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
PS5 does not apply because the project will be developed on land already owned by the company, clear of legacy disputes, and there is therefore no new land acquisition or involuntary resettlement involved; PS6 does not apply because the project will be developed on modified habitat with no significant biodiversity value and not providing priority ecosystem services; PS7 does not apply because the project will not cause adverse impacts to indigenous peoples; and PS8 do not apply as there is no known cultural heritage in the project or its area of influence.

This project has been provisionally classified as a Category B project. Social and environmental issues to be reviewed during appraisal include: Conclina’s Environmental and Social Management System (ESMS) and assessment of the Company''s capacity to manage environmental and social issues during construction (expansion), and operation of the hospital; operation, including life and fire safety, water, wastewater and waste management as appropriate; management of hazardous materials including bio-hazards; use of sustainable materials and appliances; labor and working conditions, occupational health and 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.

Environmental and Social Assessment and Management System



The project entails the remodeling and relocation of clinical services within the actual Hospital Metropolitano building. No new permits will be required for the project, but all modifications to be undertaken will be notified to the corresponding relevant authorities before the beginning of project activities.



Hospital Metropolitano is accredited by the JCI, whose mission is to provide safe and effective care of the highest quality and value to the public. In order to obtain the certification, all management systems of the organization are assessed and certified every three years, to maintain accreditation. The company has also certified its Service Quality management under ISO-9001:2000 (2007). The company has put in place a system to manage its impacts to the environment, and has been approved by the Ministry of Environment and the Secretary of Environment. The company’s management systems are in material compliance with PS1 requirements.



Policy



Hospital Metropolitano’s Environmental objectives are: (i) to prevent pollution to the environment; (ii) to reduce the use of natural resources; and (iii) commitment to reduce, recover and recycle residues as much as possible. All these actions are aimed to comply with Ecuadorian environmental regulations. The company will also: train, raise awareness and implement all the activities that are specified on its environmental management programs. The environmental policy is disclosed on its facilities and distributed to all employees.



Identification of Risks and Impacts



The Hospital Metropolitano undertook an Environmental Impact Assessment of its activities, in March 2013, and it was the base to develop its Environmental Management Plan. The assessment is due to be updated on December 2015. All major renovations of the facility and/or installation of new equipment are assessed by an internal committee of OHS. Then, the project has to be notified to the municipality, who should approve and provide recommendations depending on the project’s to potential impacts and compatibility with current permits.





Management Programs



As part of its environmental management system, Hospital Metropolitano has developed and implemented the following management programs: (i) prevention and reduction of pollution program; (ii) plan for contingency due to environmental emergencies; (iii) environmental monitoring program; (iv) follow-up plan from activities proposed on the environmental management plan; (v) community relationship plan; (vi) occupational health and safety plan; and (vii) training and education.





Organizational Capacity and Competency



The Hospital Metropolitano has put in place the necessary organizational structure with personnel adequately trained to implement, maintain and strengthen the ESMS. There is a unit for environment; health and safety (HSE) that reports to both the general manager and the director of Infrastr
ucture and logistics; and has an HSE analyst and the occupational health function (with an occupational health doctor and a nurse) under its supervision.



Emergency Preparedness and Response.



The Hospital Metropolitano has emergency preparedness and response procedures and equipment consistent with the requirements of PS1. It has an emergency response plan (Plan de Emergencias y Contingencias), an Audit (Auditoría) and a Favorable Report (Reporte Favorable) approved by the Fire department. The company regularly performs emergency drills, based on several scenarios. Fire prevention measures in the building are presented in the PS4 section.



Monitoring and Review



The Hospital undertakes a quarterly characterization of its environmental aspects, and are submitted for review and approved by the Secretary of Environment (SoE). The SoE also undertakes regular environmental audits on three points: kitchen (Dietética), laundry and laboratory. Additionally, the company monitors many other environmental and OHS aspects, described on the PS2 section (OHS).

