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.
PS1: Assessment and Management of Environmental and Social Risks and Impacts
Artemis Hospitals has implemented a company-wide quality management system (QMS) across its entire operations that embed environmental and occupational health & safety aspects and are generally aligned to IFC PS 1 requirements. The QMS at flagship hospital is accredited to India's National Accreditation Board for Hospital (NABH) standards (https://nabh.co/) while part of the flagship hospital is also accredited to Joint Commission International (JCI) accreditation standards.
Identification of Risks and Impacts: Company follows regulatory compliance approach to identify and manage E&S and life & fire safety (LFS) risks. To the best knowledge of the Company, all the operational Hospital facilities of Artemis have current and valid E&S related clearances, permits and licenses including the ongoing expansion at flagship hospital complex.
As per applicable regulations, Artemis obtained environment clearance (EC) in July 2007 for setting up Tower 1 of the flagship hospital. In April 2017, Artemis proposed an expansion of the flagship hospital for building two more towers (Tower 2 and Tower 3) and submitted an environment impact assessment (EIA) report which is disclosed by the regulator at: https://environmentclearance.nic.in/auth/ECGeneral_Report.aspx?pid=12549 and the EC for expansion was received in September 2019. Other business verticals of Artemis do not trigger EC requirements due to their small operational footprint. For the expansion proposals, the Company will adopt a regulatory compliance approach and obtain prior environmental clearance before starting the construction phase of the greenfield project, if applicable and share the same with IFC.
To identify risks during new property selection process, especially for secondary care centres and nursing hostels, Artemis Engineering team uses a checklist which largely focusses on regulatory compliance. As per E&S Action Plan (ESAP)#1, the screening checklist will be reviewed and updated to comprehensively cover E&S risks, per IFC PS requirements, and inform the property selection decision making process.
Management Programs: Company has formulated and implemented documented corporate policies, department specific operational manuals, standard operating procedures (SOPs) and institutional committees to streamline the effective functioning of its hospitals. These management programs cover both clinical and non-clinical services. In construction projects, Artemis contractually requires the Project management consultant (PMC) and construction contractor to prepare and implement appropriate management programs. As per ESAP#2, , the Company will review and update its construction phase environment, health and safety (EHS) management system covering aspects such as: construction phase EHS management plan/manual; worker accommodation guidelines in line with IFC requirements; E&S training management systems including gender based violence & harassment; labour law compliance; monitoring and reporting; environmental quality monitoring; periodical auditing; community grievance management; and senior management review.
Organizational Capacity and Competency: Artemis has instituted a two-tier management structure. comprising of corporate (operating out of the flagship hospital) and facility or unit level management teams. The E&S relevant departments are instituted at corporate level and the same management structure is replicated at the secondary care centres. Artemis Hospital has deployed a dedicated fire safety officer (FSO) in the corporate and facility level management teams that are qualified and experienced in fire safety management in hospitals.
For managing construction of any new facility in the future, Artemis has a Projects team at the Corporate level. The Project team engages experienced third-party services for planning and design, project management and construction.
Emergency Preparedness and Response: Company's management system has a documented program covering disaster, emergency preparedness and response. Every staff and workers in a facility are trained on emergency drills. More details about LFS management systems are discussed under PS4 below.
Monitoring and Review: Company has established monitoring and review procedures that are compliant to permit conditions and PS 1 requirements. In the sites where construction works are ongoing, project management consultant undertakes management review meetings, inspections and audits and submits monthly safety report to Artemis. This system will be reviewed and updated as part of ESAP#2 discussed above.
PS2: Labor and Working Conditions
Company has approximately 2550+ on-roll, direct staff and workers on its payrolls and has about 520+ contracted workers covering the entire Artemis operations. Among the direct staff and workers, there are ~53% female and ~47% male staff. Artemis has documented corporate human resource (HR) management policies, procedures, manuals and approved standing order in place that are generally compliant to IFC PS 2 requirements. These HR policies and procedures are applicable and accessible to all its staff and workers. Company provides and manages accommodation facilities for nurses in line with PS2 requirements near the flagship hospital since 2007.
According to Artemis’ management, the Company respects the worker’s freedom of association, although currently there are no workers organization representing its employees. Company has instituted multiple worker welfare committees and engages with its staff and workers through periodical employee town halls, open house forums and award ceremonies.
Company HR management systems has a documented equal employment opportunity policy that is aligned to IFC PS2 requirements. Company has not undertaken any retrenchment in the past and has no current plans to retrench its workforce. For any proposed hospital acquisition under the Project, Company currently has no retrenchment plans. Also, any expansion / acquisition is not likely to lead to job losses for any category of workers including workers engaged by third party contractors.
