99394 Environmental and Social Management System Implementation Handbook HEALTH CARE FACILITIES Although the environmental and social management system described in this Handbook is based on IFC Performance Standard 1, the process outlined herein may not provide for meeting all the requirements of IFC Performance Standard 1, or any other IFC Performance Standard. The purpose of this Handbook is to dem- onstrate a technical means of integrating environmental and social concerns into company management, so that a business can become more effective in reducing its impact on the environment, its workers and its neighboring communities. The Handbook is provided “AS IS,” and is provided without warranty of any kind, either express or implied, including, but not limited to, implied warranties of mer- chantability, fitness for a particular purpose, or non-infringement. Development of an environmental and social management system based on this Handbook does not imply any type of certification or compliance with any IFC Performance Stan- dards, including but not limited to IFC Performance Standard 1, nor does it imply endorsement by or affiliation or sponsorship with IFC. The Handbook is distributed with the understanding that neither the authors, nor the organizations and countries they represent, nor the publisher, are engaged in rendering technical advice. The information, policies and procedure templates comprising the Handbook are intended as a reference and for informational purposes only, and are not to be relied upon for operational or any other purposes. Implementation of the Handbook is solely the responsibility and risk of the final users. The material in the Handbook is set out in good faith for general guidance, and no liability can be accepted for any possible loss or expense incurred as a result of relying on the information contained herein. Neither IFC nor any other member of the World Bank Group shall be liable for any direct, indirect, incidental, special, consequential, punitive or exemplary damages, including, but not limited to, damages for loss of profits, goodwill, use, data or other intangible losses (even if IFC has been advised of the possibility of such damages) in any way arising or resulting from use or reliance on the Handbook or any such conclusion or deter- mination. The Handbook is distributed subject to the condition that it shall not by way of trade or otherwise be sold or otherwise circulated on a commercial basis without IFC’s prior written consent. IFC does not guarantee or provide any warranties as to the accuracy, timeli- ness, completeness, reliability or usefulness of this publication’s content, and is not responsible or liable for any such content or use thereof. The views, advice, opinions and other statements herein are not reviewed or endorsed by, and do not necessarily represent the views and opinions of IFC or its Board of Directors, the World Bank or its Executive Directors, or the countries they represent. 2 Table of Contents Welcome & How to Use This Handbook.....................................................................................4 Section I: Benefits of an Environmental and Social Management System in Health Care Facilities...................................................................................................................7 Section II: Understanding an Environmental and Social Management System................................... 11 Overview...........................................................................................................................12 Elements of an Environmental and Social Management System (ESMS)..................................13 System Development and System Implementation........................................................15 Using The Handbook And Companion Publications To Develop And Implement Your ESMS......................................................................................................16 Section III: Practical Guidelines for Developing and Implementing Your Environmental and Social Management System............................................................ 17 1. Policy............................................................................................................................18 Purpose of an Effective Policy............................................................................................18 Modifying Your Existing Policy Statement or Creating a New One..........................................18 Gaining Senior Management and Company Commitment.....................................................19 2. Identification of Risks and Impacts..........................................................................20 Key Risks in Health Care Facilities........................................................................................20 3. Management Programs...............................................................................................23 Identifying Preventive and Corrective Actions....................................................................24 Writing an Effective Action Plan......................................................................................25 Writing an Effective Procedure.........................................................................................26 Short Cases......................................................................................................................26 4. Organizational Capacity and Competency..............................................................38 Roles, Responsibilities and Authorities to Implement the ESMS...........................................38 Communication and Training..........................................................................................40 5. Emergency Preparedness and Response....................................................................42 Common Hazards and Emergency Situations in Health Care Facilities...............................45 Common Emergency Scenarios..........................................................................................49 6. Stakeholder Engagement...........................................................................................50 Mapping Your Stakeholders..............................................................................................51 Developing a Stakeholder Engagement Plan......................................................................52 7. External Communication and Grievance Mechanism............................................54 External Communication.................................................................................................54 Grievance Mechanism......................................................................................................54 8. Ongoing Reporting to Affected Communities.......................................................57 9. Monitoring and Review.............................................................................................58 Indicators........................................................................................................................59 Measuring and Improving Your ESMS..............................................................................62 Linking Your Action Plan and ESMS Improvement Plan...................................................63 Conducting an Effective Management Review...................................................................64 3 Welcome & How to Use This Handbook Environmental and social responsibility is becoming more and more important in today’s global economy. There are thousands of environmental and social codes and standards in the world today. The codes and standards define the rules and the objectives. But the challenge is in the implementation. An environmental and social management system (ESMS) helps companies and organizations to integrate the rules and objectives into core operations, through a set of clearly defined, repeatable processes. This Handbook is intended to be a practical guide to help you develop and implement an environmental and social management system, which should help to improve overall operations. 4 Welcome and How to Use this Handbook In the current economic climate, health care facilities are under pressure to perform or even just survive. New initiatives are often met with resistance as people struggle to keep up with their day-to-day responsibilities. Some people think that an environmental and social management system must be big, complicated and expensive. But that is not really true. To be effective, a management system needs to be scaled to the nature and size of your organization. Your facility likely already has existing management systems for managing the delivery and quality of healthcare services and staff and patient safety. This Handbook will help you expand your existing systems to include environmental and social performance. Our hope is that this Handbook will accelerate your journey of continual improvement, the benefit of your facility overall, as well as your employees, patients, and other stakeholders. 5 Quick Reference for Using this Handbook These sections provide background on environmental and Sections I – II social management systems (ESMS). This section provides step-by-step instructions on how to develop and implement an ESMS. If you see a Toolkit icon, Section III it means that there is an accompanying tool in the ESMS Toolkit. This companion publication gives tools, including forms, templates, checklists, and other useful documents, to help ESMS Toolkit you develop and implement the systems described in the Handbook. We suggest that you adapt each tool for your company. ESMS This companion publication contains a questionnaire, Self-Assessment maturity matrix, and improvement tips to help you and Improvement measure the maturity of your ESMS and develop a plan Guide for improvement. Acknowledgements This Handbook was prepared by the Sustainable Business Advisory (SBA) department with primary contributions from Irene Angeletti, Rob Horner, and Larissa Luy. The Handbook is based on primary contributions and technical expertise from the Social Accountability International (SAI) team of Rachel Kanter Kepnes, Craig Moss, Jane Hwang, Yogendra Chaudry, Caroline Lewis and Edwin Koster, with key input from Aswin Kumar Krishnamoorthy and Joy Rosen. Additional resources include United States Department of Labor Occupational Safety & Health Administration training materials and Hospital eTool. Graphic design services were provided by Pam Henry. Photography courtesy of IFC ILO Better Work and World Bank Photo Library 6 Welcome and How to Use this Handbook I Benefits of an Environmental and Social Management System Version 1.2 April 15, 2015 ESMS Implementation Handbook - Health Care Facilities 7 Labor shortages had always been a challenge for us. Now, thanks to our social management Benefits of an Environmental system, not only are and Social Management System our employees happy for Health Care Facilities and productive, but also they stay with us longer.” Today, health care facilities are confronted with a number of significant envi- ronmental and social challenges. None of the challenges is insurmountable, Hospital but if not effectively assessed and managed, they will hurt the quality of your Administrator patient care, profitability, reputation, and prospects for future sustainability. Private hospital Among these challenges are the increasing cost of energy and water, the grow- ing power and influence of regulatory agencies, and rapidly evolving commu- nity awareness and concerns about environmental and social issues. These risks are in addition to the primary risk of failing to provide high-quality health care or build patient confidence. All of these risks ultimately have financial consequences and are driving forces that should motivate you to implement a management system for your health care facility. A management system will enable you to consistently foresee and address issues confronting your facility so you can prevent potential risks from becoming actual problems. Implementing an environmental and social management system (ESMS) can have direct financial benefits. Conserving and using energy and water more efficiently helps to reduce operational costs. Reducing waste and discharges “We are seeing a direct correlation – the suppliers with better social compliance consistently score higher in key performance indicators such as on-time delivery and quality.” Senior VP Multi-National Retailer 8 Section I: Benefits of an Environmental and Social Management System “As a leading producer and exporter, we operate in compet­ itive, globalized and volatile markets. Our management system based approach towards quality, environment and social issues has helped us attract and keep our global clientele through un­ compromising product quality; prompt, reliable delivery; and fair, transparent and ethical business practices.” Managing Director - Producer and export company can minimize costs of waste disposal, which have been steadily increasing over time. A management system can help you benchmark your expenditures against industry standards and identify potential operational cost savings. The same tangible benefits can be realized on the social side as well. Clear, transparent human resource policies and procedures improve communication between healthcare staff and supervisors. This helps to anticipate and avoid labor problems. Effective occupational health and safety management proce- dures will enable you to identify workplace hazards so you can eliminate or reduce their potential negative impacts through controls and employee training on the avoidance of risks. This can not only reduce near misses, accidents and fatalities, but can also lead to bottom-line business benefits such as reduced absenteeism and worker turnover, and lower insurance premiums for workers’ compensation. “We are facing intense global competition and declining spend- ing during the current global economic crisis. Improving our environmental and social management is helping us to reduce material inputs, minimize waste and improve our competiveness and our profitability.” CFO - Manufacturer Version 1.2 April 15, 2015 ESMS Implementation Handbook - Health Care Facilities 9 Many healthcare facilities already use management systems for patient care, quality control and occupational health and safety. An environmental and social management system (ESMS) simply extends that approach to the man- agement of your facilities’ impact on the environment, your staff and other stakeholders, including the community that you serve. Ultimately, your management systems should be integrated and centralized in one comprehensive system, instead of having separate systems for quality, occupational health and safety, and the environment. This handbook will help you implement an integrated ESMS that is appropriate for the size and nature of your health care facility. 10 Section I: Benefits of an Environmental and Social Management System II Understanding an Environmental and Social Management System Version 1.2 April 15, 2015 ESMS Implementation Handbook - Health Care Facilities 11 Understanding an Environmental and Social Management System OVERVIEW A management system is a set of processes and practices to consistently implement your facility’s policies to meet your objectives. The goal is to make sure that you have the appropriate policies and procedures in place and that people consistently follow them. The management system helps to assess and control your risks and is the key to lasting improvement. A key feature is the idea of continual improvement – an ongoing process of reviewing, correcting and improving your system. The most common method is the Plan-Do- Check-Act cycle (PDCA), described below. Identifying and Developing and analyzing the risks implementing a and objectives potential solution PLAN DO What is important for you What actions will you as an organization and take? Who, what, what are you going to do where, when and how? about it? Measuring how effec- ACT Implementing the tive the solution was, improved solution What will you change if CHECK and analyzing whether it could be improved results are not what you Did you see the change you expected? expected after implementing the actions? 