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

PS5: Land Acquisition and Involuntary Resettlement is not applicable since all facilities are existing buildings/facilities, located in urban contexts. PS6: Biodiversity Conservation and Sustainable Management of Living Natural Resources, PS7: Indigenous Peoples, and PS8: Cultural Heritage are not applicable given the urban setting of the project with no recognized indigenous people or cultural heritage present.

The project may result in a limited number of potentially adverse E&S impacts, which can be avoided or mitigated by adhering to generally recognized performance standards, guidelines, or design criteria. On this basis, this project is therefore classified as a Category B according to IFC’s Policy on Environmental and Social Sustainability.

 IFC’s appraisal considered the environmental and social management planning process and documentation for the Project and gaps, if any, between these and IFC’s 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 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 and Policy: AHG undertakes an assessment for any potential acquisition including legal, business and technical aspects before finalizing the acquisition. All AHG hospitals in Turkey, City Clinic hospitals and Tokuda Hospital in Bulgaria have regulatory and environmental permits and are subject to regular audits by different public institutions and international accreditor organizations.

AHG corporate and some of its hospitals in Turkey have adopted a quality management program to develop quality standards aligned with Joint Commission International (JCI), which is the largest accrediting body for healthcare organizations in the USA. Acibadem Labs in Turkey have ISO 15189 medical laboratories certification.

City Clinic Cardiovascular Hospital in Sofia also has JCI accreditation while City Clinic Oncology Hospital and Tokuda Hospital have already applied to and are expected to receive JCI accreditation in 2016. As a requirement of this accreditation, AHG, City Clinic and Tokuda Hospital have already introduced internal regulations, measures and indicators in accordance with JCI standards for the mentioned facilities and their management systems, articulating various policies, operational procedures, roles and responsibilities and monitoring and reporting mechanisms are in place.

AHG has its corporate level environmental policy disclosed on its website (http://www.acibadem.com/en/enviromentalpolicy), highlighting company’s commitment to fulfilling environment related requirements as per the JCI standards while complying with local and national environmental laws and regulations; effective waste management, including waste treatment, recycling and reducing, and raising environmental awareness among all employees. A set of procedures and systems are in place at both corporate and facility levels that are, in general, aligned with IFC PS1. AHG, as leading partner, is undertaking an assessment of the acquired hospitals in Bulgaria in order to consolidate the existing practices, policies, procedures and systems into a harmonized environmental and social management system (ESMS) for AHG Bulgaria.

As per ESAP item #1, the company shall: a) develop an E&S policy articulating its commitment to comply with IFC PSs and a clear statement regarding the applicability of this policy to cover all facilities; b) consolidate a corporate ESMS framework including, in particular, identifying and prioritizing key E&S risks, development of E&S management plans and operational procedures, roles and responsibilities, provisions for relevant training and implementation of appropriate E&S monitoring programs. This will include a screening and due diligence procedure for reviewing potential acquisitions against IFC PSs (PS1 – PS8) including L&FS requirements; and c) conduct a gap analysis between the current environmental, social and occupational health and safety management systems at each facility vis-à-vis the corporate ESMS framework and develop specific action plans to implement corporate level policies and related standard operating procedures (SOPs), internal monitoring and reporting systems, to achieve consistent environmental and social health and safety (ESHS) and occupational health and safety (OHS) management and performance across all facilities.

Organizational Capacity and Competency: AHG Technical Services and IT Department has the group wide responsibility on ESHS management related issues. There are three separate sub-units, namely OHS, Environment and Energy Management and Maintenance under the department. Four environmental engineers are undertaking ESHS related planning, implementation and monitoring functions at corporate level.

In Bulgaria, there are dedicated infection control and OHS officers at corporate level in City Clinic and Tokuda Hospital which are supported by Technical and Maintenance Departments on waste management and life and fire safety (L&FS) issues. City Clinic also receives technical assistance from a consultancy company on technical and environmental regulatory requirements.