Grievance Mechanism and Anti-Sexual Harassment Policy: Artemis has in place a grievance redressal policy and grievance committee mechanism in line with local regulations and IFC PS2 requirements. The employee grievance policy has appeal provisions. Artemis has in place an anti-sexual harassment policy on prevention, prohibition, and redressal of sexual harassment at workplace which covers both the direct employees, and non-employees of the company. Every direct and contracted staff and workers are trained and made aware of these available grievance redress systems at orientation. On prevention of sexual harassment (POSH) related awareness and recurrent training, an independent third-party agency has been retained to deliver quarterly training to the entire workforce. Artemis publishes the data on grievances and POSH complaints received and resolved in its annual report.
Protecting the Workforce: Artemis policy specifies the minimum age requirement as 18 years for employment applicable to contractors and supply chain vendors as well. Company HR policy prohibits forced or bonded labour practices such as holding back academic certificates, salary, and other monetary & non-monetary benefits.
Occupational Health & Safety: Artemis has established and maintains an occupational health and safety management system at its flagship hospital and other centres aligned to JCI and NABH standards. Company reports zero fatalities in its operations since last two years. Artemis quality team consolidates and reports monthly performance including E&S related indicators such as: fire services, general engineering, safety incidences, infection control, laboratory services, radiation safety, and security.
Workers Engaged by Third Parties: The third party contractors engaged by Artemis comply with labour regulations and are monitored by Artemis on a monthly basis. At construction sites, the project management consultant is made responsible for contractor compliance to labour law provisions.
Supply Chain: The primary supply chain for Artemis Hospitals network comprises of service providers such as laundry and linen vendors, biomedical waste disposal facility, e-waste & other waste recyclers, manpower service agencies, equipment vendors and consumables suppliers. The Company has a documented sustainable sourcing and purchase policy, and procedures covering vendor onboarding, screening, and auditing which are aligned to supply chain requirements of IFC PS2.
PS3: Resource Efficiency and Pollution Prevention
Resource Efficiency: Company requires resources such as grid electricity, diesel, natural gas, and water for its operations. Company monitors and tracks resources consumption related key performance indicators (KPI) at all its operational footprint hospitals including flagship hospital and secondary care centres. As per ESAP#3, Company will consolidate and report the resource efficiency monitoring information collected for each key performance indicators (KPI) at the Artemis corporate level covering all its footprint operations including flagship hospitals, secondary care centres and proposed expansion projects.
Greenhouse Gas (GHG) Emissions: Artemis has started quantifying and publishing its GHG emissions in its Business Responsibility and Sustainability Report (BRSR) (https://www.artemishospitals.com/BackEndImages/downloads/Investorsdata/19th-annual-report-fy-2022-23.pdf). At Artemis flagship Hospital, GHG emissions were estimated to be less than 25,000 tons of carbon dioxide equivalent (tCO2e). As per ESAP#4, Company will consolidate and estimate the GHG emissions at the Artemis corporate level covering all its footprint operations including flagship hospitals, secondary care centres and proposed expansion projects and report to IFC.
Pollution Prevention: Artemis Hospital and its secondary care centres have installed diesel generator (DG) sets and the emissions are monitored as per permit conditions. The emission levels comply with permit conditions and IFC General EHS Guideline values specified for small combustion facilities. At flagship hospital, both trade effluent and domestic sewage generated is treated in effluent treatment plant (ETP) and sewage treatment plant (STP) respectively and monitored for compliance to permit conditions. The treated trade effluent is disposed to municipal sewerage system and treated sewage is recycled and reused for gardening. The quality of treated water from STP meets the permit conditions and IFC EHS Guidelines for Healthcare Facilities. In the secondary care centres, the domestic sewage and liquid biomedical waste is discharged into municipal sewerage system as per permit conditions.
In the proposed expansion projects, Artemis will follow regulatory compliance approach. For any new greenfield project, Artemis will install wastewater treatment plant with an objective to recycle and reuse the treated wastewater. For expanding secondary care centres, the property screening checklist will be updated (per ESAP#1 discussed above) to include wastewater disposal arrangements as a critical aspect. Before acquiring the brownfield hospital asset, regulatory compliance and pollution control plants/system efficiency will be reviewed as part of the Artemis E&S due diligence study and if gaps/risks are identified, a corrective action plan will be developed and provided to IFC.
Hazardous Materials and Wastes: Artemis has a formal and documented biomedical waste (BMW) management mechanism including hazardous materials & waste management program in place in compliance to permit conditions.
PS4: Community Health, Safety and Security
Company engages certified and competent structural engineers to inspect, audit and certify the integrity, stability, and safe usage for public use of hospital buildings as per local rules. The medical equipment’s are maintained by original equipment manufacturers (OEM) or OEM authorized vendors for ensuring its safe operations and use. Radiation equipment’s and their safe use is managed and monitored in line with Indian Atomic Energy Regulatory Board (AERB) guidelines. Artemis Hospitals have a program relating to patient safety protocol, aligned with the requirements of JCI and NABH Standards, which includes control of nosocomial infections.
