the good hospital guide - dr. soliman fakeeh hospital good hospital guide... · the good hospital...

The Good Hospital Guide

Available for download from www.dsfh.med.sa Page | 1




Welcome Message from the CEO

Dear Distinguished Readers

Since our first CSR report in 2008, we, at Dr. Soliman Fakeeh

hospital, realized that education and awareness are vital for any

CSR practice to succeed. Consequently, in 2010, we published

our first CSR digital magazine aiming to increase CSR awareness

among the community. Within the same spirit, I am pleased to

present you today the first worldwide CSR guide for hospitals

under the title: “Good Hospital Guide” as another CSR

awareness activity directed to the healthcare service sector and

is available for download, free of charge, through our website: www.dsfh.med.sa.

Through our CSR journey, we recognized that in the absence of any international

standards/guidelines specific to CSR in healthcare, companies face many challenges

when contemplating CSR. As a one of the CSR leaders in healthcare, we believed that

establishing a healthcare CSR guiding principle will provides the international market

with the required recommendations to assist any healthcare organization to

implement CSR principles in their practice.

I am proud of our CSR achievements. Our efforts in implementing CSR in our practices

were recognized by being acknowledged three consecutive years by the Saudi Arabia

General Investment Authority and by being the first hospital in the MENA region to

publish a CSR report based on the GRI G3 guidelines in 2008, the first to publish an

externally assured CSR report in 2010 in KSA and the first hospital worldwide (with the

exception of Spain) to reach an externally assured CSR report at the GRI- A level in in

2011.

I would like to thank the authors of this guide for their time, efforts and expertise in

making this exceptional guide possible and wishing all the best for all hospitals willing

to adopt responsible practice by using this guide.

Best regards

Dr. Mazen Fakeeh

CEO/Director general

Dr. Soliman Fakeeh Hospital



Preface

The Good Hospital Guide has two parts. Part One focuses on the fundamentals of

Corporate Social Responsibility (CSR) and highlights the significance of CSR in hospital

operations. This part also provides detailed information about the key CSR terms,

hospital case studies and significant CSR issues relevant to hospital functions. In short,

Part One will serve three main purposes:

1. Gives the readers a thorough understanding of what CSR is and how it is

important for the hospital industry.

2. Gives the readers real life application of CSR by providing case studies from the

industry.

3. Enables the readers to do a self-assessment that helps them assess the

organizational preparedness for CSR. This assessment identifies the key CSR

issues in each function of a hospital that helps readers judge the level of CSR

work required ion their organizations.

Part Two discusses the mechanism of implementing CSR, the essential requirements

that have to be incorporated in the hospital infrastructure before staring CSR, and the

model for developing a CSR strategy. The two main takeaways from part two are:

1. Gives the readers a list of pre-requisites or essentials that have to be in place

before any steps are taken to formalize and strategize CSR.

2. Empowers the readers with knowledge and tools to develop and communicate

their own CSR strategy.



The Good Hospital Guide Knowledge Pyramid

CSR Communication

CSR Strategy Development

Presence of CSR Prerequisites

CSR Self-Assessment

CSR knowledge & Practical Understanding



Note from the Authors

It is with immense pride and gratification that we present you with this

publication. This publication came about as the result of a growing need for a

comprehensive CSR and sustainability guide that highlights issues specific to the

healthcare service industry. We are very proud to be a part of this process and

consider it a great honor that we were chosen to be a part of this pioneering

publication.

Dr. Sherif Tehemar

Being the CSR team leader in DSFH since 2007, I was privileged by being in

charge of implementing CSR in the hospital. Through this journey, I was able with the

help of my team and the support of the leader to publish 3 CSR reports based on the

GRI (G3) guidelines. The last two were externally assured and the last one reached the

A+ level report making DSFH one of few hospitals in the world to reach this level. I am

proud of our sustainability achievement and our efforts were crowned by being

acknowledged for three consecutive years by the King Khaled Foundation for

Sustainability and received the third prize for the last two years. Through this journey,

I realized the limitation of the absence of specific CSR guidelines that are related to

hospitals…That is why we develop this guide. I hope that this guide will help any

healthcare service sector wishing to understand and apply CSR in their daily practice.

Bushra Azhar

I firmly believe in the value of good and responsible business practices for the

long term sustainability of any business. Over the last 13 years of working with

different cultures and business environments, I have witnessed first-hand, the impact

CSR can have on the culture and the community. I believe that this guide will go a

long way in acquainting the healthcare professionals with the value of good CSR

practices and provide them with tools to implement the same in their organizations.



Technical Note

The Good Hospital Guide was prepared using Dr. Soliman Fakeeh Hospital (DSFH) as the base entity through which we carried out our research. The sections related to hospital functions and activities are based on input from the internal policy documents of DSFH as well as through interviews conducted with key internal and external stakeholders.

The CSR content in the guide is based on a mix of experience based knowledge of the authors as well as from renowned international publications on CSR. A full list of these publications is given at the end of the guide.

Sections related to quality, hospital accreditations, CSR communication, relationship between CSR and healthcare practice, implementation and leadership aspects are authored by Dr. Sherif Tehemar whilst the CSR self-assessment, CSR technical knowledge, CSR implementation and evaluation are authored by Bushra Azhar in her capacity as an external CSR and Sustainability Consultant.



Special Thanks

The authors would like to express their deepest gratitude to the staff of Dr. Soliman Fakeeh Hospital

for their assistance and time during the interviews. Special thanks to:

Dr. Mazen Fakeeh, (CEO/Director General)

Mrs. Barbara Allison, (Executive Director for Quality, Risk management & Strategic

Planning)

Mrs. Rania Hussein, (Assistant Director for Quality & Risk Management Department)

Eng. Ahmed El Bana, Chief of Information Management Division

Mr. Emran Khan, Chief of Finance Division

Dr. Azza Abdel Aziz, Director of Material Management Department

Dr. Huda Ahmed, Director of Pharmacy Sevice Department

Dr. Waleed Abdel Razek, FMS Team leader

Mrs. Michele Elyas, Director of Olympia Fitness Center

Eng. Mohamed Atwa, Director of Facility Management Department

Mrs. Bassant Hamad, Director of Education Department

Miss. Reem Al Oqely, Acting Director of Human Resources Department

Dr. Rasha Ahmed, Risk Management Officer

Mr. Youssef Hijazine, Risk Management Officer



Contents Welcome Message from the CEO Preface Note from the authors Technical Note

Part One: The Fundamentals Section 1: Introduction and background

1. Corporate Social Responsibility (CSR): The definition 2. International Recognized Standards and Guidelines for CSR 3. Quality of Healthcare Service: The Accreditation Standards

4. Total Quality Management versus Corporate Social Responsibility 5. Why Dr. Soliman Fakeeh Hospital is making this guide? 6. Responsible business is good business: what is the significance of CSR for hospitals?

Section 2: CSR Elements; Terminology & Implications 1. Sustainability 2. Triple Bottom Lines 3. Governance System 4. Cause-Marketing 5. Transparency 6. Carbon Footprint 7. Environmental, Health & Safety 8. Corruption 9. Waste Management 10. Risk Management 11. Supply Chain Management 12. Stakeholders 13. Stakeholder Identification and Prioritization 14. Stakeholder Engagement

Section 3: CSR for Hospitals; Case Studies 1. Bumrungrad Hospital, Bangkok, Thailand

2. Apollo Hospitals- India

Section 4: CSR Issues Specific to healthcare Service Industry 1. Corporate Governance & Leadership 2. Human Resources and Development Programs 3. Service Delivery and Patient Care

4. Environment, Health & Safety

5. Patient Relation Management

6. Procurement & Storage

7. Finance & Account

8. Information Systems and Patient Confidentiality

9. Risk Management & Patient Safety

10. Community Investments

Part Two: The implementation Section 1: CSR Prerequisites Section 2: How to Strategize CSR Section 3: CSR Communication Appendix 1: Sample KPIs for CSR aspects Appendix 2: CSR Resources and further reading References



Part One: The Fundamentals

Part One focuses on the fundamentals of Corporate Social Responsibility (CSR) and

highlights the significance of CSR in hospital operations. This part also provides detailed information

about the key CSR terms, hospital case studies and significant CSR issues relevant to hospital

functions. In short, Part One will serve three main purposes:

1. Gives the readers a thorough understanding of what CSR is and how it is important for the

hospital industry.

2. Gives the readers real life application of CSR by providing case studies from the industry.

3. Enables the readers to do a self-assessment that helps them assess the organizational

preparedness for CSR. This assessment identifies the key CSR issues in each function of a

hospital that helps readers judge the level of CSR work required ion their organizations.



Section 1: Introduction & Background Corporate Social Responsibility (CSR) is the responsibility of a company towards anyone who can or has the potential to be influenced by a company. This section present an overview of CSR, how it is defined, the standards and guidelines commonly used and the CSR reporting process. Considering the relevance to healthcare service industry, there is a special focus on the quality management and accreditations and how these can help hospitals in their journey towards full scope CSR.

1. Corporate Social Responsibility (CSR): The Definitions

SR is a concept that has many different meanings and definitions. The way it is

understood and implemented differs greatly for each company and for each country.

CSR has been defined by the World Business Council for Sustainable Development

(2000) as: “The continuing commitment by business to behave ethically and contribute

to economic Social development while improving the quality of life of the workforce and their

families as well as the local community and society at large”

European Commission with the Green Paper -“Promoting a European framework for Corporate

Social Responsibility” defines the concept of CSR as: “A concept whereby companies integrate social

and environmental concerns in their business operations and in their interaction with their

stakeholders on a voluntary basis. Being socially responsible means not only fulfilling legal

expectations, but also going beyond compliance and investing ‘more’ into human capital, the

environment and the relations with stakeholders”.