12 Section II: Understanding an Environmental and Social Management System In the workplace, an effective management system is comprised of trained, committed people routinely following procedures. ELEMENTS OF AN ENVIRONMENTAL AND SOCIAL MANAGEMENT SYSTEM (ESMS) A solid, functioning environmental and social management system (ESMS) is made up of interrelated parts. Take a look at the nine elements of an effective ESMS. Each of these elements is important, because they help you to assess, control and continually improve your environmental and social performance, as part of the Plan-Do-Check-Act cycle. The following section presents step-by-step instructions on how to develop and implement a system using these elements. Version 1.2 April 15, 2015 ESMS Implementation Handbook - Health Care Facilities 13 MEASURING AND IMPROVING You can’t improve Most health care facilities already have management systems for quality, safety and patient care. If your facility already has systems in place, you may already be what you don’t implementing certain elements of the ESMS, and you can build on your existing systems. In this Handbook’s companion publication, ESMS Self-Assessment measure. and Improvement Guide, we provide a self-assessment rating for each of the ESMS elements. The self-assessment will allow you to measure your current level of system development and implementation. You will answer a series of questions and get your score for each element in the ESMS on a scale of 0 to 5 (5 is highest). The score measures the maturity of your system. Once you understand the maturity of your system, it is easier to target specific steps you can take to improve it. THE SYSTEM MATURITY LEVELS (5 = HIGHEST) Level 5 Mature system implemented internally and with key supply chain partners – continual improvement embedded in operations Level 4 Systems well developed and implemented internally – routine improvement projects Level 3 Systems approach adopted, but development and implementation is inconsistent – improvement sporadic Level 2 Limited system development with sporadic implementation – primarily reactive Level 1 Little systems awareness or repeatable processes Level 0 No systems awareness or repeatable processes 14 Section II: Understanding an Environmental and Social Management System REMEMBER A carefully developed, detailed ESMS is only valuable if it is well-implemented. SYSTEM DEVELOPMENT AND SYSTEM IMPLEMENTATION One of the most important things to understand about a management system is the difference between system development and system implementation. A management system is comprised of trained, committed people routinely fol- lowing procedures. If you break this statement down, you see that it talks about “procedures.” Procedures are the step-by-step way that people follow your poli- cies. Procedures are the heart of effective system development. Now let’s look at the other part of the statement – “trained, committed people routinely following procedures.” This is the implementation. There is a lot that goes into making it happen. Of course, some training is important to make sure that people are aware of the procedures and understand what they are supposed to do on a routine basis. But you also need to find a way to get their commit- ment. One common observation is that large organizations tend to be better at system development. But they often have difficulty getting people in different locations or departments to consistently implement the procedures, despite having well- documented systems. Small organizations tend to be better at system imple- mentation – if they have effective leadership. However, they are often weak at developing the documentation needed to ensure continuity when people in the organization change. The approach of this Handbook and its companion publications, Toolkit and Self-Assessment and Improvement Guide, balances system development and system implementation in each of the ESMS elements. DEFINITIONS System The documented policies and procedures. Development System Trained, committed people routinely follow- Implementation ing the procedures. An ESMS does not need to be complicated, but it does need to be documented and then put into practice. Some people mistakenly think a management system is just documents. But that is only a part of it. Management systems are about implementation and continual improvement. Version 1.2 April 15, 2015 ESMS Implementation Handbook - Health Care Facilities 15 USING THE HANDBOOK AND COMPANION PUBLICATIONS TO DEVELOP AND IMPLEMENT YOUR ESMS The Handbook and companion publications are designed to help you measure and improve the maturity rating of your ESMS. The flowchart below shows how you can use these three publications in a cycle of continual improvement. ESMS HANDBOOK • Use tools to implement • Understand the benefits of an ESMS improvement plan • Learn the nine fundamental elements of an ESMS REDO this graphic ESMS SELF- ESMS ASSESSMENT & TOOLKIT IMPROVEMENT GUIDE • Measure the maturity of your ESMS • Prioritize elements and develop an overall ESMS improvement plan 16 Section II: Understanding an Environmental and Social Management System III Practical Guidelines for Developing and Implementing Your Environmental and Social Management System This section provides step-by-step instructions on how to develop and implement an ESMS. For each element of the ESMS, we offer a quick way to measure where you are now. When you find a toolkit icon, it means there is a tool in the companion publication Toolkit to make it easier to get started. Version 1.2 April 15, 2015 ESMS Implementation Handbook - Health Care Facilities 17 ELEMENT 1 Policy 5 E&S policies and proce- dures clearly commu- The cornerstone of your ESMS is your set of nicated internally and externally. Senior man- policies. Your policies summarize the commitment agement commitment to continual improvement. that your organization has made to managing environmental and social risks and impacts. They 4 Full set of E&S policies, procedures and records, establish the expectations for conduct in all related centrally maintained and routinely reviewed. Wide awareness in company. aspects of your organization. PURPOSE OF AN EFFECTIVE POLICY 3 Policies and procedures Simply put, the policies are the rules. They tell everyone what is allowed and in place meeting selected what is not allowed when it comes to social and environmental issues such as E&S standards. Sporadic labor and working conditions, resource efficiency and pollution prevention, communication, imple- mentation and review. and community health, safety and security. A good practice for writing the policies and making them understood is a Policy Statement. The Policy Statement communicates your policies to your management, staff, board, suppliers, contractors, patients and all other stake- 2 Policies in place meeting holders. It is important for everyone to have a common understanding of the selected E&S standards. core values of the organization, how you expect people to behave and how Sporadic, conflicting or confusing procedures. external stakeholders can expect you to operate. MODIFYING YOUR EXISTING POLICY STATEMENT OR CREATING A NEW ONE 1 The Policy Statement should be clear and simple – it does not need to be long Limited E&S policies in place. and technical like a legal document. Many companies already have a corporate code of conduct that serves as a Policy Statement and includes issues such as ethics. You can expand your existing code to align with internationally recog- nized environmental and social standards for issues relevant to your organiza- tion, such as the IFC Performance Standards for Environmental and Social Sustainability. 0 No E&S standards It is important to think through the creation of the Policy Statement and tailor adopted. No related it to your operations. In developing your Policy Statement, be aware of the policies and procedures. specific risks you face in your health care facility. 18 Section III: Practical Guidelines for Developing and Implementing your Environmental and Social Management System 1. Policy GAINING SENIOR MANAGEMENT AND ORGANIZATION COMMITMENT Modifying or adopting your Policy Statement will require senior management For any change support. In some organizations, it may require approval from the Board of Directors. A high level of senior management support is critical for integrating initiative, think environmental and social commitment throughout all levels of your organiza- tion. of three critical Committing to environmental and social policies probably requires some stages: change in the behavior of your workers, contractors and suppliers. This can be challenging. There are different strategies and different techniques for chang- Awareness; ing organizational behavior, but experts agree that to create lasting change, senior management must be committed to the effort. Commitment; The first step is building awareness. There are many issues that occupy your employees’ attention day-to-day. As just a written document, your Policy and Statement may not get their attention or seem relevant to their daily activities. Senior management needs to make this Policy Statement come alive. Implementation. To do so, they need to communicate the importance of environmental and social issues, by making them an ongoing part of high-level Board and man- agement discussions, public speeches, and messages to employees. Your senior Once people are aware of the Policy Statement, the next step is building com- mitment – also known as “buy-in.” You will probably meet resistance: “Why management do we need to do this? It is too much work. I’ve already got enough to do. How does this help our delivery of health care services?” Senior management can help you to needs to effectively shape and communicate the message internally and externally. They need to send a clear message that this is a long-term commit- accelerate all ment by the organization. The key message is that this will contribute to the organization’s success and three stages. Use the Toolkit item Checklist for that each person will benefit - Developing a Company Policy but that they will also be held Statement to get ideas of what you accountable. could include in your policy. Once you have convinced people that they need to do something, senior management needs to drive implementation. They do not need to lead the effort on a day-to-day operational level, but they do need to adopt the policy and oversee the implementation plan. Resources will be nec- essary in order to communicate the policy internally and externally, integrate new procedures and train all relevant staff and suppliers. Crafting the initial messages Use the Toolkit item CEO Letter can be a good time to talk Announcing the ESMS - Internal to through the above stages with get started. your senior management. Consider accompanying the Policy Statements with a message from the CEO. Version 1.2 April 15, 2015 ESMS Implementation Handbook - Health Care Facilities 19 ELEMENT 2 Identification of Risks and Impacts 5 Mature system, routinely reviewed and updated The primary objective of a risk assessment is to as part of a continual improvement plan. Internal identify the potential negative environmental and external inputs. Proce- dures extended to contrac- and social impacts so that you can develop the tors, subcontractors, third parties and supply chain as relevant. appropriate strategies to address them. 4 Systematic, documented identification and prior- itization of E&S risks In the following pages, we present the key issues and impacts. Routinely reviewed and updated across existing, new and that come up in health care facilities. changing activities. Wide awareness and engage- ment in company. KEY RISKS AND IMPACTS IN HEALTH CARE FACILITIES 3 Awareness and engage- ment of staff in identifica- tion and prioritization of 1. Environmental: Pollution Prevention and Resource Efficiency E&S risks and impacts. • Generation of significant volumes of general health care waste (comparable to External experts involved domestic solid waste) as required. • Generation and inadequate management of hazardous health care waste, which requires precise segregation and special handling and treatment. Such waste includes: infectious, pathological, radioactive, pharmaceutical, and genotoxic/ cytotoxic waste, sharp items, pressurized containers, products containing heavy 2 metals (e.g. mercury, cadmium) or persistent, bio-accumulative toxic (PBT) Procedures in place for compounds, and chemical waste from laboratories and cleaning/disinfecting identification of E&S risks operations, such as formaldehyde and halogenated solvents and impacts across all key activities. • Air emissions from hospital waste incinerators • Exhaust air from infectious disease wards and other health care facilities potentially contaminated with biological agents, pathogens, or other hazardous materials • High energy and potable water consumption in hospital buildings • Leakages and spills from storage tanks for compressed gases (oxygen) and other 1 Basic identification and materials stored in bulk (boiler, generator and vehicle fuels) assessment of E&S risks • Inadequate wastewater treatment and disinfection prior to discharge, leading to and impacts, but limited surface or ground water contamination to a few activities. • Improper management of radioactive sources and retired equipment that may contain sources and/or other hazardous materials 0 No identification or assessment of E&S risks and impacts. 20 Section III: Practical Guidelines for Developing and Implementing your Environmental and Social Management System 2. Identification of Risks and Impacts 2. Occupational Health and Safety • Nosocomial (hospital acquired) infections among patients and staff • Needle-sticks, surgical cuts, and other injuries posing transmission risk of blood-borne diseases such as Hepatitis C, HIV-AIDS, etc. • Environmental services (sanitation) workers’ exposure to infectious and communicable diseases • Occupational dermatitis and allergic reactions due to workplace exposures (e.g. disinfectants and cleaning agents or latex) • Negative impacts on mental health, due to high levels of stress • High rates of fatigue, gastrointestinal, psychological and cardiovascular conditions, and increased injury rates due to long working hours and shift work • Injuries from repetitive manual work (e.g. improper patient movement or cleaning activities) • Exposure to violence, including verbal or physical assaults, from patients and their attendants • Exposure to hazardous substances such as cytotoxic drugs, anesthetic gases, and substances used for sterilization (e.g. ethylene oxide, formaldehyde, and glutaraldehyde) 3. Labor • Lack of oversight of recruitment agencies for nurse staffing, with associated risk of forced labor • Lack of protection of migrant migrant workers (e.g. in-home nurses or caretakers) • Inefficiently planned work schedules leading to excessive working hours, inadequate rest periods, and insufficient time off • Excessive overtime not properly compensated • Exposure to violence and sexual harassment • Lack of awareness or due diligence of supply chain labor risks in hospital procurement processes due to focus on cost minimization (e.g. risk of child labor or forced labor in factories that produce hospital linens) 4. Community Health, Safety and Security • Inadequate design, construction, and maintenance of facilities to assure life and fire safety in health care facilities to which the public has access • Inadequate design, construction, and maintenance of detection and suppression systems, compartmentation, smoke control, and facility egress for patients, attendants and visitors with compromised maneuverability and mobility • Lack of emergency potable water reserves for the community • Air emissions, odors and mists/fumes from improper air handling leading to cross contamination and pathogen transmission • Increased vehicle traffic around health care facilities from patients, employees and visitors leading to congestion and risk of accidents • Increased emergency vehicle traffic and associated noise Version 1.2 April 15, 2015 ESMS Implementation Handbook - Health Care Facilities 21 Top 3 risks and opportunities in Health Care Facilities 1 Patients and health care providers are at risk of being exposed to The following are key considerations for a robust risk infections inside health assessment system: care facilities. Without • Cover environmental, OHS, labor and community risks; proper controls in place, infections can also spread • Conduct at regular intervals – at least once a year; to surrounding commu- nities. Infection control • Conduct any time there are significant changes to systems are required to operations; detect cases and prevent • Conduct any time there are external changes such as infections from spreading. new laws or regulations; 2 Due to the demanding nature of health care work, health care provid- • • Include input from all levels of workers and managers; Include input from affected communities and other ers and staff often work external stakeholders; excessive hours. This can • Use external consultants and experts if your staff does have negative impacts on not have the capability; workers’ health and can also impact the quality of • Assess and prioritize risks according to both the severity care that they deliver. It is and probability of negative impacts; important for health care • Consider risks in your supply chain in addition to those facilities to be aware of in your facility; and the risks associated with excessive working hours so • Scale as appropriate to the size and complexity of your they can plan and monitor business. working hours and shifts appropriately. 