Bumrungrad Hospital - Imperial Capital Limited

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Bumrungrad Hospital

Bangkok, Thailand

A Dose of Sustainability for a

Clean and Safe Healthcare Facility

Barbara Shaw

[email protected]

Chief Investment Officer

Imperial Capital Ltd.

mailto:[email protected]

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Table of Content

Introduction……..………………………..…………..………………………..…………… 3

Organization and Its Context………..……….…….…………………,,………………………… 5

Stakeholder Engagement ……………..…..……….………………………….……………….. 6

Organizational Governance …….……………………………………………………………….. 7

Risk Management and Sustainability …………………………………………………………. 8

Managing Sustainability Performance…………………………………………………………10

Activities, Processes, Monitoring, Measurement + Review……..……………….….………… 12

Reporting Sustainability ……..……….…………………….………………………………... 14

Continual Improvement and Conclusions……...………..……………………………………..... 16

References ……..………....……..…………………………………….………………………. 18

Appendices………..……………………..………………………………………………………. 25

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Introduction

Bumrungrad International Hospital (BH) is an internationally accredited, multi-specialty hospital

located in Bangkok, Thailand. Founded in 1980. Bumrungrad is a Thai word that means ‘care for

people.’ The hospital offers state-of-the-art diagnostic, therapeutic and intensive care facilities in

a one-stop medical center and its medical professionals are some of the most reputable in the

industry, many of whom have been board-certified in the US and UK. Today, it is the largest

private hospital in Southeast Asia, with 556 beds and over 30 specialty centers, treating over 1.1

million patients every year. BH seems well positioned to continue to ride on this growth trajectory,

underpinned by Thailand’s growing popularity as a medical tourism destination, increased

spending on healthcare per capita, and technological and medical advancement that enable

treatment of more medical illnesses.

Bangkok can be seen as the heart of Thailand. It is the cultural, educational, political and economic

center of Thailand. (United Nation, 2005) Bangkok is well known for its canals and rivers that

run in and around the city which led to its famous reference as “Venice of the East.” These

qualities, together with the low cost and high quality medical treatment provided by hospitals and

private clinics, have made Bangkok one of the top medical tourism destinations in the world.

(Cornell, 2012)

The growth and development of medical tourism and the healthcare industry have coincided with

the city’s rapid industrial and population expansion in the last three decades, and all have clearly

outpaced its environmental management, resulting in sharply increased air pollution, untreated

domestic sewage, industrial wastewater and solid hazardous waste in Thailand. (World Bank,

2013) The development of the healthcare industry and its impact on the community is particularly

acute in Bangkok as it houses a disproportionate number of doctors and medical facilities within

the country; being home to almost 40% of the country’s doctors, in its 120 public and private

hospitals, and over 4000 registered clinic, while the size of Bangkok city is only 1,568 sq.

kilometers, a fraction of the entire country’s 500,000 sq. kilometers. (BangkokInsights, 2007)

The healthcare industry often resonates with the notion of “first, do not harm.” However, this

traditional perception of the role of a hospital has been put into question globally as there are

increasing concerns that today’s healthcare system inadvertently contributes to environmental

degradation, and subjects its staff, patients and the larger community to health problem due to the

manner in which hospitals are managed. While data is not available for the Asia region, a report

in the United States estimates the US healthcare industry produces as much as 8% of the country’s

total carbon emission. (The University of Chicago Medicine, 2014). Many hospital activities may

actually be bringing harm to its people and community. Many healthcare sector NGOs, including

the HHI (Healthier Hospitals Initiative) and HCWH (Healthcare Without Harm) cautioned that the

majority of current hospital practices are basically unsustainable, as they are dependent on a

constant stream of sick people to maintain it while the majority of illness is preventable.

(Resilience, 2012)

BH seems to be aware of the necessary future path of the healthcare industry. BH CEO, Dennis

Brown, noted in its last annual report that, “in the future, people will not only seek advanced

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treatment to cure disease, but also to prevent it.” (Bumrungrad, 2012 p.5) “Prevent” was the only

italicized word in the entire CEO Message. This is an ideal time for BH to engage

SustainabilityChamp (SC) to provide a guidance on how to build a sustainable healthcare practice.

To secure business sustainability, BH needs to safeguard not only the health of patients, but also

hospital workers and the whole Bangkok community. It seems to be a global phenomenon where

nurses record the highest risk for work-related asthma of any occupation, as much as 50% higher,

particularly for those front line hospital staff who have high exposure levels to disinfectants,

cleansers and latex. (American Society, 2008) BH is already battling with shortage of nurses for

the hospital, it is vital to take measures and minimize such threats to its workforce and create a

clean and safe work environment. (Bumrungrad, 2012 p.69)

In pursuit of the vision of delivering preventive measures, it is necessary for BH to, first and

foremost, provide a clean and safe hospital environment to its workforce, patients, and even the

rest of the community who may be affected by how the hospital is being managed every day. For

instance, when the hospital carries out renovation work, construction workers health safety should

also be taken in to consideration in the construction planning phase; or in the case of waste

management, how the infectious and hazardous waste stream are handled will directly affect the

health of all the stakeholders of the community along the value chain, including even pedestrians

who may be passing by waste landfills. Medical waste from medical care centers that is not

disposed properly may lead to greater threat than the original diseases themselves (Department of

Health, 1990) According to the Pollution Control Department of Thailand, there are thousands of

reported cases of illness caused by hazardous substance exposure in Thailand. (PCD, 2012)

SC’s mission is to introduce a sustainability management system, as a means to undertake a risk

management program to address the threats that may hinder BH ability to meet the objective of a

clean and safe hospital, while addressing the three responsibilities of sustainability, namely

environmental stewardship, societal well-being, and economic prosperity of the community. The

first step is to identify the specific set of context that is unique to its setting and relevant to BH’s

objective. SC will then recommend a stakeholder engagement process to identify stakeholders

with relevant interests in BH operating environment. The “voice of the customer” is a critical

element to help ensure stakeholders interests are addressed so BH will gain the social license to

operate in Bangkok.

It is necessary to revisit BH’s existing organizational governance system, whether it is a formal or

informal one, and update it to incorporate sustainability best practices in the company’s strategic

plan so that it will become a companywide operating procedure to ensure that sustainability is what

every member and staff does at BH everyday rather than being pursued as independent initiatives.

Leadership has a pivotal role in defining governance system and prescribing the core values of the

hospital in its drive for a clean and healthy hospital environment. Finally, a measurement system

will be established from the key drivers of performance and results, with the aim of prescribing an

iterative process that enables BH to continue to improve and develop other objectives in similar

fashion so as to realize the hospital’s goal of truly becoming a healthcare institution that care for

its people.

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Organization and its Context

Sustainability cannot be applied in the same manner by every organization. (Pojasek, 2013 p.1)

Every organization has a unique set of context based on its operating environment. BH needs to

address all three sustainability responsibilities based on its context, as determined by the internal

and external factors of BH. (Pojasek, 2013 p.1) The internal and external context that are relevant

to the goal of creating a clean and healthy hospital environment can be derived from BH’s

organizational profile, see table in Appendix 1. Internal context refers to anything in BH’s internal

environment that may influence the way in which the organization manages its internal risks. Our

SWOT based context analysis determines that the key risks and challenges for BH in providing a

clean, healthy and safe hospital environment emerge from the internal environment.

In the past years, BH has been undertaking continuous renovation works around the hospital to

maximize profit. This included the addition of inpatient and ICU rooms in the main hospital

building and the conversion of entire 12th floor to 58 additional bed. (Bumrungrad, 2012) These

activities can generate considerate environmental impact as well as health and safety threats to

staff, patients, visitors and even construction workers around the hospital vicinity.

Waste management is also a key determinant of health and safety at BH, particularly the

hazardous or infectious waste generated and how the waste stream is managed. Not only are

patients and medical staff exposed to the risk of toxic or infectious medical waste and chemical,

but it also extends to the entire community body as many dumping grounds are in public area of

open landfills. Hazardous material and toxic chemical are not only present in the emissions and

disposal of wastes, but also in various cleaning/sterilizing and disinfecting agents, that can have

significant negative effects on workforce health and safety.

