own in-house software for HR management. The practical elements of its HR strategy are to focus on onboarding new staff quickly and effectively, to attend to employees'' occupational health and safety (see below under "Occupational Health and Safety"), to provide areas for relaxation during breaks, to give regular feedback on employee performance, to recognize superior work publicly, and to offer competitive benefits, including the performance-based bonuses. Rede D''Or invests heavily in feedback, training, and education for its staff, including a formally structured training program for different employee types and categories (e.g. frontline employees involved in patient care vs. cleaning and food services vs. managers), specialized courses on specific topics in healthcare, and educational opportunities outside of the company''s in-house offerings. Rede D''Or regularly conducts employee satisfaction surveys, the results of which are transformed into an action plan for improving the workplace environment, and it has an in-house grievance mechanism, Canal da Ética, that employees can access anonymously. Complaints submitted through this mechanism are handled by Rede D''Or''s audit and compliance team, which maintains the company''s system of internal controls but also coordinates with the HR department or other relevant department for the resolution of grievances. The company did not report any significant cases of investigations or lawsuits by the Public Prosecutor for labor issues.



Non-Discrimination and Equal Opportunity



Rede D’Or has well-
defined statements regarding non-discrimination and equal opportunity. Fair treatment is observed in the company, including processes of hiring, promotion and termination of employment. Rede D’Or has a well-defined selection process, an annual performance assessment, and leadership programs to promote personnel with defined skills.



Protecting the Workforce



Rede D''Or systematically applies all Brazilian legislation and regulations on labor standards, including respect for labor rights, minimum age requirements, and prohibitions against forced labor. Conditions of employment are defined in the contracts that Rede D’Or signs with its employees and in the list of benefits, both of which are communicated to the employees during induction. The company employs workers associated with close to 50 different occupational and regional unions; a significant portion of the workforce belongs to affiliates of Brazil''s main nursing and healthcare worker unions. Collective agreements further define the benefits and conditions of employment. In addition to benefits defined in Brazilian legislation, employees have access to a health care plan, dental services, pharmacy discounts, transportation subsidies, and grants for educational courses offered by Rede D’Or. The company does occasionally employ young workers as part of the Menor Aprendiz program, but it does so within the rules and norms of this government-sanctioned program, including protecting participants against handling hazardous materials or engaging in any hazardous activities. For all other workers the minimum age for employment is 18 years.



Occupational Health and Safety



Rede D’Or manages OHS risks by seeking compliance with Brazil''s national and local regulations, which constitute a comprehensive and well-defined system of norms and procedures. The company meets Brazilian requirements for its hospitals, for example, by implementing a generic mandatory Risk Prevention Plan (known by its Portuguese acronym, PPRA) and Health Monitoring Program (PCMSO), providing training and personal protective equipment for its employees, and applying a specially-defined Brazilian regulatory norm (norma regulamentadora) for the health sector: Safety and Occupational Health in the Health Services (known as "NR-32").



As part of its shared services department, the company has a corporate OHS group based in its headquarters and staffed by six safety specialists. Throughout all of its hospitals Rede D''Or has a total of 168 OHS staff, including safety engineers, safety technicians, and physicians and nurses specialized in occupational health. The OHS team is responsible, together with the whole human resources department, for communicating with all of Rede D''Or''s hospitals and monitoring compliance with Brazilian occupational health and safety requirements, especially the compulsory use of appropriate personal protection equipment given different work-related risks. Requirements also include setting
up internal committees for accident prevention (CIPA), which are responsible for investigating and analyzing occupational accidents, incidents, and health issues, as well as the above-mentioned processes of identifying and preventing workplace environmental risks (PPRA), monitoring occupational health (PCMSO), and complying with the regulatory norm on Safety and Occupational Health in the Health Services (NR-32).



Rede D’Or records and investigates all lost-time accidents, with records readily retrievable from its databases, and it can demonstrate follow-up after accidents and implementation of measures to prevent recurrence of such incidents. Despite these measures, the lost-time variations frequency rate for Rede D’Or’s operating sites vary considerable: from highs of 67 and 51.5 in the Distrito Federal and Rio de Janeiro, respectively, to a moderate rate in Pernambuco (43) and the lowest rate in São Paulo (38). While many of these injuries are relatively minor, the overall lost-time accident frequency rate is high, and clearly some locations are more problematic than others. Moreover, there is some evidence of the recurrence of preventable incidents, such as cuts and punctures from sharp instruments. A major constraint cited by Rede D''Or staff is the large number of affiliated specialists who use Rede D''Or facilities, often with their own surgical or support personnel, increasing the difficulties associated with a rigorous, unified system for avoiding workplace injuries. Under the ESAP, Rede D''Or will therefore develop an internal action plan by October 31, 2014 for reducing or even eliminating the most persistent workplace injuries.



