Healthcare Providers and Services, and Healthcare Technology · Sustainability Topics for Sectors:...

Sustainability Topics for Sectors: What do stakeholders want to know?

HEALTHCARE PROVIDERS AND SERVICES, AND HEALTHCARE TECHNOLOGY

May 2013 Page 1 of 26

This table shows a list of topics identified as relevant by different stakeholder groups. They can be considered as stakeholders’ suggestions or requests for topics to be monitored or disclosed by organizations.

Additional information about the project can be found at https://www.globalreporting.org/reporting/sector-guidance/Topics-Research/Pages/default.aspx

45 – Healthcare Providers and Services, and Healthcare Technology

21 Topics

Providers of patient health care services. Includes dialysis centers, lab testing services, and pharmacy management services. Also includes

companies providing business support services to health care providers, such as clerical support services, collection agency services, staffing

services and outsourced sales & marketing services. Owners and operators of health care facilities, including hospitals, nursing homes,

rehabilitation centers and animal hospitals. Owners and operators of Health Maintenance Organizations (HMOs) and other managed plans.

Companies providing information technology services primarily to health care providers. Includes companies providing application, systems

and/or data processing software, internet-based tools, and IT consulting services to doctors, hospitals or businesses operating primarily in the

health care sector. Distributors and wholesalers of health care products not included elsewhere.

Sustainability Category

Topic Topic Specification (if available)

Explanation Reference(s)1 Constituency

Environmental Toxic chemicals and materials

Hazardous chemical and toxin use

Health care facilities around the world are reducing their use of hazardous chemicals and products. For example: More than 6,000 health care facilities in the U.S. are eliminating mercury-containing medical devices in favor of safer non-mercury alternatives Hospitals from Stockholm, to Prague, and throughout the U.S. are phasing out phthalate-containing PVC medical devices and switching to safer plastics

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Many hospitals are reducing pesticides by using integrated pest management techniques Many hospitals are choosing safer, less toxic building materials for new construction and renovation projects. Green chemistry is the design of products and processes that reduce or eliminate the use and generation of hazardous substances. Green chemistry seeks to reduce and prevent pollution at its source. High-priority chemicals and materials include: Mercury PVC (vinyl plastic) and phthalates Brominated flame retardants Glutaraldehyde and ethylene oxide Pesticides Volatile organic compounds in building materials Hazardous ingredients in cleaning products. Green chemistry is the design of products and processes that reduce or eliminate the use and generation of hazardous substances. Green chemistry seeks to reduce and prevent pollution at its source. The ubiquitous exposure to toxic chemicals in everyday life has increasingly become a health concern. Unfortunately, many products used in health care contribute to hazardous exposures — including cleaners and disinfectants, phthalates in medical devices, flame retardants in furniture, formaldehyde in furniture and solvents in labs. Emerging scientific research is raising the level of

concern about the health impacts of chronic chemical exposures. We now know that: Even small doses of chemicals can cause disease — interfering with sexual development, disrupting hormones and causing cancer at very low levels. Children and developing babies are most vulnerable. Hundreds of synthetic chemicals are found in human breast milk and in the cord blood of babies in the womb. Chemicals can act like drugs in our body, disrupting systems at low levels of exposure, and potentially causing harm in combination. Chemical Related Diseases: As chemical use has grown in industrialized societies, so have chemical-related diseases, including cancer, asthma, birth defects, developmental disabilities, autism, endometriosis and infertility. Mounting scientific evidence links the incidence of these diseases in part to environmental toxicants. Health care institutions have a particular ethical responsibility to use products containing chemicals that pose less risk to human health — and due to their massive buying power, the health care system can play a key role in shifting the economy toward green chemistry. A growing number of hospitals are taking a "better safe than sorry" approach to chemicals — eliminating suspected hazards and switching to safer alternatives. Benefits of this approach to the bottom line can include reduced disposal costs, reduced liability and improved health for employees.