In 2010, ISO 26000 defined social responsibility as: “The responsibility of an organization for the

impacts of its decisions and activities on society and the environment, through transparent and

ethical behavior that:

Contributes to sustainable development, including health and the welfare of society;

Takes into account the expectations of stakeholders;

Is in compliance with applicable law and consistent with international norms of behavior;

and



Is integrated throughout the organization and practiced in its relationship”

In 2011, The European Commission put forward a new definition of CSR as: “The responsibility

of enterprises for their impacts on society”

The Commission mentioned that respect for applicable legislation, and for collective

agreements between social partners, is a prerequisite for meeting that responsibility and to fully

meet their corporate social responsibility, enterprises should have in place a process to integrate

social, environmental, ethical, human rights and consumer concerns into their business operations

and core strategy in close collaboration with their stakeholders, with the aim of:

maximizing the creation of shared value for their owners/shareholders and for their

other stakeholders and society at large;

Identifying, preventing and mitigating their possible adverse impacts.



2. Internationally Recognized Standards and Guidelines for CSR

or companies seeking a strategic approach to CSR, firm guidance in form of

internationally recognized principles and guidelines is available.

The table below highlights some of the most commonly used principles and guidelines:

Standard Purpose More Information

ISO 26000 Guidance on CSR related issues http://www.iso.org/iso/catalogue_detail?csnumber=42546

OHSAS 18001 Guidance on Occupational Health and Safety

http://www.ohsas-18001-occupational-health-and-safety.com/

AA 1000 Series Guidance on accountability & Sustainability

http://www.accountability.org/standards/index.html

SA 8000 Standards for decent working conditions

http://www.sa-intl.org/index.cfm?fuseaction=Page.ViewPage&PageID=937

ISO 19000 To help companies manage their environmental impacts

http://www.iso.org/iso/en/iso9000-14000/

IFC Sustainability Framework

Guidance to IFC projects for sustainable development

http://www1.ifc.org/wps/wcm/connect/Topics_Ext_Content/IFC_External_Corporate_Site/IFC+Sustainability+Framework

One of the most widely used CSR guidelines for reporting is issued by Global Reporting

Initiative (GRI). The GRI was formed by the United States based non-profits CERES (formerly the

Coalition for Environmentally Responsible Economies) and Tellus Institute, with the support of the

United Nations Environment Program (UNEP) in 1997. It released an “exposure draft” version of the

Sustainability Reporting Guidelines in 1999, the first generation in 2000, the second generation was

released in 2002 at the World Summit for Sustainable Development in Johannesburg — where the

organization and the Guidelines were also referred to in the Plan of Implementation signed by all

http://www.iso.org/iso/catalogue_detail?csnumber=42546

http://www.iso.org/iso/catalogue_detail?csnumber=42546














attending member states. Later that year it became a permanent institution located in Amsterdam,

the Netherlands.

The Third Generation Guidelines (G3), released in 2006, are the most used, credible, and

trusted framework largely because of the way they have been created: through a multi-

stakeholder, consensus-seeking approach. The G3 consist of principles and disclosure items (the

latter includes performance indicators). The principles help reporters define the report content, the

quality of the report, and give guidance on how to set the report boundary. Principles include those

such as materiality, stakeholder inclusiveness, comparability and timeliness. Disclosure items

include disclosures on management of issues, as well as performance indicators themselves.

The G3.1 Guidelines released in 2011 are an update and completion of G3 and is much more

comprehensive. A fourth generation of reporting guidelines G4 is in the process of completion at

the moment. Up to 2011, there are 9319 CSR reports published based on GRI guidelines.

CSR report based on GRI guidelines can report at application level A, B or C depending upon the

number of indictors reported. If the company decides to get its report externally assured, it gets a

“+” so an A level report becomes A+ after assurance and so on.

Graphic from the GRI website



3. Quality of Healthcare Service: The Accreditation Standards

ccreditation is considered a standard through which a healthcare facility or service is

shown to offer quality of service that meet minimum standards and guidelines offered

by various domestic and international quality boards.

Healthcare and hospital accreditation in the western countries is standard practice, but such

is not the case for many international healthcare providers. Due to the growing popularity of

healthcare tourism, however, international facilities are increasingly desirous of being rated (or

graded) by U.S. and International accreditation organizations in order to offer competitive

procedures in the fields of healthcare.

One of the most well-known accreditation agencies in the world are the Joint Commission,

the Joint Commission on Accreditation of Healthcare Organizations, (JC and JCAHO), and the

Australian Council on Healthcare Standards International (ACHSI). The accreditation bodies evaluate

medical facilities based on a standard of requirements that must be met in order to 'pass'

inspection. Such considerations are key focal points of such inspection teams:

Medical staff credentials and training

Nursing staff credentials and training

Medication Management

Infection Control

Environment of Care

Patient Rights

Provision of Care Treatment Services

Accreditation guidelines ensure an external review and evaluation of quality as well as

management practices in a wide range of medical fields and scenarios. The focus is on patient care,

from the moment they access care to when they are discharged from a hospital or medical facility.

Other factors taken into consideration for accreditation include:

Quality of hands-on care

Education and training of staff

Proof of educational credentials

Ethical standards



Accreditation incorporates every department in healthcare facilities, including

laboratory, pharmacy, infection control services, human resources and health

information technology services.

Other accreditation standards that are not specific to healthcare sector but relevant to CSR

are: ISO 9001, ISO 14001, OHSAS 18001 and HACCP. These standards are always of added values in

environment, safety and energy management. An EMS meeting the requirements of ISO

14001:2004 will enable an organization of any size or type to identify and control the

environmental impact of its activities, products or services, and to improve its environmental

performance continually. The OHSAS specification is applicable to any organization that wishes to

establish an OH&S management system to eliminate or minimize risk to employees and other

interested parties who may be exposed to OH&S risks associated with its activities.



4. Total Quality Management versus Corporate Social Responsibility

hobadian and Gallear in 1996 defined Total Quality Management (TQM) as a

structured attempt to re-focus the organization’s behavior, planning and working

practices towards a culture which is employee driven, problem solving, stakeholder

oriented, values integrity, and open and fear free. Furthermore, the organization’s

business practices are based on seeking continuous improvement, the devolution of decision

making, the removal of functional barriers, the eradication of sources of error, teamwork, honesty,

and fact-based decision making.

TQM is one of the most robust management systems, and it has been implemented

worldwide in different sectors. Corporate Social Responsibility (CSR), on the other hand, is a more

recent phenomenon and dates back to the 1980s. However, CSR, like TQM, impinges on all facets of

organizations.

In the field of TQM and CSR, concerns were raised about the degree of overlap between

these two powerful and all-embracing concepts. However, as TQM has the advantage of good

penetrating power in the organizations it can act as a solid framework for developing CSR within

the organization.

TQM ensures a balance between the goal of organization and the quality of service. Equally,

CSR considers the value-based behavior as the root to sustainable performance. Hence, TQM can

play an important part in facilitating a deeper penetration of CSR in a broad range of organizations.

TQM officers in the organization have the responsibility of ensuring that the ethical basis of

quality is not overlooked and that quality management takes a leadership role in promoting ethical

practices.

Therefore, CSR will not simply happen because an organization has TQM: to make it happen

it is necessary to have a CSR team/department capable to address the issue explicitly. Moreover,

the CSR team will adjust the elements of TQM so that they consciously address facets of CSR.



Due to a growing awareness of the involvement of corporations in society, companies

develop new values, strategies and policies that support their functioning in areas that were once

left to others (people and planet). More and more companies accept this new position in society

and strive to be proficient and transparent in these issues. In this way CSR is about redefining the

role of corporations in society. This development has led to a wide range of approaches that all

address social responsibilities of corporations, and also to a growing interest in indicators for

managing social performances.



5. Why Dr. Soliman Fakeeh Hospital is making this guide?

he mission, vision and values of Dr. Soliman Fakeeh Hospital are built on the concept of

responsibility that focuses on patients’ need while taking into consideration the

community. DSFH believes that healthcare is a sustainable social investment and that is

why we do not see Corporate Social Responsibility (CSR) practice as an added cost. The

CSR strategy demonstrates a commitment to patients, employees, environment and community by

setting clear goals and objectives that respect the triple bottom line (People, Planet and Profit).

DSFH considers The Saudi Arabia Responsible Competitiveness Index (SARCI) an excellent

governmental initiative to help businesses in the Kingdom improve their own competitive

performance, and support the Kingdom’s competitive performance and social and environmental

development, through the way companies manage their environmental and social footprints. DSFH

has been a major participant in SARCI since it began 4 years ago. From 2008 till 2011, DSFH

published three CSR reports; two of them were externally verified and the latest one is an A+ level

based on the third generation of the GRI guidelines (G3).

A review of the Fortune top 1000 companies list, reveals that among the 14 listed in the

“Healthcare: Medical Facilities”, not one has issued any kind of non-financial reports. A GRI reports’

list dating back to 1999 shows that among the 1003 organizations reporting in the year 2008, only

eight from the healthcare service have reported their sustainability performance (DSFH was the

first in the Middle east and North Africa). Considering the level of trust that people have in

hospitals, it is strange and unfortunate to see so few reports coming out from hospitals. It is also

regrettable that there is no comprehensive guidance available on implementing CSR in hospital

operations.

Based on DSFH reporting experience, that was guided by the GRI framework; it became

apparent that there is a growing need for standards/guidelines specific to CSR in healthcare. As a

one of the CSR leaders in healthcare, DSFH took this as an opportunity to share its learning and

experience with others in the industry. The guide will help other hospitals start their CSR journey

and hopefully, one day we will see a much larger percentage of healthcare service providers

proudly exhibiting their CSR victories through a CSR report.



6. Responsible business is good business: what is the significance of

CSR for hospitals?

here are many reasons why it pays for companies to be socially responsible. The

healthcare industry has a variety of challenges that people might not notice. Issues such

as strict compliance with laws and regulations, intense labor shortages in qualified

medical and nursing staff, increased and costly technological advancements, and

implementation of international quality standards make this industry one of the most challenging

operational industry. Consequently, hospitals have to work harder than other industries to win and

retain that trust while managing the operational challenges.

CSR could play a major role in this context by highlighting the performance of the hospital in

a transparent and sincere way and result in better understanding from the community about the

above mentioned challenges that this sector faces. Moreover, CSR will help the healthcare sector to

elaborate on social issues that could serve to improve their images and enhance the stakeholder

engagement by making their performance indicators available to public.