3 Health care facilities, especially hospitals, use high amounts of Now that you have an understanding of the typical risks in health care facilities, you can first use the Risk Identification Worksheet to identify your potential risks and negative energy and water in order impacts based on your operations and operating environment. to provide the requisite Then you can use the Process Mapping or the Physical services. This use of natural Mapping tools to identify in more detail where problems are resources can have serious likely to arise within your operations. implications on the envi- ronments surrounding hos- Often it is not possible or practical for you to deal with every pitals. Improving energy single environmental and social impact that your facility and water use efficiency could possibly have. You can use the Risk Assessment Form can reduce costs for health to prioritize which risks should be addressed first. care facilities and lessen the impact on the sur- For more information on environmental, OHS and community risks rounding communities. and impacts in your industry, consult the WBG EHS Guidelines at www.ifc.org/sustainability. 22 Section III: Practical Guidelines for Developing and Implementing your Environmental and Social Management System ELEMENT 3 Management Programs 5 Management Programs are centered on Action Verified progress against objectives and targets; significant improvements Plans and improved procedures to avoid, minimize in E&S performance. Dem- onstrated commitment to or compensate for the risks and impacts that were continual improvement using annual improvement plans. identified. 4 Routine, consistent imple- mentation of actions/ For example, if you have a policy commitment activities to proactively manage E&S risks and impacts. Measurable com- to avoid discrimination in the workplace and you pany-wide objectives and targets. Periodic review have identified this as a risk factor based on the and update. 3 lack of a system for employees to express their Actions/activities in place to manage E&S risks and impacts, following the complaints, you may implement a complaint mitigation hierarchy – avoid, minimize, offset/ procedure as a way to minimize the risk of compensate. Proactive approach to managing issues. discrimination. Or, if one of your policy objectives 2 Procedures and assigned is the reduction of sharps injuries, and you have responsibilities to address and mitigate E&S risks identified this as a risk factor because of the and impacts across all key activities. Primarily reac- tive. high rates of occurrence, you may take action by replacing sharps with other instruments. 1 A few informal programs or activities to mitigate E&S impacts. No systems awareness or repeatable processes No process for mitigating E&S risks and impacts. 0 Version 1.2 April 15, 2015 ESMS Implementation Handbook - Health Care Facilities 23 3. Management Programs IDENTIFYING PREVENTIVE AND CORRECTIVE ACTIONS It is good practice to emphasize preventive and proactive actions: (1) try to avoid causing social or environmental damage; (2) if not possible, then mini- mize the impact; (3) if not possible, then compensate or offset the damage. First, attempt to take actions to avoid or prevent the negative impacts. For example, suppose you are expanding operations and have identified potable water as a key risk. You might change your new facility location or design it differently, so that you avoid contamination of groundwater close to home- owners and communities. Or, suppose you have identified a certain sanitation process that exposes health care workers to certain hazardous materi- Prioritizing Your Actions als. You might change your processes to avoid using these materials or reduce the risk of exposure. AVOID In many cases, complete avoidance is not possible – you may not  be able to relocate or find alternative processes or materials. In these MINIMIZE cases, you should try to minimize the impact. For example, suppose  that you are located in an area where women are traditionally given COMPENSATE/OFFSET lower status and less access to education, and in the workplace they are often mistreated by male co-workers and supervisors. Given this cultural context, it is important to be clear in your recruitment, hiring and training procedures, in order to make sure that women are hired on equitable terms and given equal access to training and promotion opportunities. You can also develop non-discrimination procedures to ensure that rules for recruitment, hiring and training are clear for everyone to follow. Additionally, you can conduct training to make sure that everyone is aware of and follows the procedures. In some cases, it may not be possible to completely avoid or minimize certain negative impacts. Then you should find ways to offset them with comparable positive impacts or provide compensation to those impacted. For example, suppose your operation uses a large amount of water. Despite taking action to minimize water consumption, there are still periods of the year when water be- comes scarce in the local community. You might collaborate with community leaders to dig new wells or provide alternate sources of drinking water. 24 Section III: Practical Guidelines for Developing and Implementing your Environmental and Social Management System 3. Management Programs WRITING AN EFFECTIVE ACTION PLAN Whatever actions you decide to take, think of them as a continual improvement process - you will need to set targets, set deadlines, measure the results, and ad- just the plans if necessary. You need to assign responsibilities and start to involve the right internal people and departments. As you develop your Action Plans, these are the key questions that you need to think about: • What – environmental and social risks you want to address • How – related actions and procedures to be implemented to address the risk • Why – reasons (objectives) for the actions and procedures, and the expected results (targets) • When – timeframe and deadlines • Who – responsible people Use the Toolkit item Action Plan Chart to get started. The above examples address some of the risks highlighted in the industry. These are just some of the actions that might be taken. You can adapt them to your situation and add as needed – be flexible to meet your organization’s specific situation. As you tailor your action plans, consult with your workers and manag- ers, experts and external stakeholders, including your suppliers and community. They can offer insight into important issues and effective actions. They can also help you obtain commitment for plans you are trying to implement, and provide candid feedback about how well the plans are working. This will be critical to the continual improvement of your systems. For recommendations on how to address environmental, OHS and community risks and impacts in your industry, consult the WBG EHS Guidelines at www.ifc.org/sustainability. Version 1.2 April 15, 2015 ESMS Implementation Handbook - Health Care Facilities 25 3. Management Programs WRITING AN EFFECTIVE PROCEDURE Procedures serve as step-by-step instructions for workers, supervisors and managers. They allow for everyone to have a common understanding of how to behave. They enable the rules to be followed even when there is staff turn- over. Clear, detailed procedures help to embed your social and environmental policies into your daily operations. It is a good practice to document your procedures. The key is to make your procedures as clear and as brief as possible. You can use text, checklists, flowcharts, or simple illustrations. The format for your procedure can vary depending on the audience. A written procedure may be more appropriate for managers and supervisors, while illustrations may be useful when dealing with less literate or immigrant workers. Keep your procedure as short and simple as possible. Use the Toolkit item Outline of Procedure and the Sample Procedure Flowchart to get started. Simply documenting a procedure is not enough. Effective implementation is the ultimate goal. Most importantly, employees need to be aware that a new procedure exists and understand why it is important to follow. They need the skills and knowledge to be able to implement it. This is achieved through routine communication and effective training. You will learn more about this in the next chapter, Organizational Capacity and Competency. Finally, you must ensure that your employees have access to the current version of each procedure. Out-of-date documentation should be removed or clearly marked as outdated to ensure that no one unintentionally follows the old procedure. SHORT CASES Here we present several short cases that illustrate some of the actions that companies can take to avoid, minimize or offset/ compensate common environmental and social key risks in health care facilities. Action Plans can be scaled to the size of your facility and the nature of the risks you face. 26 Section III: Practical Guidelines for Developing and Implementing your Environmental and Social Management System 3. Management Programs CASE STUDY: KENYA Health Insurance and Outpatient Care Services RISK: Improper disposal of health care waste Kenya Health Services (KHS) Group is one of the largest providers of health insurance and outpa- tient care in East Africa. The Group recently restructured its operations. KHS now plans to enter the inpatient care market by acquiring two medium-sized hospitals. However, a recent study conducted by a Japanese international cooperation agency revealed that health care waste man- agement practices at most Kenyan hospitals, including the two that KHS plans to acquire, do not comply with international requirements. Hospitals do not segregate different types of wastes and manage hazardous health care waste poorly. Health care waste is openly stored on hospital prop- erty and is not secured against pilfering and vandalism. This results in the reuse of scavenged syringes and needles, which are documented vectors for outbreaks of hepatitis A, B, and C, and HIV infections. Furthermore, hospitals often resort to open-air burning of collected wastes. This practice is a significant source of air pollution and releases dioxins, furans, and mercury. Existing facilities for adequate external hazardous health care waste management in the area, such as incinerators, are often out of order or utilized improperly. As a result, 60 per cent of hazardous health care waste is not disposed of properly in Kenyan hospitals. I M PAC T • Contamination of local environment due to inappropriate storage, treatment and disposal of hazardous medical waste • Release of toxic air emissions, including dioxins, furans, and heavy metals, due to uncontrolled burning of medical waste AVO I D • Avoid hazardous waste generation at hospitals by substituting products or equipment containing hazardous materials , such as mercury, polyvinyl chloride (PVC), halogenated compounds, and carcinogenic, mutagenic or reprotoxic (CMR) substances. • Prohibit the open-air burning of waste. • Restrict the access to and handling of waste to trained, authorized personnel only. • Eliminate incineration of any waste chemically treated with chlorinated disinfectants or containing chlorinated plastics. M I N I M IZE • Develop and implement policies and procedures for the proper segregation, labeling, storage (color-coded), treatment, and disposal of waste. Waste treatment and disposal should be conducted differently according to the type of waste, such as: the incineration of pathological and microbiological waste; the shredding and landfill of contaminated plastics; the deep burial of sharps in hard wall disposal containers; and waste immobiliza- tion of unwanted pharmaceuticals. • Maintain records of all pits used for deep burial of waste. • Train personnel on all policies and procedures. • Use autoclave to disinfect and treat biomedical waste as appropriate. Train staff to monitor autoclave indicators to ensure that medical waste is treated for the necessary amount of time at the correct pressure and temperature during the process. O FF S E T • Assist in the remediation of land and water sources contaminated by hazardous medical waste streams from hospitals. Version 1.2 April 15, 2015 ESMS Implementation Handbook - Health Care Facilities 27 3. Management Programs CASE STUDY: INDIA Public Hospital RISK: Improper treatment of liquid effluents A public hospital in Mumbai was recently issued a notice by the Maharashtra State Pollution Control Board (MSPCB) for failing to control liquid effluents from its operations. The order requires the hospital to install an effluent treatment plant (ETP). This order emanates from a study that concludes that the spread of multiple drug-resistant (MDR) bacteria may be traced to hospital effluent discharges in the municipal sewage system. In India, rampant misuse of antibiotics has contributed to the development of antibiotic resistance, and many effluent contributors do not meet pre-treatment requirements for their discharges. The study found that concentrations of MDR bacteria were alarmingly high in samples of effluents collected from five hospitals, including this hospital. The government advised the public that the spread of MDR bacteria to the community is a matter of grave concern and has instructed the hospi- tal to address this issue. However, the hospital claims that there is not enough space or land available to build the effluent pre-treatment works and integrate the out-of-date facility sewerage infrastructure. I M PAC T • Contamination of municipal sewage system with multiple drug-resistant (MDR) bacteria AVO I D • Develop and implement procedures regarding the prescription and disposal of antibiotics • Train doctors on procedures to avoid unnecessary prescription or over-prescription of antibiotics. • Train other health care personnel on the proper administration of antibiotics. Health care pro- viders should ensure that patients finish their full course of prescribed antibiotics (even if they are feeling better) so that drugs are fully effective and do not breed resistance. • Train cleaning and maintenance staff on the proper disposal of antibiotics. • Inform patients not to flush any unused drugs in the toilets. • Develop, implement and train personnel on infection prevention and control procedures. Proce- dures should prevent the spread of infection between individuals through hand-washing before and after patient contact; appropriate use of alcohol-based hand rub solutions; and the use of barrier equipment such as gloves, gown, masks and goggles. Procedures should also seek to prevent microbial transmission through contaminated surfaces, such as door handles, over-bed tables, and equipment, such as stethoscopes and blood pressure cuffs. • Conduct a water and waste audit to identify and quantify wastewater streams and wastewater contamination sources. • Ensure that all clinical and other solid wastes are collected and disposed according to regulatory guidelines (e.g. incineration, immobilization, etc.) so that they do not interact with liquid waste streams. M I N I M IZE • Consult with local authorities and communities to find a site for an effluent treatment plant (ETP) and install it. Since most microbiota adhere to suspended solids, focus on developing aeration, set- tling, flocculation and clarification processes to ensure efficiency. The settling of solids will reduce pathogens and make the chlorination efficient at lower doses to prevent any contamination after final discharge. • Develop and implement proper procedures for the ETP and train personnel accordingly. Proce- dures should ensure that treated effluent is effectively chlorinated before its final discharge (e.g. chlorine dosage of 5-20 mg/L for a contact time of at least 30 minutes at pH < 7) and sludge is adequately disinfected before its final disposal. Sludge disposal must be conducted according to local regulations and laws. O FF S E T • Work with the community and local NGOs to build awareness about proper antibiotics usage (e.g. use antibiotics only when prescribed by a doctor; do not share antibiotics with others or use left- over prescriptions) and disposal of unused drugs. • Introduce and implement community programs to collect and dispose unused antibiotics. 