Toxins with an especially heavy impact in the health care sector may be found in: Cleaners and disinfectants Dioxin-containing byproducts Electronic equipment Flame retardants Fragrance chemicals Mercury-containing medical devices and wastes Pesticides Phthalates and DEHP PVC Health care institutions, like institutions outside the health care sector, regularly use a surprising number of highly toxic materials. These toxins affect patients, hospital staff, and hospital visitors. Many of these toxins are defined and regulated by federal, state and local laws. Others are used daily but hardly regulated at all. They include carcinogens, materials that damage the skin and organs, and materials that corrode, irritate, or release other toxins in the course of normal use, storage, transportation or disposal.

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Plastics use and management

Plastic, a valuable material, can generate significant positive, or negative, impacts on economy, environment and society. Plastic should be treated as a resource and managed judiciously. A disclosure on management approach for plastics,

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including governance, strategy, risks, opportunities, considering: opportunities for product redesign, increasing recycled content, implementing reclaim and/or reuse which could attract economies, brand loyalty, investment, employee goodwill, and; risks to the business, stakeholder health, environment and society (including reputational/social license to operate, regulatory, investor, insurer, and liability risks) for plastics that are directly harmful to stakeholders, or indirectly through plastics being wasted/littered. Performance indicators regarding the types and volumes of plastics being used, collected and/or distributed downstream; the portion that is made of post-consumer-recycled, bio-based, biodegradable, compostable, and/or oxobiodegradable material; the ratio of expected life-span of plastic products/packaging in contrast to the duration of their intended use; these volumes broken down by end of life disposition. Most of this disclosure can be captured through the existing GRI framework (e.g. GRI G3 EC9, EN1, EN2, EN22), but commentary is needed to ensure disclosers appreciate the materiality of plastic; other questions can be added to the framework. Refer to the Plastic Disclosure Project ( www.plasticdisclosure.org ) for more details on the suggested questions. PDP will align its questions to GRI G4 to assist disclosers. Plastic are in high use in these "activity groups", and can have significant positive, or negative, impacts on the economy, environment and society: Economics: There

are significant cost savings available to organisations that treat plastic as a resource (e.g. through redesign, use of recycled content, reclaiming, etc.) and risks of increased direct costs (regulation, liability, cost of capital, insurance) to organisations that do not lead in this area as well as indirect economic costs to impacted industries (e.g. food production, tourism). Environment: Plastics that are wasted or littered become extremely harmful to the environment, which will have a material effect on biodiversity and the global food chain, both nearby and far outside the local area of operations. Society: Some plastics are harmful to stakeholders during manufacture, use and/or disposal (e.g. due to phthalates, BPA), impact the wellbeing of society (e.g. effect of litter on community spirit and their interest in sustainability). While a valuable invention, which benefits society in many ways, the negative impacts associated with society's growing use of plastic are not fully recognised. Roughly 85% of plastic used in products and packaging is not recycled, and most plastic produced in the last 60 years still remains in the environment today. Discarded plastics persist in the environment for dozens or hundreds of years, accumulating across the globe, often out of sight of the producers and users. The direct physical impacts of plastic are significant to the organisation in increased costs or missed opportunities, and related economies (e.g. over $1.2bn in annual damages to ocean-related industries in Asia-Pacific), the environment through harming habitats and species, and

to stakeholders health when exposed to the chemical ingredients; and are magnified if fragmentation of the plastic occurs, making it available for ingestion to additional species, who adsorb the chemical ingredients and/or the toxins carried on the plastic. These negative impacts could be avoided and turned into positive impacts, if plastic was treated as a resource to be managed judiciously (e.g. the US economy lost $8.3bn worth of plastic packaging in 2010) - "It is not good business practice to throw away valuable resources".