Mishandling of above issues can also become a source for Hospital Acquired Infection (HAI),

defined as infectious disease that first appear three days after admission to a hospital, caused by

bacteria, viruses, fungi or parasites. (HealthCareAsia, 2013) HAI often comes from the hospital

environment, contaminated equipment, healthcare workers, or another patient. Infectious diseases

contributed to higher consumption of healthcare services and also generate more waste through the

use of disposables of personal hygiene care. HAI can cause absenteeism and exacerbate the

problem of nurse shortage at BH. (Danchaivijitr, 1993)

External context are factors that are outside of BH’s sphere of influence but should try to address

and mitigate any negative impact. The Bangkok city is situated on a low-lying flat plain on both

sides of the Chao Phraya River, and is susceptible to flooding in spite of various efforts since 1983

to improve the drainage system. (Kastrup, U. 2006) Post-flood hospital must still be able to

provide clean water and an infection free environment; and hospitals should be the last to go down,

not the first, in case of severe flooding. (Apisarnthanarak, 2013) Context is a key building block

of BH’s organizational profile and sustainability efforts as they reveal the sources of uncertainty

that helps to articulate an organization’s objectives by considering the external and external

environment in which the objectives are pursued. Context also helps to determine the influence

and priority of stakeholders, which is our next topic for discussion. (Pojasek, 2013 p.1)

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Stakeholder Engagement and Social License to Operate

A stakeholder is defined as “an individual or group that has an interest in any decision or activity

of an organization.” (ISO, 2010) What sets sustainability apart from business as usual, is the

requirement to engage with external stakeholders to determine their “interest” in the manner with

which the organization operates along with any product or service; sometimes it can simply be the

right to be heard. (Pojasek, 2013 p. 1-2) BH does seem to acknowledge the importance of engaging

external shareholders and claims that it “recognizes its responsibilities towards each stakeholder,

for sustainable mutual benefits.’ (BH, 2013 p.90) Stakeholder engagement is defined as:

“Activity undertaken to create opportunities of dialog between an organization and one or more of its

stakeholders, with the aim of providing an informed basis for the organization’s decisions.” (ISO, 2010)

A stakeholder engagement process helps to ensure that all stakeholders who have interests that are

relevant and significant to sustainability, are effectively engaged. BH has already identified a

number of its important stakeholders, see Appendix 2. (BH, 2013 p. 99) Other necessary inclusion

would be NGOs and government agencies even though they may not be as “friendly” relative to

other stakeholders. (Pojasek, 2013, p.5). It is also beneficial to breakdown the Employees category

by departments in order to engage them in their respective context to help drive a clean hospital

environment. The housekeeping team for instance, play an important and direct role in maintaining

a clean and safe hospital environment, BH can engage them to learn their career expectations and

try to address their interests and strive to continually motivate their performance. (Harvard

Business School, 2010 p. 18) In light of the continuous renovation works, external stakeholders

of designers and construction workers should also be engaged to ensure work and health safety

standards are aligned with pre-renovation efforts. In the area of waste management, the external

waste collection organization(s) should be engaged to better coordinate and manage the waste

management stream. Infection Control Team and Steering Committee specifically for this purpose

should also be set up if not already, to help drive the engagement process. (See Appendix 2)

One of the criteria for performance excellence set by the Baldrige National Quality Award

(MBNQA) is Customer Focus, which addresses an engagement strategy that focuses on listening

to the “voice of the customer” in order to capture meaningful views and information that would

contribute to an organization’s sustainability. We suggest some additional listening methods, in

addition to its existing engagement methods, as detailed in Appendix 2, to help strengthen BH

existing engagement process. Baldrige also mentioned that customers are increasingly turning to

social media sand organizations should also exploit this method of engagement. (Baldrige, 2011)

The social license to operate exists when the activities of an organization has the ongoing approval

within the local community and other stakeholders. (Pojasek, 2013 p.5) Any internal and external

stakeholders that create uncertainty for BH should be engaged effectively in order to secure its

social license to operate. Our proposed active and continuous stakeholder engagement process

ensures that all relevant stakeholders are engaged to enable BH to discover the uncertainties in its

sustainability efforts, and develop appropriate strategies to neutralize or remove the negative

effects, so as to improve the chance of protecting its social license to operate and meetings its

objectives and sustainability responsibilities. Internally, stakeholder engagement effort can be

communicated in the strategy plan, and externally, it can be disseminated through various

communique, including presentations, publications, or on its website and other social media.

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Organizational Governance

Organizational governance is a core function of every organization as it provides the framework

for decision making and serves as a system to implement its decision in pursuit of its objectives.

(Pojasek, 2013b p.1) Objectives are the tactical components used by organizations to reach their

goals. (Pojasek, 2014 p.5) Objectives should be established in a responsible manner and reflect the

seven principles of Sustainability as provided by ISO 26000 (2010). See Appendix 3.

In accordance with these principles, we have established the objective of creating a clean and safe

hospital environment for the purpose of strategic planning. (Pojasek, 2013a p.4) A number of

international frameworks describe strategic planning broadly as a process of strategy development,

implementation and continuous monitoring or update. (EFQM, 2010) (NIST, 2011) (SAI Global,

2007). In layman terms, strategic planning starts with examining the present, envisioning the future,

choosing how to get there, and making it happen. (Malcolm Baldrige, 2007) Characterizing the

organization and its context provides the initial information that is needed for strategic planning.

(Pojasek, 2013c p.3) Through the use of a strategic planning framework, leadership and

organizational governance are means of developing and using BH’s unique set of context and

stakeholder engagement to drive sustainability results over the long term. One of the benefits of

hospital good governance practices is to facilitate the successful implementation of important

strategies. (Ruparel, 2013) It is the responsibility of leaders to integrate a set of good governance

principles into the governance system, such that the governance system can in turn, be able to

evaluate the accountability and performance of the senior leaders. (NIST, 2011-2012)

At this stage, BH demonstrates limited specified commitment to good governance system, and it

has not made sustainability part of what every person at BH does every day. Under its

Environmental Policy for instance, all that was mentioned is, “we will minimize the environmental

impact of the hospital's operations on the neighboring communities due to such potential hazards

as infectious waste water management, etc.” (Bumrungrad, 2014) The “etc.”, being part of the

environmental declaration, does not provide adequate information or assurance of BH efforts in

environmental stewardship. A good start would be to provide more transparency to it

environmental related footprint, for instance waste management value chain and toxic chemical

release data. In the case of HAI, its direct competitor, Singapore General Hospital, provides up-

to-date HAI data on its website and BH can establish a mechanism to benchmark such degree of

organizational accountability to maintain its competitive advantage. (SGH, 2013) (AS, 2003 p.2)

In addition to its hospital accreditation, the US Joint Commission International (JCI), which

commands a checklist of 350 medical standards, BH can consider adopting the healthcare sector

Baldrige Performance Excellence Program (Baldrige) so as to achieve all round organizational

excellence that is driven by its seven leading performance criteria and based on the unique

organizational profile of BH and. (NIST, 2005) The Baldrige program is compatible with the JCI.

(NIST, 2010) It is also beneficial for BH to put in place a Code of Conduct to set the standards of

behavior, convey the governance policy, and helps to establish a culture of compliance. The Code

of Conduct must also stipulate commitment to the three responsibilities of sustainability. This way,

BH can establish good organizational governance and keep it up to date, with education and training,

to make sustainability part of what everyone does every day at the BH. (Pojasek, 2014)

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Risk Management and Sustainability

Every organization desires to achieve its objectives. All activities of an organization however

involve risk, which is defined as ‘the effect of uncertainty on objectives’. (Pojasek, 2013a p.1)

Negative uncertainties are threats while positive ones are opportunities. Sustainability is often

used to address opportunities while risk assessment process is employed to address threats.

(Pojasek, 2013b p.1) Employing a management system with a proven risk management approach

improves BH’s ability to manage its risks and meet its objectives. BH can benchmark its risk

management efforts to the guidance document, ISO 31000, which includes three core elements,

the principles, framework and process. (Pojasek, 2013a p.2) The eleven principles of ISO 31000

(Appendix 6) provide the foundation to the framework and also the process, where risk assessment

and treatment take place. (Pojasek, 2013a p.3) The framework is an organization’s management

approach and can take the form of a management system. (Pojasek, 2013b p.1). The risk

management framework are arrangements that enable risks to be managed. (AS/NZS, 2013 p.6)

ISO Annex SL

BH can apply the ISO 14001 framework, an environmental management system, with guidance

from ISO 31000. Our objective of providing a clean and healthy hospital environment answers to

one of the stated core texts of the consolidated ISO Annex SL management system standard

framework, Health and Safety. See Appendix 5. Once the commitment from leadership is

established and incorporated into organizational governance, the strategic planning process of

framework design, implementation, monitoring & review, and improvement, a plan-do-check-act

(PDCA) cycle, can be applied. (Pojasek, 2013a p.6)

When applying the PDCA risk management framework, it is important to comply with the eleven

principles of ISO 31000, although the significance of each of them varies depending on the

organization and its context. (Pojasek, 2013a p.6) The 11 risk management principles of ISO

31000 can develop, implement and continuously improve this framework. (Pojasek, 2013a p.2)

Context helps to reveal and assess the nature and complexity of BH’s risks. (ISO, 2009) We have

identified a number of key contexts and stakeholders that are relevant to creating and maintaining

a clean and safe hospital environment. Let’s walk through an example.

Following our context analysis, we have identified renovation works as an uncertainty for BH. It

has been stated in its latest annual report that BH has continually undergone renovation works at

its facility, with the aim to increase the number of hospital beds and the level of intensity of medical

services to generate higher revenue and profit margin. (BH, 2013) The specific renovations

included the addition of inpatient and ICU rooms in the main hospital building, conversion of

entire 12/Fl. to 58 additional beds, and the relocation of meeting rooms to make way for 4 more

outpatient floors. (BH, 2013) In the table in Appendix 7, SC demonstrates how by embedding the

11 risk management principles into the framework that is used to address the uncertainties posed

by renovations works, some of the stated benefits in the ISO 31000 guidance document can be

achieved. (ISO 31000:2009 p.2) By adhering to the principles and deciding on respective actions

that will be undertaken to address the effects, BH shall be able to maximize opportunities to offset

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the risks to objectives. The JCI Standard only requires the hospitals to manage the “environment

during demolition, renovation, or new construction to reduce risk to those in the organization.”