Some of the key benefits are as below:

Getting license to operate– from key stakeholders not just shareholders

The private sector is gaining a much bigger role and responsibility for economic

development globally. This responsibility is not limited to economic issues but must also include

social and environmental contribution. Hospitals that fail to recognize this responsibility are at the

risk of being denied the social acceptance that comes from the community. Without this

acceptance, hospitals can never function in a profitable and sustainable manner.

Reputation Management

Reputational risk is considered as one of the most crucial threats facing an organization and

is even more critical for a hospital. This includes risks not only to loss of patients, but goes beyond



to hospital itself, and may even impact the whole industry. In case of a reputational crisis involving

the hospital, the consequences could be huge in terms of lost trust, legal costs and patient loyalty.

A damaged reputation might require years to rebuild and cost a large sum of money. A hospital

which has a sound CSR mechanism and a history of exceptional service to society and environment

often does not suffer as much as a hospital with no CSR plans, in the incidence of a reputation

crisis.

More Efficient use of resources

Utilization of a holistic CSR framework in hospitals can result in higher efficiency in

operations, for instance, improved efficiency in the use of energy and natural resources can result

in substantial cost savings. A better waste management system will not only reduce the amount of

waste but will also ensure its safe disposal.

Enhanced patient loyalty

Patients need to be able to trust a hospital in order to recommend it to someone. Trust is

probably the most valuable currency in the healthcare industry and it doesn’t come easy. In order

for hospitals to earn patient trust and loyalty, they need to go beyond healthcare services and

create an emotional bond with the patient through ethical business practices. Patient loyalty goes a

long way in contributing towards sustainable business growth of a hospital.

Increased Ability to Attract and Retain Quality Employees

There is clear evidence linking the employee morale and loyalty to the social performance of

the company. This is especially vital in the case of a hospital. If a hospital employee continually

witnesses violation of ethical norms in the hospital, he or she would not want to be involved with

that hospital.

Responsible Competiveness

When competitors adopt less costly but not socially responsible and ethically sound

healthcare solutions, a hospital should take advantage of this challenge and explore new innovative

and green solutions. This raises the barriers to entry and will make CSR as the industry norm with

your company being the pioneer.



Attracting Investors and Business partners

Investors no more only rely on financial data but also look at how a company deals with the

relevant social and environmental issues. If a company is not prudent enough to pay any attention

to these issues, with time it will lose credibility and no investor wants to invest in a company that

has no credibility or stakeholder trust. In order for a healthcare service provider to attract investors

who can fund their expansion, they need to focus on social, environmental and economic

performance in addition to financial performance.

Governmental Support

A CSR program developed in accordance with the overall government direction can help the

company win favors from the government. Many governments give financial incentives for sound

CSR initiatives, including environmentally friendly innovations. Hospitals that demonstrate they are

engaging in practices that go beyond regulatory compliance are being given massive support from

governments in form of waivers and less scrutiny.

Improved Bottom Line

All of the above factors inevitably translate into better financial performance over the years.



Section 2: CSR Elements: Terminology & Implications

In order to successfully apply CSR in any organization a clear understanding of the key CSR terms is a must. This section highlights the most commonly used CSR terms and elements that are commonly used. Moreover, due to the importance of stakeholder in the CSR implementation process, the mechanism of their identification and engagements is described in detail.

1. Sustainability

Sustainability means that a company performs its operations in a manner that meets the

needs of the present without compromising the ability of future generations to meet their own

needs.

Sustainable development involves devising a social and economic system, which ensures

that these goals are sustained, i.e. that real incomes rise, that educational standards increase that

the health of the nation improves, and that the general quality of life is advanced.

Sustainability refers to a comprehensive way of doing business that delivers great economic

value and opens up new opportunities in terms of social, economic and environmental impacts.

Companies can generate substantial business value through sustainability, while improving the

quality of life and protecting the environment.

Healthcare service sector improves the quality of life through their preventive and

therapeutic approaches and by improving the community wellbeing. This is inherently a

sustainable business and with some improvements can be made more holistic.

2. Triple Bottom Line

The triple Bottom Line (abbreviated as TBL or 3BL, and also known as people, planet,

profit or the three pillars) captures an expanded spectrum of values and criteria for measuring

organizational (and societal) success: economic, ecological, and social.



Triple bottom line accounting means expanding the traditional company reporting

framework to take into account not just financial outcomes but also environmental and social

performance.

Triple Bottom Line concept is based on the principal that for a company to truly prosper, it

needs to worry about the three elements in its bottom line (people, planet and profit) instead of

the conventional focus on profits only. The concept draws attention to the fact that company

sustainability is in fact dependent on elements beyond profitability. Some companies use TBL as

basis of their CSR/ Sustainability strategy such that their CSR objectives fall under the People,

Planet, Profit pillars.

It is imperative that hospitals focus on Triple Bottom line rather than just the financial

bottom line because of the nature of its services.

3. Governance System

It is the framework of rules and practices by which Board of

directors ensures accountability, fairness, and transparency in a company's relationship with its

stakeholders (financiers, customers, management, employees, government, and the community).

The presence of an effective governance system, within an individual company and across

an economy as a whole, helps to provide a degree of confidence that is necessary for the proper

functioning of a market economy.

Corporate Governance is a mechanism to ensure that a company management is running

the business to the best of its ability and to the maximum benefit of shareholders. It is usually only

relevant for publically traded companies and includes elements such as procedures for reporting,

supervision and internal controls. Purpose of a strong corporate governance structure is to ensure

that the rights of the shareholders are safeguarded and also to ensure that all companies are

subject to the same standard of transparency and disclosure so as to assist stakeholders in decision

making.



Effective corporate governance and leadership is crucial for the healthcare sector to identify

its mission and vision and to provide a clear direction to achieve its goals. This process is

clearly identified in every healthcare accreditation standards and is a must when managing CSR

initiatives. Presence of solid corporate governance and structure with a committed leadership is the

most essential prerequisite for CSR to succeed.

4. Cause Marketing

Cause Marketing or cause-related marketing refers to a type of marketing involving the

cooperative efforts of a "for profit" business and a non-profit organization for mutual benefit.

Cause related marketing can be any type of marketing effort by a company that makes use

of association with a social or charitable cause. Cause Marketing differs from CSR in that the latter

comprises a set of activities in line with the company strategy and meant to address issues specific

to the company stakeholders, while cause marketing is only a marketing effort that makes use of a

social cause to gain free publicity and also raise money for the cause.

A very popular and well received Cause Marketing effort is the Pepsi Refresh Project. The

campaign invites people to post proposals for change in their communities and other users to vote

on their ideas. Funds are awarded to the most popular proposals. In 2010, 7,000 projects garnered

51 million votes. 287 ideas from 203 cities and 42 states won $11.7 million. The campaign resulted

in huge media exposure for Pepsi at multiple forums and locations which would not have been

possible with a stand-alone advertisement campaign.

In a healthcare setting, hospital’s management should be aware of the difference between

CSR and Cause-Marketing. CSR should be embedded in the hospital strategic plan according

to a clear defined strategy with a SMART objectives and goals. On the other hand, Cause-Marketing

if undertaken should be carefully used with defined objectives and for a specific cause.

5. Transparency

Transparency can be defined as the lack of hidden agendas and conditions, accompanied by

the availability of full information required for collaboration, cooperation, and collective decision



making. Transparency can also be referred to the practice of being open about the company issues

and proceedings and providing full information about any negative or scandalous news related to

the company as well as regular business operations.

Transparency does not mean that a company has to make all information public but that

enough information is made available to everyone that will enable open exchange of opinions and

facilitate decision making.

It is interesting to mention that mining and extractive industries' is one of the most

notorious industries when it comes to availability of information about business operations. The

Extractive Industries Transparency Initiative (EITI) is a non-profit multi-stakeholder organization

meant to help mining companies improve their image and contribute to sustainable development

of mining communities by being transparent and responsive to local needs. Some 20 countries have

EITI across the world—from Peru, to Trinidad and Tobago, Azerbaijan and Nigeria.

For the healthcare sector, transparency is a must-have. With the increase in medical errors

and reports of companies trying to hide these instances, more and more people are losing

trust in hospitals. By being more open about their operations and owning up to many mistakes,

hospitals can build trust among the community.

6. Carbon Footprint It is the total amount of greenhouse gases produced to directly and indirectly support

human activities, usually expressed in equivalent tons of carbon dioxide (CO2).

The carbon footprint is the sum of all emissions of CO2 (carbon dioxide), which was induced

by company activities in a given time frame. When companies use oil, gas, electricity or coal in their

factories or offices, they generate CO2. The fuel used by delivery trucks, pool cars or any form of

transportation also has a carbon emission element. The purpose of calculating a company’s carbon

footprint is two-fold; to monitor and control the footprint and to minimize the footprint by planting

trees and other “carbon off-set “activities. Other greenhouse gases which might be emitted as a



result of company activities are e.g. methane and ozone. These greenhouse gases are normally also

taken into account for the carbon footprint.

Google just released its carbon footprint numbers. Google's 2010 electricity

consumption was 2,259,998 MWh, which results in 1,457,982 metric tons of carbon dioxide. This is

enough electricity to power about 41 Empire State Buildings, and is more than the carbon footprint

of the country of Togo.

Generators, fuel, Freon and incinerators are usually considered the source of GHG emissions

in a hospital setting. Efforts in reducing the GHG emissions should be considered and

highlighted as environmental initiatives while being monitored on yearly basis.

7. Environment, Health and Safety (EHS)

Environment, Health and Safety (EHS) refers primarily to corporate programmes to promote

employees’ health and protect their safety; environmental protection programmes were

traditionally included in the same management category.

Inclusion of elements such as employee safety and wellbeing, environmental conditions and

occupational health concerns in the overall company management is referred to as EHS. Effective

management of EHS issues entails the inclusion of EHS considerations into corporate and facility-

level business processes in an organized, manner.

IFC publication, “Environmental, Health, and Safety (EHS) Guidelines” are technical

reference documents with general and industry-specific examples of international best practices in

EHS. The guidelines can be used as a general resource as well as an industry specific resource.