Healthcare waste management

Healthcare, medical research facilities and laboratories

Medical waste is all waste materials generated at health care facilities, such as hospitals, clinics, physician's offices, dental practices, blood banks, and veterinary hospitals/clinics, as well as medical research facilities and laboratories. The Medical Waste tracking Act of 1988 defines medical waste as "any solid waste that is generated in the diagnosis, treatment, or immunization of human beings or animals, in research pertaining thereto, or in the production or testing of biologicals." This definition includes, but is not limited to: blood-soaked bandages culture dishes and other glassware discarded surgical gloves discarded surgical instruments discarded needles used to give shots or draw blood (e.g., medical sharps) cultures, stocks, swabs used to inoculate cultures

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removed body organs (e.g., tonsils, appendices, limbs) discarded lancets Hospitals generate millions of tons of waste each year. In the past, many hospitals simply dumped all waste streams together, from reception-area trash to operating-room waste, and burned them in incinerators — and this is still common practice in many developing countries. Yet medical waste incineration is a leading source of dioxin, mercury, lead and other dangerous pollutants that threaten human health and the environment. Despite these dangers, many governments, public health agencies, international organizations and transnational corporations continue to promote incineration technologies as waste management "solutions."

Infectious waste Infectious waste is waste that is suspected to contain pathogens (disease-causing bacteria, viruses, parasites, or fungi) in sufficient concentration or quantity to cause disease in susceptible hosts. The subcategories of infectious waste are (a) waste contaminated with blood or other body fluids; (b) microbiological cultures and stocks of infectious agents from laboratory work; and (c) waste from infected patients in isolation wards. Waste contaminated with blood or other body fluids include: free-flowing blood, blood components, and other body fluids (semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal

527 Civil Society Organization

fluid, amniotic fluid, saliva and other body fluids visibly contaminated with blood); dressings, bandages, swabs, gloves, masks, gowns, drapes, and other material contaminated with blood or other body fluids; and waste that has been in contact with the blood of patients undergoing hemodialysis (e.g. dialysis equipment such as tubing and filters, disposable towels, gowns, aprons, gloves, and laboratory coats). With regards to infectious healthcare waste, there are four approaches to healthcare waste treatment. A decentralized approach is one where the technology is installed on-site at the healthcare facility. By treating the waste as close as possible to the point of generation, this approach has the advantage of eliminating the transport of hazardous healthcare waste. Another approach is centralized treatment at an off-site facility designed to handle the waste from hospitals, clinics, medical laboratories, doctors‘ offices, and other health facilities in a large urban center, province, or region. This approach requires the transport of infectious waste from many sources to the central treatment facility and is only possible if there is a good infrastructure for collection, transport and temporary storage. Its major benefit is cost reduction as it takes advantage of the economies of scale. A third approach is cluster treatment wherein a hospital serves as a hub for treating waste from surrounding nearby hospitals, clinics, and other facilities. Cluster treatment is an option for small municipalities, parts of a

province, or districts that may be too far from a central treatment facility but have an adequate infrastructure for collection and transport of infectious waste within their area. A fourth approach is mobile treatment. In this approach, the treatment technology is mounted on a mobile platform, such as a specially designed mobile container or a flatbed truck, and is brought to hospitals and other health facilities within a service territory. The mobile treatment system treats and converts infectious waste into regular waste as the mobile unit is parked on the hospital grounds. After treatment, the system is driven to the next healthcare facility. Improper treatment and disposal of healthcare waste pose serious hazards of disease transmission due to exposures to infectious agents among waste pickers, waste workers, health workers, patients, and the community in general.

Pharmaceutical products and items for handling them

For a healthcare facility, several practical options exist for small quantities of pharmaceutical waste: return of expired pharmaceuticals to the donor or manufacturer; encapsulation and burial in a sanitary landfill; chemical decomposition in accordance with the manufacturer‘s recommendations if chemical expertise and materials are available; and dilution in large amounts of water and sewer discharge into a sewer for moderate quantities of relatively mild liquid or semi-liquid pharmaceuticals, such as solutions containing vitamins, cough syrups, intravenous solutions and eye drops.

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Pharmaceutical waste includes expired, unused, spilled, and contaminated pharmaceutical products, drugs, vaccines, and sera that are no longer needed. The classification also includes discarded items used in the handling of pharmaceuticals, such as bottles, boxes, gloves, masks, vials, and tubing contaminated with pharmaceutical residues. Improper treatment and disposal of pharmaceutical healthcare waste pose risks, because for example waste scavengers might collect the expired, unused, spilled, and contaminated pharmaceutical products, drugs, vaccines, and sera that are no longer needed, and take or sell them.