(VEHS, 2014) There is a stark difference between the actions to be taken during renovations based

on JCI standard versus those if they are to adhere to the ISO 31000 risk principles, which require

actions to be aligned with the organization’s external context, and the interests of external

stakeholders when deriving a sustainability action plan, even though the actual renovation works

may only take place within the hospital premise. We will discuss more about how to create a

shared value system with the community later on.

The ability to address the negative effects of renovation works using ISO Annex SL with embedded

risk management principles throughout the process, will not only result in a safer hospital

environment, but also safer community health, and help BH secure the social license to operate.

Similarly for the context of hospital acquired infection (HAI), by applying the risk management

principles, BH will need to be more inclusive and involve all internal and external stakeholders

who have interests in HAI when addressing this uncertainty before any decisions and activities are

undertaken. There is a need to develop a process approach to address the negative effects to patient

and staff safety for further assessment and treatment. The context of waste management also cannot

be adequately addressed by JCI standards which only require adherence to current law and

regulations. (JCI, 2014) In other words, it does not advocate a community wide consideration of

the entire waste management stream which includes the activities that lie outside of the hospital

premise even though those activities can bring harm to those along the entire waste management

value system, in the community, if the hospital’s decisions and activities were not planned with

consideration of external context and stakeholders in the planning stage.

This exercise shall be re-applied to address other contexts and respective uncertainties, whether it

presents an opportunity or a threat for BH. Embedding risk management into this framework

enables BH to, amongst other benefits, effectively address the three responsibilities of

sustainability, improve the identification of threats and opportunities, as well as establish a sound

and reliable basis for decision-making and strategic planning. (ISO 31000: 2009)

A final step in Risk management is the process, which entails risk assessment and treatment A

context must be determined before risk identification, analysis, evaluation and treatment, takes

place. Prioritization of risk occurs at the risk evaluation stage where decision is made about which

risks need to be treated and prioritized for treatment implementation. (Pojasek, 2013a p. 10) BH

can employ a risk prioritization matrix to help prioritize need and urgency. (Risk Ranking, 2009)

In the matrix, one axis displays the likelihood of occurrence, i.e. probability, and the other axis is

the severity if the incident occurs. By assigning a score to the probability and to the severity of

uncertainty caused by the context, the quadrant that shows the highest probability and highest

severity would be the context of the most immediate relevancy and in need of treatment most

urgently. Plotting a risk matrix would help BH prioritize issues on hand and give guidance on the

timing of treatment and allocation of resources accordingly. See Appendix 14 for an illustration.

Ultimately, the aim is to embed the process of risk management into the organization’s governance,

strategy and planning, leadership, reporting processes policies, and values & culture. (ISO, 2009)

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Managing Sustainability Performance and Lead Measures

There are several universal attributes and characteristics that apply at any company, including a

healthcare facility like Bumrungrad. (Pojasek, 2011 p.82) Every business activity is:

Performed by people (Employees, Members and Volunteers);`

Managed by leaders (Leadership);

Planned both strategically and tactically (Strategic Planning);

Influenced by a broad range of stakeholders (Stakeholder Engagement);

Improved through knowledge and information (Information and Knowledge Management);

Executed and controlled with a process focus (Operations Focus); and

Constrained by limited resources (Resource Efficiency) (Pojasek, 2011 p. 82)

As organizations seek to enhance its probability of achieving business success and sustainability,

it would move through several phases where the scope of its approach broadens from quality

management to business excellence, and finally business sustainability. (Pojasek, 2007 p. 82) With

conviction from leadership and mandate from organizational governance, BH shall be able to

champion the final phase of business sustainability by adopting a performance framework that is

focused on monitoring and driving performance itself so that the results could be improved in a

“looking forward” manner. (Pojasek, 2014a p.1) These performance criteria form the backbone

of the performance framework, and can be developed into quantitative leading indicators even

though they may not seem important since they measure behaviors change. (Pojasek, 2014a P.6)

The information on these lead indicators is actually key to help close the gap between what

organizations should do and what they are actually doing! (Pojasek, 2014a p.7) Acting on the lead

measures is one of the least-known secrets of the style of sustainability and risk management.

(Pojasek, 2014b p. 4)

Since 2002, BH meets the US Joint Commission International (JCI) Accreditation Standards for

hospital care. (BH, 2013) The 350 JCI standards were exclusively developed to evaluate health

care organizations and are recognized as a complete accreditation program throughout the world,

having accredited 375 hospitals in 47 countries outside of the US. (Helen Ziegler and Associates,

2014) JCI is designed to focus on two fields; patient-centered standards (7 criteria) and

management-centered standards (6 criteria). (Yousefian, 2013 p.956) As shown in the top chart

of Appendix 8, with the exception of “Governance, Leadership & Directing,” the other five JCI

management criteria are all lagging measures, which tell the level of success in terms of achieving

the objective, regarded as more of a “work in progress” measurement. (Pojasek, 2014a p.7) These

measures lack the characteristics of good lead measures, which (1) have to be predictive of being

able to change the course of associated lag measures, and (2), can be influenced by the people in

the organization. (Pojasek, 2014a p. 7) BH needs to employ a framework with forward looking

measures to deliver organizational excellence.

An extensive study has been commissioned by the Ministry to Health and Medical Education of

Iran to design a comprehensive health care excellence model that can align JCI accreditation system

requirements with organizational excellence models of health care sector. (Yousefian, 2013 p.956)

Upon presenting the research finding to 150 staff members of the Ministry, 74% of the respondents

of the questionnaire believes a health care excellence model can cover the requirements of the JCI

accreditation standards. (Yousefian, 2013 p.962-963) 81% of respondents believe applying a

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performance excellence model would create positive effect on hospital service quality enhancement.

(Yousefian, 2013 p.962) The paper concluded the sound feasibility of adapting the accreditation

standards of JCI with a number of health sector Excellence Model, in particular the European

Foundation for Quality Management (EQFM). See Appendix 9 for sample of adapted model.

Waste management is one of our identified contexts earlier and it is important for community health

for infectious and hazardous waste to be handled properly. JCI only stipulates that the organization

is “responsible for adhering to local, state and federal regulations for proper handling and disposal

of hazardous materials and wastes.” (JCI, 2014) There still seems to be no legal obligation for

infectious and hazardous materials to be separately handled in Thailand now, due to unclear

demarcation amongst central agencies. (Panyaping, 2006) (Municipal, 2000) If BH is to adhere to

ISO 31000 risk management principles or benchmark to the Baldrige criteria of workforce focus,

customer focus, and process management, proper waste management would be in place.

The lack of leading measures of JCI on one hand, and the assurance of coverage of accreditation

requirement in organizational excellence model(s) on the other, provide a strong premise for BH

management system to incorporate an organizational excellence model. Pojasek highlighted

EFQM simply sets out the ideal to be attained, while Baldrige asks an organization to answer

questions with the aim of leading it to find a best practice. (Pojasek, 2011b p. 90-91) Blazey used

the questions in Baldrige, together with best-practice statements in EFQM to define how an

organization should be operating to achieve performance excellence. This “hybrid framework,”

clearly defines a targeted “state of excellence” to be achieved. (Pojasek and Hollist, 2011b p.91)

In practice, it may be difficult for BH to change to a new performance excellence framework from

JCI given it has very much become a marketing point since 2002. BH can incorporate one or more

frameworks to focus on best-practice performance criteria, which contain leading measures that

can be scored to measure the performance and behaviors required for employees to act on such

best-practices as part of how BH operates every day. (Pojasek, 2014b p.3) Whether it is EFQM,

or Baldrige, their performance criteria can be quantified for BH to trend their improvement and see

if the results are trending in the same direction. (Pojasek, 2014a p.2)

Quantifying Leading Indicators in Performance Framework

Performance frameworks, such as the EFQM, typically score the leading indicators using a scoring

matrix. (Pojasek, 2014a p.6) RADAR (Results, Approach, Deployment, Assessment and

Refinement) are commonly used, with Results being scored separately. Approach is “overall way

by which something is made to happen… comprise of processes and structured actions within a

framework of principles and policies.” (Pojasek, 2014a p.6) If SC is to score BH on one of the

performance criteria, say stakeholder engagement, based on a scale of 1 to 10 at this time, BH

would be assigned a score of 5, as the current approach still displays some distance from one that

employs leading indicators to drive its sustainability strategy. The score would be similar for

Deployment and Assessment as they are both underscored by the Approach. BH has reached a

level of business excellence, it is ideal time to incorporate a management system that employs

leading performance criteria to address the three responsibilities, as means to achieve best-practices.