3. Management Programs CASE STUDY: ALBANIA Private Healthcare Group RISK: High energy and water consumption City Healthcare Group is one of the largest healthcare companies in Albania. The company owns and operates various large hospitals across the country and is currently in the process of modern- izing most of its facilities to minimize operational costs. However, high energy and water consump- tion are major concerns for most of the Group’s hospitals. Elbasan hospital, which has 350 beds, uses over 350,000 gallons water per day. This is significantly higher than most modern hospital facilities; the hospital has received numerous notices from a local environmental agency. Further- more, the city of Elbasan is experiencing a growing electricity shortage. During the last winter season, most of the city experienced extensive power cuts for 12-14 hours a day. Energy restrictions and power cuts pose significant challenges for the hospital, given the strict temperature, humidity, and air quality requirements and associated demands on the hospital HVAC system. I M PAC T • Depletion of water supply in surrounding areas • Negative health impacts on patients and personnel due to interruption of HVAC system AVO I D • Investigate alternative energy options to complement electricity sourced from the municipal grid. Examples include: • Install a suitable capacity solar panel system. • Install solar water heaters. M I N I M IZE • Conduct an energy audit to identify energy-saving opportunities, such as: • Insulate hot water pipes to minimize heating loss. • Identify and seal leaks in duct systems delivering heated or cooled air. • Install heat exchangers to preheat incoming fresh cold air with outgoing stale heated air. Heat exchangers will work conversely during summer months, cutting down the amount of energy needed for air-conditioning. • Incorporate variable speed drives on fans and compressors to reduce amount of elec- tricity used by the motors of these devices. • Conduct a water audit to identify opportunities for water conservation, such as: • Install water efficient equipment (e.g. dual flush toilets or low volume showerheads). • Regularly fix drips and leaks. • Improve cooling towers management. • Install water-saving sterilizers or retrofit existing sterilizers. • Recover condensate from air handling and refrigeration units. • Make operational changes to improve water efficiency, especially related to cleaning practices and laundry and food preparation activities. • Develop, implement and train personnel on water conservation policies and procedures. • Publicize the water conservation policy to patients and visitors and increase their aware- ness of the need to conserve water by placing signs in throughout the hospital, especially in patient rooms and restrooms. Version 1.2 April 15, 2015 ESMS Implementation Handbook - Health Care Facilities 29 3. Management Programs CASE STUDY: ETHIOPIA Private Hospital RISK: Lack of potable water and emergency water supplies Established in 1959, City Memorial Hospital is one of the largest and most respected hospitals in Addis Ababa with 370 beds. It aims to serve the most vulnerable populations in Addis Ababa, and has a potential patient base of 5 million people. The hospital employs over 1000 clinical and non- clinical staff and sees an annual average of 20,000 inpatients. Due to the rapid expansion and growth of the capital, demand for potable water in the city has increased drastically. This has led to a shortage of water in the city, which affects the operations of businesses and essential services like restaurants, hotels and health care facilities. City Memorial Hospital authorities often com- plain that the hospital receives its water supply only once a week, which forces the hospital to use chemically and bacteriologically infected water from local storage. The quality of water delivered to the hospital is also negatively impacted when city water lines are not pressurized. To deal with the water shortage, the hospital decided to drill groundwater wells about a year ago. However, inconsistent power supply and inadequate water treatment and storage facilities make it difficult for the hospital to maintain a safe water supply for its operations. In addition, during a recent emergency mock-drill, staff noticed that the hospital fire hydrants were not functioning due to lack of power and adequate water storage. I M PAC T • Disruption of hospital services and adverse health impacts due to insufficient and contaminated water supply • Spread of fire due to lack of emergency water supplies for fire hydrant system AVO I D • Install a fire suppression water storage tank to store raw water (i.e. water prior to treat- ment, such as groundwater) according to National Fire Protection Association (NFPA) standards. This water can be used for fire suppression and other non-potable water applications. • Estimate flow rate per bed and hour in normal operating conditions. Install a waste disinfection unit and potable water storage tanks that can contain sufficient water to meet the requirements for an established period of time. • Develop and implement procedures for potable water disinfection and storage, including regular maintenance, cleaning and monitoring of the water disinfection unit and water storage tanks. M I N I M IZE • Conduct a water audit to identify opportunities for water conservation. • Develop and implement water conservation policies and procedures. • Make operational changes to improve water use efficiency, especially related to cleaning practices and laundry and food preparation activities. • Train personnel on water conservation practices and post post signs/checklists through the building about conserving water. • Increase patient and visitor awareness of the need to conserve water by placing signs in patient rooms and restrooms and publicizing the water conservation policy. 30 Section III: Practical Guidelines for Developing and Implementing your Environmental and Social Management System 3. Management Programs CASE STUDY: PHILIPPINES Community Hospital RISK: Contamination of indoor air Country Hospital is one of the oldest hospitals in Antipolo City, Philippines. The 150 bed hospital is owned by a local Trust and has been known for providing quality health care services to the local community for more than a century. For the last several months, hospital employees and patients have been complaining of poor air quality, stuffiness, and unpleasant odors, accompanied by symp- toms of eye, nose, and throat irritation and nausea. Absenteeism among the staff is on the rise, which often results in the disruption of essential services during outpatient department hours. Concerned with the growing patient complaints and disruption in essential medical services, the Hospital Administrator recently consulted the Maintenance Manager, who suggested that the problem may be due to HVAC system inadequacies, such as a deficiency of air exchanges, poor air distribution, poor thermal control, and inadequate maintenance procedures. The Maintenance Manager created a team to further investigate the issue and implement suitable control measures. Upon careful investigation, the team discovered several other issues including cross contamination from the underground parking garage, infectious disease wards, food preparation area, sterilization units, and operating rooms. These issues are contributing to the indoor air quality problems in the hospital. I M PAC T • Negative health impacts on personnel and patients due to poor indoor air quality AVO I D • Implement an inspection and preventive HVAC maintenance program to prevent re-occurrence. • Develop and implement policies and procedures related to the cleaning and servicing of the HVAC system. Regularly drain, clean and replace HVAC components (e.g. drain pans, ducts, air dampers, cooling towers, filters, etc.) to minimize the potential for microbial growth or contamination. • Review and modify the orientation of air intakes and exhausts to eliminate cross-contamination from local pollution sources, such as parking areas, garages, loading zones and cooling towers. • Relocate intake points or consider adding specialized filtration, such as activated carbon. • Ensure that the minimum outside air damper settings are enough to provide adequate amounts of outside air and that these are not being closed inappropriately for energy efficiency. • Determine pressure relationships within the facility and implement engineering controls (air flows from positively pressurized to negatively pressurized spaces). M I N I M IZE • Train appropriate personnel to monitor air quality levels regularly and make the necessary adjust- ments in the HVAC system as required. • Monitor carbon dioxide levels regularly and determine the adequacy of the outside air supply. • Monitor carbon monoxide levels regularly as an indicator of the infiltration of combustion byproducts. • Monitor respirable suspended particles as an indicator of filtration effectiveness. O FF S E T • Provide timely medical treatment to affected personnel and patients. Version 1.2 April 15, 2015 ESMS Implementation Handbook - Health Care Facilities 31 3. Management Programs CASE STUDY: UNITED STATES Public Psychiatric Hospital RISK: Unsafe food preparation A state-owned psychiatric hospital has 320 employees and 128 patient beds. More than forty people recently were affected by an outbreak of food poisoning. The illness was caused by food contamination with Clostridium perfringens, which is found on raw meat or poultry. C. per- fringens is the third most common cause of food poisoning in the United States. Though it can sometimes be safely ingested, C. perfringens forms spores that can withstand cooking tempera- tures and can germinate to develop infective bacterial colonies. This outbreak was traced to a contaminated chicken salad that was served to patients and staff. The contaminated salad was likely prepared hours in advance of being served and stored at an inappropriate temperature. The mishandling of the prepared food created an environment in which the bacteria could grow and then infect those who consumed the affected food. Subsequent investigations highlighted severe deficiencies in the food preparation services at the hospital. I M PAC T • Bacterial gastroenteritis (food poisoning) among staff and patients due to improper food storage and preparation. AVO I D • Establish a Hazard Analysis and Critical Control Points (HACCP) program. • Establish and implement standard criteria for the purchase of food and food handling equipment. • Develop and implement procedures for food handling and storage, and for cleaning and disinfection of food handling equipment in order to avoid microbial contamination and maintain a high level of food safety. Any food that is past a certain preparation time or date, or otherwise suspected of being contaminated, must be discarded. • Assign a responsible, trained person to oversee food preparation and handling. He or she shall monitor food preparation personnel to ensure that they follow safe food handling and storage procedures and regularly clean and disinfect food handling tools and equipment. • Conduct periodic, mandatory training for food preparation personnel on food handling procedures to prevent contamination M I N I M IZE • Ensure that all water used for drinking or food preparation is appropriately filtered and purified for potability. • Dispose of any chipped, broken or cracked eating or drinking utensils. • Seal all holes in the building to ensure pests cannot gain access to the building and imple- ment a pest control system. • Post signs with food handling instructions in food preparation areas. O FF S E T • Provide medical care and timely assistance to affected persons. 32 Section III: Practical Guidelines for Developing and Implementing your Environmental and Social Management System 3. Management Programs CASE STUDY: BRAZIL Private Hospital Network RISK: Needlestick and sharps injuries The largest network of private hospitals in Brazil includes 23 hospitals and 30 oncology clinics, as well as urgent care clinics, research institutes, and corporate offices distributed throughout the country. This network includes over 30,000 staff members. Thousands of affiliated specialists also utilize facilities in the network with their own surgical and support personnel. Despite a comprehensive management system and 168 Occupational Health and Safety staff, hospitals in the network are experiencing high rates of lost-time due to workplace injury, especially from the recurrence of preventable incidents such as cuts and punctures from sharp instruments. These accidents have been primarily attributed to the large number of affiliated specialists who are not included in the network’s management system. One recent case resulted in the transmission of HIV to a member of the nursing staff. This unfortunate event raised potential issues about the effectiveness of the hospitals’ occupational health and safety system. I M PAC T • Transfer of diseases among health care personnel AVO I D • Develop, implement and communicate policies and procedures for affiliated specialists’ personnel. Policy may require affiliated specialists to use trained hospital personnel. • Utilize engineering controls to eliminate personnel exposure, including the use of safer medical devices, such as: needles that are able to retract, sheath or blunt immediately after use; needleless IV connectors; and safety lock winged needles. • Eliminate the use of the following devices when possible: hollow bore needles; needle devices that need to be pulled apart by the health care provider; needles that are left exposed on a syringe after use; and needles attached to tubing, such as butterflies, that can be difficult to place in sharps containers. M I N I M IZE • Develop and implement policies and procedures to decrease injection use and eliminate the use of unnecessary sharps, such as towel clips during surgery. • Prohibit the recapping of used needles and ensure that used needles are disposed in sharps containers after use. • Ensure that sharps containers are available in all areas where sharps are generated and easily accessible to all personnel. Sharps containers should: • Be placed no higher than 54 inches from the floor • If not wall-mounted, be in close proximity to the work site to prevent injuries while sharp objects are being transported to the container • Be closable, puncture-resistant, leak-proof, spill-proof and free of contamination • Be changed when they are three-quarters full so that needles never need to be forced into the container • Train all personnel, including affiliated specialists, on safe work practices for handling sharps and provide specific instructions for when sharps must be used. Safe work practices include using instruments to hold needles; using verbal cues while passing sharps; avoiding hand-to-hand transfer of sharps by placing them in a neutral designated area for retrieval; minimizing splash or splatter; and double gloving. • Post signs in work areas detailing steps to avoid preventable sharps-related injuries. O FF S E T • Provide adequate vaccination and treatment to protect workers at risk of bloodborne pathogen exposure from infection. • Promptly obtain serological testing of source patients where necessary and begin post-exposure prophylaxis within four hours of exposure. • Ensure counseling, testing and treatment is available to personnel 24 hours a day in case of occupational exposure. • Follow standardized procedures in case of exposure to HIV or Hepatitis C, with repeated serological investigations for up to one year. • Provide compensation to affected workers in accordance with local and national regulations. Version 1.2 April 15, 2015 ESMS Implementation Handbook - Health Care Facilities 33 3. Management Programs CASE STUDY: SOUTH AFRICA Public Hospital RISK: Excessive mandatory overtime A large public hospital in South Africa with 1,300 beds and almost 500,000 patients annually has 2,000 staff, including 750 nurses and 400 doctors. The nationwide nursing shortage impacted this hospital, leaving it with almost 40% fewer nurses than required for its size. As a