The huge quantities of medicines ending up in waste or in aquatic systems are a major environmental health issue. The increasing documentation of low-dose health effects makes pharmaceuticals a priority area from an environmental health perspective. Hundreds of different active pharmaceutical compounds are being discovered in waterways all over the world. Concern is increasing about the harm these might be doing to human health and the environment. Although levels are usually too low to result in acute effects such as organ damage, there are two cases where drugs have had drastic effects: where the anti-inflammatory diclofenac has virtually wiped out the vulture population of Asia, while man-made estradiol has

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caused fish to start changing sex. Although the levels of other drugs don't cause acute reactions, there is little or no information about the non-acute effects which low doses might have on wildlife and humans. There are suggestions in research that contaminated water affects fish in subtle ways, such as changing breeding behaviour. This may cause declines in populations, or even be an indicator of other problems. Ordinary risk assessment is of limited value in determining the environmental hazard posed by low levels of pharmaceutical compounds, as it only looks at acute effects, struggles to assess the potential effects of mixtures of compounds, and has no way to anticipate freak reactions. What we do know is that pharmaceutical compounds are biologically active and they are detectable in our waterways. We can be sure that it would be better if they were not there. Therefore, we need to take steps to deal with the problem. While patients should be allowed access to the best available pharmaceutical treatment, other things being equal, we should consider the medicine's PBT (persistence, bioaccumulation and toxicity) when developing, manufacturing, prescribing, purchasing,

donating and disposing of medicines. Our collective aim should be to protect people and the environment from contamination of hazardous chemicals that wouldn't otherwise be there.

Technology for waste sterilization and/or destruction

A wide range of alternative technologies are now commercially available. Steam sterilization in autoclaves is the most common alternative treatment method. Since autoclaves have been used in the treatment of infectious waste for many decades, their operation is well established. Several types of steam sterilizers or autoclaves are available: gravity-fed, pre-vacuum and pulse or multivacuum cycle autoclaves. Unlike incinerators, autoclaves heat the waste to temperatures high enough to disinfect but not hot enough to burn and create air pollutants such as dioxins and furans. A post-treatment shredder or grinder could be used if the waste is to be rendered unrecognizable and if reduction of waste volume is desired. Microwave treatment is another type of alternative technology. For years, the most common microwave device has been a medium- to large-scale, semi-continuous system using an internal shredder, rotating internal screw, and industrial magnetrons to generate microwave energy. There are also commercial dry heat treatment technologies. Moist heat has been shown to be more effective than dry heat in achieving disinfection, so dry heat systems generally require longer exposure times and higher temperatures to meet minimum disinfection levels. Medical waste incineration is a leading source of dioxin

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pollution, one of the most potent carcinogens known to science. Fortunately, there are viable alternatives to incineration that are safer, cleaner, do not produce dioxin, and are just as effective at disinfecting medical waste. These technologies can be used on all types of medical waste, including pathological and chemotherapy waste. Given that alternatives to incineration are available, a complete phase-out of medical waste incineration is possible and appropriate. This will require changes in state laws, persuasion of hospital systems that non-burn approaches are both effective and environmentally preferable, public education, and better segregation and reduction of waste by hospitals. Pathological and chemotherapeutic wastes can be treated using alkaline hydrolysis technology which combines steam sterilization with tissue digestion using sodium or potassium hydroxide.

Investment and commitment in the management of health care waste (a by-product of healthcare that includes sharps, non-sharps, blood, body parts, chemicals, pharmaceuticals, medical devices and radioactive materials). Poor management of health care waste potentially exposes health care workers, waste handlers, patients and the community at large to infection, toxic effects and injuries, and risks polluting the environment.