AHG follows a need-based approach and when required appoints team of coordinators from the corporate office to work at newly acquired facilities in order to consolidate management systems and to build management capacity. AHG plans to implement a similar approach with newly acquired hospitals in Bulgaria. As per ESAP item #2, AHG Bulgaria shall assign an Environmental, Health and Safety Coordinator at corporate level, with relevant expertise and experience, to ensure the ESMS is implemented, monitored and reviewed at all facilities consistently.

Emergency Preparedness and Response: Additionally, AHG has corporate level special emergency committees and plans for several types of possible emergencies which may arise at hospitals.  All facilities of AHG, Tokuda Hospital and City Clinic are in line with national emergency response and preparedness standards. The National Fire Brigade is conducting regular checks at the hospitals.

Each facility has its operational procedure including necessary training arrangements and logs, evacuation exercises and periodical fire drill programs. Facility management and safety manuals including detailed guidance on regular checks of all equipment and systems are available for each facility.

The facilities visited have clear marking for all exits and evacuation plan are posted at each room and floor; smoke detectors, fire sprinklers, portable fire extinguishers, fire hoses, and alarm system are also present. Flammables are kept in separate cabins and the ambient air temperature is regulated using special ventilation systems. Periodical fire drills including staff and patients are conducted at least twice per year at each facility, the outcomes and corrective actions are reported to management. Face to face LFS trainings are conducted every 3 months for the staff and records are signed by employees following completion of each training.

As per the ESAP item #3, AHG Bulgaria shall a) develop a consolidated emergency response and preparedness plan applicable to all its facilities that will include management procedures for earthquakes, fires and other large scale emergency situations as well as potential emergencies such as radiation safety, hazardous materials safety, and control of outbreaks and infections; and b) integrate, in its ESMS, a consolidated emergency response and preparedness operational procedure for each facility to ensure their management, monitoring and reporting implementations consistently.

City Clinic has 883 employees of which 246 are medical doctors while Tokuda Hospital Group has 1.270 employees of which 385 are medical professionals including doctors, nurses and administrative staff. AHG Bulgaria will have 2.153 employees in total. City Clinic and Tokuda Hospital Group have 109 and 158 employees respectively in the cleaning departments and have 21 and 22 employees respectively in the security departments. Tokuda Hospital has 50 contracted out workers for catering services.

Human Resources (HR) Policies and Procedures: AHG, City Clinic and Tokuda Hospital do not have a formal documented HR policy but each has its own HR procedures related to recruitment, remuneration, orientation, performance, promotion, talent management, disciplinary actions, training, working hours, leave and vacation. HR procedures are available to all employees through the companies’ intranet and recruitment procedures, conditions and positions are also available via their external career websites. City Clinic and Tokuda Hospital are in the process of developing an ethical code of conduct as recently required by Bulgarian regulations.

As per ESAP item #4: a) AHG, as leading international healthcare company, shall develop its own HR policy to align its procedures with international best practices by articulating its commitment to issues such as fair treatment, non-discrimination and equal opportunity, promoting safe and healthy working conditions, employees’ right to freedom of association, retrenchment, protecting vulnerable categories of workers including those engaged by third parties; and b) the company will integrate AHG’s HR policy and procedures into its own management system.

Working Conditions and Management of Worker Relationship: All the full time and short time staff of AHG, City Clinic and Tokuda Hospital are overall under long term contracts. All facilities have centralized recruitment and payroll systems. All employees sign individual contracts and monthly payroll is directly accredited to their bank accounts. Weekly working hours are 40 and there is reduced working time scheme for radiology and nuclear medicine staff that are working in two shifts as required by national regulations.

Non-discrimination, Protection of Workforce and Workers’ Organizations: None of the companies employs child or forced labor, and each complies with local labor laws and IFC PS2 requirements to protect the workforce. All employees are over the age of 20, which is above the minimum required age of 16 and minimum required age for hazardous work which is 18 in Turkey and Bulgaria. The majority of the employees in each company are females (75 percent in AHG, 74 percent in City Clinic and 76 percent in Tokuda Hospital) and AHG was awarded with Workplace Gender Equality Appreciation Award in 2013 by the Turkish Ministry of Work and Social Security for equal opportunities measures adopted within the company. None of City Clinic and very minor (around a dozen) number of Tokuda Hospital and AHG employees are members of workers’ organizations and none of the companies is party to any collective bargaining agreement. AHG will include specific statements in its HR policies and procedures, which will be adopted by AHG Bulgaria as defined under ESAP item#3, that recognize and respect employees’ rights to join a lawful organization of their own choosing and commit to comply with the laws pertaining to freedom of association and collective bargaining across all its locations in compliance with PS2 provisions.