Working Conditions and Management of Working Relationship



Hospital Metropolitano, being the leading high-complexity hospital in Ecuador, makes it a sought after employer in the health sector. It has a total of 1061 employees, of which 60% are women, and it is expected that 27 new jobs will be created due to project activities. There are currently 26 employees hired as contractors, all working as security guards. Employees are free to associate in unions, but had not chosen to do so.



The company has comprehensive document that details its human resource policy and relevant procedures (Reglamento Interno de Trabajo) that complies with Ecuadorian regulations and is in material compliance with PS2 requirements. The document is distributed to employees upon hiring. The Hospital Metropolitano offers several benefits to all its employees, such as: health plan, life insurance, food plan, and uniforms, among many others. Minimum salaries are in compliance with local requirements. The company has a mechanism to receive grievances from employees, through several channels: direct supervisors, email and directly with the HR office.



Occupational Health and Safety (OHS).



All new employees and contractors undergo OHS training tailored to the risks of the job description. Employees enjoy a healthy and safe work environment, thanks to the several management programs in place that address OHS risks throughout the Hospital.



The Hospital performs regular assessments of: biohazard contamination risks, noise in key hospital areas (laundry, kitchen, laboratories, neonatology, sterilization, and floor polishing), diffusional monitor analysis reports (concentration of gases), radiation dose monitoring, ergonomy, and psychosocial risks. Results from all these assessments shows that hospital operations are in compliance with local regulations. There is an occupational health doctor on site that performs new employee’s fitness for work assessments and treats occupational diseases and injuries that arise in the workforce.



The Hospital records and reports to the government all workplace accidents, with or without lost time, according to Ecuadorian regulations. There were seven (7) cases of workplace injuries (with more than 3 lost days) for the 2014 calendar year. The lost time frequency rate (LTIFR, injuries per million hours worked; excluding commuting to/from work accidents and at least one lost day) for this period is 4.6; which is lower than the industry average for Health facilities LTIFR in the US at 8.0.

Resource Efficiency



Current energy consumption at the Hospital Metropolitano is 3,600,000 kWh/year, and its energy consumption per area is 447 kWh/m2; the global benchmark for Hospitals is 400 kWh/m2. The Hospital monitors its resource use, and it is considering obtaining the EDGE certification. To obtain the certification, the engineering department is still assessing which energy saving measures will be implemented as part of the project. There are two diesel boilers, rated at 150 BHP. Both boilers are expected to be in service for 5 more years, provided that they pass an upcoming non-destructive test (July 2015).



Some of the resource efficiency measures currently in place are: natural ventilation on public spaces, residual heat recovery from hot water (laundry), energy-saving light bulbs in internal spaces (except the occupational therapy section), variable refrigerant volume A/C system, and condensed water recovery from boiler.



Greenhouse Gases



The Hospital does not have a car fleet, and the current greenhouse gas emission calculations correspond to an annual consumption of: (i) 3,600,000 kWh of electricity; (ii) 5,647 kg of gas (LPG); (iii) 10,200 gal of diesel. The annual CO2 equivalent emissions are 2,143 ton/year. Upon IFC’s project completion the CO2 equivalent emissions are estimated to be 1,714 tons/year.



Water Consumption



The hospital sources its water from the municipal supply. Water consumption is 74,736 m3/year or 1.39 m3/day/bed and is above the US median value of 1.19 m3/day/bed for healthcare facilities. The hospital has a plan to gradually implement several water efficiency measures such as: water-saving shower heads and faucets, low flow urinals, toilets and sinks. This plan is aimed to be completed by 2016.



Pollution Prevention



In regards to air emissions, the hospital performs boiler emissions tests every quarter and test results are in compliance with local regulations. In regards to water effluents, the hospital has three points of discharge to the municipal sewage line that are monitored quarterly, as required by the environmental management plan. These points are: kitchen, laundry and laboratory. In the kitchen area, there are grease traps and to avoid solid discharges, the company installed filters and siphons. Wastewater quality values are in line with regulatory requirements, with the exception of occasional Biochemical Oxygen Demand (BOD), Chemical Oxygen Demand (COD) and temperature values measured in the kitchen and laundry areas.