As part of its expansion plans, Rede D''Or anticipates increase its total number of beds by 1,900 through a series of brownfield and greenfield projects. While a 70-person in-house team manages the design, permitting, and construction of additional hospital wings or brand-new hospitals, the company does outsource the actual construction of such structures to qualified companies. Rede D''Or currently monitors OHS of such third-party construction workers through checks on contractors'' application of the standard Brazilian regulatory norm on civil construction (this norm, referred to as NR-18, is also known by its Portuguese acronym, PCMAT for "Programa de Condições e Meio Ambiente de Trabalho na Indústria da Construção Civil"). In addition, Rede D''Or frequently has smaller-scale remodeling, repair, or maintenance work (e.g. external window-cleaning) underway where there may be significant occupational health or safety risks. Under the ESAP, Rede D''Or will also a establish its own in-house guide for managing and overseeing OHS vis-à-vis third-parties, applying a checklist approach that will serve as the basis for identifying and discussing any performance gaps with contractors. This guide will be developed by December 31, 2014, site supervision staff will be trained in it by February 28, 2015, and the en
hanced system will be applied as of March 1, 2015, with the results on contractor compliance reported for each calendar year to the IFC through the Annual Monitoring Report.



Workers Engaged by Third Parties



Rede D''Or outsources a number of ancillary support services for its operations, including imaging diagnosis, unarmed security, specialized maintenance functions (HVAC, elevators, and medical equipment), and catering services at many of its hospitals (particularly for food services for non-patients – most food for patients is prepared in house). Outsourced services also include transportation and disposal of solid waste, including hazardous hospital waste, and transport of radioactive drugs. Standard contract clauses require such companies to respect worker rights, maintain all occupational health and safety protections, and pay all social security and similar payments required by Brazilian legislation and regulations. Third-party performance is managed through the monthly receipt and review of contractors'' worker payments and other requirements of staff contracts. As noted immediately above, Rede D''Or''s ongoing operations and expansion projects encompass some high-risk work activities executed by third-parties for which the company will be monitoring contractor OHS performance through an internal guide and monitoring system required under the ESAP. In addition, Rede D''Or will publicize the availability of its ouvidoria system – to be revamped by December 31, 2014, under the ESAP to include non-patient-related grievances as well – so that third-party workers have a channel to raise issues or lodge complaints directly with the company.



Supply Chain



Rede D''Or buys standard hospital supplies, medications, office supplies, and other inputs necessary for maintaining its operations (gases, fuel, etc.). A key element of its business strategy is to aggregate purchasing at the central level and seek cost savings through renegotiated contracts with suppliers. Part of its supply chain also involves removal and disposal of hazardous hospital waste, which is discussed under Performance Standard 4 (Community Health, Safety, and Security). Aside from its focus on realizing savings through bulk purchasing, Rede D''Or did not report having any special measures in place for verifying the labor practices used by suppliers in its supply chain. The company does, however, require third-party contractors working at its hospitals to undergo an induction program that identifies specific risks related to the work to be done and how those risks will be mitigated.

IFC’s assessment considered the project’s compliance with environmental requirements, optimization of resource inputs, including energy efficiency and waste minimization practices, as well as the storage and handling of hazardous materials used in the construction and operations of facilities.



Resource Efficiency



Rede D’Or is strongly oriented toward optimizing the use of resources including electricity and water. All facilities use efficient cold light bulbs, which save energy and reduce the internal thermal load. Whenever feasible, the design of new buildings has incorporated the use of natural lighting to reduce the use of electricity. The company will continue to identify opportunities to conserve resources in its operations, including in the construction of new facilities. The group''s energy use is 24,750 kWh/bed, which compares favorably with the global benchmark for hospitals (30,000 kWh/bed).



All units have auxiliary power from backup diesel generators for 30-60 minutes, depending on the hospital. It is also a Group policy to have at least two diesel generators on stand-by at each unit to maintain the power supply for at least 6 hours in case of emergencies. There are contingency plans for receiving extra fuel quickly in the event of longer periods of energy shortage. In order to save on costs of energy sourced from the main power grid, some facilities use their generators on a daily basis during peak consumption periods (in the early evening).



Given the scope and extent of Rede D''Or''s planned construction activities, the IFC encourages the company to seek to incorporate further resource efficiency gains in the design of any new hospitals or wings it plans to build.