This will help BH achieve its objectives and goal, and eventually long term business sustainability.

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Activities, Processes, Monitoring, Measure + Review

It is important to avoid implementing sustainability as pockets of initiatives around the organization;

sustainability needs to be weaved into the fabric of an organization such that it becomes what

everyone at BH does every day. The adoption of a process approach to link sustainability to

activities, processes, products and services become a source of opportunity and competitive

advantage to help achieve organizational sustainability. (Pojasek, 2014a p.1) A process map comes

in handy when one tries to take a process view. (Pojasek, 2003 p. 2) We can use process maps for

the core process or the processes that support the core processes, as well as the processes that are

used to provide oversight to the core processes and their supporting processes. (Pojasek, 2014a p.5)

Our objective here is to establish a clean and safe hospital environment where one of the identified

contexts is the handling of waste material generated at BH. We can use our context of Waste

management for illustration purpose; it is obviously a process that supports the core process of

medical service provision at BH.

From Value Chain Model to Creation of Community Level Shared Value System

An academic journal in Thailand provided some information on the general procedures of waste

management. (Panyaping, 2006 p.91) In Chart 1 of Appendix 10, SC has incorporated Panyaping’s

information, to exhibit a process map of waste management within the hospital from source to the

point it leaves the hospital. Chart 1 is only concerned with the activities that take place inside the

hospital with its internal stakeholder. However, it is necessary to address external context and

stakeholders in order to deliver shared value in the community, because the long term success of

every organization is interdependent with the society and the community prosperity. (Pojasek,

2014a p.8) The process map in Chart 2, Appendix 10, takes into consideration the entire value

system, the community and external factors, by incorporating Procurement of materials made in

the community, as well as the final Treatment and Disposal that take place outside of the hospital.

The manufacturing of those materials procured by BH creates sustainability footprint along the

value system, and is the ultimate source of waste generation. Incorporating this activity enable BH

to try to influence the uncertainty from this context, be it positive or negative, and enables BH to

take part in creating shared value in the community. Similarly, incorporating the Treatment and

Disposal activity into the value system enables BH to take into account the sustainability impact

generated after the waste material after it leaves the hospital site. Although BH does not have direct

control over these activities, it should try to neutralize or reduce any negative effects to create

shared value in the community. There is a realization that long term success of each organization

is interdependent with society and the community prosperity. (Pojasek, 2014a p.8)

Monitoring, Measure and Review

The purpose of monitoring is to generate information needed to ensure that risk is managed

effectively. (Pojasek, 2014b p.5) Selecting the right metrics to be measured and monitored is a

key part of an organization’s strategy for success. (Pojasek, 2014b p.2) BH can determine what

needs to be monitored by asking questions such as (Pojasek, 2014b p.5):

13

What are the type of operations that have significant impact on the environment, society or the economy?

What needs to be kept in check with compliance obligation?

What are the interests of stakeholders?

What are the organizational threats and opportunities?

What are the value chain controls associated with supplier and customers?

What helps progress towards the organization’s objectives?

Baldrige also asks series of question about how the information is selected, gathered, analyzed,

managed and used to improve future performance. (Baldrige, 2011-2012) Information and

knowledge management is one of the key performance criteria that help to identify those activities

that need to be monitored, measured and help drive the process to create performance excellence.

Using Performance Framework to Measure Lead Indicators

Metrics should be set at the highest level and flow down to all levels and functions, to avoid

disconnect or inconsistencies. (Pojasek, 2014b p.3) Measurement can be either quantitative or

qualitative. The Baldrige program enables organization to “score” their results and then aggregate

the scores to create an aggregate category. (Pojasek, 2014b p. 3) The diagram here presents the

Strategic Measure Model for determining the metrics from an internal perspective. (Brown, 1996)

Here, BH should focus on what it needs to do to maintain its competitive

advantage and social license to operate. (Pojasek 2014b p.4) Based on

the internal and external context we established earlier against on our

objective of creating a clean and safe hospital environment, BH needs

to minimize Hospital Acquired Infection (HAI) rate, minimize

renovation related injuries and HAI, minimize workforce sickness due

to exposure to toxic chemical and infectious elements, minimize waste

generation, as well as pollution generated during waste treatment and

disposal. These are the desired results, or lagging indicators, but

oftentimes, these metrics are being measured and monitored and

targeted for improvement!

Whether it is a qualitative or quantitative measurement, we need to

employ process focus to develop, monitor and measure the leading

measures that incorporates environmental, social and economic

elements to achieve organizational sustainability (Pojasek, 2013) BH

can employ the Michael Porter Value Chain Support Functions

categories or the Baldrige Performance Functions (See Appendix 11) (Pojasek, 2014a p.7) All of

the elements categorized within Porter’s support activities or Baldrige Performance Functions can

be used as topic guidelines for leading indicators. For instance, under the category of Procurement

in Porter’s support functions, reducing the purchase and use of cleaning agents with toxic chemical,

increasing procurement of reusable items can be monitored and measured; or under the category

of Technology Development, BH can explore and procure new x-ray technology to reduce toxicity;

and under Infrastructure, BH should ensure proper procedures and precaution are established before

renovation works begin. (Waste Source, 1992) This way, BH can effectively monitor and measure

leading criteria and link them to results (lag indicators) and create a ‘life cycle of sustainability

results’ that are ready for reporting and improvement purposes.

14

Reporting Sustainability

Once the metrics are determined, monitored and measured, BH can start to present the results of its

sustainability efforts. Reporting on sustainability not only helps to complete the ‘life cycle of

sustainability results’ for continual improvement of your operations and is also a key part of

stakeholder engagement to learn more about their interests. It is important to remember that

reporting should focus not only on internal stakeholders within the value chain, but also the external

shareholders given the hospital operates in a community setting. (Pojasek, 2014 p.1) With this

awareness, BH can begin to quantify and report on the threats and opportunities related to the

environmental, social and economic factors as revealed in the contexts and stakeholder engagement

process.

Sustainability reporting is how BH can demonstrate transparency and accountability for your

sustainability activities to help gain the social license to operate. (Pojasek, 2014 p.1) Sometimes

the level of transparency itself reported becomes a contentious topic with ‘demanding’ stakeholders

and the organization can even be penalized based on the information disclosed. (Pojasek, 2014 p.2)

ISO 26000 (2010) provides a list of considerations when seeking to be more transparent. One of

the key notions is the requirement of transparent disclosure when the organization is reporting

performance on relevant and significant issues of sustainability (ISO Annex SL). (ISO, 2010)

Accountability is to be answerable to the overall impacts of your decisions and activities on the

environment, society and the economy. This calls for more than merely operating within the rules

and regulations set by relevant government agencies, but the need to address the three

responsibilities of sustainability to achieve business sustainability. ISO 26000 provides some

guidance on such behavior. (ISO, 26000)

Engaging stakeholders at each step of the reporting continuum (Kaplan, 2004) is an efficient and

effective way to help ensure that the reporting of performance will not be a contentious one, but

rather a statement on how well the organization and stakeholders were engaged. (Pojasek, 2014

p.4) When the right sustainability metrics are used and BH and stakeholders can see how they help

to optimize the three-responsibility performance and understand the long-term impacts of the

hospital’s decisions and activities, the process becomes a value rather than a cost center. (Pojasek,

2014 p.6)

Risk Management Approach to Sustainability Reporting

Sustainability is a means to address the risks associated with the activities of an organization.

(Pojasek, 2013, p.4) Using Risk management to create information for reporting is consistent with

the strategies for sustainability management and avoids the complications associated reporting

standards that do not recognize context and the size of an operation. (Pojasek, 2014 p.1) There is

a tendency to rely too much on financial concepts to explain operational practices. As Kaplan

pointed out in his working paper on balanced scorecards, “the measurement system should be

expanded beyond financial indicators to include an array of quality metrics relating to customer,

manufacturing processes and employees.” (Kaplan, 2010, p.11) There is a clear link between

reporting metrics and the Baldrige performance criteria including customer/stakeholder

engagement, employee engagement, as well as Operations Management, to manage and report risk

15

measures. Kaplan also went on and iterated that “The key was to have a more robust measure and

management system that included both operational metrics as leading indicators and financial

metrics as lagging outcomes, along with several other metrics to measure a company’s progress in

driving future performance.” (Kaplan, 2010, p.18) To gauge whether a lagging indicator is worth

monitoring and measuring, the Baldrige program provides some guidance (Pojasek, 2014 p.10):

• Is the result important or significant to the organization?

• Is the result associated with a written action plan already in place?

• Does the organization already track this result and seek to follow trends in the results?

• Does the organization actively benchmark this result with others?