Retrenchment: Current staffing and organizational restructuring plans of AHG does not anticipate any retrenchment of existing workforce in City Clinic hospitals and Tokuda Hospital. AHG will include its HR policy and procedures which will be adopted by AHG Bulgaria as defined under ESAP item #3 statements about its retrenchment policy and commitment to prepare a plan when necessary applicable to all its subsidiaries, in line with IFC’s Good Practice Note on Managing Retrenchment and PS2 requirements.

Grievance Mechanism: City Clinic and Tokuda Hospital do not have a written grievance policy and procedure but have an established practice on receiving and handling grievances. Every complaint is treated as a separate case, submitted with a formal letter to the general director. AHG has an internal grievance mechanism and procedure accessible to all employees through company’s intranet page. Individuals can log a complaint through this system and direct the complaint towards the unit. As required under ESAP item #5, AHG Bulgaria shall develop an official internal grievance mechanism and procedure applicable to all its facilities and accessible to all employees, which would allow for anonymous complaints and will be incorporated in its HR policy and procedures in compliance with IFC PS2 requirements.

Occupational Health and Safety, Infection Control and Prevention: Each company has initiated several infection control and prevention initiatives as required under JCI, in order to protect patients, visitors and personnel from healthcare-associated infections. Infection control and prevention manuals for medical staff and standard operational procedures for infection control and prevention are in place. Several voluntary vaccination and periodic check programs were initiated at each hospital for employees entering into contact with blood and other body fluids. Staff are provided with necessary personal protection equipment including gloves, mask, goggles, aprons and radiation detection devices. Evidences of good practice, such as hygiene kits at the entrance of each room, spill kits including personal protective equipment at each floor and usage of galosh were observed at the visited hospitals. Each incident is reported by the hospital hygiene inspectors and followed-up by centrally appointed infection control and OHS officers who analyze the incident and prepare an incident report that includes recommendations for corrective actions to be taken. As required under ESAP item #6, AHG Bulgaria shall integrate a consolidated OHS related standard procedure in its ESMS including risk assessment, training, and incidence recording, reviewing, monitoring and reporting procedures in compliance with IFC PS2 requirements.

Training: AHG owns a Faculty of Medicine in Turkey and provides continuous professional development trainings to its staff with best-in-class equipment and technology within its faculty premises. The company has talent management, class based and e-learning programs. Class-based learning programs are available in 470 subjects and e-learning programs in 108 subjects. Total e-learning attendance reached over 58.000 in 2015. AHG will be able to extend these programs to AHG Bulgaria upon translation of e-learning content. City Clinics and Tokuda Hospital have also their own training programs. Induction for new employees, in-service trainings for specific jobs, OHS and fire safety trainings which are conducted for the employees in each facility constitute the major component of employee orientation programs and relevant log of who has taken the trainings is being recorded.

Resource Efficiency and GHG Emissions: Tokuda Hospital and City Clinic’s two hospitals in Sofia have Building Management Systems which monitors and controls energy usage, heating and air conditioning. Electricity is provided from the national grid for all facilities. There are standby spare fuel diesel generators at each hospital. The generators have internal fuel systems and no separate stand-alone fuel tanks are installed. As Tokuda Hospital benefits from two separate connections to the national grid, the backup generator in the hospital is not in use. At all facilities 85 percent of heating, ventilation and air-conditioning, electrical and other equipment comply with A+ energy efficiency requirements and the latest generation medical equipment are selected to ensure energy efficiency.

Only Tokuda Hospital and Cardiovascular Hospital in Sofia use boilers for heating. Other hospitals of City Clinic in Varna and Burgas are connected to central heating systems of the respective municipalities.

None of the facilities monitors GHG emissions. Based on the information available, the current GHG emission of AHG Bulgaria is expected to be 9,402 tons/year. AHG Bulgaria electricity consumption, energy efficiency indicators and GHG emission will be monitored and reported for all facilities to IFC on an ongoing basis.