Pollution Control



Water Supply: The water used in hospital facilities is always provided by the local municipal or state water companies. All facilities are further equipped with dechlorination and activated carbon filtration systems to further treat municipal water prior to internal consumption and use in medical or other activities. Water quality monitoring is performed by an external service provider on a monthly basis.



Indoor Air Quality: The company contracts service providers to perform periodic testing and cleaning of internal air ducts to safeguard the health of employees and patients and prevent transmission of infectious agents through the internal ventilation system.



Management of Solid and Hazardous Waste



Rede D’Or has a corporate hospital waste management plan (known by its Portuguese acronym, PGRSS) in accordance with the Brazilian regulation No. 306 of ANVISA (National Agency for Sanitary Vigilance), issued in 2004, and Resolution No. 358 of the National Environmental Council (Conselho Nacional do Meio Ambiente, or CONAMA), issued in 2005. All waste generated in the company''s hospitals is collected, stored, and disposed of following this corporate hospital waste management plan, which is adapted at the facility level dep
ending on the types of waste streams generated at each location. The plan includes procedures for the segregation and management of waste flows inside the units and for their proper handling, collection, temporary storage, and transport and disposal.



The hospital chain generates three broad types of liquid and solid wastes consisting of (i) common household waste from the patient care areas, kitchens, coffee shops, and toilets; (ii) infectious waste, which is specially collected and stored in a segregated manner; and (iii) chemical waste, which is also specially collected and stored in a segregated manner. All wastes are accumulated in temporary storage areas, where they are collected by external service providers licensed by relevant environmental authorities for transport, treatment, and disposal. Common and organic wastes are disposed of at a sanitary landfill, while chemical, infectious, and skin-piercing wastes are incinerated by a licensed company. All such service companies are audited by representatives of the hospitals'' infection control committees. Hazardous substances from the hospital group''s biological laboratories are treated separately and collected by a certified company due to the pathological risks of discharge via laboratory effluents.



Liquid effluents, mainly those from sanitation and food services, are in most cases discharged into the municipal sewage systems. All the units connected to the municipal sewage network are equipped with a “filter sink” consisting of decantation, filtering, and chlorination, which provides an initial pre-treatment of hospital effluents prior to the discharge into the public sewer collection and treatment network. Rede D’Or complies with the conditions defined in its operating licenses, including the collection and disposal of sludge by authorized companies.



The sites for temporary storage of waste – whether domestic waste, chemical waste, or hazardous waste – were observed by the IFC to be clean, well-organized and with appropriate access restrictions, thereby preventing contact with or handling by unauthorized people. The company''s PGRSS requires the tracking and monitoring hazardous wastes in spreadsheets, which are forwarded to the audit and compliance department in headquarters on a monthly basis.



Rede D''Or also seeks to minimize the storage of hospital supplies composed of hazardous materials, such as fuel (for diesel generators) or radioactive agents. As much as possible, materials are purchased on demand and supplied by specialized firms. All personnel involved in handling these substances receive training and the required protective equipment.



For non-hazardous wastes, there is a policy of selective collection of cardboard, white paper, metal, plastic and glass. Garbage bins for separating recyclable waste streams are distributed throughout the units.



Green House Gas Emissions



The company’s direct and indirect emissions of greenhouse gases (GHGs) from
fuel consumption by diesel-powered auxiliary generators and from its general electricity consumption do not exceed 8,500 tons of CO2 equivalent/year. The company is therefore not considered to be a significant emitter of GHGs.

Infrastructure and Equipment Design and Safety



Company facilities are regulated by ANVISA (the National Agency for Sanitary Vigilance), which reviews and approves hospital engineering designs, issues operating licenses, and regularly inspects all of the group''s hospitals for compliance with patient health and safety requirements. Both the company and this public agency monitor patient morbidity and mortality statistics as indicators of company performance and quality of care. In addition, the company monitors readmission rates to determine whether its healthcare services have been fully successful; it otherwise analyzes cases of readmission to identify shortcoming in its care and management systems.



The company takes active steps to manage and reduce the risk of hospital-related infections. In all of its hospitals it currently implements clinical and non-clinical risk management committees to prevent hospital infections (known by its Portuguese acronym, CCIH). These committees analyze infection risks and monitor the effectiveness of prevention and control measures, including waste collection, access control, and facility cleaning, and they are also involved in investigating cases of hospital-related infections to understand and address their causes. As noted above, the company has secured or is currently in the process of securing quality accreditation for all of its hospitals under one or more of the following schemes: the Brazilian National Accreditation Organization (ONA), QMentum/Accreditation Canada, and Joint Commission International (JCI). Assuring high-quality patient health and safety management are key standards under these schemes.



