Rede D'Or

Environmental & Social Review Summary

This Environmental and Social Review Summary is prepared and distributed in advance of the IFC Board of Directors’ consideration of the proposed transaction. Its purpose is to enhance the transparency of IFC’s activities, and this document should not be construed as presuming the outcome of the Board of Director’s decision. Board dates are estimates only.
Any documentation which is attached to this Environmental and Social Review Summary has been prepared by the project sponsor and authorization has been given for public release. IFC has reviewed this documentation and considers that it is of adequate quality to be released to the public but does not endorse the content.

Project number

28144

Country

Brazil

(IDA)

Region

Latin America and the Caribbean

Sector

Hospitals and Clinics

Department

Reg Manufact, Agri & Services, CAF/CLA

Company name

Hospital e Maternidade S?o Luiz S.A.

Environmental category

Status

Active

Date ESRS disclosed	April 21, 2010
Last Updated Date	February 8, 2012
Previous Events	Invested: December 29, 2011 Signed: July 6, 2010 Approved: July 1, 2010

View Summary of Proposed Investment (SPI), click here

Overview

Category & Applicable Standards

Key Issues & Mitigation

Community Engagements

Client's Documentation

Overview of IFC's scope of review

IFC’s appraisal consisted of a review of Rede D’or (“D’or ” or “the company”) project information and documents including internal environmental, health and safety policies and guidelines as well as licensing information and other documents provided by the company. The appraisal included visits to the company’s headquarters in Rio de Janeiro and to eleven of the company’s hospitals in Rio de Janeiro (Rios D’or, Copa D’or, Barra D’or, Quinta D’or, Provita, Israelita, das Clinicas de Bangu, Real Cordis, Rio de Janeiro – Vila Valqueire, Dr. Badim and Joari). IFC also interviewed representatives from the Human Resources Internal Controls departments.

Project description

Founded in 1977, Rede D’Or is a for-profit healthcare company that owns a network of 46 image centers and laboratories for medical diagnostics and 16 hospitals (including three under construction at the time of appraisal) with over 1,500 beds total, in the states of Rio de Janeiro and Pernambuco.

The company plans to invest over the next 4 to 5 years to support its organic growth strategy to expand existing facilities and build four new hospitals (three already under construction) to reach 2,700 beds total. The group also plans to acquire existing hospitals.

Key environmental and social issues and mitigation

PS1: Social and Environmental Assessment and Management Systems

Management Program - D’Or Strategic Vision statement includes a series of sustainability targets involving energy use, water consumption and solid waste generation. The company has a formal Environmental Agenda consisting of policies describing in more detail its sustainability targets and policies. The corporate management program includes a set of plans and procedures covering the following environmental, health, safety, and social aspects: energy conservation; water conservation; health services waste management; and occupational risk prevention. Brazilian law does not require Environmental Impact Assessments for new hospital development. However, hospital facilities are required to obtain a series of operating licenses applicable to hospitals including in some cases environmental licenses and approval of hospital waste management plans (PGRSSs).

Organizational Capacity - Responsibility for management of environmental, health and safety issues at the corporate level falls within the scope of the Corporate Licensing and Internal Institutional Control Department and more specifically the Department of Coordination of Environmental and Sanitary Licensing. This department is staffed by a full time corporate coordinator responsible for ensuring consistent application of environmental programs and procedures in all company facilities. The Internal Controls Department has other divisions responsible for human resources management, licensing, audits, training programs, management of construction/refurbishment in each unit, negotiation of contracts with service providers, and contingency and continuity plans for all the company’s facilities.

At the facility level, environmental, health and safety (EHS) matters are the responsibility of Hospital Directors who further delegate EHS matters to designated registered waste management professional responsible for the implementation of the waste management plan according to Brazilian legal requirements. Also following Brazilian legal requirements, hospital operations must have a team of work safety technicians, engineer, and nurse, headed by a work safety doctor. In all of its hospitals the company currently implements clinical and non-clinical risk management committees at each unit to prevent hospital infections (CCIH).

Training - The company has developed a training program at the corporate level to address aspects related to waste management as well as a Safety Program - Accident Prevention and a Security Dialogue and Risk Management with participation of professionals in the operational and administrative staff.