Every hospital should have a holistic EHS program in place. Issues like health and safety of

the workforce, waste management and environmental conservation should all be a part of

the EHS and hospitals may also consider getting certifications for their EHS such as ISO 14001 and

OHSAS.



8. Corruption

There are several definitions in the literature for “corruption”. However, the one that gains

wide acceptance is “Corruption is the abuse of power by an official for private gain”.

Economic corruption is an important form of corruption; however, it is not the only form of

corruption. There are non-economic forms of corruption, including many types of police corruption,

judicial corruption, political corruption, academic corruption, and so on. Indeed, there are at least

as many forms of corruption as there are human institutions that might become corrupted. Further,

economic gain is not the only motivation for corruption. There are a variety of different kinds of

attractions that motivate corruption. These include status, power, addiction to drugs or gambling,

and sexual gratification, as well as economic gain.

Every organization including healthcare should closely address issues of corruption. This can

be managed through anti-corruption policy, strategic framework for controlling corruption,

prevention programs and education.

9. Risk Management

Risk management is the identification, assessment, and prioritization of risks followed by

coordinated and economical application of resources to minimize, monitor, and control the

probability and/or impact of unfortunate events or to maximize the realization of opportunities.

The strategies to manage risk typically include transferring the risk to another party,

avoiding the risk, reducing the negative effect or probability of the risk, or even accepting some or

all of the potential or actual consequences of a particular risk.

Certain aspects of many of the risk management standards have come under criticism for

having no measurable improvement on risk, whether the confidence in estimates and decisions

seem to increase.

It is the responsibility of the governance bodies in a hospital to identify and prioritize the

risks through Risk matrix and formulate policies and procedure for managing the risks

accordingly.



10. Waste Management

Waste management is the collection, transport, processing or disposal, managing and

monitoring of waste materials. The term usually relates to materials produced by human activity,

and the process is generally undertaken to reduce their effect on health, the environment or

aesthetics.

Waste management is a distinct practice from resource recovery which focuses on delaying

the rate of consumption of natural resources. The management of wastes treats all materials as a

single class, whether solid, liquid, gaseous or radioactive substances, and tried to reduce the

harmful environmental impacts of each through different methods.

The management of waste is a key component in a business' ability to maintaining ISO14001

accreditation. Companies are encouraged to improve their environmental efficiencies each year by

eliminating waste through resource recovery practices, which are sustainability-related activities.

One way to do this is by shifting away from waste management to resource recovery practices like

recycling. Materials such as glass, food scraps, paper and cardboard, plastic bottles and metal can

be recycled.

In hospitals, waste is categorized into 3 types; general, infected and pathological waste.

Existence of efficient and effective waste management system is crucial in any hospital not

only from CSR perspective, but also for the health of the community. Hospitals should comply with

national and international laws and regulations for waste disposal.

11. Supply Chain Management (SCM)

Supply chain management (SCM) is the management of a network of interconnected

businesses involved in the provision of product and service packages required by the end customers

in a supply chain. Supply chain management spans all movement and storage of raw materials,

work-in-process inventory, and finished goods from point of origin to point of consumption.



The term "supply chain management" entered the public domain when Keith Oliver, a

consultant at Booz Allen Hamilton, used it in an interview for the Financial Times in 1982. The term

was slow to take hold and the lexicon was slow to change. It gained currency in the mid-1990s,

when a flurry of articles and books came out on the subject. In the late 1990s it rose to prominence

as a management buzzword, and operations managers began to use it in their titles with increasing

regularity.

With the supply chain costing as much as 40 percent of the typical hospital’s budget, the

strategic importance of hospital supply chain is evident. A company practicing CSR has to

take steps to ensure that their vision of CSR is shared by their suppliers and to encourage them to

also engage in responsible actions.

12. Stakeholders

Stakeholders are persons, groups, or organizations that have direct or indirect stake in an

organization because it can affect or be affected by the organization's actions, objectives,

and policies.

The stakeholders in a corporation are the individuals and constituencies that contribute,

either voluntarily or involuntarily, to its wealth-creating capacity and activities, and that are

therefore its potential beneficiaries and/or risk bearers.

Anyone who can affect or has the potential of being affected by a company’s activities is a

stakeholder and needs to be involved in the decision making process and their issues addressed

accordingly. All stakeholders are not equal and different stakeholders are entitled to

different considerations. For example, a company’s customers and employees though equally

important are not entitled to the same considerations. The primary stakeholders in a typical

company are its shareholders, employees, customers, suppliers, community, environment,

regulatory authorities and trade unions or civil society organizations.

Freeman’s Stakeholder theory supposes that organizations have a direct relationship to the

external environment and a direct impact on multiple stakeholders. The theory focuses on creating

value for each of the stakeholders rather than merely the stockholders. Freeman’s work also

identifies stakeholders as those individuals or groups who can impact or are impacted by an



organization’s successes or failures. Stakeholders can include suppliers, customers, employees,

governments, stockholders, community members, and other groups that potentially could be

impacted by organizational actions.

13. Stakeholder Identification and Prioritization

The first step in the process of stakeholder engagement is stakeholder identification–

determining who your stakeholders are, and their sub groups if any. From this flows stakeholder

analysis, a more in-depth look at stakeholder group interests, how they will be affected and to what

degree, and what influence they could have on your company’s CSR agenda. The answers to these

questions will form basis o your stakeholder engagement and consultation process.

Step 1: Identify stakeholders directly and indirectly affected by the Hospital in its area of

influence

When identifying affected stakeholders, the best approach is to start by identifying the

geographical boundary of the hospital and its allied facilities. Use this analysis to establish the area

of influence and determine who might be affected and in what way. This process will begin to

reveal those most directly affected by the hospital operations, whether from occupying houses

near the building or the effects of air and water emissions, from off-site transportation of hospital

waste, or even the socio-economic effects of job creation.

By mapping the sphere of influence in this manner, the hospital can identify the distinct groups

with respect to environmental and social impacts.

Step 2: Identify those whose “interests” determine them as stakeholders

It is also very important to include in your stakeholder analysis those ggroups or

organizations whose interest determine them as stakeholders. These are generally groups who

have motivations other than a direct relationship such as media.

Step 3: Be strategic and prioritize

It is not practical to engage with all stakeholder groups and being strategic as to whom you

are engaging with not only saves time but will also deliver better results.



The most commonly used model for stakeholder prioritization is the interest-influence grid

developed by Imperial College London. The level of influence and importance of each stakeholder is

established through internal consultations and determine the relative importance of each

stakeholder group. Another popular model introduced by Murray-Webster and Peter Simon is the

three-dimensional version of the above, which also takes into account the attitude of stakeholder.

It also might be helpful to consider the following questions when drawing up the list of top

priority stakeholders:

1. What type of stakeholder engagement is required by regulations?

2. Who are the most vulnerable among the stakeholder groups and that they may be consider

priority despite low influence/ low interest.

3. Which group is expected to support the hospital most in their CSR efforts and which are

expected to cause opposition and why?

4. Who is it critical to engage with first, and why?

Keep Informed Manage Closely & Engage

Deeply

Monitor with Minimum Effort

Consult & Keep Satisfied

Stekeholder Prioritization

Leve

l of

Inte

rest

Degree of Influence

Hig

h

High Low

Low



5. What is the optimal sequence of engagement?

Step 5: Verify stakeholder representatives

Identifying stakeholder representatives and planning the stakeholder engagement process

in consultation with them and through their support is imperative to the success of engagement.

When working to identify representatives, make every effort to ensure that these individuals are

indeed spokespersons of the stakeholders and can be relied upon to serve as communicators and

mediators between hospital and its stakeholders.

14. Stakeholder Engagement and analysis

Stakeholder Engagement is a means of describing a broad, inclusive, and continuous process

between a company and those potentially impacted by the company that encompasses a range of

activities and approaches, and spans the entire life of a project. It is meant to involve the

stakeholders in the decisions impacting them.

Stakeholder engagement is the process by which an organisation involves people who may

be affected by the decisions it makes or can influence the implementation of its decisions. It is a

two way communication process meant to give stakeholders the chance to influence the decision-

making process. This differentiates it from regular communications processes that seek to issue a

message or influence groups to agree with a decision that is already made. Like any other business

function, stakeholder engagement needs to be managed. It should be driven by a well-defined

strategy and have a clear set of objectives, timetable, budget, and allocation of responsibilities. All

staff should be made aware of the program, and understand why it’s being undertaken and what

implications it might have for project outcomes



1. Plan ahead

The findings of the stakeholder prioritization exercise will tell you who needs to be

consulted and why. Getting clear answers for these questions up front can save you time, reduce

costs, and help keep expectations in check.

Graphic from the IFC handbook



2. Consult using basic principles of good practice

For a good stakeholder consultation process, the techniques, methods, approaches and

timetables will need to be tailored for the local situation and the various types of stakeholders

being consulted. Ideally, a good consultation process will have these elements:

1. Will be targeted

2. Will be conducted at the right time.

3. Will be meaningful to those consulted because the content is presented in a readily

understandable format and the techniques used are culturally appropriate

4. Will be two-way so that both sides have the opportunity to exchange views

5. Will be all-inclusive meaning all sub-groups within priority stakeholder groups are consulted

6. Will be localized to reflect appropriate timeframes, context, and local languages

7. Will be free from manipulation or coercion

8. Will be documented to keep track of who has been consulted and the key issues raised

9. Will be reported back in a timely way to those consulted.

3. Be open-minded

Engagements are not always happy cordial events. A lot of times, especially when the

hospital is only just starting its CSR sustainability program, some misgivings tend to rise to the

surface. Although you think you are prepared to handle this, it can be very disconcerting and you

will feel as if you are being personally attacked. Try to take things in a stride; don’t try to defend the

hospital if the qualms are justified. Do mention that you value their opinions and promise to come

back with a resolution soon after. And then keep that promise.

4. Talk less, Listen more:

It is called a dialogue for a reason. The best engagement session are the ones where the

hospital representative only acts as a facilitator and lets the participants decide where they want to

go with the conversation? The kind of responses you get from unbridled, uninhibited minds will be

priceless and much more genuine than if you try and put words in their mouths.