Under the first investments that the IFC made in Rede D''Or and the São Luiz hospital group, which was absorbed into the company in 2010, the IFC required the hospitals to introduce life and fire safety features into expansion and greenfield designs according to international standards that go beyond Brazilian regulatory requirements. For example, a hospital owned by São Luiz was required to include sprinkler systems at a late stage of the design process for an expansion wing (at that time, São Paulo''s fire code did not include this requirement, which was only added in 2010). Under the ESAP for the first investment, Rede D''Or was to design and construct any greenfield building or expansion project on the basis of international life and fire safety (L&FS) norms and not just local Brazilian fire-code requirements. The company was to contract an independent third-party consultant to ascertain that such features were duly included in designs and then verify that structures were built accordingly. During the appraisal for the second investment it came to light that international L&FS norms were not fully applied to structures built under the first investment, and the IFC and the company are currently determining the best course of action to rectify this non-compliance.



Under the ESAP, Rede
D''Or will develop a comprehensive guide (master plan) for new hospital construction – whether greenfield or expansion projects – with regard to life and fire safety systems. The relevant corporate standards for design criteria and minimum technical requirements, due by December 31, 2014, will be based on internationally accepted codes and standards, such as those of the U.S. National Fire Prevention Association (NFPA), in addition to whatever Brazilian legislation and norms might require. The client will monitor and report to the IFC on how these corporate criteria and minimum requirements on L&FS are applied to each new construction from January 2016 onward. Any updates or modifications to this guide will be reviewed by an independent L&FS expert. For those greenfield or expansion projects for which construction has begun or will begin in 2014-15, the L&FS requirements of the ESAP for the first IFC investment will apply, namely that the client will engage the professional services of a Life and Fire Safety Engineer specialized in international norms (such as those of the NFPA) to review the design of the L&FS system for buildings currently scheduled for construction in 2014-15 and to carry out post-construction inspections to verify that the system was installed as designed.



Hazardous Materials Management and Safety



As required by Brazilian legislation and the hospital group''s operating licenses, Rede D''Or manages hazardous wastes in accordance with relevant norms and regulations. Please see above under PS3 (Resource Efficiency and Pollution Prevention) for more details on these measures.



Community Exposure to Disease



As required by Brazilian legislation and the hospital group''s operating licenses, Rede D''Or manages community exposure to communicable diseases accordance with relevant norms and regulations. Please see above under PS3 (Resource Efficiency and Pollution Prevention) for more details on these measures.



Emergency Preparedness and Response



The company has a formal management program to ensure compliance with local life and fire safety (L&FS) requirements across all of its operations. In addition, Rede D''Or seeks to adopt a proactive approach to prevent incidents that could cause a fire or any other emergency that would require moving or evacuating patients, for example, regular inspections to ensure that CO2-based kitchen fire suppression systems and any equipment operating under pressure are functioning properly. As noted above under PS1, measures also include a well-developed system for emergency preparedness and response. Most units have emergency plans, evacuation plans, and contingency plans, based on standard Rede D''Or requirements but which are tailored to the location, size, and physical characteristics of each hospital, in order to address situations such as fires, power failure, lack of water, release of medical gases, etc. The company also trains its staff on fire safety including communication
in case of fire alarms, joint tactical actions designed to isolate and extinguish fires using manual or automatic equipment, classification of the types of fires and fire suppression methods (i.e. suffocation, compartmentalization, cooling, and chemical suppression), and finally the types of fire extinguishers and fire hydrants and their correct use. Most units have specialized response committees (known as brigadas) for preventing and responding to fires or other emergencies. The company is currently developing an internal action plan to ensure that all units will have such committees and that staff undergo regular training provided through local fire departments, with whom Rede D''Or seeks to maintain close, proactive relations.



As noted above under PS1, there are a number of ways that Rede D''Or''s approach to emergency preparedness and response, and life and fire safety in particular, could be improved. ESAP Action Items have therefore been included on updating the company''s emergency response plans, on developing corporate guidance on new-building design from a L&FS perspective, and on outside review and post-construction verification by qualified L&FS experts specialized in international (e.g. NFPA) norms regarding building designs for expansion projects or greenfield sites.



Security Personnel



Rede D''Or employs unarmed security guards, both in-house and contracted via third parties, for access control and emergency response purposes.