Monitoring and Reporting - The environmental and social performance in each unit is evaluated as part of an internal audit program covering key aspects associated with the quality of medical services and prevention and control of hospital infections. The audit program includes some environmental aspects according to internal indicators (use of energy, water, natural gas, occupational accident rates, etc) monitored by the Internal Controls department.

For facilities which are certified under one or more hospital certification schemes, EHS monitoring is based on safety and risk management requirements of the respective certification bodies, which include the need for frequent audits. The Barra D’Or and Quinta D’Or hospitals are subject to third party certification maintenance audits by the Instituto Qualisa de Gestão (IQG) and Accreditation Canada twice annually and for recertification every three years. The Copa D’Or hospital is also audited twice annually and recertified every three years by the Consórcio Brasileiro de Acreditação (CBA) and Joint Commission. Under the hospital certification schemes, audit activities 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 (referred to as “sentinel events”) as well as recording of near-misses. If applicable, these events are investigated in depth to develop necessary corrective action plans.

The results of all environmental, health, and safety monitoring activities are compiled into internal corporate reports that help corporate management track the performance of each facility against the targets established in the environmental agenda (i.e energy conservation, correct implementation of waste management plans and procedures) as well as occupational and patient health and safety management programs (i.e. occupational accident rates, patient health indicators, etc). Hospitals disseminate internally social and environmental performance during formal monthly meetings of senior management.

PS2: Labor and Working Conditions

The company currently employs about 13,800 workers, of which about 700 are administrative staff and the remainder working in professional medical functions. About 94% of the workforce is directly hired while 6% are outsourced employees. The division by gender indicates that 67% are women and 33% are men. The outsourced employees provide services transportation and destination of solid waste, imaging diagnosis, transport of radioactive drugs and maintenance of internal systems such as HVAC, lifts and medical equipment.

Human Resources policy - The company has a formal Human Resources policy which defines aspects of recruitment, selection, internal recruitment, training and development, wages, progression, agreements, benefits, minimum age and performance assessment. The policy also includes a non discrimination clause.

Company hiring practices are performed following Brazilian labor law (Consolidação das Leis do Trabalho – CLT). During the admission process the company communicates the terms of employment, the non disclosure agreement of the Company’s documents, the employees rights such as transport and food subsidies, vacation period, procedures in the case of labor injuries and accidents and benefits such as life insurance, medical plan, dental care plan, subsidies on medicines and educational support. The company also holds workshops on a variety of topics including internal rules; occupational health and safety; attendance and working hours; employee’s obligations; payment processing; cessation of employment and the corporate Ethics Code.

The Ethics Code focuses on the attention to health and quality of life of the patients and articulates the company’s commitments as well as employee responsibilities and allowed and prohibited activities with clients and suppliers.

Workers organization - A Collective Agreement has been negotiated between the company and the Union of Health Employees. Other unions with less representation include union representing some of the nurses, physicians, nutritionists and pharmacists. IFC found no evidence that the company restricts employees’ right to freedom of association.

Internal grievance mechanism - The internal grievance mechanism (“Canal de Etica”) is the way by which employees can present complaints following a clear procedure preserving the author identity and clearly forbidding retaliation in any case. The grievance mechanism is current disclosed to the company through internal handouts, but the Company intends to promote further actions to increase employee’s knowledge on it. Once the Complaint is posted, it is received by the head of the Institutional Internal control department who addresses it accordingly with support of the Internal Audit department. An ethics committee analyzes each complaint within a pre-determined timeframe.

Protecting the workforce - The minimum age for admission in Rede D'or is 16 year of age for work in laboratories and 18 for work in the company’s hospitals.