result, nurses are forced to work excessive overtime hours. Approximately 30% of the nurses receive up to 30% of their salary in overtime pay, in violation of the national labor law. Furthermore, record-keeping is inconsistent, which leads to failures in overtime recording. As a result, it is not possible to deter- mine if the hospital is making sufficient overtime payments consistently. One nurse claims to have worked 187 overtime hours in a month, including one shift that lasted 22.5 hours without breaks. The overtime work is mandatory and nurses have been threatened with dismissal if they refuse to work extra hours. These extra hours of work are also dangerous for both patients and personnel, since overworked staff can make serious mistakes due to fatigue. I M PAC T • Worker fatigue and potential for workplace injuries and improper patient care AVO I D • Establish, communicate and implement policies and procedures for working hours in keeping with industry standards and national laws, including provisions for overtime work, shift work, work at inconvenient times and on-call duty: • Normal working hours should not exceed eight hours a day, unless there are exceptions in national law, collective bargaining agreements or other sources. • Overtime should not exceed 4 hours a day (for a maximum of 12 working hours per day). • Overtime should not be mandated on a regular basis. • Allow workers to refuse overtime without penalty. • Workers should receive 24 hours of continuous rest each week. Shift workers should receive 12 hours off between shifts. • If recruiting nurses from other countries to compensate for the domestic nursing staff shortage, follow international and national laws in the recruitment process. Ensure that all migrant nurses can move freely within and outside the country, and that they are treated fairly and equally to national personnel. • Partner with government and teaching institutions to recruit and train nurses and nurse’s aides. • Identify tasks that can be transferred to other workers; recruit, hire, promote and train additional workers 34 Section III: Practical Guidelines for Developing and Implementing your Environmental and Social Management System 3. Management Programs M I N I M IZE • Train senior management, supervisors and workers about labor regulations regarding working hours and the linkages between excessive overtime and increase risk of workplace injury or illness and improper patient care. • Avoid scheduling tasks that are demanding, dangerous, safety-critical or monotonous during the night shift, particularly during the early morning hours when workers’ alertness is lowest. • Limit the scheduling of consecutive shifts to a maximum of 3 days for long work shifts (over 8 hours), night shifts and shifts that begin early in the morning. • Limit day shifts to a maximum of 12 hours (including overtime) and night shifts to 8 hours. Consider the needs of pregnant and older nurses, since they may be more vulnerable during night shift work and working long hours. • Plan appropriate workloads for the length and timing of each shift. Schedule a variety of tasks to be completed during each shift to create a more dynamic working environment and increase workers’ alertness. • Develop and implement policies and procedures for improved record-keeping of working hours. • Monitor working hours records on a continuous basis and adjust work planning as needed. • Ensure all overtime is recorded and paid at premium rate. • Implement an employee grievance mechanism and complaint resolution procedure for addressing worker concerns about excessive working hours or other issues. • Modify the timing of shifts or create more flexible working schedules to cover gaps in coverage and prevent excessive overtime and extended work shifts. O FF S E T • Retroactively compensate workers for overtime work at the established overtime premium rate. • Consider implementing a “time in lieu” (time off) system at a premium rate to compensate for overtime hours. • Provide adequate breaks and rest facilities. • Provide suitable medical assistance or counseling to workers suffering from fatigue or work-related stress. Version 1.2 April 15, 2015 ESMS Implementation Handbook - Health Care Facilities 35 3. Management Programs CASE STUDY: GERMANY Nursing Staffing Agency RISK: Mistreatment of temporary migrant workers One of the largest European temporary professional staffing agencies was recently exposed by a newspaper as having forced its temporary nursing employees, the majority of whom are mi- grants from North Africa, to work up to 84 hours a week without overtime pay. In addition, the agency is accused of withholding workers’ identification documents and passports. The workers were threatened with deportation and wage deductions if they complained about this working arrangement. Since they had to pay down their debt for high recruitment fees, the workers felt they had no choice but to work the long hours required by the agency, even though this was in violation of national working time regulations. The Agency Director admitted that he was aware of the employees’ working conditions and is now facing complaints by the Labor Inspection Au- thority. The police have also filed charges against the agency. I M PAC T • Forced labor due to withheld identification documents and high recruitment fees • Negative health impacts on workers due to excessive overtime AVO I D • Establish, communicate and implement policies and procedures on hiring, remuneration, terms of employment and working hours, especially for migrant workers. • Working hours policies should include the following: • Normal working hours should not exceed eight hours a day, unless there are exceptions in national law, collective bargaining agreements or other sources. • Overtime should not exceed 4 hours a day (for a maximum of 12 working hours per day). • Overtime should not be mandated on a regular basis and should be paid at a premium rate. • Workers should be allowed to refuse overtime without penalty. • Workers should receive at least one day off in every seven consecutive days worked. • Train personnel on procedures to ensure that they are understood and implemented. • Revise organization policies so they prohibit the withholding of workers’ original documenta- tion, including identification documents or passports. • Charge recruitment fees to employers so that workers are not required to pay excessive fees, which may force them into debt bondage. M I N I M IZE • Limit overtime hours to the legal amount and pay premium rate for overtime hours worked. • Regularly conduct internal audits to ensure compliance with local and international law. • Ensure that all workers understand their rights, including wages, benefits and deductions. This may necessitate the translation of materials into workers’ native language. • Ensure that all workers have access to their contracts in a language they understand. Dis- tribute pay stubs with clear calculations of payments and deductions when wages are paid. • Implement a non-retaliatory grievance mechanism and complaint resolution procedure to address worker concerns about excessive working hours, payment or other issues. Workers should be able to submit complaints confidentially or anonymously. O FF S E T • Pay back-wages for overtime hours worked at a premium rate. • Reimburse workers for recruitment fees. 36 Section III: Practical Guidelines for Developing and Implementing your Environmental and Social Management System 3. Management Programs CASE STUDY: EGYPT Public Hospital RISK: Improper infection control Lapses in hospital infection control measures at a public hospital in Egypt recently exacerbated an outbreak of a deadly viral disease that infected more than 60 people and resulted in 10 fatalities. Epidemiologists have said that the spread could have been kept under control if the country’s officials and scientists had collaborated earlier on detailed analyses of viral transmission, the disease’s etiology (origin/cause), current incidence and prevalence of the disease, as well as geographical distribution. This data is essential to design and implement prevention measures. Previous viral outbreaks, such as SARS, were contained effectively because epidemiologists and clinicians around the world worked together to create an effective response in a relatively short period of time (6 months). One health expert emphasized the importance of implementing robust infection control procedures in hospitals as well as institutionalizing data collection and analysis. The public hospital must incorporate these activities into its daily operations so that the virus is not transmitted from patient to patient or from patients to health workers. I M PAC T • Spread of disease to the local community, with potential for fatalities, especially in vulnerable populations AVO I D • Develop and implement procedures for infection control to limit the transmission of organisms between patients, and between patients and staff. Procedures should include instructions for adequate hand-washing, glove use, appropriate aseptic practice, isolation strategies, and sterilization and disinfection practices. • Restrict visitor and staff interaction with infected patients. Restrict patient movement through the hospital. • Develop and implement procedures for the early detection of cases, especially by screening patients admitted from other hospitals and high-risk patients. • Protect patients with appropriate use of prophylactic antimicrobials, nutrition, and vaccinations. • Work with the local authorities and community to develop, communicate and implement preventative public infection control policies that encourage the following behavior: • Wash hands often with soap and water for 20 seconds. If soap and water are not available, use an alcohol- based hand sanitizer. (Ensure that young children are taught proper hand washing practices.) • Cover nose and mouth with a tissue when coughing or sneezing. • Avoid touching eyes, nose and mouth with unwashed hands. • Avoid personal contact with ill individuals. • Clean and disinfect frequently touched surfaces, such as doorknobs. M I N I M IZE • Treat blood and body fluids from all patients as infectious, whether or not an infection has been confirmed. Utilize appropriate disposal techniques to prevent further spread of infection. • Ensure that all personnel wear appropriate personal protective equipment (PPE), including gloves, gowns, and eye and face protection. Provided PPE in adequate sizes and quantities for personnel. • Monitor and evaluate individuals who come in close contact with someone that has developed the virus for 14 days. • Work with local authorities to improve cooperation and information-sharing locally, with other countries, and with international health organizations: • Increase lab testing capacity to detect cases of the disease. • Assist in the development of guidance and tools for health departments to conduct public health investigations when disease cases are suspected or confirmed. • Provide recommendations for healthcare infection control and other measures to prevent spread of disease. • Assist in the dissemination of up-to-date information about the disease to the general public, international travelers, and public health partners. • Cooperate with other facilities to implement Advanced Molecular Detection (AMD) methods for rapid detection of pathogens and timely treatment. O FF S E T • Provide timely medical care to affected persons. • Work with local authorities and other hospitals to develop quarantine and disease response containment procedures and training. Version 1.2 April 15, 2015 ESMS Implementation Handbook - Health Care Facilities 37 ELEMENT 4 Organizational Capacity and Competency All levels of the company are trained and engaged – A well-implemented ESMS is ultimately about 5 multiple units and workers as well as managers. E&S trained, committed people. How do you make staff has implementation authority. Management that happen? commitment is reflected in resources devoted to E&S management and training. ROLES, RESPONSIBILITIES AND AUTHORITIES TO IMPLEMENT THE ESMS First, you need senior management commitment. Senior management 4 Multiple units have E&S commitment starts with adopting the ESMS policies, but it must go responsibilities, and senior management is involved. beyond that. Senior management support is critical to implementing a E&S is managed as an sustainable ESMS. It is the responsibility of senior management to lead inte- grated system. New the effort. They don’t have to lead the effort on a day-to-day basis, but they staff receives some E&S do need to send a clear message, to all employees at all levels, that this is a management guidance. long-term commitment by your organization. Beyond senior management commitment, you need a team that takes responsibility for the ESMS. This does not need to be a full-time job for 3 All levels of the company anyone, but senior management needs to ensure realignment of reporting are involved in aware- duties, allocation of appropriate time and authority to carry out the work ness training. E&S roles involved. and responsibilities are assigned and part of daily A well-balanced ESMS Team is a prerequisite for meaningful engagement operations. E&S staff is with your peers and colleagues. It should include knowledgeable profes- trained and competent. sionals from environment, health and safety, operations or production, contracts and purchasing, human resources, for example. E&S roles are defined and 2 assigned. Each issues is In fact, the success of a management system depends on departments that handled only by one func- have traditionally been seen as beyond the reach of environmental and tional area. Some aware- social issues, such as human resources, procurement and maintenance. For ness training is provided at orientation and addi- example, human resources manages training needs related to the labor as- tional training is provided pects; procurement manages the qualifications and performance of suppliers for EHS staff. and contractors; and maintenance ensures that the equipment runs effi- ciently and that spills, leaks and other emergency situations are minimized. No assigned staff with 1 E&S management respon- The ESMS Team should not work in isolation when identifying risks and sibilities. Some limited impacts, developing improved procedures, designing actions plans, etc. To awareness and E&S roles be truly effective, the ESMS Team needs to consult with people from all and responsibilities start- levels of the organization, including supervisors and workers, as they are ing to get defined. No key frontline identifiers of problems. systems awareness or repeatable processes. 