Rede D''Or currently has multiple mechanisms for patients/clients and for its own staff to raise issues with the company''s management regarding quality of service or workplace concerns, but the company does not currently have a specific measures in place to consult with neighbors – whether commercial or residential – regarding construction projects and the disruptions from noise, dust, and traffic that might accompany them. Brazilian national legislation (Estatuto da Cidade) established the principle that municipalities should require Neighborhood Impact Assessments (estudos de impacto de vizinhança, or EIV) for analyzing and managing disruptions that could arise from larger-scale construction projects, but municipalities are left to define the specifics of how to regulate this issue. Therefore, in municipalities where an EIV is not already required, Rede D''Or will, as part of the ESAP, nonetheless commission such a study for all construction or major renovation projects before the issuance of the municipal construction permit (alvará de construção or equivalent). The company will make such all such studies available on its website and use signage at the worksite to publicize both the availability of the EIV and the existence of the ouvidoria as a channel for the general public to register complaints with the company.

Rua Voluntários da Patria, 138
CEP 22270-010
Rio de Janeiro, RJ Brazil

Broad Community Support is not applicable for this project

Title	Anticipated completion Date	Status	Comments	Completion Date
Policy: Develop a comprehensive environmental and social policy, to be approved at the board level, and communicate it widely throughout the organization and to key external stakeholders.	12/30/2014	Completed	Completed	12/23/2014
Risk Identification: Review the company's current approach for identifying risks and impacts in light of Brazilian regulatory requirements, good international industry practices, and the World Bank's Environmental, Health, and Safety (EHS) Guidelines for Health Care Facilities.	12/30/2014	Completed	Completed	12/23/2014
Emergency Response System: Provide the IFC with an up-to-date summary of the status, by hospital, for (1) its fire safety certificate (Auto de Vistoria do Corpo de Bombeiros, AVCB, or equivalent), (2) the completeness of the unit's emergency response plans, (3) designation of crisis management and emergency response teams, and (4) the status of yearly trainings (both internal and external) for emergency response staff.	10/30/2014	Completed	Completed	10/27/2014
Life and Fire Safety: Based on the advice of a consultant specialized in international norms, develop a comprehensive internal guide (Master Plan) for new hospital construction – whether greenfield or expansion projects – with regard internationally accepted life and fire safety standards and apply this guide to all new constructions from 2016 onward. Any updates or modifications to this guide will be reviewed by an independent expert.	12/30/2014	Completed	Completed	11/04/2015
Life and Fire Safety: For those greenfield or expansion projects for which construction has begun or will begin in 2014-15, engage the professional services of a Life and Fire Safety Engineer specialized in international norms (1) to review a Master Plan (engineering design) for buildings currently scheduled for construction by end-2015 and (2) to carry out post-construction inspections to verify that the system was installed as designed.	12/30/2015	Completed	Completed	11/29/2015
External Grievance System: Redesign the ouvidoria system to include external issues, questions, and grievances unrelated to quality of medical services or patient care.	12/30/2014	Completed	Completed	12/23/2014
External Grievance System: Publicize changes to the ouvidoria system to make it clear that external issues, questions, and grievances unrelated to quality of medical services or patient care are also possible to raise through this channel.	03/30/2015	Completed	Completed	11/04/2015
Public Reporting: On an annual basis, report publicly on the company's key risks, impacts, indicators, and other aspects of environmental and social performance.	06/29/2016	Completed	Completed	05/30/2016
Workplace Injuries: Develop an internal action plan by, for reducing or even eliminating the most persistent workplace injuries.	10/30/2014	Completed	Completed	10/27/2014
OHS for Third-Party Construction Workers: Establish an own in-house management guide for OHS in civil construction, applying a checklist approach that will serve as the basis for identifying and discussing any performance gaps with contractors. Train site supervision staff in this system and begin applying it to all construction projects.	12/30/2014	Completed	Completed	12/23/2014
OHS for Third-Party Construction Workers: Train site supervision staff in the new in-house management guide for OHS in civil construction and begin applying the checklist system to all construction projects.	02/27/2015	Completed	Completed	11/04/2015
Stakeholder Engagement (2015): If not already required, commission a Neighborhood Impact Assessment (EIV in Portuguese) for all construction or major renovation projects in 2015, make such available on the company's website, and use signage at worksites to publicize them and the ouvidoria (grievance mechanism).	12/30/2015	Completed	Completed	11/04/2015
Stakeholder Engagement (2016): If not already required, commission a Neighborhood Impact Assessment (EIV in Portuguese) for all construction or major renovation projects in 2016, make such available on the company's website, and use signage at worksites to publicize them and the ouvidoria (grievance mechanism).	12/30/2016	Completed	Completed	01/01/2017
Stakeholder Engagement (2017): If not already required, commission a Neighborhood Impact Assessment (EIV in Portuguese) for all construction or major renovation projects in 2017, make such available on the company's website, and use signage at worksites to publicize them and the ouvidoria (grievance mechanism).	12/31/2017	Pending	In Progress