Wastes, Hazardous Materials Management



The company tracks its conventional, hazardous and recyclable wastes. There are special rooms to store hazardous chemicals and hazardous wastes in the Hospital, according to local regulations. Disposal is done through a licensed third party as per Ecuadorian requirements and Good International Industry Practice (GIIP).

Community Health and Safety



Infrastructure and Equipment Design and Safety



The hospital has an emergency response plan that considers fire, radiological emergency and natural disaster scenarios. The plan is evaluated and approved when is in full compliance with the relevant requirements set by: the fire department of the metropolitan district of Quito (Cuerpo de Bomberos del Distrito Metropolitano de Quito), Secretary of Risk Management EQU 911 (Secretaría de Gestión de Riesgos EQU 911), and the Environment Secretary (Secretaria de Ambiente). The hospital regularly performs emergency drills (separate, for each department), tracks drill performance and develops emergency response improvements based on findings.



Life and Fire Safety arrangements in the hospital are in compliance with local regulations. During the last Hospital inspection made by the fire department there were no observations. There are fire extinguishers, fire hoses, fire alarms and smoke detectors (not connected to the fire alarm control panel) throughout the facility, but no sprinklers. A fire alarm control panel is installed, and there is a plan agreed with the authority to implement automatic detection in the hospital; current coverage is 15% of the hospital area.



As part of the ESAP, a suitably qualified professional will conduct a complete life and fire safety review of the Hospital Metropolitano, including the remodeling project and fire prevention measures to be implemented during construction activities against local requirements and good international practices. Based on the review, if found necessary and in addition to the existing plan agreed with local authorities, the Hospital Metropolitano and IFC shall agree to implement an upgrade L&FS plan to mitigate identified risks. In addition, upon completion of the plan, a qualified L&FS professional shall review that measures are in place and in compliance with IFC’s requirements.



Community Exposure to Disease



The company has implemented measures to avoid intra-hospital infections as part of the requirements to obtain the JCI certification, which focuses high-quality patient health and safety management on its operations. Some of these measures are presented on the OHS section of PS2.



Security Personnel



Hospital Metropolitano arrangements for its security personnel are in compliance with PS4 requirements. Security services are subcontracted to the firm SEPRONAC and the contract is monitored by the Manager of Security. The company’s quality management system is ISO 9001:2008 certified and follows the Ecuadorian regulations in place for security contractors. The company performs background checks on new employees and periodically provides periodic training to its employees. There are 17 security employees distributed throughout the facility. Security personnel is trained to assist hospital employees in case of an emergency

Stakeholder Engagement

The community may submit any grievance related to the Hospital Operations through the municipality, who has the obligation to communicate and seek resolution with the Hospital. As part of the ESAP, the Hospital Metropolitano will develop a community grievance mechanism that will work in parallel with local regulations. This mechanism will make the interaction between the hospital and the nearby community timely and more effective. In addition, Hospital management will disclose on its facilities, project information during the execution of the project expansion activities and operations.

Geovanny Noboa
mailto:gnoboa@hmetro.med.ec
Hospital Metropolitano
Av. Mariana de Jesús s/n y Nicolás Arteta
Teléfono: (593 2) 399 8000
Línea Gratuita: 1-800-hmetro (463876)

Broad Community Support is not applicable for this project

S.no	Description	Anticipated Completion Date	Status
1	The Hospital Metropolitano shall develop and implement a grievance mechanism for the surrounding community and hospital users.	09/01/2015	Completed
2	A qualified life and fire safety professional shall undertake a L&FS review of the Hospital Metropolitano including the remodeling project, against local requirements and good international practices. Based on the findings of the review and, if found necessary in addition to the existing plan agreed with local authorities, the Hospital Metropolitano and IFC shall agree to implement an upgrade L&FS plan to mitigate identified risks. As Indicator of completion there will be an agreed L&FS upgrade plan	07/30/2015	Completed
3	Upon completion of the plan, a qualified life and fire safety professional shall review that measures are in place and in compliance with IFC’s L&FS requirements.As indicator of completion, there will be confirmation that L&FS upgrade plan has been fulfilled to IFC’s satisfaction.	02/25/2016	Completed