0 No internal awareness and no formally assigned responsibility for E&S. 38 Section III: Practical Guidelines for Developing and Implementing your Environmental and Social Management System 4. Org. Capacity and Competency As with the overall management system, the team should be scaled to the size and complexity of your organization. Your organization might not have multiple departments with distinct roles; maybe a few people cover several functions. The key is to involve people across the range of functions. If a team already exists in your facility (e.g. fire safety team) consider building your ESMS Team upon it. Once the ESMS Team is selected, the team members need to select a team leader. This is an important role, especially in the beginning. The team leader needs to set the tone for the group and keep people motivated. All new initia- tives face hurdles, and developing and implementing an ESMS is no exception. The team leader needs to help the team overcome the inevitable hurdles, and should have direct access to senior management. Take a look at the Toolkit item Roadmap and Time Estimate for Developing and Implementing an ESMS in the Toolkit for a list and sequencing of activities to develop and implement an ESMS. Version 1.2 April 15, 2015 ESMS Implementation Handbook - Health Care Facilities 39 EXAMPLE OF AN ESMS TEAM Quality Human When selecting a resources control team leader, look Environmental health & safety for someone who Production has the following Select a team leader qualities: • communicator; Procurement/ Worker Sourcing • problem-solver; Representatives • project manager; • pragmatic; and COMMUNICATION AND TRAINING • respectful to all. Now that you have identified the actions to be taken and updated your proce- dures, you need trained, committed people who follow the ESMS procedures. This is the end goal of communication and training. There are three key steps that build on each other: 1. They need to be aware of the ESMS. • What is it? • What are its goals? • What do I need to do? 2. They need to understand that the ESMS is necessary and will improve the organization. • How does this help our organization? • How does it help my department? • What will change? • What is in it for me? 3. They need to obtain the skills and knowledge to be effective in their roles. • What are the new policies and procedures? • What exactly do I need to do? • How do I do that? • What will happen if I don’t do it? 40 Section III: Practical Guidelines for Developing and Implementing your Environmental and Social Management System 4. Org. Capacity and Competency TIP Your ESMS Team needs detailed training to Effective Communication and Training develop the necessary knowledge and skills. They will need to understand the basics of the Plan-Do- Ask yourself if the goal of this specific com- Check-Act cycle and know the nine elements of munication or training module is to build an ESMS. This Handbook provides the informa- awareness, to gain commitment and/or give tion they will need, but additional help may be people the knowledge and skills needed to necessary. In addition to the detailed training of implement. the team, everyone will need to receive awareness training so there is a shared understanding of the goals of the ESMS. The chapters in this Handbook provide an easy way to structure efficient general training. You can give everybody an overview about what you have learned here about developing and implementing an ESMS. You may also need to provide training that is specifically related to your Ac- tion Plan and new operating procedures. Examine the specific actions and who is going to be involved. This is a quick way to determine what training will be needed by the various departments and people in your organization. Ask yourself what knowledge and skills do people need to effectively implement new procedures, carry out allocated responsibilities and complete the action plan. Use the Toolkit item Training Plan Worksheet as template and tie it to your Action Plans and improved procedures. AWA REN ESS CO M M ITM ENT I M PLEM ENTATI O N Version 1.2 April 15, 2015 ESMS Implementation Handbook - Health Care Facilities 41 ELEMENT 5 Emergency Preparedness and Response 5 Regular engagement with Even when you have considered all the risks and put local community and gov- ernment for onsite and offsite emergency plan. the appropriate management programs in place, Formal resource-sharing agreements with neighbor- accidents and emergency situations can happen. ing companies. Your organization is a dynamic operation, and many 4 Senior management and all units and shifts, includ- ing contract and tempo- things change from day to day – people go in and rary workers, participate in emergency risk assess- out of your workforce, materials and suppliers enter ment, preparedness plan- ning and mock drills. and exit your supply chain, patients are admitted Continual improvement. and discharged from your facility, and equipment 3 All onsite and off-site emergency issues have are added to and removed from your facility. A been identified and an effective preparedness plan is in place. The plan management system will help to maintain continuity meets the local regulatory requirements and the local and consistency throughout these changes. industry best practices. However, there may be a momentary lapse or 2 The emergency prepared- ness plan is in place, but gaps in the system (e.g. someone not properly there is no evidence of consistent implementa- trained, someone not following the procedures, tion. Some trainings are provided to the workers on a machine breakdown), or an external force (e.g. emergency requirements. natural disaster) that can lead to an accident or 1 Emergency management planning is not effective, emergency situation at your facility. While it is not as all emergency risks have not been identified. always possible to prevent such situations, you can Occasional trainings are provided to workers. be prepared to respond effectively to prevent and mitigate any harm to your patients, community and 0 Very limited emergency control and personal pro- tective equipment. No for- the environment. mal plan in place. 42 Section III: Practical Guidelines for Developing and Implementing your Environmental and Social Management System 5. Emerg. Preparedness and Response The key to effective response is effective preparation. The following steps will help you to anticipate the possible scenarios and prepare accordingly: • Identify the areas where accidents and emergency situations may occur, and communities and individuals that may be impacted. This should begin during your overall risk and impact assessment, through your process analysis, physical mapping and consultations with workers, experts and the community. • Develop response procedures for each identified emergency situation that clearly explain what actions need to be taken. These need to be detailed clearly for everyone in your facility to understand what he or she needs to do. • Provide the necessary equipment and resources to effectively implement the response plans. A stockpile of fire extinguishers does not put out fires, unless people can effectively find and use them when needed. Think about equipment that is easy for people to use and is located where it can be immediately accessed during accidents and emergencies. • Assign responsibilities so that each activity has people responsible for carrying it out. Also designate people who will routinely analyze how well the system is working and update the risk assessment and plans. • Communicate so that everyone in your facility understands the importance of the emergency preparedness and response system and is encouraged to help monitor and improve its effectiveness. Also include people in the community who may be affected, if it is appropriate. • Provide periodic training so that everyone in your facility has an overview of the system, and knows the response plans. Don’t just lecture about what to do – ask for and obtain input on what needs to be addressed and what can be improved. Even with the most detailed procedures and plans, people will need to exercise individual judgment and adapt to quickly changing situations. This is more likely to happen if you engage people in all aspects of the system beforehand. • Work with government agencies and community groups to identify areas where you can collaborate to respond effectively to internal and external situations. • Conduct periodic checks and drills to test how well the system is working and to re-assess the risks to reflect changing conditions. Incorporate your findings to continually improve your system. • Remember, it is essential that the emergency response plan be site specific. Even if you have similar operations at two different sites, it does not mean that the same emergency plan would be effective at both locations. An emergency response plan at each site should be independently reviewed for its suitability and effectiveness. Look at the Sample Fire Response Procedure and Sample Chemical Spill Response Procedure Flowchart for examples. Version 1.2 April 15, 2015 ESMS Implementation Handbook - Health Care Facilities 43 5. Emerg. Preparedness and Response An Emergency Preparedness and Response Plan should include: • identification of potential emergencies based on hazard assessment; • procedures to respond to the identified emergency situations; • procedures to shut down equipment; • procedures to contain and limit pollution; • procedures for decontamination; • procedures for rescue and evacuation of staff and patients, including a designated meeting place outside the facility and strategies to relocate patients in need of continual monitoring and care; • location of alarms and schedule of maintenance; • list and location of equipment and facilities for employees responsible for responding to the emergency (fire-fighting equipment, spill response equipment, personal protection equipment for the emergency response teams, first aid kits and stations); • protocols for the use of the emergency equipment and facilities; • schedule for periodic inspection, testing and maintenance of emergency equipment; • clear identification of evacuation routes and meeting points; • schedule of trainings (drills), including with local emergency response services (fire fighters); • procedures for emergency drills; • emergency contacts and communication protocols, including with affected communities when necessary, and procedures for interaction with the government authorities; • procedures for periodic review and update of emergency response plans. 44 Section III: Practical Guidelines for Developing and Implementing your Environmental and Social Management System 5. Emerg. Preparedness and Response Common OHS Hazards and Emergency Situations in Health Care Facilities Occupational Health and Safety (OHS) hazards in the workplace can be divided into five categories: physical, chemical, biological, ergonomic and radiological. You should identify the specific hazards that are relevant to your facility’s operations during your risk assessment, using methodologies such as job safety reviews or job hazard analyses. The results of these analyses and the tasks required to mitigate the identified hazards should be incorporated into action plans, which also stipulate the assigned responsible staff and expected timelines for completion. Your management program should seek to first avoid negative impacts from each hazard, by eliminating or substituting the equipment, material, or work practice that is causing the hazard. If it is not possible to eliminate the hazard, you should seek to minimize its impacts by instituting engineering controls (e.g. by installing machine guards or active ventilation) and administrative controls (e.g. job rotation, clear work instructions or warning signage). You should also provide technically appropriate personal protective equipment (PPE) and train your personnel on the appropriate use and maintenance of supplied PPE. OHS emergency situations often occur because of gaps in a management system. Thus, even though the hazards may seem to be very different, such as slips and falls on spilled liquids vs. exposure to radiation, they are often the result of the same root cause – ineffective implementation of the ESMS. The tables below describe common workplace hazards and their associated poten- tial impacts. They also illustrate how inadequate implementation of any of the 9 ESMS elements can be the root cause of such situations. The examples below are not an exhaustive list of root causes. You should identify gaps in your own system to determine potential root causes of problems during your risk assessment. Version 1.2 April 15, 2015 ESMS Implementation Handbook - Health Care Facilities 45 5. Emerg. Preparedness and Response PHYSICAL HAZARDS Examples Potential Impacts • Slipping on wet floors, spilled liquids or • Sprains and strains bodily fluids • Fractures • Interaction with unguarded or improperly • Cuts and amputations operated machines (e.g. kitchen equip- ment) • Burns and scalds • Handling hot or sharp items from auto- • Hearing threshold shifts and loss claves or sterilizers • Heat stress, dehydration, heat stroke • Exposure to high noise levels • Eye injuries (e.g. in laundry area) • Electric shock or electrocution • Exposure to high temperatures • Asphyxiation and burning in case of fire (e.g. in laundry area or kitchen) • Death • Use of medical lasers Fires or explosions from ignited equipment • Touching faulty or damaged electrical or gas can lead to massive loss of life and cords or wires destruction of property. • Involvement in a vehicular accident (e.g. due to traffic near the emergency entrance) • Violent assault from patients or their at- tendants • Ignition of medical (e.g. oxygen hood or cauterizing devices), lighting or cooking equipment • Explosion of medical gas cylinders Potential Root Causes Management Program: Monitoring and Review: Organizational Capacity and • Lack of, inadequate, or • Lack of tracking of accidents Competency: improperly implemented and near-misses • Insufficient worker training safety procedures and on safety procedures equipment procurement • Failure to assign a respon- and maintenance sible party for managing safety hazards • Failure to train contract or temporary workers 46 Section III: Practical Guidelines for Developing and Implementing your Environmental and Social Management System 5. Emerg. Preparedness and Response CHEMICAL HAZARDS Examples Potential Impacts • Exposure to hazardous drugs through • Headaches, nausea, dizziness inhalation, skin contact, skin absorption, • Decreased mental abilities ingestion or injection • Skin irritation and burns • Exposure to hazardous vapors, fumes or gases (e.g. mercury, ammonia, formalde- • Irritation of eyes, nose and throat hyde, ethylene oxide, waste anesthetic • Respiratory disorders gases) • Damage to internal organs • Skin contact with hazardous chemicals • Damage to nervous, immune, and (e.g. sterilizers and disinfectants, such as reproductive systems glutaraldehyde). • Cancer • Prolonged exposure to latex • Allergic reactions • Ignition of improperly stored and handled flammable substances (e.g. ethylene oxide) • Asphyxiation or burning in case of fire • Death Potential Root Causes Emergency Preparedness Management Program: Monitoring and Review: and Response: • Use of incompatible or • Fail to monitor and review • Lack of or inadequate damaged storage containers work practices to ensure emergency response plan • Uninformed or incorrect that chemical safety proce- in case of extreme labeling dures are being followed chemical exposure and improved as needed • Insufficient monitoring of • Insufficient or ineffec- allowable chemical concen- tive worker training and trations in the workplace mock drills • Inability to follow Material Safety Data Sheets instruc- tions • Inadequate PPE Version 1.2 April 15, 2015 ESMS Implementation Handbook - Health Care Facilities 47 5. Emerg. Preparedness and Response BIOLOGICAL HAZARDS Examples Potential Impacts • Exposure to bloodborne pathogens (e.g. hepatitis B • Debilitating diseases among or C and HIV) or other bodily fluids that may carry dis- workers and patients eases (e.g. Ebola or methicillin-resistant Staphylococcus • Death aureus) • Spread of diseases among local • Exposure to nosocomial infections communities impacting public • Needlestick and sharps injury health and local economic • Exposure to surgical smoke plume productivity • Exposure to foodborne illness due to contaminated food (e.g. E-coli or salmonella) Potential Root Causes Management Program: Stakeholder Engagement: Monitoring and Review: • Lack of or inconsistent • Lack of or inadequate • Failure to monitor and hand-washing methods stakeholder engagement to review work prac- • Failure to use universal address potential spread of tices to ensure that precautions diseases within the facility or safety procedures are to the local community being followed and • Improper labeling, storage improved as needed or mishandling of biological to address biological materials, needles and sharps risks • Ineffective exposure control plan • Inadequate PPE ERGONOMIC HAZARDS Examples Potential Impacts • Handling, lifting or positioning patients • Strains and sprains to muscles and connec- (especially immobile patients) or heavy tive tissues causing pain, inflammation, loads numbness, or loss of muscle function • Repetitive motions, especially in an • Lower back injuries awkward position • Extended periods of standing (e.g. during long surgeries or procedures) • Continued forceful exertion Potential Root Causes Policy: Identification of Risks and Organizational Capacity and • Lack of, inadequate Impacts: Competency: or improperly imple- • Inadequate risk assess- • Insufficient worker training on mented ergonomic ment to identify ergonomic proper methods of performing safety policies and hazards. duties (e.g. proper ways to lift procedures patients or heavy materials) • Lack of worker consultation in designing work areas and • Failure to assign a responsible processes party for managing ergonomic • Lack of worker awareness hazards about ergonomic hazards in • Insufficient number of staff to the facility perform duties 48 Section III: Practical Guidelines for Developing and Implementing your Environmental and Social Management System 5. Emerg. Preparedness and Response RADIOLOGICAL HAZARDS Examples Potential Impacts • Exposure to radiation from portable or • Nausea, vomiting, stomach pains fixed x-ray machines or radiation therapy or diarrhea • Radiation sickness • Cancer • Death Potential Root Causes Identification of Risks and Management Program: Organizational Capacity and Impacts: • Use of expired radiation Competency: • Lack of awareness of licenses or improperly main- • Insufficient worker radiation sources and tained radiation sources training on proper associated risks in the • Deficient procedures re- radiation controls facility garding allowable exposure • Failure to assign a respon- limits and worker exposure sible party for managing periods radiological hazards • Inadequate PPE Emergencies In addition to emergencies that may result from hazards in your health care facility, all workplaces are vulnerable to other types of accidents and Caused by emergencies resulting from external events. The following list includes External Events common types of manmade and natural disasters, all of which can result in significant worker or patient injury or death, as well as cause disruptions to your operations, destruction of property, and severe financial losses. During your risk assessment, you should identify the emergencies that are most likely to occur in your area and create a comprehensive emergency response and preparedness plan so you can respond properly and minimize damage to your facility, workers and patients in case of unplanned external events. Possible manmade or natural disasters include: • Storms, including tornados, typhoons and hurricanes (many can result in flooding) • Flooding • Earthquakes and associated tsunamis • Volcanic eruptions • Local and regional fires • Explosions including accidental, military or terrorism • Civil unrest • Violent assault against health care workers • Chemical spill or release of hazardous substances through ruptured containers due to transport accidents, earthquakes and other natural disasters Version 1.2 April 15, 2015 ESMS Implementation Handbook - Health Care Facilities 49 ELEMENT 6 Stakeholder Engagement 5 Stakeholder engagement Your facility may have an impact on the lives of is part of regular activities. Awareness and engage- ment at senior levels. Flu- many people and organizations. All of these ent and inclusive commu- nication and consultation people and organizations are your stakeholders process with stakeholders. - they have a stake in your environmental and Multiple and ongoing public consultation and social performance. 