5. You can’t make everyone happy:

Not all causes are created equal and it is important to know that not all issues raised in the

session warrant an action. What is important for the hospital is to address an issue or a cause that



has a strategic dimension and represents a solid need of the society. Prioritization of the CSR issues

is paramount to the success of your CSR program. However, don’t forget to identify the

unaddressed issues and have a resolution ready for the next session. “We didn’t think it is

important enough” is not the most judicial response.

6. Be Less Formal:

These gatherings are called engagements for a reason. Try to be frank and open and let

others relax so that people do actually get to connect. People are at their most helpful and

evocative when they feel they are not being judged. In a formal, stiff environment you will hardly

see anyone bringing out creative and workable solution, they are too busy keeping appearances.

7. Expect to go off tangent:

While it is great to have an agenda, do keep in mind a good engine session is the one that

takes its own shape and form as it evolves. Do not force the agenda unless you are looking for

specific information (like indicators for a CSR report). Let the session evolve on its own and you will

be surprised with the outcomes.

8. Document the process and results of consultation

Documenting consultation activities and their outcomes is critical to stakeholder

engagement process. The timing, place, agenda. Attendees, topics etc. need to be documented for

future reference and as evidence.

The stakeholder identification and consultation section is based on and guided by the IFC

Publication “Stakeholder Engagement -A Good Practice Handbook for Companies Doing

Business in Emerging Markets” and “Stakeholder Engagement Lessons” article on Good Business

Sense.



Section 3: Corporate Social Responsibility in Hospitals: Case Studies This section demonstrates two case studies for hospitals that have successfully implemented CSR initiatives. Case studies are always of a great value as they describe experiences of others in managing particular issues, represent an opportunity for innovations, and to develop analytic and problem solving skills as well as they allows the exploration of solution. Unfortunately, there was considerable rare information in the literature for CSR in hospitals. An issue that may explain why DSFH is making this guide.

1. Bumrungrad Hospital, Bangkok, Thailand

umrungrad International is an internationally accredited, multi-specialty hospital located

in the heart of Bangkok, Thailand. Founded in 1980, today it is the largest private

hospital in Southeast Asia, with 554 beds and over 30 specialty centers. Bumrungrad

offers state-or-the-art diagnostic, therapeutic and intensive care facilities in a one-stop

medical center.

Bumrungrad serves over a million patients annually. Over 400,000 are internationals. They

include thousands of expatriates who live in Bangkok and nearby countries, plus visitors from 190

countries around the world who come for treatment. English is widely spoken. The hospital has a

medical coordination office staffed by doctors, nurses, and interpreters who serve the special

needs of international patients. It is a public company traded on the Thai stock exchange. It has

been featured by CBS's 60 Minutes, NBC’s Today Show, Time, Newsweek, and other international

press as a leader in medical tourism.

Corporate Social Responsibility Achievements:

The Bumrungrad Hospital Foundation (BHF) is a registered non-profit foundation

established in May 1990 by the founders of Bumrungrad International. The Foundation is involved

in a wide range of charitable activities benefiting the health of underprivileged Thais throughout

the country. It also promotes health education to the general public. Donations to the Foundation

are tax-deductible.



50 Paediatric Heart Surgeries

On the occasion of HRH Princess Maha Chakri Sirindhorn's 50th Birthday in 2006, BHF and

Bumrungrad International performed 50 paediatric cardiac surgeries for disadvantaged children

with life threatening heart defects.

"Mend-A-Broken Heart" Charity Heart Surgeries

In 2001, BHF, Bumrungrad International, the Heart Centre at Bumrungrad International, the

Heart Foundation of Thailand, the Chin Sophonpanich Foundation and several corporate entities

jointly sponsored 20 heart surgeries for underprivileged children and young adults in Thailand.

Thompson Fund Mobile Free Clinic

This project, sponsored by the Thomson Fund and supported by the medical team of

Bumrungrad International, has provided free medical care services to a total of 100,000

underprivileged patients since 2001. Most are elderly people in 30 districts within the greater

Bangkok metropolitan area.

Charity Medical Relief

A mobile medical team from Bumrungrad joins with staff from Bangkok Insurance Co. Ltd to

provide free treatment once a year to some 10,000 villagers in Mukdahan and Sakon Nakorn

provinces in northeast Thailand. A handicraft-training project in Nong Kong village, Mukdahan

province, was also initiated to provide supplementary income to many underprivileged people.

Patients in Need

BHF sponsors or subsidizes the expenses for the underprivileged who require surgical

procedures but cannot afford medical treatment.

Community Education

Seminars, symposia, health fairs, and activities to promote public health awareness.



Innovations in Information Technology

The key to this private hospital’s tremendous success is IT. BH has recognised that hospitals

must be information driven if they are to deliver comprehensive, accurate care. In December 1999,

the hospital made the leap to a single new system, a vast integrated database that uses the most

modern processor and server technology to keep its infrastructure requirements simple. The

database holds information relating to inpatient and outpatient profiles, appointments and

treatments, admission, billing, accounting, HR, records and imaging, radiology, pharmacy stocks

and labels, laboratory results and even the kitchens to ensure good dietary management. The

hospital uses a package called Hospital2000 that runs on Microsoft software, and uses Intel

processors to power the whole operation. To support all this, the staff complement of over 2,000

includes a mere eight IT people who “spend their time fixing paper jams and clearing up viruses”.

Medical errors and infection rates have fallen. The central database holds 35 million scanned

images and is adding around 10,000 a day.

2. Apollo Hospitals- India

ith over 8500 beds across 54 hospitals, and a significant presence at every touch-

point of the medical value chain, Apollo Hospitals is one of Asia’s largest

healthcare groups. Commenced as a 150 bed hospital, today the group has grown

exponentially both in India and overseas. Its growth is often said to be

synonymous with India emerging as a major hub in global healthcare. Apollo Hospitals has JCI

accreditations for 7 of its hospitals, the largest by any hospital group in the region.

True to its founding principles, the group has made quality healthcare accessible to the

people of India, and even overseas. It has become an institution of trust, and a beacon of hope to

so many searching for a cure for their ailments.



Corporate Social Responsibility Achievements:

Apollo Dil Ki Daud, Indraprastha Apollo Hospitals, New Delhi

"Apollo Dil Ki Daud", a mini marathon organized by Indraprastha Apollo Hospitals in

support with the Billion Hearts Beating Campaign, in an endeavour to spread awareness about

prevention of heart disease and to emphasize the importance of a healthy lifestyle. 1000 people

participated in the mini marathon supported by the Billion Hearts Beating Campaign.

"SAVE" India Campaign, Indraprastha Apollo Hospitals, New Delhi

Apollo launched its “SAVE” India Campaign. This is a comprehensive vascular

screening programme to increase awareness about the ailments of stroke, aneurysm and vascular

disease, evaluation to prevent disability or death due to stroke, aneurysm rupture or leg ulcers or

gangrene.

Adoption of the Bhat Village, Gujarat, Apollo Hospitals Ahmedabad

Apollo Hospitals, Ahmedabad adopted the Bhat Village with a population of

approximately 10,000, in Gujarat, and organized Health Cleanliness Programs and Health

Awareness drive, all of which were extremely well received.

Apollo Life Saver Training Program, Apollo Hospitals Bangalore

Apollo Hospitals Bangalore conducted the Apollo Life Saver Community Training

Program with an objective to train one person in the family on Basic Life Support.

"Plant a tree this monsoon" Campaign, Indraprastha Apollo Hospitals, New Delhi

In an endeavour to spread awareness about eco-friendly environment and to

emphasize the importance of clean and green surroundings, on the occasion of the 15th

Anniversary, Indraprastha Apollo Hospitals, New Delhi in support with the Green Leap Delhi

Campaign planted 500 plants / saplings at the hospital on 27th July 2011 with Senior Team of the

Apollo Hospital Management.



Section 4: CSR Issues Specific to healthcare Service Industry

This section is presented in the forms of questions. These questions are meant to highlight some of the key issues relevant to CSR in this particular area. By going through these questions with your management and leadership, you should be able to see where there is a baseline CSR available in the hospital functions. These questions hence serve as a CSR self-assessment for any hospital contemplating CSR and will be the basis of the gap-analysis and action plan at the implementation stage.

1. Corporate Governance & Leadership

ffective CSR requires the existence of solid corporate framework with clear

understanding and commitment of the leadership to implement CSR practices.

Moreover, effective leadership and governance are required of establishing,

maintaining and monitoring the quality of the service delivered.

Key Questions

1. Does the hospital have an organizational hierarchy with identified job description?

2. Does the organization have a strategic plan with AMART objectives and goals? And How CSR

issues are addressed in the strategy?

3. Is there a clear understanding of the CSR impact of the hospital’s operations?

4. How is CSR managed and who is in charge? And how CSR is communicated at the higher

level of the organization?

5. How issues like anti-corruption, grievance and conflict of interest are addressed at the

higher level of the organization?

6. Is there a mechanism in place to ensure the evaluation of the governance? And were issues

like environmental initiatives and community activities are considered when evaluating the

board of governance?

7. Does the governance allocate budget for CSR practices and how it is managed?

8. How issues like philanthropic investments and community activities are managed at the

corporate level? And how those activities are selected?



9. Does the governance body and leaders participate collaboratively in implementing

responsible practice within the organization?



2. Human Resources and Development Programs:

ood hospital service depends on good quality and competent medical and non-

medical staff. Hospitals are service providers and no service company can achieve its

full potential without good Human Resource. The hospital hiring and evaluation

mechanism should include detailed background and reference checks along with a

fully transparent process. For a hospital to continuously be in touch with the latest healthcare

research and trends, it is vital to have a robust training and development program in place for all

employees.

Key Questions:

1. Is the process of the hiring cycle from the time of job advertisement till having the

employee on board is fully transparent?

2. Is there a dedicated person who systematically checks references, verify licenses, degrees,

and internships, explore employment history, and otherwise ensure that those who work at

the hospital are fully qualified to do their tasks?

3. If a clinical or nonclinical worker begins behaving in a negligent, improper, or inept manner,

are there adequate procedures to identify and remedy the problem and to ensure that

patients do not suffer?