Traffic & Transport Safety: The flagship hospital and the secondary care centres are located in well developed urban centres that has a good road network. Traffic movement is regulated by the Artemis Security Team as per traffic & parking management plan.
Life and Fire Safety (LFS) Management at Artemis: Artemis has instituted a LFS management system and installed LFS infrastructure that complies to Indian National Building Code (NBC) standards and local requirements that are integrated in the hospital planning and design phase. Artemis retains experienced fire safety professionals as part of the project design and commissioning teams. The secondary care centres are less than 15m high buildings and LFS infrastructure as per Indian NBC standards and local code requirements for low rise healthcare buildings have been provided.
Company has documented LFS management program, dedicated fire safety organization with qualified and experienced staff, training and auditing systems, emergency response plans specific to manage fire events and periodic monitoring & reporting on fire safety performance to senior management. As a part of documented management program, Artemis has developed and implemented a Hospital Fire Safety Plan and Management of Change (MOC) related to brownfield construction and renovation plan. Hospital Fire Safety Plan includes evacuation plan for critical patients and patients in operation theatre.
As the Company plans to develop a greenfield hospital under the IFC project, as per agreed ESAP#5, the Company at the design stage, will commission a suitably qualified LFS professional to prepare and submit a LFS Master Plan, including preliminary drawings and specifications, and certify that the design meets the requirements of good international industry practice (GIIPs) such as internationally recognized LFS codes in addition to ensuring alignment with local fire code requirements. Post construction and before commissioning of the greenfield hospital building, the LFS professional will conduct a review as part of the project completion test at the time of life and fire safety systems testing and commissioning and certify that construction of these systems has been carried out in accordance with the accepted design. Any remedial measures needed to bring the new building into compliance with IFC’s LFS requirements will be completed within a timeframe agreed with IFC subject to feasibility and regulatory approvals.
Artemis had commissioned an independent third party to undertake LFS audit of operational towers of its flagship hospital (Tower 1 and 2) in October 2023. Tower 3 building under brownfield expansion is nearing completion and expected to be commissioned by June 2024. As per agreed ESAP#6, Company will revise and update the 2023 LFS audit report to cover the entire hospital complex including Tower 3 building before its commissioning. The revised LFS audit will be undertaken based on a terms of reference agreed with IFC and the audit objective will be to evaluate compliance with Indian NBC regulations and with the LFS principles described within the World Bank Group’s General Environmental Health and Safety Guidelines. The LFS audit will identify areas where hospitals' fire safety provisions are not adequate and produce a time-bound LFS Action plan. The Company will implement the corrective actions as per the agreed schedule.
Secondary care centres (Artemis Lite and Artemis Daffodil) are established following an asset light approach wherein land and buildings are taken on a long lease or rent from the landlord. To assess the LFS risks in the existing secondary care centres and to formulate a generic LFS Master Plan, as per ESAP#7, Company will commission a suitably qualified LFS professional to undertake LFS risk-based audit of latest Artemis Lite Hospital. The LFS audit will be undertaken based on a terms of reference agreed with IFC. The LFS audit will identify areas where hospitals' fire safety provisions are not adequate and produce a time-bound LFS Action plan. Artemis will implement the corrective actions as per the agreed schedule. In addition, based on the results of this LFS risk-based audit, Artemis will formulate a generic LFS Master Plan applicable for Secondary care centres and apply the recommendation at corporate level in similar upcoming facilities (Secondary care centres) proposed under the project.
As the Company plans to acquire an operational Hospital (target asset) under the IFC project, as per ESAP#8, Company will commission a suitably qualified LFS professional to undertake LFS audit of the target asset as soon as it gets physical access to the facility. The LFS audit will be undertaken based on a term of reference agreed with IFC and the audit objective will be to evaluate compliance with Indian NBC regulations, construction codes and with the LFS principles described within the World Bank Group’s General Environmental Health and Safety Guidelines. The LFS audit will identify areas where target hospitals' fire safety provisions are not adequate, and in these cases the consultant will identify feasible changes or adaptations that would allow Artemis to eliminate the identified LFS risks. The consultants LFS audit will summarize the recommended corrective actions in a time-bound Fire Safety Action plan and Artemis will implement the Corrective Actions as per the agreed schedule.
Security Personnel: Security and Operations department is responsible for the security of the hospital premises, nursing hostels and has additional responsibilities on vehicular parking management, LFS and emergency response actions. Across all Artemis hospitals, no armed security has been engaged. Security operations are managed by a team of company's direct staff under whom a security team of supervisors and security guards are fielded by the outsourced security agencies that are licensed by the Government. The company trains security personnel about policies and procedures on child labour, basic safety, soft skills to engage with patients/attendants, restrained behaviour, first-aid, life & fire safety and emergency response.