Occupational Health and Safety - D’or is in compliance with Brazilian laws which include requirements for monitoring the health and safety risks of employees by implementation of a PCMSO Program for Medical Control of Occupational Health (PCMSO) including entry, exit and periodic health examinations for occupational diseases. The PCSMO is performed by doctors from a Specialized Services, Safety Engineering and Occupational Medicine (SESMT) group of the hospital, focusing on identification and prevention of biological hazards, also in compliance with national legal requirements.
The company also is implementing a required Environmental Risks Prevention Program (PPRA) to identify task-specific hazards and occupational exposures (i.e. exposures to noise, heat, cold, radiation, vibration, and biological hazards). The PPRA, as any preventive program, requires recognition, evaluation and control of the occurrence of environmental risks, involving actions under the responsibility of the Hospital. They are implemented with maps of risk training for all employees.
Facilities are subject to periodic audits by local labor authorities to evaluate the company’s compliance with the national labor and occupational safety laws. A review of sample of inspection reports indicates that the company has been asked to implement corrective actions mainly related to the maintenance of employee records and implementation of life and fire safety equipment.
Additionally, nuclear medicine and imaging facilities are periodically audited by CNEN, the Brazilian authority responsible for radiation. The company also has a formal contract with a service provider accredited by CNEN to supply dosimeters to professionals occupationally exposed to radiation sources.
The employees who work directly with patients receive guidance on protective measures against accidents at work, risk exposure, control of vaccines, toxicological and ergonomic guidelines, and monitoring during the period of absence due to accidents at work. The use of personal protection equipment (PPE) is compulsory protecting employees against infectious diseases or the use of radioactive materials for example. For work performed in a hospital, the PPEs typically required vary depending on the risks of the activity to be performed by may include gloves (Latex, PVC) jackets made of cotton long sleeves and below the knees, Jaleco disposable items for use on cotton jacket, caps, masks and disposable slippers, gas masks, and dust mask depending on the risks associated with the job activities.

PS3: Pollution Prevention and Abatement

Resource Conservation and Energy Efficiency - The institution maintains tight control of water, electricity consumption, production of medical waste and sewage discussed at monthly meetings of sector coordinators sector. The new Hospital buildings are designed to maximize the use of natural light to help reduce the need for lighting-related energy consumption. All facilities use efficient cold light bulbs, which save energy and reduce the internal thermal load. During peak hours when electricity costs the most, some hospitals use auxiliary generators. In some cases the hospitals use rain water and artesian wells to external cleaning and gardening and in order to save water, taps in the lavatories are equipped with timed dispensing mechanisms. The company has hired a consultant to implement an energy efficiency program of its portfolio and is monitoring and targeting reductions in energy use.

All units count with backup energy generators auxiliary power for essential equipment during 30 to 60 minutes, depending on the unit. It is also a policy of the Group to have at least 2 diesel generators to maintain the electric energy supply for at least 6 hours. There are contingency plans to receive extra fuel in a short period of time in case of longer periods of energy shortage. In order to save on energy costs; some facilities use their generators on a daily basis during peak consumption hours from about 17:30 to 20:30. The company’s direct and indirect emissions of greenhouse gases (GHGs) from fuel consumption in auxiliary generators and electricity consumption are approximately 2,500 tons per year. The company is therefore not considered a significant emitter of GHGs.

Liquid Effluents Management - 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. Some units described below also have a sewage treatment plant installed as required by local regulators.

The Hospitals Barra D'OR and Joari have on-site wastewater treatment plants whose effluents are monitored and controlled prior to discharge. Both effluent treatment stations are currently working with activated biological treatment followed by on-line chlorination prior to discharge into local sewage network.

Air Emissions Prevention - There is no internal incineration of medical waste in any of the company’s hospitals. There are special filtering units for some areas in the hospital such as intensive care and operating rooms prior to the point of exhaust to the atmosphere.

Solid Waste Management - All waste generated in hospitals is collected, stored and disposed of following a corporate hospital waste management plan (PGRSS) adapted at the facility level depending on the type of waste streams generated at each location. The plan includes procedures for segregation, management of waste flow inside the units, proper handling, collection, temporary storage and transport and disposal. The sites for temporary storage of waste, whether domestic waste, chemical waste or hazardous waste, were observed to be clean, organized and with restricted access to unauthorized people.