4. Who creates and implements the process for credentials review, supervision, and so on?

5. Are there any programs in place to continually develop the knowledge of the medical and

administrative staff? How often are these programs conducted?

6. Are there any programs to ensure continued employability (retention) of the staff?

7. How does the hospital handle staff complaints and grievances?

8. Do the staffs received proper training and orientation on human rights issues and are they

educated on CSR issues?

9. Does the employee get the necessary information about his/her career path from the

moment he joins the hospital?



10. Is there any system in place that allows the employees to express freely their ideas and

suggestions and declare their inputs about particular concerns?

11. Do the staff work reasonable hour shifts and there is no forced over times?

12. Does the organization oversight the living conditions ensure that a well-balanced leisure-

work is maintained for the staff?

13. Is there a mechanism for whistle blowing?

14. The staff is given all perquisites and rights as per the local labor laws?

15. What is the system for monitoring recruiting agency regarding human rights?



3. Service Delivery and Patient Care

he primary responsibility of a hospital is to ensure quality of care to its patients. This is

one aspect that makes or breaks a hospital. This responsibility includes administrative

as well as medical and moral aspects, with duties owed to correct diagnosis, due

diligence in care provision and empathy towards the patient. The hospital's primary

obligations are to develop norms to which the hospital and staff must conform, to serve patients by

providing the best care possible, to allocate resources so as most effectively to respond to the

needs of the community, and to create policies which allow staff members to refrain from

performing acts which they consider immoral.

From the moment a patient enters the hospital to the time he leaves, the hospital has the

overall responsibility for his physical and emotional health. A good hospital would ensure that this

principal is kept sight of throughout the service delivery cycle:

Key Questions:

1. Does the hospital have a local or international certification that ensures good quality care?

2. Is the service delivery cycle including all the controls at different stages (identification,

diagnosis, referral, admission etc.) fully documented and accessible to all staff?

Patient identification

Registration

diagnosis

patient admission

patient care and provision of treatment

discharge

post care instructions

follow- up visits

3. Is all Staff trained on the service delivery cycle and its controls?

4. How often the service delivery cycle is evaluated for improvement and based on feedback?

5. How often the service delivery cycle evaluated for health and safety impacts?

6. Is there a process to track report and investigate any non-compliance incidents?



7. Have there been any concerns raised by general public about the service delivery of the

hospital and how does the hospital address these concerns?

8. Does the hospital have a complete, documented plan for post care and how is it

communicated to the patients?

9. Does the hospital have a system for quality improvement activities and a dedicated

department to deliver the same?

10. Does the hospital have any processes / measures that are used to monitor the quality of

care?

11. Are there documented Policies and/or procedures to address the identification, location,

labeling, and storage of medications and equipment?



4. Environment, Health & Safety (EHS)

rotecting the health and safety of staff, patients and members of the community who

may be affected by your activities is an essential responsibility of a good hospital.

Similarly, the environmental impacts of the organization’s activities are now being

considered a primary responsibility of any company. Failure to include health, safety and

environment as a key business imperative can prove detrimental to the overall sustainability of the

hospital.

Key Questions:

1. Does the hospital have a board approved policy for EHS? The policy should set out the

board’s own role and that of individual board members in leading EHS direction of the

hospital.

2. How often is the EHS policy of the hospital revised to include elements or risks?

3. Is there a committee or a senior management person responsible for HSE implementation in

the hospital?

4. What has the management done to ensure that the hospital, at all levels including the

board, receives competent health and safety advice?

5. How is the management ensuring that all staff – including the board – are sufficiently

trained and competent in their health and safety responsibilities?

6. What systems are in place to ensure your organization’s risks are assessed, and that sensible

control measures are established and maintained?

7. Have the management set targets to improve health and safety and do you benchmark your

performance against others in your sector or beyond?

8. Does the hospital; has a disaster plan and plan of action that shows preparedness in case of

disaster?

9. Does the EHS department conduct general inspections of facilities, life safety surveys, and

compliance surveys for compliance with applicable regulations and standards?

10. Is there a comprehensive fire safety plan including complete monthly inspections of all fire

extinguishers, annual maintenance of all extinguishers and hydrostatic testing of extinguishers

per code and regular fire drills.



11. Is there a comprehensive waste disposal system that coordinates and guides Hospital staff on

proper collection and disposal of all types of hospital wastes, including sampling and

identification of unknown waste substances?

12. Is there a reporting system to maintain, manifest and track waste disposal from Hospital

operations?

13. Are there any plans for waste minimization? This may include training and assisting in waste

reclamation, conservation of raw materials, and less hazardous product substitution. Identify

strategies to recycle, reduce and reuse Hospital resources.

14. Does the hospital have a comprehensive plan for preventable occupational health and safety

issues and conducts employee occupational training on topics such as Hazard Communication,

respiratory protection, hearing conservation, and other specialized occupational health and

safety topics?

15. Does the hospital monitor the GHG emissions and other carbon footprint and is there any

action plan to reduce those emissions?

16. Does the hospital conduct indoor air quality surveys, including sampling, identifying and

developing appropriate remedial actions to eliminate potential sources of airborne

contaminants?

17. Does the hospital have a Chemical Hygiene Plan and Laboratory Safety Plan, including lab

inspections and chemical fume hood inspections?

18. Does the hospital have an EHS plan for third party contractors working on-site?

19. Does the hospital have a clearly defined and well communicated plan for prevention and

control of infection?

20. Does the hospital have a plan to reduce its resource usage including CO2 emissions and use of

ozone depleting substances?



5. Patient Relation Management

or many years, commercial businesses have realized the benefits of deploying CRM

(customer relationship management) systems that help them build long-term customer

relationships. Similar concept can be used to establish patient relationship management

systems in hospitals. With such a system in place, care givers can establish ongoing

relationships with their patients, enabling them to increase focus on prevention, and giving them a

new tool to help improve patient well-being and satisfaction.

Key Questions:

1. Does the hospital have a comprehensive complaint management system and is it clearly

communicated to all patients?

2. Does the hospital have a separate patient relationship management function or dedicated

person?

3. Does the hospital have a clearly defined department or a dedicated person in charge of

patient relation management?

4. Does the hospital have an established and documented process for soliciting patient

feedback? Is there a process to close the feedback loop by engaging patients who are not

satisfied?

5. What is the process of patient disclosure? For example the doctor/ nurse sit with the patient

to explain the diagnosis and the proposed treatment options, justification for admission etc.

6. How does the hospital communicate Patients’ Rights?

7. Is there a process for patient counseling?



6. Procurement and Storage

his is a key function in any hospital and involves many controls that a good hospital

should implement. The purpose of these controls is to ensure that all hospitals supplies

are up to the standards of good quality care and should also be within the budget.

Storage of hospital supplies and medicines is also a key area of interest in CSR.

Key questions

1. Does the hospital supplier selection criterion include responsible business practices?

2. Does the hospital have a pharmacy and therapeutic committee which determines the supply

tender? What is the process of Purchase Order Generation? Who does it and on what basis?

3. What are the quality checks when the supply is received?

4. How does the hospital ensure the suitable storage conditions for the medicines/ supplies?

5. What is the process for disposing off expired or damaged medicines/ supplies?

6. Is there any process for recalled medicines? How does the hospital ensure this information

is communicated to all?

7. Does the hospital have a plan or process to give preference to local businesses?

8. Does the hospital have a plan or process to give preference to environmentally friendly

products?



7. Finance and Accounts

ospital industry is usually heavily regulated and this regulation impacts accounting

and financial reporting in many ways. Most notably, hospitals rely extensively on

third party payers, such as insurance companies for much of their revenues. Hospitals

receive, in addition to patient care revenue, income from ancillary services such as

laboratories, gift shops, and physician office leases. Having stringent controls throughout the

finance and accounts cycle ensure that the financial system is fully transparent and free of any

unethical practices.

Key questions:

1. Does hospital finance and accounts department have adequate internal controls to ensure

there is no financial embezzlement?

2. How often is the billing and revenue cycle of the hospital is analyzed for anti-corruption and

other financial fraud risks?

3. Does the hospital have an internal periodic financial reporting cycle?

4. Does the hospital use any international financial reporting standards to prepare its financial

statements and are these statements audited by external auditors?

5. Does the hospital consider the value generated and distributed on yearly basis?



8. Information Systems and Patient Confidentiality

ospital function involves the use of abundance of information which has to be

collected, managed, reviewed, processed and mined. High quality healthcare service

depends on adequate documentation of every patient’s medical history, diagnostics,

treatment and medical conditions. A clinical decision based on good medical record is

indispensable.

Key Questions:

1. Does the hospital have a comprehensive, fully integrated hospital information system that

covers all functions?

2. Does the hospital information system have adequate controls to ensure data integrity?

3. Is the hospital staff fully trained on the hospital information system?

4. Does the Hospital information system employ verification techniques for access to data and

tracks unauthorized access?

5. Are there adequate controls in the system to ensure that the data cannot be manipulated,

changed and or otherwise released without the relevant authority?

6. What controls are in place at the Hospital information system to ensure patient data

security and confidentiality?

7. Does the hospital have a process to allow access to medical records by the patient or the

family?

8. Does the hospital information system employ unique medical records and/or identification

numbers to ensure data integrity?



9. Risk Management and Patient Safety:

atient safety is key concern for health care professionals around the world. During the

last decade, many studies have been conducted to assess the prevalence, severity and

causes of a large variety of different types of adverse events in hospitals, as well as the

effectiveness of various approaches to enhance safety. Hospital risk management and

patient safety program ensures that the risks are identified and mitigated without any adverse

effects to the patient:

Key Questions

1. Has the hospital identified the key risks facing the operations and high risk services and/ or

departments?

2. Does the hospital have a comprehensive organization wide risk management program?

3. Has the hospital developed a risk register that covers all aspects of hospital operations and

how often is it reviewed for improvements and/ or changes?

4. Does the hospital have an organization wide program for anti-corruption? Is the staff

adequately trained on this program?