A Maturity matrix can be used to report on the hospital’s position along the sustainable

development path. (BSI, 2006) It is an assessment tool for evaluating an organization’s level of

progress towards a goal. Criteria that will be evaluated are listed in the left-hand column, and the

rows describe the stage of development for the organization. A maturity matrix is presented in

Appendix 12 for reference purpose. In the absence for such example in Thailand or Asia hospitals,

SC benchmarks a template from an England based Health and Wellbeing Board (GGI, 2011) In

the matrix, either the Baldrige performance criteria or Michael Porter’s support functions are used

as leading indicators to gauge the level of development along the left hand column. One lagging

indicator, Insurance or Litigation claims, is also added for illustration purpose as this criterion is

likely to be significant to BH, already in existing action plan, tracked already, and benchmarking

with competitors will help maintain its competitor advantage. An additional column on the left has

been added (not part of the usual maturity matrix) just to demonstrate how each of the key elements

that is being measured and reported addresses at least one of the risk management principles, to

ensure that the risks that create uncertainty on BH ability to meet the objectives, are being

monitored, addressed, and reported. (Pojasek, 2014 p.9)

Another way of reporting the progress of BH sustainability program can be in the form of a maturity

grid. See Appendix 13. Here, SC has assigned a score, from 1 to 5, to represent the stage of

development for that particular criterion. BH receives a relatively high score of 4 for Workforce

Focus because the hospital is quite advanced in employee engagement efforts given there is already

a threat of staff shortage in Bangkok area, and there seems to be very limited issues with Litigations

and Insurance Claims, although this should be qualified by the fact that general rules and

regulations on patient protection through the Codes of Medical Conduct and Patient Bill of Rights

seem to provide limited protection to patients’ right at this time and difficult to find information on

this the topic on government websites. (Bumrungrad, 2014) A score of 3 are assigned to Leadership,

Customer Focus, Technology Development, and Info & Knowledge Management. BH

demonstrates the capability and fair awareness of the need to make improvement in these areas,

and with the adoption of a sustainability management system, BH shall be able to spearhead

progress in these area. A low score of 2 is assigned to Operation Focus and Procurement as BH

has yet to demonstrate its ability in process management, given current limited visible achievement

in how organizational processes is managed, including planning of healthcare process, support

activities and operation, key process indicators and quality assurance and improvement.

Procurement is also a criterion that BH can work on to demonstrate how it can be used to help

achieve business sustainability.

16

Conclusion

Universally, people want to live vibrant healthy lives. (Resilience, 2012) A healthcare system

designed to create a clean and healthy healthcare environment would meet the criteria of sustainable

healthcare. By following the guidelines discussed in this consultation paper, BH shall be able to

practice sustainability by implementing a sustainability management system (Appendix 5) and

following the plan-do-check-act (PDCA) cycle to drive continual improvement so as to

continuously work on positive effects of uncertainty (opportunities) to offset the negative effect

(threats).

A clean and safe hospital environment is a pre-requisite for any healthcare facility that wants to

"first, do no harm." The aim of addressing the organization’s sustainability situation is to

understand the key risks and challenges posed by the internal and external context in order to

achieve its intended objectives, including those responsibilities with respect to environmental

stewardship, social well-being and the economic prosperity of the organization and the community

as a whole. (Pojasek, 2013 p.4)

One of our highlighted key internal contexts, waste management, can create a long list of negative

effects if mismanaged. The list may include the following (CWE 2014):

1. Injuries from sharps leading to infection to all categories of hospital personnel and waste handler.

2. Nosocomial infections in patients from poor infection control practices and poor waste management.

3. Risk of infection outside hospital for waste handlers and scavengers and at time general public living in the

vicinity of hospitals.

4. Risk associated with hazardous chemicals, drugs to persons handling wastes at all levels.

5. “Disposable” being repacked and sold by unscrupulous elements without even being washed.

6. Drugs which have been disposed of, being repacked and sold off to unsuspecting buyers.

7. Risk of air, water and soil pollution directly due to waste, or due to defective incineration emissions and ash3.

Implementing sustainability methods to ensure the entire waste management value system adheres

to the seven principles of Sustainability (Appendix 3) helps to offset above negative outcomes and

create new opportunities for BH. Some examples of positive effects are (CWE 2014):

1. Cleaner and healthier surroundings.

2. Reduction in the incidence of hospital acquired and general infections.

3. Reduction in the cost of infection control within the hospital

4. Reduction in the possibility of disease and death due to reuse and repackaging of infectious disposables.

5. Low incidence of community and occupational health hazards

6. Reduction in the cost of waste management and generation of revenue through appropriate treatment and

disposal of waste

Every organization faces a set of unique context and thus organizational profile (Appendix 1) as

determined by its community. All of its respective contexts, categorized within ISO Annex SL

(Appendix 5), can be addressed by undertaking a sustainability approach to offset their negative

effects. In the case of creating a clean environment, positive outcomes include reduced potential

liability claims on the hospital, reduced insurance premiums, reduced emissions from waste

handling, reduced illness related to renovations works, toxic exposure and in turn reduced staff

illness rates. The list goes on. At the same time, BH benefits from many positive effects, including.

most importantly, the support from the community stakeholders to operate in the community by

17

gaining the social license to operate. Other benefits may include an increased and more loyal

customer base as a result. With lower rate of staff illness and insurance related costs, BH is also

likely to see reduced threat of workforce shortage and higher economic benefits down the path.

A governance system’s most important task is to enable the organization to manage the risks

associated with its activities and decisions and embed sustainability into the organization. BH

needs to have a governance system in place and be continuously kept up to date, to make

sustainability part of what everyone does every day, while addressing the three responsibilities of

sustainability; environmental stewardship, societal well-being and economic prosperity of the

community as a whole.

Leadership plays a critical role in defining the governance system with their own set of core values

and ethical behavior. They also serve as role models, set the vision and are responsible for

developing an effective management system that incorporates the principles of sustainability. It is

the responsibility of the leaders to integrate a set of good governance principles into organizational

governance such that the governance system can in turn, be able to evaluate the accountability and

performance of the senior leaders. (NIST, 2011)

It is important that once the strategy plan is established, the plan is communicated to internal

stakeholders so that everyone at the hospital understands and buys into the strategic plan and will

make sustainability what they do every day around the hospital. Effective stakeholder engagement

(Appendix 2) would mean a constructive relationship with stakeholders are established where

sustainability results are well communicated to external stakeholders to enable continual

improvement based on continuous engagement. It would be ideal for the hospital to continue to

deepen relationship with stakeholders until there is emotional bonding! Information from the

stakeholder engagement can be disseminated through various forms on paper or by social media.

The principles of ISO 31000 Risk Management guidance document (Appendix 6) should be applied

throughout the sustainability management framework, with a process approach by incorporating

the forward looking performance criteria as prescribed by one of the performance excellence

models, Baldrige (Appendix 4) or EFQM (Chart 2 in Appendix 8) into JCI. A risk assessment

process can then be undertaken to prioritize actions and treatments of the risks posed by the

uncertainties. By focusing on the leading measures and some meaningful lagging indicators, a

monitoring (Appendix 12) and measuring system (Appendix 13) can be established to create a 'life

cycle of sustainability result' for BH to assess and work on for continual improvement in order to

maximize sustainability opportunities for offsetting the threats to business sustainability.

Sustainability cannot be addressed as individuals, but requires organizations to come together as

partnerships and build a sustainable industry as a community by engaging all stakeholders in an

inclusive manner. At the frontline of the societal well-being, BH is in an ideal position to take

leadership role to implement sustainability to address the three sustainability responsibilities;

environmental stewardship, societal well-being and economic prosperity. With the commitment

from leadership, a strong governance system and process focus internally, and an effective

stakeholder engagement program and management framework that embed risk management

principles in an iterative process, BH is on its way to fulfil its true mission of ‘caring for people.’

18

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22

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Sustainability Performance. Retrieved from

http://isites.harvard.edu/fs/docs/icb.topic1396216.files/Operations%20Focus%20Performance.pdf

The Joint Commission. (2014). Standards FAQ Details. Environment of Care. Retrieved from

http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFAQId=91&

StandardsFAQChapterId=64

Yousefian, Shiva. Harat, Ali Taghizadeh. Fathi, Mohammad, Ravand, Mostafa. (2013).