4 participation in a cultur- ally appropriate manner. Look at the diagram below and think about how your organization inter- Stakeholder feedback acts with each group. Your relationship with each group is different, and is actively considered. you need to adapt the way you engage with each of them to mitigate risks Reporting to communities and effective grievance to your business. mechanism is evidenced Systematically engaging with affected communities in the identification by formal records. and management of the impacts that negatively affect them contributes to building trust, credibility and local support. Engaging with them also Stakeholders have been 3 provides the opportunity to highlight the positive aspects of your presence. identified and engaged in several events with This lowers the risk of negative sentiments that could lead to costly litiga- effective dialogue. Some tion or disruption of operations. procedures and assigned responsibility for engaging with stakeholders. FINANCIAL D AN D COMMUNIT Y AC S T V E Some public events, lim- EN O G R TIV 2 ATI I R L E S OU IS ited ongoing engagement P HE N PS T T O process. Sporadic and ES selective responses UN D ITI M M C TE when approached by CO F F E NGO stakeholders. A s Limited channels in place. FACILIT Y 1 ERS A few meetings and S/ O R NION WO R K discussions, but not an NS C IA E R TI O ongoing process yet. EU K AD W SO TR ST AS O OW CK N T H ER EN O 0 M LD S RN ER Little or no transparency SUPPLIERS/ VE S/ GO with stakeholders. CONTRACTORS 50 Section III: Practical Guidelines for Developing and Implementing your Environmental and Social Management System 6. Stakeholder Engagement Other stakeholders such as activists and NGOs may not be directly affected by your operations but may have an interest in what you do. Keeping these groups informed and maintaining an open communication channel may lower the risk of negative campaigns that could affect your organization’s reputation. MAPPING YOUR STAKEHOLDERS The first step in building a relationship with your stakeholders is to identify them. To start, look back at your risk assessment and the areas of potential negative impacts and identify who would be directly or indirectly impacted. Once you have identified your stakeholders, you should prioritize the different groups based on the nature and severity of the impacts, and the ability of these groups to influence your operations. Engagement should be stronger and more frequent with those groups that are more severely affected, as well as with those that have a greater ability to influence your organization. Also, as you identify your stakeholders and the issues that may affect or interest them, you can tailor your communication material and methods to effectively engage with each of them. INTERNAL AND EXTERNAL STAKEHOLDERS Workers are an important internal stakeholder group. They also need to be involved in the identification of risks that affect them and be consulted when developing action plans and procedures. However, the methods of engagement with them will differ from those used for external stakeholders. Use the Toolkit item Stakeholder Map and Impact Zoning Tool for Affected Communities to get started. Version 1.2 April 15, 2015 ESMS Implementation Handbook - Health Care Facilities 51 For effective DEVELOPING A STAKEHOLDER ENGAGEMENT PLAN After mapping your stakeholders, the next step is to develop a plan for how consultation to engage with the groups that you have identified. Your stakeholder engage- with affected ment plan can be simple. But it is important to be proactive and to address key environmental and social concerns. communities : At a minimum, even if your facility does not have adverse impacts on com- munities or other stakeholders, you should always implement a procedure to • Start early; receive communications from the public and accordingly adjust your man- • Disclose meaningful agement program (see Element 7, External Communications and Grievance Mechanisms). and accurate If it is determined that there are affected communities, you need to imple- information; ment a Grievance Mechanism (see Element 7, External Communications and Grievance Mechanisms) and actively engage them in consultation, regularly • Use culturally disclosing clear and meaningful information on both your impacts and poten- appropriate means to tial benefits, and providing communities with opportunities to express their concerns and suggestions. reach them; In the case of potentially significant adverse impacts to individuals and • Provide opportunities communities, you should engage them in a process of Informed Consultation and Participation (ICP). Compared to a consultation process, an ICP should for two-way dialogue ; ensure a more in-depth exchange of information and a higher level of partici- pation from affected stakeholders in decision-making, so that their proposed • Document to keep mitigation measures are incorporated into the organization’s action plan. track of issues raised; Finally, you should periodically report to affected stakeholders on the actions and your organization is putting in place to address the issues identified through the engagement process (see Element 8, Ongoing Reporting to Affected • Report back on how Communities). their input has been Regular communication with the various stakeholder groups is an excellent way for you to understand how your operations affect them and to get early used and considered warnings of potential problems. In all your efforts to reach out to stakeholders, ensure that you do so early on – relationship-building takes time. Don’t wait until a crisis arises to act, as it will be more difficult without those relationships in place to manage the problem. Use the Toolkit item Stakeholder Engagement Plan Worksheet to record how you will engage with the important stakeholder groups. 52 Section III: Practical Guidelines for Developing and Implementing your Environmental and Social Management System 6. Stakeholder Engagement TIP Effective Stakeholder Engagement •• Be strategic and prioritize which stakeholders to approach – you may not have the resources to engage them all at once. •• Update your stakeholder map regularly and in the case of significant events (e.g., changes to your operations, govern- ment elections, natural disasters, etc.). •• Be aware of what issues are important to each group. •• If you are dealing with a representative for the group, make sure that he/she legitimately represents the interests of the affected groups and communities. •• Engage with stakeholders in their own communities and places where they feel comfortable. •• Reach out to vulnerable and marginalized groups. •• Keep a record of questions, comments and suggestions. Records provide important information that should be used to adapt your Action Plans and improve your ESMS. •• Recognize that your employees are a good link to stakeholders in the “outside world.” •• Be prepared to respond to stakeholders, and do not generate expectations that cannot or will not be fulfilled. DEFINITIONS Stakeholder Any person or organization that has an interest in or is affected by your organization. Affected People or communities who are subject to organization-related adverse impacts on their environment, infrastructure, way of life, Communitites personal safety, health or livelihood. For more information on how to develop and implement a Stakeholder Engagement Plan, refer to the Good Practice Handbook “Stakeholder Engagement,” IFC (2007). Version 1.2 April 15, 2015 ESMS Implementation Handbook - Health Care Facilities 53 ELEMENT 7 External Communications and Grievance Mechanisms 5 Proactive and responsive external communication If your facility has social and environmental and grievance mechanism. Stakeholders are consulted impacts in the community, inquiries, concerns and on ESMS effectiveness and are part of the regular complaints are bound to arise. How you respond review process. to and manage these issues will have significant 4 Effective grievance mecha- nism is evidenced by for- implications for how your organization is perceived mal records. There is rou- tine review of the records and, possibly, whether or not it succeeds. and the effectiveness of the program. EXTERNAL COMMUNICATIONS Grievance mechanism is Even if affected communities per se are not identified, you should always 3 fully implemented; how- establish and maintain a publicly available and easily accessible channel for ever, there is not enough stakeholders to contact you (e.g., phone number, website, email address, etc.). evidence of its effective- ness. No tracking of inter- External stakeholders can provide valuable information, such as suggestions nal or external awareness; on healthcare improvement, advance warning in critical situations, feedback limited tracking of cases. on interactions with your employees, and/or comments from regulators, NGOs and individuals regarding your facility’s environmental and social performance. 2 Procedures and assigned The procedure for external communication should include methods to (i) responsibilities for receiv- receive, register and validate external communications and requests for infor- ing and handling com- mation from the public; (ii) screen and assess the importance of the issue raised plaints. Awareness is limited to those directly and determine how to address it; (iii) provide, track, document and publish handling the complaints. responses; and (iv) adjust the management program when appropriate. GRIEVANCE MECHANISMS 1 Some basic procedures The purpose of a grievance mechanism is to establish a way for individuals, for receiving complaints. groups or communities affected by your facility to contact you if they have an Responsibility limited to inquiry, a concern or a formal complaint. one person or unit. 0 No mechanism in place. 54 Section III: Practical Guidelines for Developing and Implementing your Environmental and Social Management System 7. Ext. Communication and Grievance In practice, a grievance mechanism should: • Establish a way for people to contact you – openly or anonymously – to pose their questions, to express concerns or to file a complaint. Examples are suggestion boxes, a toll-free telephone hotline, an email address, and regular meetings arranged to discuss particular problem areas. • Assign a person or team in your organization to be responsible for receiving, registering and processing all grievances. • Establish procedures to register, screen, categorize, investigate and determine resolution and redress options. • Establish a system to communicate decisions taken and progress on pend- ing actions. It is important that people know when they can expect a response. Not all complaints can be resolved in the same way. Simpler issues, such as an emergency vehicle running over chickens in the road, might be dealt with by the same team responsible for registering the complaint. More complex problems, such as allegations of widespread groundwater contamination, might require immediate intervention by senior managers and more dedicated resources for investigating, documenting and reporting. For complex and recurring problems, consider reaching out to third-party facilitators that can act as independent mediators. TIP The more serious the claim is, the more indepen- Implementing a Grievance Mechanism dent the mechanism should be to determine the resolution and options for redress. •• Scale it to fit the level and complexity of social and environmental risks and The most important thing is to make sure the griev- impacts identified in your organization. ance mechanism is accessible and trusted. Tailor it for the local community so that it is easy for them •• Design the process to be easily to raise concerns. This requirement mandates hav- understandable, accessible, trusted ing the right people leading this effort inside your and culturally appropriate. organization. The grievance mechanism must be accessible at no cost and without retribution to the •• Publicize the availability of the party that originated the complaint and should not grievance procedure so people know impede access to judicial or administrative remedies. where to go and whom to approach. •• Commit to a response time and keep to Don’t underestimate the value of a well-implement- it as this will increase transparency and ed grievance mechanism. The information you re- a sense of “fair process.” ceive can act as an early-warning system before the problem becomes too costly and time-consuming •• Keep records of each step to create a to address. “paper trail.” Version 1.2 April 15, 2015 ESMS Implementation Handbook - Health Care Facilities 55 7. Ext. Communication and Grievance Look at the Toolkit items Checklist for an Effective Grievance Mechanism and Grievances Log to get started. Seriousness of the claim Independent mediator Multistakeholder group including representatives of Affected Communities, NGOs, government Organization team Independence of the mechanism TIP A Grievance Mechanism is UNDERSTANDABLE AND TRUSTED when: •• affected communities understand the procedure to handle a complaint; •• people are aware of the expected response time; and •• confidentiality of the person raising the complaint is protected. CULTURALLY APPROPRIATE AND ACCESSIBLE when: •• claims can be presented in the local language; •• technology required to present a claim is commonly used (e.g., paper, text messaging, internet); and •• illiterate persons can present verbal complaints. AT NO COST when: •• people don’t need to travel long distances to present a claim; and •• the organization covers the costs of third party facilitation. For more information on how to develop and implement a Grievance Mechanism, refer to the Good Practice Note “Addressing Grievances from Project-Affected Communities,” IFC (2009), and the Advisory Note “A Guide to Designing and Implementing Grievance Mechanisms for Develop- ment Projects,” CAO (2008). 