Water, in general, is supplied from the municipal network for domestic use. Oncology Hospital uses grid water purification system while bottled water is used for drinking water in all other hospitals. Water quality is monitored periodically as per the relevant local regulation.

Waste Water: Sofia, Varna and Burgas municipal waste water treatment plants all provide a three-stage treatment: mechanical, biological and treatment of collected sediments in accordance with ISO 17025. All domestic waste water from toilets and showers, together with other liquid effluents (e.g. waste biomedical test liquids like blood, urea etc., and chemicals from laboratories) are discharged to the municipal waste water collection networks as per the environmental permit conditions, except from the Cardiovascular Hospital in Sofia.  This facility has its own sewage treatment plant based on anaerobic treatment with level of water treatment of 97 percent. After local treatment, waste water is discharged to the city network.

Those hospitals providing radiotherapy, chemotherapy and nuclear therapy have separate waste water collection and settling tanks for potentially radioactive water waste. Potentially radioactive waste water is kept until radioactivity has fallen under the requirements of local legal regulations and then released to city networks.

Community Health and Safety: Medical, analytical and laboratory equipment is checked and monitored in accordance with Bulgarian laws by the relevant government institutions. As discussed under PS2, all hospitals have detailed procedures in place to prevent hospital-acquired infections and relevant plans for emergencies. The blood transfusion center at the Cardiovascular Hospital goes through regular checks by the National Hematology Center. There are no incidents of infection recorded due to transfusion operations.

AHG has an ambient air quality management requirement in its corporate standards. In City Clinic hospitals and Tokuda Hospital filtrated fresh air is used for cooling of each room. Heating, ventilation and air-conditioning system in hospitals are composed of chillers, air handling units and fan coil units. Chillers are providing necessary cooling for the complex, air handling units are serving the specialized departments of the hospitals and fan-coil units are used for the patient rooms (except the intensive care units), treatment rooms and consultation area.

Infrastructure and Equipment Design and Safety: To prevent any potential hazards from the use of medical technologies, quality personnel are conducting daily checks of nuclear and radiotherapy devices. Radiotherapy departments of Oncology Hospital and Tokuda Hospital are located in the basement floor, isolated by led covered walls and shielded doors. Emergency alarms and special three-color visual indicators are placed all around the radiotherapy floors indicating ambient radiation levels. Fresh air is pumped to these departments through accelerators located outside the hospital.

Life and Fire Safety: As per ESAP item #8, AHG Bulgaria shall commission a third party L&FS review for all facilities in order to identify L&FS risks and develop time bound action plans to eliminate the identified risks. In case of any future greenfield investment, the company will develop a L&FS masterplan in accordance with local and international code as per WBG General EHS Guidelines, and provide L&FS certification at the design stage and after the construction by a competent professional.

Security Personnel: Security personnel are employed as staff at all facilities of City Clinic while Tokuda Hospital outsources security services. All security personnel are unarmed and working in two shifts. They are not receiving special trainings for use of force as their role is to regulate access to the facilities.

AHG corporate website, AHG hospitals, City Clinic and Tokuda hospitals all provide contact information on their respective websites. In addition to this, AHG has a corporate level external grievance mechanism accessible through each AHG hospital’s website. Weekly grievance committees are held to evaluate grievances. There are also patient rights and relations officers appointed at each hospital who are working under the supervision of the Patient Rights and Relations Director appointed at central level.

Tokuda Hospital works in collaboration with Bulgarian Association for Patients’ Defense for external civil audit of the hospitals and for evaluation of patients’ satisfaction. The Association has its own patient satisfaction forms and patient claims boxes placed at each floor of the hospital. The claims and demands collected through these boxes are independently analyzed by the Association and the result is reported to hospital management. A call center, open 24 hours, is also available to the public.

Contact Person: Mr. Ilian Grigorov

Company Name: Acibadem City Clinic

Address: 1, Samara street, Sofia 1715, Bulgaria

Email: ilian.grigorov@cityclinic.bg

Phone: +359 895 584 846