Advances in Environmental Biology, 7(6):956-967, 2013. ISSN 1995-0756. A Proposed

Adaptation of Joint Commission International Accreditation Standards for Hospital-JCI to the

Health Care Excellence Model. Retrieved from http://www.aensiweb.com/aeb/2013/956-967.pdf

References (Activities, Processes, Monitoring, Measurement and Review)

Baldrige. (2011-2012). Criteria for Performance Excellence. Information and Knowledge

Management. Retrieved from

http://isites.harvard.edu/fs/docs/icb.topic1389556.files/Supplement%20to%20the%20Case/Baldri

ge%202011_2012%20Information%20and%20Knowledge%20Managment%20Criterio.pdf

http://www.sciencepub.net/life/life0302/life-0302-17.pdf


http://isites.harvard.edu/fs/docs/icb.topic1396591.files/Performance%20Frameworks/Supplemental%20Reading%20Framework%20Business_Sustainability.pdf

http://isites.harvard.edu/fs/docs/icb.topic1396591.files/Performance%20Frameworks/Supplemental%20Reading%20Framework%20Business_Sustainability.pdf

http://isites.harvard.edu/fs/docs/icb.topic1396591.files/Chapter%2010%20Sustainability%20in%20Operations%20Support%20Final.pdf

http://isites.harvard.edu/fs/docs/icb.topic1396591.files/Chapter%2010%20Sustainability%20in%20Operations%20Support%20Final.pdf




http://www.aensiweb.com/aeb/2013/956-967.pdf

http://isites.harvard.edu/fs/docs/icb.topic1389556.files/Supplement%20to%20the%20Case/Baldrige%202011_2012%20Information%20and%20Knowledge%20Managment%20Criterio.pdf

http://isites.harvard.edu/fs/docs/icb.topic1389556.files/Supplement%20to%20the%20Case/Baldrige%202011_2012%20Information%20and%20Knowledge%20Managment%20Criterio.pdf

23

Chummel, Charoen. (2009). International Conference on Science, Technology and Innovations

for Sustainable Well-Being, 23-24 July 2009, Mahasarakham University, Thailand. Infectious

waste incineration management in North Isan Regional Hospitals. Retrieved from

http://app.eng.ubu.ac.th/~resproject/upload/p1/charoen-infectious_waste(3).pdf



0302-17.pdf

Pojasek, Robert B. (2003). Environmental Quality Management. Selecting Your Own Approach

to P2. Retrieved from

http://isites.harvard.edu/fs/docs/icb.topic1396216.files/Process%20Focus%20Readings/Selecting

%20Your%20Own%20Reprint%202003.pdf

Pojasek, Robert B. (2013). Strategies for Sustainability Management. Operations Focus.

Retrieved from


Pojasek, Robert B. (2013b) Strategies for Sustainability Management. Employees, Members,

and Volunteers in an Organization. Retrieved from

http://isites.harvard.edu/fs/docs/icb.topic1393001.files/People%20and%20Organizational%20Per

formance.pdf

Pojasek, Robert B. (2014a). Strategies for Sustainability Management. Chapter 9. Linking

Sustainability to the Process. Retrieved from

http://isites.harvard.edu/fs/docs/icb.topic1396216.files/Chapter%209%20Process%20Focus.pdf

Pojasek, Robert B. (2014b). Strategies for Sustainability Management. Chapter 10. Monitoring,

Measurement, Analysis, and Review. Retrieved from

http://isites.harvard.edu/fs/docs/icb.topic1400440.files/Chapter%2012%20Monitoring%20Measu

rement%20Analysis%20Review.pdf

Waste Source Reduction: Hospital Case Study. (1992). Minnesota Office of Environmental

Assistance. Retrieved from http://www.mntap.umn.edu/health/resources/IMC.pdf

Reference (Sustainability Reporting)

British Standards Institute (BSI) 2006. Guidance for Managing Sustainable Development. BS

8900. London, UK: British Standards Institute.

Bumrungard International Hospital. (2014). How are a patient’s rights to competent medical

treatment protected? Retrieved from http://www.bumrungrad.com/Hospital-FAQs/How-are-a-

patient-s-rights-to-competent-medical-tr

Good Governance Institute. (2011). Board Assurance Prompt – Health and Wellbeing Boards.

September 2011. Retrieved from

http://app.eng.ubu.ac.th/~resproject/upload/p1/charoen-infectious_waste(3).pdf



http://isites.harvard.edu/fs/docs/icb.topic1396216.files/Process%20Focus%20Readings/Selecting%20Your%20Own%20Reprint%202003.pdf

http://isites.harvard.edu/fs/docs/icb.topic1396216.files/Process%20Focus%20Readings/Selecting%20Your%20Own%20Reprint%202003.pdf


http://isites.harvard.edu/fs/docs/icb.topic1393001.files/People%20and%20Organizational%20Performance.pdf

http://isites.harvard.edu/fs/docs/icb.topic1393001.files/People%20and%20Organizational%20Performance.pdf


http://isites.harvard.edu/fs/docs/icb.topic1400440.files/Chapter%2012%20Monitoring%20Measurement%20Analysis%20Review.pdf

http://isites.harvard.edu/fs/docs/icb.topic1400440.files/Chapter%2012%20Monitoring%20Measurement%20Analysis%20Review.pdf

http://www.mntap.umn.edu/health/resources/IMC.pdf

http://www.bumrungrad.com/Hospital-FAQs/How-are-a-patient-s-rights-to-competent-medical-tr

http://www.bumrungrad.com/Hospital-FAQs/How-are-a-patient-s-rights-to-competent-medical-tr

24

http://isites.harvard.edu/fs/docs/icb.topic1402767.files/Sustainable%20Healthcare%20Informatio

n/BoardAssurancePromptHealthandWellbeingBoards_Maturity%20Matrix.pdf

International Organization for Standardization (ISO). 2010. Guidance on Social Responsibility.


Kaplan, Robert S, (2010). Harvard Business School. Conceptual Foundations of the Balanced

Scorecard. Retrieved from http://www.hbs.edu/faculty/Publication%20Files/10-074.pdf

Pojasek, Robert B. (2013). Strategies for Sustainability Management. Chapter 3. Sustainability

from the Perspective of an Organization. Retrieved from



Pojasek, Robert B. (2014). Strategies for Sustainability Management. Chapter 13. 8-14 Apr

Sustainability Reporting. Retrieved from

http://my.extension.harvard.edu/icb/icb.do?keyword=ext&subkeyword=k100396&pageid=icb.pa

ge661885&pageContentId=icb.pagecontent1445388&view=message&viewParam_message_id=1

026457#a_icb_pagecontent1445388

References (Conclusion)

CWE (2014). Current World Environment. Mathur, Praveen. Need of Biomedical Waste

Management System in Hospitals – An Emerging issue – A Review. Retrieved from

http://www.cwejournal.org/vol7no1/need-of-biomedical-waste-management-system-in-hospitals-

an-emerging-issue-a-review/

NIST (2011). Criteria for Performance Excellence 2011-2012. Gaithersburg, MD: US Department

of Commerce and Government Printing Office.

Pojasek, Robert B. (2013). Strategies for Sustainability Management. Chapter 4 Organization and

its Context. P. 1 Retrieved on March 11, 2014 from

http://isites.harvard.edu/fs/docs/icb.topic1384701.files/Organization%20and%20its%20Context%

20Week%201%20Revised.pdf

Resilience (2014). Adams, Kim. Sustainable healthcare. August 3, 2014. What is Sustainable

Healthcare? Retrieved from http://www.resilience.org/stories/2012-08-03/sustainable-healthcare

http://isites.harvard.edu/fs/docs/icb.topic1402767.files/Sustainable%20Healthcare%20Information/BoardAssurancePromptHealthandWellbeingBoards_Maturity%20Matrix.pdf

http://isites.harvard.edu/fs/docs/icb.topic1402767.files/Sustainable%20Healthcare%20Information/BoardAssurancePromptHealthandWellbeingBoards_Maturity%20Matrix.pdf

http://www.hbs.edu/faculty/Publication%20Files/10-074.pdf

http://www.cwejournal.org/vol7no1/need-of-biomedical-waste-management-system-in-hospitals-an-emerging-issue-a-review/

http://www.cwejournal.org/vol7no1/need-of-biomedical-waste-management-system-in-hospitals-an-emerging-issue-a-review/



http://www.resilience.org/stories/2012-08-03/sustainable-healthcare

25

APPENDIX

26

Appendix 1

Organizational Profile

Bumrungrad Hospital, Bangkok, Thailand

ORGANIZATIONAL DESCRIPTION: Organization’s operating environment, key relationships with customers, suppliers, partners and stakeholders.

a. Organizational Operating Environment

1) Product/Service Offerings - Hospital Accreditation - Internationally accredited by Joint Commission International (JCI)

- 30 specialty centers - State-of-the-art diagnostic, therapeutic and

intensive care facilities - One-stop medical center

2) Vision/Mission/Core Values/Purpose/Core Competencies

-Vision – World Class Medicine, World Class

Service

-Mission – To provide world class healthcare with

care and compassion

-Core Value – Health and Safety of the Community

-Culture – it is observed in reading the annual

reports this listed private hospital has a profit-driven

culture

3) Staff/Volunteer/Member Profile

- Doctors

- Nurses

- Technicians

- Housekeeping Department

o Waste Handling

o Janitors

o Cleaning Staff

- Kitchen Department

- Infection Prevention Team

4) Assets - One hospital premise – continuous renovation to maximize number of beds and intensity of services - Two new hospital sites under construction - Medical Equipment

27

5) Regulatory Requirements - Ministry of Public Health/Thai Medical Council - Department of Health - Pollution Control Department (PCD) - Code of Medical Conduct/Patient Bill of Rights - Office of Environmental Policy & Planning

(OEPP) - Department of Environmental Quality

Promotion (DEQP) - Local Authority – Bangkok Metropolitan

Administration (BMA)

b. Organizational Relationships

1) Organizational Structure/Governance

- BH was Asia’s first hospital accredited by US Joint Commission International (JCI) since 2002

- Annual Report primarily focused on financial reporting

- Very limited scope of Environmental Policy - CSR mainly silo philanthropic projects - No Sustainability Report - No disclosure of tenure of Board of Directors

in Corporate Governance disclosure - Audit Committee with 3 independent directors

to review 1) the sufficiency of compliance with accounting standards and credibility of the financial reports, 2) the adequacy and effectiveness of the internal control system and 3) compliance with regulations and always and 4) review potential conflict of interests with related parties

- Medical Ethics Committee for protection of patient’s rights

- A third party consultant engaged to review BH customer engagement level

- Investment Committee – review projects before proposing to Board of Directors (three non-executive and one executive director)

- Governing Board – Responsible for hospital policy implementation(two directors, two management, and five physicians)

- Corporate Social Responsibility Committee (2011)

- As at the end of 2013, the four independent directors account for 36% or 1/3 of Board of Directors.