5. Does the risk management program include at a minimum the following elements:

Identification and management of risk regarding medication errors

Identification and management of risk regarding fall incidents

Identification and management of risk regarding diagnostic errors Identification and

management of risk regarding other adverse elements and events such as hazardous

substances and dangerous goods

Reporting and management of incidents and near misses

Staff immunization

Vulnerability tests and a Disaster Recovery Plan



10. Community Investment ospitals working in a certain community owe it to the communities to contribute

towards enhancing their lives. Good hospitals normally have community relations

departments which handle these activities. Even if there are no community

relations/CSR departments, it is important to contribute in whatever way a hospital

can toward enhancing the quality of life for the communities.

Key Questions

1. Does the hospital have a plan or program to encourage local hiring?

2. Does the hospital offer any pro bon services to the community?

3. Does the hospital invest in the community by way of health and wellness education, free

medical camps, awareness and diagnostic session for manageable diseases etc.?

4. Does the hospital have a plan and/ or department to address community concerns?

5. How often does the hospital engage key community representatives in order to seek their

opinion?

6. Does the hospital have a process to measure the impact and effectiveness of its community

investment programs?

7. Does the hospital have conduct community awareness regarding CSR issues?

8. How is Social Development addressed by the hospital?



Part Two: CSR Implementation

Part Two discusses the mechanism of implementing CSR, the essential requirements that

have to be incorporated in the hospital infrastructure before staring CSR, and the model for

developing and communicating a CSR strategy. The main takeaways from part two are:

1. Gives the readers a list of pre-requisites or essentials that have to be in place before any

steps are taken to formalize and strategize CSR.

2. Empowers the readers with knowledge and tools to develop their own CSR strategy.

3. Highlights some of the ways in which readers can develop Measurement metrics for their

CSR activities.

4. Describes the communication tools that can be used in hospital setting

5. Gives the readers a horde of further readings and CSR resources.



Section One: CSR Prerequisites

This section describes those essential requirements which are imperative for the success of any CSR program in a hospital. These prerequisites have to be in place before a hospital considers formalizing its CSR programs. The section also gives you a check list to ensure all essential elements are in place.

The essential prerequisites for implementing successful CSR program are identified in the table

below.

Essential Requirements for a Successful CSR in the Healthcare Service Sector

1. Commitment of the Leadership

2. Existence of cultural of transparency

3. Presence of an organization strategy with clear CSR objectives and goals

4. Presence of CSR department or CSR committee with clear responsibilities

5. Presence of Solid Organizational Structure Hierarchy and committees reporting framework

6. Clear understanding of community’s culture

7. Proper identification and mapping of the stakeholders with focus on the sector’s interest that they represent

8. Presence of an active Total Quality Management Department

9. Well-established data management process

10. Proper differentiation between the Public Relations activities and that of CSR

1. Leadership Commitment

orporate Social Responsibility (CSR) is a long-term approach to business that addresses

the needs of all stakeholders. It is considered an opportunity to create honest, and true

stories that both business and community can be proud of. CSR must be sustainable -

remaining a fundamental part of the business regardless of changing fortunes.



By applying successful CSR initiatives the leaders take organizations beyond compliance with

legislation and lead them to honour ethical values and respect people, communities and the

environment.

In general, leaders with wisdom vision are the ones who consider the long-term outcome of

the triple-bottom-lines (People, Planet, and Profit) for their organizations. Consequently,

sustainability takes place only when there is an active leader/manager within the company who

adopts this approach. Several researchers emphasized the role of the leader in transforming the

company into a sustainable, socially responsible organization. His/her sustainability work starts by

carefully examining all the factors that determine the sustainability performance of his/her

company and its suppliers.

The most critical success factor for sustainability is true leadership within the organization.

Leadership ensures the commitment of management and drive for the implementation of

responsible practices. This kind of leadership should be flexible to change and able engage in

dialogue with different members of society.

This kind of leadership is called Transformational leadership. It is considered the most

outward oriented type of leadership and directed at formulating and implementing a new

organizational vision that is embedded in a broader vision of society and the active involvement of

external stakeholders. The key to real transformational leadership lies in the effectiveness of their

actions.

Yes No

Does Your leader understand the CSR concept?

Is your leader willing to implement CSR?

Does your leader focus on short or long-term profit?

Is your leader a visionary leader?

Is your leader engaged or willing to engage in the future with external community’s committees, groups..etc.?



2. Existence of Culture of Transparency

s mentioned previously, CSR is an endless learning journey that requires sharing

knowledge and information between organizations, companies, public and

governmental sectors and most importantly between the employees themselves.

Consequently, a culture of transparency is always required for proper

communication between the different sectors and to the hospital’s stakeholders. Building a

culture of transparency is not an easy task and requires commitment of the leader and directors

to foster such culture. Encouraging employees to discuss concerns and reports on mistakes is

always considered an opportunity for improvement, while reporting to the public will help the

hospital to gain the trust of the community it serves.

3. Existence of CSR Governance

SR cannot be initiated, executed or managed unless a CSR governance system

exists. It is the responsibility of the highest Governance Body to initiate and

allocate the roles within the CSR governance system. The roles typically include:

To identify key CSR issues that may affect the business operations

To evaluate CSR practices in light of changes in public perception, industry best practices

and evolving priorities and needs in the communities;

To conduct stakeholders mapping and review their engagements

To ensure that CSR strategic goals are achieved by proper planning and monitoring CSR

practice

Yes No

Does your hospital encourage you to report on mistakes?

Does your hospital have an open-door policy or any mechanism that allow you to raise concerns to the higher management?

Does your hospital consider mistakes an opportunity for improvement?

Does your hospital share its performance in a sincere and transparent ways with its stakeholders?



To work effectively and efficiently in increasing awareness of CSR both internally and

externally

To recommend new CSR initiatives relevant to the four pillars of Sustainability to the and

monitor their implementations once approved

Moreover, CSR structure should be totally separated from the PR management department. BY

doing so, you ensure that your CSR activities are really directed to the benefits of the

community and not just an

Yes No

Does your hospital have a department or team responsible for CSR?

Does the CSR authority have an executive power?

Does the CSR department is part of any Public Relations activities?

Does the CSR department/team report to the high authority of the hospital?

Does the CSR department/team have a process in place for stakeholder engagement?

4. Existence of Solid Organizational Hierarchy and committees reporting

framework

n organization is a collection of people, systems and procedures which are put

together to perform service. In order to better manage the huge resource

base and assets, organizations need to be in some sort of organizational

structure so that it can perform through a clear and defined reporting

mechanism that ensures and get the productive use of organization's resources.

Clear defined reporting structure based on organizational framework is crucial for successful

implementation of CSR. CSR initiatives require the presence of this mechanism to ensure proper

communication in both vertical and horizontal levels of the hospital.



Yes No

Does your hospital have a defined organizational hierarchy?

Does the organizational hierarchy facilitate the communication both horizontal and vertical level?

Does the responsibilities of the identified departments and directors are clear?

5. Existence of Quality Management Department and Certifications

uality Management Department is imperative to the success of a hospital

and is essential to build patient trust in the hospital. The rationale is to

ensure the quality of healthcare service provided and to monitor the

performance of the different departments as well as to continuously

conduct performance improvement projects that advance the service

delivered to the patients. Other roles include setting and benchmarking KPI

and to act as hub for the flow of information as well as the reporting structure of the different

committees.

Quality Department is mandatory for implementing CSR in any hospitals. CSR will stands on

the solid base of the quality framework in the hospital. Policies, quality programs, safety plan, risk

management and some relevant indicators are essential pre-requisites and will definitely facilitate

the process of implementing and reporting on CSR indictors. Moreover, it will help to assess the

performance on a yearly basis and will support the benchmarking practice.

Yes No

Does your hospital have a Total quality Management Department?

Does the hospital have policies and framework for risk management?

Is there any process in place that allows collecting, analyzing and benchmarking indicators?

Does the hospital have plan to ensure the safety and quality of service provided?



Section 2: How to Strategize CSR

Implementing CSR in any hospital requires clear CSR strategic directions with clear and defined objectives and goals that are SMART and have key performance indicators that allow monitoring, trending and benchmarking. Formulating a CSR strategy is a challenge process. This section will highlight the methodology that should be followed when formulating CSR strategy.

ne of the challenges that hospitals need to overcome when developing a

business strategy that incorporates the principles of sustainability is to take

into account all the factors relevant for their short- and long-term future.

The adoption of a sustainable approach requires a much longer timeframe

and perspective than the short- to medium-term planning horizon most business leaders use.

Successful CSR requires a hoard of important elements including clearly articulated business

drivers, priority issues and the objectives to be achieved.

Step 1: Identify CSR Business Drivers

Business drivers for CSR are the benefits that the hospital hopes to achieve through

implementing CSR. An internal analysis of your company’s strengths, weaknesses, opportunities

and threats greatly assists in identifying principal CSR business drivers. Business drivers for CSR are

also determined through conducting interviews with the owners/ top management of the hospital.

Use the benefits given in section 1 of part one of this guide.

After you have identified a list of drivers, rank them in order of importance so that the top priority

ones can be addressed quickly.

Step 2: Identify CSR issues through Stakeholder Engagement

In this step, you need to determine the CSR issues facing the hospital and its stakeholders in

all four dimensions; workplace, community, marketplace and environment. This process is aided by

a robust stakeholder engagement process. For details on the mechanics of stakeholder

identification, prioritization and consultation please see section 2 in part one of this guide. Typical

issues in each pillar are:



Workplace:

1. Health and Safety

2. Employee Compensation

3. Employee development

4. Responsible HR practices

Marketplace

1. Transparency

2. Ethical conduct

3. Labelling and product safety

Community:

1. Job creation

2. Health and safety

3. Community investments

Environment:

1. Resource conservation

2. Biodiversity

3. Waste management

4. Carbon management

Step 3: Prioritise your CSR issues based on your business drivers

Compare the CSR issues identified with the business drivers in step1 and ask the following

questions:

1. To what extent will addressing this issue assist me in achieving my principal business

objective?

2. To what extent is addressing this issue my responsibility as a hospital?

3. To what extent is this issue real and addressable through private sector? i.e. is it an issue

typically falling in the public sector domain.