56 Section III: Practical Guidelines for Developing and Implementing your Environmental and Social Management System ELEMENT 8 Ongoing Reporting to 5 Affected communities’ issues and concerns are proactively addressed. Affected Communities There is ongoing com- munication to avoid risks and impacts before new Affected communities will want to know what projects as well as to address existing issues. actions your organization has put in place to resolve 4 Reporting to affected the issues identified when engaging with them. communities is regu- larly implemented and Keeping affected communities informed of what you are doing is a critical evidenced in documen- element for building and maintaining a good relationship. If people know tation. Key units are when they will receive an update, it helps to build trust. It can also reduce the involved in the review amount of time you spend responding to questions. of the key issues. 3 The frequency of this communication will be proportional to the scale of stake- When applicable, con- holders’ concerns, but it should be at least annual. If your activities change or sultation processes have new environmental and social risks emerge, you do need to contact stakehold- been implemented. ers outside of the regular schedule to discuss these changes. External consultants are involved as required. No TIP You can also decide to ongoing review. report back to the wider Ongoing Communication public on your progress 2 •• Provide an immediate update if new in meeting your commit- ments to avoid, reduce Procedures in place environmental or social risks emerge. for reporting, usually and mitigate any negative •• Report progress on implementation of assigned to E&S staff. environmental or social your commitments. Primarily reactive. impacts from your organi- •• Report monitoring results on issues that zation’s activities. Sustain- interest the community. ability reporting initiatives, guidelines, including 1 •• Use the opportunity to communicate the benefits generated by your facility. sector-specific guidelines, Some basic communica- and good practices are also tions with affected com- •• Translate information into local languages rapidly emerging in this munities, mostly limited and easily understandable formats. area. The most notable to meetings. •• Try to maintain continuity in who deals is the Global Reporting with the community. Initiative (GRI). •• Involve your employees as communication 0 links to the community. •• Consider conducting a stakeholder No reporting. survey to learn how your organization is perceived. Look at the Toolkit item Reporting to Affected Communities for examples of formats and venues you can use. Version 1.2 April 15, 2015 ESMS Implementation Handbook - Health Care Facilities 57 ELEMENT 9 Monitoring and Review 5 Robust system of continual We’ve talked about the relationship between learning and improvement. Senior management receives periodic reports about E&S your ESMS and the Plan-Do-Check-Act cycle of performance and progress toward E&S objectives and continual improvement. Monitoring and review targets. All key project deci- sions consider E&S. are critical, because this is how you check and Monitoring, supervising and adjust the system. 4 auditing activities are inte- grated and included in man- agement review. Includes consultation with workers, So far, you’ve formed or assigned a team to customers and suppliers. E&S objectives and targets are included in job descrip- lead the effort. You have developed your ESMS tions and performance reviews. and started to implement your action plans in 3 Routine review of monitor- response to the risks and impacts you identified. ing and supervision activi- ties, including participation of workers. Corrective You’ve started to train people. The next step actions routinely imple- mented. An E&S internal is to monitor the effectiveness of your ESMS audit plan is in place. and your action plans and make the necessary 2 Key E&S monitoring plans in place, with inspection and adjustments. supervision activities. Pri- marily reactive and guided by external experts, custom- ers and investors. PLAN DO 1 Few monitoring plans to sat- isfy regulatory requirements. No formal review activities. No systems awareness or Monitoring is the CHECK ACT repeatable processes step of the PDCA cycle Review is the ACT CHECK step of the PDCA cycle 0 No monitoring of E&S performance. 58 Section III: Practical Guidelines for Developing and Implementing your Environmental and Social Management System 9. Monitoring and Review TIP Monitoring measures intent, implementation and effectiveness Intent: 1. Are the nine elements of the ESMS in place? Implementation: 2. Are the action plans being carried out? 3. Are procedures being followed? Effectiveness: 4. Are you in compliance with laws and regulations? 5. Are you making progress toward your overall objectives and targets? 6. How is the environmental and social performance of the organization in general? INDICATORS A key aspect of monitoring is defining relevant indicators. These are quan- titative or qualitative measures of progress against set goals. Some indicators might focus on performance, evaluated against the criteria defined in your environmental and social policy. Some examples of key performance indicators could be: • energy consumption; • water consumption; • volume of non-hazardous and hazardous waste disposal; • liquid effluents discharge; • emissions to air; • facility indoor air quality; • infection rates; • number of need-stick and sharps injuries; • absenteeism frequency; • accidents (injuries, ill-health, property damage), incidents and near misses; • lost time injury frequency, incidence, and severity rates; • emergency response incidents; • average working hours and wages paid; • wage levels; • incidences of disciplinary and discrimination complaints; and • employee demographics matching access to training, jobs, and wages. Version 1.2 April 15, 2015 ESMS Implementation Handbook - Health Care Facilities 59 9. Monitoring and Review Measuring and You can also use this information when reporting to a wider public on your ESMS performance. When selecting your key performance indicators, you may Improving refer to voluntary guidelines such as the Global Reporting Initiative. Remember, you Other indicators can look at the processes or inputs that you use to try to achieve performance. can’t improve what For example, in your action plan, you might have included worker training as you don’t measure. a necessary step to raise awareness among workers about OHS, so that they can help to identify and address key risks and hazards. In this case, you might evaluate your progress against the action plan by tracking the percentage of workers who have been trained, or the percentage of workers who can correctly describe the risk analysis procedure. Some examples of process indicators include: • procedures in place for chemical, fuel and hazardous waste handling, storage, and disposal; • processes analyzing for water and energy conservation; • percentage of workers who can explain safe work practices; • percentage of workers who can explain the emergency response procedures; • percentage of workers trained on infection control; and • communications from stakeholders. It is helpful to have a mix of performance and process indicators, to get a deeper understanding of whether you are measuring the appropriate things and whether you are taking the appropriate actions. For example, a performance indicator such as “zero incidences of forced labour” does not tell the full story: Was this the result of effective procedures and training or was the system inad- equate in identifying and recording incidences? For environmental and OHS performance indicators and benchmarks relevant to your industry, consult the WBG EHS Guidelines at www.ifc. org/sustainability Look at the Monitoring Plans in the Toolkit for more examples of common key indicators. 60 Section III: Practical Guidelines for Developing and Implementing your Environmental and Social Management System 9. Monitoring and Review THE BASICS OF MONITORING Visual observation Interviews physical walk-throughs of your consultations with workers, facility and surrounding land. managers and external stake- Examples of what you might holders. Examples of topics observe: physical obstructions you might discuss: Do workers and blocked exits, fire detec- and managers understand tion, alarm and fighting equip- the policies and procedures? ment, infection control warning How are they impacted? Are signs, storage of hazardous ma- there ideas for improvement? terials, housekeeping, drinking Do workers feel comfortable water and sanitation facilities, filing complaints? How are information displayed on notice external stakeholders boards , worker and supervisor impacted by the organization? body language and interactions. Are there ideas for improve- ment? Do external stakehold- ers feel comfortable filing complaints? Measuring and testing Document review checking using equipment that looking through documents is properly calibrated. Examples and records. Examples of of what you might check: emis- what you might review: water sions to air, effluents, indoor air and energy bills, waste dis- quality, ambient temperature, posal records, staff injury log, light levels. chemical use and discharges records, inspection records, OHS records, complaints logs, wage slips, time cards, poli- cies and procedures, training records. Look at the Toolkit item Auditing Guidance for guidelines on how to conduct an audit. Version 1.2 April 15, 2015 ESMS Implementation Handbook - Health Care Facilities 61 9. Monitoring and Review Monitoring and auditing are words that are often used interchangeably, which can be confusing. Auditing is a formal, on-site evaluation against a specific set of criteria. Audits can be conducted internally by your own staff or by outside parties. Monitoring is an umbrella term that includes various methods for evaluating performance. These may include: visual observation, measuring and testing, questionnaires, surveys, interviews with employees and external stakeholders, and document review. It is important to design your monitoring program to obtain qualitative and quantitative information. It is also important that workers and managers are monitoring the workplace on an on going basis. MEASURING AND IMPROVING YOUR ESMS While your Action Plan monitoring looks at whether corrective actions are being implemented and are achieving the intended results, your ESMS moni- toring is looking at the maturity of your system development and implementa- tion. The Action Plan lists new actions you are taking to address risks. But for the new actions to be sustainable, you also need to improve your ESMS. The two need to be linked. This Handbook’s companion publication ESMS Self-Assessment and Improve- ment Guide provides you with a practical tool to monitor the maturity of your ESMS. For each of the nine ESMS elements, we provide self-assessment ques- tions that show you the level of your ESMS development and implementation on a scale of 0 to 5 (5 is the highest). Conducting the ESMS self-assessment is an important first step that enables you to see where you stand now. The results form the basis of your ESMS Improvement Plan. The ESMS self-assessment responses should be based on Visual Observation, Measuring or Testing, Document Review and Interviews. Let’s take another look at the nine elements of the ESMS and maturity ratings. 62 Section III: Practical Guidelines for Developing and Implementing your Environmental and Social Management System Purpose of Action Plan and ESMS Improvement Plan Action Plan: specific actions to correct environmental, labor and community problems and remediate negative impacts ESMS Improvement Plan: steps targeted to continually improve the management system to support activities in the Action Plan Ongoing Reporting Risks and Impacts Preparedness and Communications Identification of Monitoring and Organizational and Grievance Management Communities Capacity and Engagement Mechanisms Competency Stakeholder to Affected Emergency Response Programs External Review Policy Mature system implemented internally and with key supply chain partners – continual 5 improvement embedded in operations 4 Systems well-developed and implemented internally – routine improvement projects Systems approach adopted, but development and implementation is inconsistent - 3 improvement sporadic 2 Limited system development with sporadic implementation – primarily reactive 1 Little systems awareness or repeatable processes 0 No systems awareness or repeatable processes LINKING YOUR ACTION PLAN AND ESMS IMPROVEMENT PLAN It is important to understand the link between the Action Plan and the ESMS Improvement Plan. The Action Plan lists specific projects and activities. The ESMS Improvement Plan is about making system improvements needed to support the activities and to make the necessary changes in how the organization operates. Improving environmental and social performance and integrating it into your routine operations takes time. The improvement plan for your ESMS needs to be practical. It needs to be designed with the understanding that people have their core operating responsibilities in your organization. You cannot improve everything at once. The ESMS Team plays the critical role of leading the improvement effort. Prioritizing what to work on first is an important job for the team in coordination with senior manage- ment. The ESMS Self-Assessment and Improvement Guide will help you to get started. Version 1.2 April 15, 2015 ESMS Implementation Handbook - Health Care Facilities 63 9. Monitoring and Review CONDUCTING AN EFFECTIVE MANAGEMENT REVIEW The purpose of the management review is to routinely involve senior manage- ment in evaluating the development and implementation of the ESMS. The management review is led by the ESMS Team. In the beginning, we recom- mend conducting a management review every three to six months. Once the ESMS is well-established, once a year is usually fine. It is important to keep a written record (called minutes) during the meeting of the key topics discussed and the decisions made. The minutes should be kept in a central log. For the ESMS Team, the management review is an important opportunity to keep senior management involved. Remember, the sustainability of the pro- gram requires ongoing commitment from senior management. Typical Agenda for a Management Review: • Review progress on Action Plan • Review progress on ESMS Improvement Plan • Review compliance with environmental and labor laws and regulations • Review progress on environmental and social performance • Discuss possible adjustments in risk assessment • Prioritize activities for next three, six and 12 months • Review and approve needed resources by senior management 64 Section III: Practical Guidelines for Developing and Implementing your Environmental and Social Management System Additional References Consulted 1. Andrea Chambers and Cameron Mustard. March 2014. “Needlestick injury prevention: Lessons learned from three acute-care hospitals in Ontario.” Institute for Work & Health. 2. Susan Q. Wilburn. 2004. Needlestick and Sharps Injury Prevention Online Journal of Issues in Nursing. 9 (3) 3. Department of Health, Health Services and Clinical Innovation Division. July 2013. Management of food safety in Hospital and Health Service facilities: Guideline. Queensland. 4. Society for Healthcare Epidemiology of America. 2014. “Hospital food safety measures reduce risk of contaminated hospital food.” ScienceDaily. 5. 2010. “Wanted: 2.4 million nurses, and that’s just in India.” Bulletin of the World Health Organization 88 (5): 321-400. 6. US Department of Labor Occupational Safety & Health Administration. “Hospital eTool.” OSHA. https://www.osha.gov/SLTC/etools/hospital/index.html. 7. International Labour Office, International Council of Nurses, World Health Organization and Public Services International. 2002. “Framework Guidelines for Addressing Workplace Violence in the Health Sector.” 8. World Health Organization and International Labour Organization. 2014. “HealthWISE: Work Improvement in Health Services Action Manual.” 9. Centers for Disease Control and Prevention. 2014. “Emergency Preparedness and Response: Preparation and Planning.” Last updated September 30, 2014. http://emergency.cdc.gov/planning/. 10. OSHA. www.osha.gov Version 1.2 April 15, 2015 ESMS Implementation Handbook - Health Care Facilities 65 Address: 2121 Pennsylvania Avenue, NW Washington, DC 20433 USA Tel. 1-202-473-3800 www.ifc.org/sustainability Copyright The material in this publication is copyrighted. IFC encourages the dissemination of the content for educational purposes. Content from thispublication may be used freely without prior permission, provided that clear attribution is given to IFC and that content is not used for commercial purposes. March 2015