28

2) Stakeholders (including customers)

Internal - Management - Doctors and Nurses - Janitors and cleaning staff - Technicians - Kitchen staff

- R&D Lab scientists External - Past/present/future Patients - Contractors/Construction workers - Competitors

- Regulatory bodies - Third party waste collectors - NGOs - Community

3) Suppliers and Partners - Medical device and equipment makers

- Pharmaceutical and drugs suppliers

- Utility providers

- Cleaning supply vendors

- Partners with Intelligent InSites for

advanced software technology

- Partners with Motorola to provide

wireless network

ORGANIZATIONAL (STRATEGIC) SITUATION

a. Competitive Environment

29

1) Competitive Position - BH is top tier in terms of medical services

available as accredited by US JCI, well known

as a hospital run as a ‘business’ as opposed to a

‘hospital’. In other words, very strong in

marketing.

- Strong Marketing - Only top tier private

hospitals within the community are BH

competitors. BH is known to excel in marketing

aspects, as some studies shown, vs other local

hospitals.

- Cultural Edge - Compares with key regional

medical tourism competitors, Singapore General

Hospital, BH may have a niche over them due to

visitors’ preference for Thai culture and

hospitality.

- Human Resources - BH suffers more staff

shortage problem than regional peer as

government impose Thai language test for all

healthcare practitioners, so it is not able to hire

overseas nurses and doctors.

3) Comparative Data - Bangkok is situation in a flood plain zone and can

pose a constant threat to BH operation compares

to regional hospitals

- Recent domestic political turmoil makes Bangkok

a less desirable tourist and medical tourism

destination.

- Limited data for comparison purpose. Some

indirect report of Hospital Acquired Infection

rate, which sounds very low compare to officially

disclosed data from Singapore and global

numbers. .4% for BH vs. 1 in 7 in Singapore.

b. Strategic Context

30

b. Strategic Context - 2015 Asean Economic Community (AEC) provide significant opportunity for BH to gain patients from Myanmar, Cambodia, Laos, and Cambodia. -BH manner of operation creates some tension with a number of regulatory bodies at the BMA. The government accuses BH of reining in all the qualified doctors by offering premium package and shorter hours compare to public hospitals. BH however says that all of their doctors have overseas certification and would not have returned to the country if not for hospitals like BH who created an ultra-high end hospital in Bangkok. This cannot however be used as argument for nurses who are also in shortage at hospitals in Thailand. - The government otherwise seems supportive of private hospitals which help to promote the tourism industry in Thailand - Until the new wings come on stream, BH has been continually maximizing growth by renovating existing premise including moving operations to remote area to increase number of beds in the BH premise - To combat shortage of nurses and support staff within the community, BH continues to offer premium package to fill vacancies. - BH opens “referral” offices in strategic locations around the world to promote medical tourism to BH in Bangkok. It seems some of these locations can become potential location for BH to open its overseas hospitals, as stated in latest annual report. - BH continuously undertake renovation project in existing premise in order to maximize profitability by adding beds as well as increasing the level of complexity of operations (intensity)

c. Performance

Improvement System

31

- Established a Corporate Social Responsibility

(CSR) Committee in 2011 to emphasize health

- Promotion and health education.

- Business Continuity Plan to address natural

disaster, e.g. Flooding

- Safety and Environment Risk Assessment to

drive Hospital Administrative Policy

- Engaged a consulting firm to give advice and

provide training sessions for all relevant

executives and employees

- Corporate Internal Audit Division

- Disaster Preparedness Plan

- Emergency Response Plan (ERP)

- Government Flood Protection Plan

- End -

32

Appendix 2

Key Stakeholder Engagement List for Clean & Safe Environment

Stakeholder Group

Engagement

Status Current Engagement

Model (BH, 2013) How to Improve

Yes Not

Yet

Dissatisfied Patients X Individual

Meeting/Mediation Follow-up Questionnaire

Existing Patients X Patient Experience Survey Continuous effort to

engagement

Prospective Patients X Website Publications/more

Interactive Social Media

Employees - Nurses X Town Hall Meeting,

Individual Dev. Plan (IDP)

Focus Group/ Staff

Survey

Employees –

Housekeeping Staff X Town Hall Meeting, IDP

Focus Group/One-on-

One Interview/Survey/

Employees –

Infection Control Team

X Town Hall Meeting, IDP

Focus Group/One-on-

One Interview/Survey/

Scorecard template

Cleaning Agents Supplier X

Contractual agreement/

Purchasing Policy

Sustainability Supplier

Questionnaire

-Government Agency

-Pollution Control

Department

-Department of

Environmental Quality

Promotion

X N/A

Courtesy Calls/Roundtable

Discussions/Workshops/

Consultation processes

Construction workers X N/A Workshops/Education

Forums

Third party waste collection

company X N/A Workshops/Focus Group

Steering Committee for

Clean & Safe Environment X N/A

To provide continuous

feedback/input for

improvement/Scoreboard

Competitors X Compete within rules and

regulations

Round-table/ Win/Loss

Analysis

Shareholders X Shareholder’s Meeting Sustainability Report

Community X

CSR Committee formed in

2011 – health promotion

and health education

Scorecard

Template/Interactive

Website/Social

Media/Clean and Safe

Campaign/

33

Appendix 3

Seven Principles of Sustainability

1. Accountability

2. Transparency

3. Ethical Behavior

4. Respect for Stakeholder’s Interest

5. Respect for the Rule of the Law

6. Respect for International Norms of Behavior

7. Respect for Human Rights (ISO 26000, 2010)

Accountability – the organization should be accountable for its impacts on the community

(society), the economy and the environment while accepting a duty to respond to the scrutiny of its

stakeholders.

Transparency – an organization should be transparent in its decisions and activities that impact

on the community (society), the environment and the local economy by disclosing in a clear,

accurate, and complete manner, and to a reasonable and sufficient degree, the how it affects

sustainable development should this be deemed to be significant within the community setting.

Ethical Behavior – an organization should behave ethically based on the values of honesty, equity,

and integrity. These values imply a concern for people, animals, and the environment, and a

commitment to addresses the impacts of its activities and decisions on stakeholders’ interests.

Respect for Stakeholder Interests – an organization should respect, consider and respond to the

interests of stakeholders (Chapter 5).

Respect for the Rule of Law – an organization should accept that respect for the rule of law is

mandatory.

Respect for International Norms of Behavior – an organization should respect international

norms of behavior while adhering to the principle of respect for the rule of law.

Respect for Human Rights – an organization should respect human rights and recognize both

their importance and their universality. (Pojasek,

References



Pojasek, Robert B. (2013). Strategies for Sustainability. Chapter 3. Sustainability from

Perspective of an Organization. Retrieved from





34

Appendix 4

(NIST, 2005)

Reference

National Institute of Standards and Technology. Baldrige National Quality Program: Health Care

Criteria for Performance Excellence. 2005. Retrieved from

http://www.academia.edu/248995/Improvement_of_hospital_management_in_the_context_of_he

alth_sector_reform_and_its_linkages_to_primary_care_in_Thailand_Rapid_situation_assessment

_and_recommendations




35

Appendix 5

ISO Annex SL

Harmonized Structure of ISO Management Systems (ISO/IEC, 2013)

Quality

Environment

Energy Management

Health & Safety

Social Responsibility

Sustainability

Human Resources Management

Financial Management

Business Continuity

Asset Management

Information Security

Fraud Countermeasures and Controls

Event Sustainability

Enterprise Risk Management

Governance

Code of Conduct

Other Management Programs

Reference

International Organization for Standardization and International Electrotechnical Commission

(ISO/IEC). 2013. Consolidated ISO Supplement – Procedures Specific to ISO. (Directives, Part 1)

Geneva, Switzerland: International Organization for Standardization. Retrieved from

http://isites.harvard.edu/fs/docs/icb.topic1393001.files/Chapter%208%20Sustainability%20Mana

gement%20System.pdf



36

Appendix 6

11 Principles of ISO 31000 (ISO, 2009)

Risk Management

1. Risk management creates and protects value. • By overcoming the uncertainty and meeting the organization’s objectives the performance will be improved

• Supports the three responsibilities of sustainability

• Leads to the social license to operate, product/service quality, project management, efficiency in operations, governance and reputation.