The CSR issues that give a positive answer for all three questions are your top priority CSR issues.



Step 4: Develop CSR Goals and Objectives to address priority CSR Issues

Once the CSR issues are identified, the next step is to set goals and objectives that will help

achieve the priority CSR issues. One way of doing that is to use Locke's Goal Setting Theory, the

other is to use Balanced Score Card Model. The actual model however is not important. What is

important is to set goals that are reflective of the issues identified in the previous step sand will

help your hospital achieve the drivers.

Step 5: Develop CSR programs and Policies to achieve objectives

For each of the goals and objectives set above, you need to either develop a CSR program or

a CSR policy that will help achieve them. Ask these questions for each element:

1. Do you have a written policy that supports achieving this goals?

2. Do you have an existing practice that supports this goal but is not yet formalized?

3. Do you have a CSR programme/ initiative that supports achievement of this goal?

For each CSR program it is important to develop a roadmap that clarifies:

a. Timeline, cost and stages

b. Objectives, targets and criticalsuccess factors at each stage

c. Person/ department responsible

d. Allocated resources

4. Any required training for implementers

5. Any possible llinkages to existing programs

6. Any possible ways to roll-over and magnify the program in future

7. Possible external partners such as Ministry of Health, Non-governmental organisations

(NGOs), media etc.



Section 3: Communicating your CSR effectively

CSR program should be communicated to all stakeholders. This requires a communication model that ensures the success of your dialogue session. This section describes the communication mechanism that can be applied in any hospital that adopts CSR practice.

he role of Corporate Social Responsibility (CSR) in management is becoming

more central than ever before, as is evident from the fact that so far more than

1500 companies worldwide have published their CSR reports. One of the key

aspects of good CSR practices involves effective and transparent

communication channels with internal and external stakeholders. This process is a key to identify

issues of concerns that the company should address and after these have been addressed, to

inform about the ensuing performance. Consequently, there is an increased demand for

establishing an appropriate communication strategy that helps identify proper communication

tools and confirms that the right information is collected and disseminated. Studies have shown

that despite this growing importance of CSR communication, organizations still have to learn how

to communicate their CSR. The purpose of this article is to present some key areas that help create

a workable model for communicating CSR inside and outside an organization.

The Challenges

Perhaps the biggest challenge that companies face in communicating CSR is to be able to

structure the message about the significance of CSR for the company. Externally, the other

challenge is justifying, explaining and convincing different stakeholders and interest groups why

certain CSR issues are logical and necessary to be undertaken by the company.

The source of information is another key challenge. What and how the stakeholders get their

information remain fundamental issues that need to be addressed. TV, internet, CSR reports,

magazines and newspapers are most often the source of information. Furthermore, do the

reporters or columnists have the necessary CSR background to comment on ethical practices? The

answer remains unknown!



The Timing

It is important to classify the timing of the dialogue into three phases; beginning, midpoint

and culmination. The communication techniques, channels and content at all three stages will vary

significantly. At the beginning, two essential objectives should be achieved. Firstly, to educate the

stakeholder about CSR and secondly, to identify the CSR issues that should be addressed. The

midpoint communication revolves around updating the stakeholders on the progress of the CSR

process, discussing the status of the performance indicators, and to address any challenges and

formulating action plans if necessary. At the culmination, the communication is about celebrating

the achievements and owning up to any shortcomings.

The Audience

The company should realize that the type of audience dictates the direction the

communication model takes. The audience/ stakeholder for every organization are unique and

represent their own unique issues and concerns. A mining company for example will have to worry

about the communities being uprooted as a result of the discovery whereas a hospital has to worry

about the patients and the communities surrounding the hospital. The trick is to have a hand on

pulse of the stakeholder through an effective engagement mechanism and to feed the findings of

the engagement into the structure of the CSR communication model.

The Content

In general, the stakeholders often determine the content of the CSR message. Investors and

owners are more interested about the cost, revenues, and the financial implication of adopting CSR

principle, thus their messages should contains more statistical information. Regulators and policy

makers need to be convinced about the necessity of creating new policies and regulations, and

regarding industry wide CSR practices. Consequently, their message should contain the benefits

that community will gain by applying the ethical principles and how the CSR contributes to the

welfare of the community at large.

CSR community messaging serves two main purposes; the contribution the company is

making to community wellbeing and the importance of such practices. The later ensures that the

company celebrates its CSR victories and former is meant to tap onto community power to



encourage companies to do better. Similarly, social organizations need to be aware about the

difference between philanthropic activities and CSR and their messaging will reflect that.

The CSR messaging to internal stakeholders also needs to be customized at each

management level. While at the executive level, the message should be more strategic in nature;

that for mid management level should be more about the implementation aspect of CSR. CSR

message at the lower management level should be emphasize the benefits of adopting CSR practice

in their daily works and how it can positively affect their work environment and their future.

The Channels

A successful and holistic CSR communication plan should make use of as many channels as

possible to enhance the reach of its message. Whether it is through representation on external

committees or through a carefully planned social media presence, utilization of multiple channels

to position your CSR message is paramount for the success of your CSR program. A page on your

corporate website dedicated to your concept of CSR goes a long way in cultivating the knowledge

and understanding of your CSR stance among stakeholders. The language should be culturally

sensitive and the content a representation of the Company’s unique brand of CSR. One on One

meeting with key stakeholders is also a great way not only to cultivate trust but also to get your

message across. This may seem tedious but planned in a careful and periodic manner takes much

less effort and gives much better results than dinner parties with 200 people. Lastly, a CSR report

that tracks the progress of the company on key CSR issues as well as on operational aspects that

have a social dimension. A well-presented CSR report is considered the ultimate evidence of a

company’s commitment to CSR and of its pledge to transparent and inclusive communication.



Appendix 1: Sample KPI related to CSR aspect

CSR Aspect Sample Key Performance Indicators (KPI)

Workplace Responsibility

Number of injuries related to infectious agent exposure

Programs and initiatives to reduce hospital specific occupational hazard (Hazard of infection, allergy, etc)

Number of employees going through regular performance reviews

Result of Staff Satisfaction Survey

Community Responsibility

Initiatives and programs contributing to public health (disability programs, promotion of health habit, etc)

Initiatives and programs to support research and the generation of knowledge

Environmental Performance

Amount of medical waste generated

Amount of hazardous waste generated

Amount of infectious waste generated

Initiatives and programs to reduce/eliminate the use of hazardous substance (Mercury, PVC/DEHP, etc)

Initiatives and programs for the recycling of Single Use Devices SUDs (Sharps, Syringes, etc)

Market Responsibility

Initiatives and programs to facilitate access to service

Patient satisfaction (programs and results)

Accreditation of service/ accreditation of healthcare professionals

Level of transparency through number of medical error cases reported and made public

Number of suppliers screened for responsible business practices.



Appendix 2: CSR Resources

Name of Organization Purpose More Information

International Institute of Sustainable Development

Public Policy Research Institute aimed at sustainable development

http://www.iisd.org/about/

World Business Council for Sustainable Development

Guidance for companies to contribute to sustainable development

http://www.wbcsd.org/about.aspx

Social Accountability International (SAI)

Standards for decent working conditions http://www.sa-intl.org/

Organisation for Economic Co-operation and Development (OECD)

Promoting policies that help improve lives http://www.oecd.org/home/0,2987,en_2649_201185_1_1_1_1_1,00.html

GreenBiz News and insights related to CSR and Sustainability

http://www.greenbiz.com

Fair Labour Association (FLA)

Dedicated to improving working conditions

http://www.fairlabor.org/fla/

Business for Social Responsibility

Guidance on CSR related areas http://www.bsr.org/

Harvard Kennedy CSR Initiative

Research and Guidance on CSR areas. http://www.hks.harvard.edu/m-rcbg/CSRI/





http://www.sa-intl.org/

http://www.sa-intl.org/

http://www.oecd.org/home/0,2987,en_2649_201185_1_1_1_1_1,00.html






http://www.bsr.org/

http://www.hks.harvard.edu/m-rcbg/CSRI/

http://www.hks.harvard.edu/m-rcbg/CSRI/



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About The Authors

Dr. Sherif H. Tehemar is an oral and maxillofacial consultant and Director of the

Dental Department at Dr. Soliman Fakeeh Hospital (DSFH), Jeddah, KSA and

research fellow and adjunct in the Oral Biology & Maxillofacial Surgery

Department, School of Dentistry, Medical College of Georgia, USA. Since 2007,

he is the chairperson of the CSR committee and member of several committees

at DSFH. Dr. Tehemar has presented numerous lectures and published several

articles related to CSR and Total Quality Management nationally and internationally. He has five

years of experience in the CSR field. Dr. Tehemar was in charge as a team leader for CSR to

introduce the sustainable practice within DSFH. His responsibilities include formulating.

Implementing and monitoring a CSR strategy and related policy and the publication of the first CSR

report for DSFH based on the GRI guidelines in 2009. Under his leadership, DSFH was the first to

publish CSR report in the healthcare sector in the MENA region in 2008 and the first to publish an

externally verified report in 2010. Based on this accomplishment, DSFH won the third prize of SARCI

for two consecutive years. You can contact him at [email protected] or visit his website

www.drtehemar.com

Bushra Azhar is a Corporate Social Responsibility (CSR) and Sustainability

Consultant based in the Middle East with extensive experience in mining,

healthcare, utilities and family owned business conglomerates. A former

corporate VP and academic, she started her career with one of the big four

firms and has 13 years of experience under her belt with 5 years in CSR related

roles. She is the author of a research study examining the growth of CSR in

Saudi Arabia and is also responsible for developing half of the CSR reports in the

Kingdom. She works with local companies in helping their businesses become more sustainable and

their practices more ethical. She is the founder of Good Business Sense (www.gbsense.com), a blog

dedicated to spreading simple, practical CSR knowledge and the idea that good CSR is simply Good

Business Sense. You can contact her on [email protected] or follow on Twitter @bushraazhar.



For more information, please contact Dr. Sherif Tehemar, BDS/DDS, MSc., PhD, FACOMS, CSSGB

Tel. +96626655000 ext. 7100. Email: [email protected]

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