The hospital policy regarding the management of toxic materials not recommended storage for long periods. The material is purchased on demand as well as the of diesel for the generator set, which is supplied by a specialized firms; All personnel involved in handling these substances receives training and the required protective equipment; The hospital generates three (3) broad types of liquid and solid wastes consisting of (i) common household waste - from assistance area, kitchen, coffee shop and toilets; (ii) infectious waste - collected and stored selectively and in a segregated manner; (iii) chemical waste – also collected and stored selectively and in a segregated manner. All wastes are accumulated in temporary storage areas where they are collected by external service providers licensed by the environmental authorities for transport and treatment/disposal.
Common and organic wastes are disposed at a sanitary landfill (Central de Tratamento de Resíduos Nova Iguaçu), while chemical, infectious and skin-piercing wastes are incinerated by a licensed company (Creamor, located in Rio de Janeiro). Waste collection and transport services are provided by another license service provider, Multiambiental. The waste from radiology is transported to a site in Campo Grande, neutralized and recovered due to its significant silver content. The hazardous and contaminated waste from laboratory operations is collected by the company Clean Environmental Services Collection and Transport, which is licensed by the state Environmental Authority, FEEMA. The treatment used for decontamination of infectious waste is performed by the company Trush Sterilization Services which is also licensed by FEEMA.

The average monthly rate of generation of waste in a hospital is 3,260 kilograms of common waste and 525 kilograms of hazardous waste per bed (with about 1,500 beds in the company’s hospitals, total monthly generation is about 4,800 tons of non-hazardous and 787 tons of hazardous waste). The PGRSS requires the monitoring and consolidation of the waste generation in spreadsheets which are forwarded to the Internal Controls department in headquarters on a monthly basis.

The selection process for waste management service providers includes a technical and commercial assessment performed by the Corporate Internal Control, evaluating their technical capacity and compliance with existing laws. All companies are also audited by representatives from the Infection control committee and from the hospitals staff.
There is a policy of selective collection of cardboard, white paper, metal, plastic and glass. Selective garbage bins are distributed throughout the units.

PS4: Community Health, Safety and Security issues
Patient Health and Safety Management – 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 at each unit to prevent hospital infections (CCIH). The committees ensure management of infection risks and application of prevention and control measures which include environmental aspects such as waste collection, access control, and facility cleaning requirements.
The company has a department in its headquarters which is in charge of coordinating facilities’ engineering design and construction management. The construction management department develops site inspections, preliminary studies, executive projects, budgeting, monitoring, and commissioning of construction of new buildings and refurbishments. This department is in charge of managing the relationship with contractors. The department has five civil engineers, sixteen architects and seven supervisors in order to monitor all phases of the project to ensure expected technical quality and strict compliance with legal requirements.
Company facilities are regulated by the National Agency for Sanitary Vigilance which reviews and approves hospital engineering designs and which regularly inspects all company facilities for compliance with patient health and safety requirements. Both the company and the public agency monitor patient morbidity and mortality statistics as indicators of company performance and quality of care.
Rede D’Or received Joint Commission International (JCI) accreditation for its Copa D’Or hospital, in November 2007. Hospitals Barra D’or and Quinta D’or are accredited by both ONA and the Canadian Council on Health Services Accreditation, while Hospital Badim is accredited by ONA. The company is currently considering quality accreditation for all of its hospital facilities by the Brazilian National Accreditation Organization (ONA).

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 maintains contracts with service providers who 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.

Life and Fire Safety - The company applies national life and fire safety standards in the design of new facilities or renovation of existing buildings. The company will engage the services of life and fire safety engineering professional to review the design of both new hospitals and renovation / expansion of existing ones to ensure and certify compliance with IFC Life and Fire safety requirements addressed in the General Environmental, Health, and Safety Guidelines. In addition, after completion of construction, the life and fire safety design professional will inspect each building to certify that the facility has been constructed in accordance with the design.

Emergency Preparedness and Response - All units have Emergency plans, evacuation plans, and contingency plans for. Each unit works with tailor made contingency plans appropriate for its location, size and physical characteristics, in order to address situations such as fires, power failure, lack of water, release of medical gases, etc.

The training on fire safety includes topics related to communication in case of fire alarms, the 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, insulation, cooling and chemical suppression) and finally the types of fire extinguisher and fire hydrants and their correct use.

The training also includes lectures on the role of the fire brigade, knowledge of escape routes, course on fire fighting, lectures on accident prevention, dialogues within the security sector, an annual week of lectures on accident prevention (SIPAT), CIPA monthly meetings, internal sector supervisions, biosafety training and the training in the use of the emergency kit.

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