2. Risk management is an integral part of all organizational processes. • It is embedded in every process at every level of the organization

• Risk management is the responsibility of every leader and is part of what every employee does every day

3. Risk management is part of decision-making at all levels in the organization.

• It is used to make informed choices

• Risk management helps to prioritize actions and distinguish between courses of action

4. Risk management is used to deal with uncertainty. • It helps address the nature and type of uncertainty that the organization must deal with • It uses sustainability to create opportunities to offset threats

• It contributes to an approach to maximize the organization’s efficiency

5. Risk management is systematic, structured and timely. • This approach contributes to efficiency and to consistent, comparable and reliable results • Makes sure that the approach to risk management is demonstrated to be systematic, structured and timely

6. Risk management is based on the best available information. • Decision makers must make sure they understand and take into account any limitations of the data or modeling. This

includes any divergence among experts.

7. Risk management is tailored.

• It must be aligned with the organization’s internal and external context and risk profile.

8. Risk management takes human and cultural factors into account • Make sure that the approach to risk management recognizes and considers the human and cultural factors that can influence

the achievement the organization’s objectives • Recognize the capabilities, perceptions and intentions of external and internal people

9. Risk management is transparent and inclusive. • The approach to risk management must be open, visible and accessible

• The approach to risk management must engage stakeholders and involve decision makers from all parts of the organization

10. Risk management is dynamic, iterative, and responsive to change.

• The risk management program must continually sense and respond to change

• As internal and external events occur, context and knowledge change. This needs to be captured by the monitoring and review process.

• New risks emerge, some change and others disappear.

11. Risk management facilitates continual improvement of the organization.

• Risk management should be used to improve all aspects of the organization

• Develop and implement strategies to improve the risk management maturity of the organization. (Pojasek, 2014)

References

International Organization for Standardization (ISO). (2009). Risk Management – Principles and Guidelines. ISO

31000. Geneva, Switzerland: International Organization for Standardization Press. Retrieved from


Pojasek, Robert B. (2014). Strategies for Sustainability Management. Chapter 7 Risk Management and

Sustainability. Retrieved from



37

Appendix 7

References

International Organization for Standardization (ISO). (2009). Risk Management – Principles and

Guidelines. ISO 31000. Geneva, Switzerland: International Organization for Standardization Press.

Retrieved from


Action to address Opportunity or ThreatAn example of the stated benefit of ISO

31000 (ISO, 2009)

#1

Risk Management creates and

protect value - Supports the three

responsbilities of sustainability

Examining the environmental, societal and economic impact of

renovation works

Effectively address the three

resopnsibilities of sustainability

#2

Risk Management is an integral part

of all organizational processes -

Responsibility of every leader and is

part of what every employee does

every day

Embedding renovation procedures into Code of Conduct,

organizational governance, general hospital policy, housekeeping

policy, infection control policy...

Increase the likelihood of achieving

objectives

#3Risk Management is part of decision-

making at all levels

Listening to and addressing the voice of the nurse, housekeeping,

patients, infection control team, construction workers and

designers before, during and after renovation works.

Improve operational learning

#4

Risk Management is used to deal

with uncertainty - Use sustainability

to offset threats

Renovation creates uncertainty and potential negative effects on

health and environment and liability of BH

Improve operational effectiveness and

efficiency, helps ensure compliance with

legal and regulatory requirements and

international norms

#5Risk Management is systematic,

structured and timely

BH needs to systematically address each renovation work project

and in a timely mannerImprove organizational resilience

#6Risk Management is based on best

available information

Decision makers at BH must take every effort to generate and be

furnished with best available information when applying the

system framework to address the issue

Improve governance, transparency and

accountability

#7

Risk Management is tailored -

aligned with internal and external

context and risk profile

This uncertainty was result of context analysis Create the need to identify and treat risk

#8Risk Management take human and

cultural factors into account

these factors have been revealed and addressed in context

analysis and stakeholder engagement process

Establish a sound and reliable basis for

decision-makign and strategic planning

#9Risk Mangement is transparent and

inclusive

BH needs to provide more information and data and include more

stakeholders in addressing risks posed by renovation works.Improve stakeholder confidence and trust

#10Risk Management is dynamic,

iterative, and responsive to change

BH needs to continually monitor the impacts of renovation works,

and continue to seek innovative methods to minimize negative

effects on stakeholders' health and community environment.

Encourage proactive management

#11Risk Mangement facilitates continual

improvement of the organization

By addressing the uncertainties from renovation works, BH will

also improve overall functioning of the entire hospital facility and

community at large

Increase the likelihood of achieving

objectives and effectively address three

responsiblities

Mandate/Commitment to address Uncertainty posed by Renovation Works at Bumrungrad Hospital

Risk Management Principles

(ISO, 2009)


38

Appendix 8 (Yousefian, 2013 p.957-958)

Reference

Yousefian, Shiva. Harat, Ali Taghizadeh. Fathi, Mohammad, Ravand, Mostafa. (2013). Advances in

Environmental Biology, 7(6):956-967, 2013. ISSN 1995-0756. A Proposed Adaptation of Joint Commission

International Accreditation Standards for Hospital-JCI to the Health Care Excellence Model. Retrieved

from http://www.aensiweb.com/aeb/2013/956-967.pdf


39

Appendix 9 (Yousefian, 2013 p.963-964)

Reference: Yousefian, Shiva. Harat, Ali Taghizadeh. Fathi, Mohammad, Ravand, Mostafa. (2013). Advances in

Environmental Biology, 7(6):956-967, 2013. ISSN 1995-0756. A Proposed Adaptation of Joint Commission

International Accreditation Standards for Hospital-JCI to the Health Care Excellence Model. Retrieved from


40

Appendix 10

Process Map

Chart 1

Process Map depicting BH primary activities (Panyaping, 2006):

Chart 2

Process Map that incorporates Chart 1 + activities that address external context1 (Panyaping,

2006);

1 SC assumes with a high degree of confidence that BH does not operate its own incinerator as academic journals stated

that hospital waste treatment at private hospitals is generally carried out by external private party nowadays.

(Chummuel, 2009)

Reference



0302-17.pdf

Procurement →Usage/

Surgery →

Waste

generation→

Waste

Segregation→ Transport → Storage → Transport

Manufacturing

of various

hospital

amenities

→ Procurement →Usage/

Surgery →

Waste

generation→

Waste

Segregation→ Transport → Storage → Transport →

Treatment

and

Disposal



41

Appendix 11

Reference

Pojasek, Robert B. (2014). Strategies for Sustainability Management. Chapter 9. Linking

Sustainability to the Process. Retrieved from


Porter Value Chain Support Functions Baldrige Performance FunctionsFirm Infrastructure • Leadership

• Financing • Strategic Planning

• Planning • Information & Knowledge Management

• Investors

Human Resource Management • Employees

• Recruiting

• Training

• Compensation

Technology Development • Operations Management

• Product Design • Customer/Stakeholder Engagement

• Testing Process Design

• Material Research

• Market Research

Procurement • Operations Management

• Components • Customer/Stakeholder Engagement

• Machinery

• Advertising

• Services


42

Appendix 12

Maturity Matrix

Minimal Involvement → → → → → Full Engageme nt

Risk Management

Principles ↓

Progress Level →

Key Elements ↓

0

No

1

Basic level Principle

accepted with

commitment to

action

2

Early

Progress Early Progress

in

Development

3

Results Initial

Achievement

evident

4

Maturity Comprehensive

assurance in

place

5

Exemplar Others learning

from our

consistent

achievements

Is risk management

embedded in every

process at every

level of the

organization?

Leadership -

Is leadership

committed to this

objective and driving

other performance

criteria?

Systematic,

Structured and

timely?

Operation Focus -

How are services and

activities designed to

improve operational

effectiveness

Transparent and

Inclusive?

Customer Focus -

Are all relevant

stakeholders well

engaged?

Decision-making at

all levels of

organization?

Workforce Focus - Are relevant

employees engaged?

Dynamic, iterative

and responsive to

change?

Procurement - Are actions being

taken here to address

waste reduction

Continual

improvement of

the organization

Technology

Development - Are innovation and

R&D driving

performance

excellence?

Based on best

available

Information? Help

create opportunity

and offset threat?

Information &

Knowledge

Management -

How are information

used to drive towards

the objective?

Deal with

Uncertainty, Helps

to create value

Insurance or

Litigation claims -

medical errors or staff

illnesses

43

Appendix 13

Bumrungrad Hospital Maturity Grid

3

2

3

4

23

3

4

0

0.5

1

1.5

2

2.5

3

3.5

4Leadership

Operation Focus

Customer Focus

Workforce Focus

Procurement

TechnologyDevelopment

Info & KnowledgeMgnt.

Litigation andInsurance Claim

44

Appendix 14

Risk Matrix

Reference

Risk Ranking and Risk Prioritization Tools (2009). Sherri B. Dennis, Ph.D. Workshop on

Produce Safety in Schools. Retrieved on March 16, 2014 from

http://jifsan.umd.edu/docs/workshops/producesafety/presentations/Dennis%20-%20Risk%20Ran

king%20and%20Risk%20Prioritization%20Tools.pdf



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