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Healthcare waste is a by-product of healthcare that includes sharps, non-sharps, blood, body parts,

chemicals, pharmaceuticals, medical devices and radioactive materials Poor management of healthcare waste exposes healthcare workers, waste handlers and the community to infections, toxic effects and injuries

Social Migrant workers Recruitment and employment

Recruitment and employment of migrant workers Number of migrant workers employed Countries of origin Gender of workers Positions within company Length of contracts Recruitment channels Any fees for recruitment Passport retention Migrant workers both internal and external are a significant and growing feature of all company activities. There are over 200 million migrants in the world. They are found within nearly all business sectors and across all regions. Many migrant workers, particularly those working in unskilled jobs are subject to discrimination and are vulnerable to exploitation and abuse. For many migrants exploitation begins during recruitment. Exorbitant fees and other charges, often at usurious rates of interest can leave many migrant workers effectively bonded labour whatever the subsequent conditions of employment.

Company due diligence and reporting should therefore extend into the supply chain for labour.

Privacy of medical records and genetic data

The storage and uses made of health records and the results of genetic tests raise questions in relation to the right to privacy. This case raises questions about the right to privacy of the people from whom the samples were taken. There has, for example, been concern that samples of this kind could be used in paternity suits or to assess health insurance risks. AT the other hand, Retention of the samples has significant potential public health benefits, such as retrospective diagnosis from the stored blood spot, even after the individual is deceased, to help provide counselling to the family. Approved research can provide information that is of public health interest or information that can provide a better understanding on how diseases develop, identifying potential opportunities for intervention.

Access to quality medical treatments

Racial and ethnic disparities

Measures taken to eliminate racial and ethnic disparities in providing treatments. Minorities can be treated in a disadvantageous way in health care as in all other areas in life

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Care quality Staff training, staffing ratios per patient and turnover rates

Adequate and properly trained staff are critical to healthcare, oil and gas and financial services. Healthcare providers, including hospitals, nursing homes and home health care need to report on staffing ratios per patient and their turn-over rates. This information

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directly indicates the quality of care provided. with the Volker rule (US Dodd-Frank) are critical to solvency. Extensive academic research and judicial decisions as well as federal and state legislation make these material indicators for sustainability. See, for example, "Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction," JAMA. 2002; 288(16):1987-1993. doi:10.1001/jama.288.16.1987;

Clinical trials Consent processes

Article 7 states that “no one shall be subjected without his free consent to medical and scientific experimentation”. Several companies and research bodies have faced media and legal scrutiny over consent processes used in clinical trials, irrespective of their medical success or failure

Disease spread control

Health care facilities

Acute respiratory diseases during health care may constitute a public health emergency of international concern as defined in the International Health Regulations

Food quality Catering services

Healthcare providers should take into account the following topics when designing the menu for their patients: * Antibiotics *Chemicals in the food system Genetically engineered foods *greening serviceware *hospital food environments *climate change (by buying local products for example)

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Health care facilities across the continent are recognizing that the food system — how our food is produced and distributed — is misaligned with dietary guidelines, and is largely reliant on methods of production and distribution that harm public and environmental health. The food system is inherently a deeply complex and interwoven concept that must be considered from an integrative, ecological perspective in order to develop solutions that nourish our health and that of the planet. Healthy Food in Health Care has selected a broad-reaching scope of topics of concern that form the basis for our work. These issues, like antibiotic resistance, for example, cut to the core of a hospital’s operations. Others, like climate change and genetically engineered foods, are matters of serious public health concern that we believe the health care community has a capacity and power to influence.

Health service effectiveness

Cost effectiveness of key health interventions

Some systems devote resources to expensive interventions with small effects on population health, while at the same time low cost interventions with potentially greater benefits are not fully implemented. The impact of interventions on population health is vital. But it is also important to determine the role of different interventions in contributing to other socially desirable goals, such as reducing health inequalities, and being responsive to the legitimate expectations of the population The impact of interventions on population health is vital.

But it is also important to determine the role of different interventions in contributing to other socially desirable goals, such as reducing health inequalities, and being responsive to the legitimate expectations of the population

Medicines management

Patient safety and environmental impacts

Rational use of medicines requires that "patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements, for an adequate period of time, and at the lowest cost to them and their community Irrational use of medicines is a major problem worldwide. WHO estimates that more than half of all medicines are prescribed, dispensed or sold inappropriately, and that half of all patients fail to take them correctly. The overuse, underuse or misuse of medicines results in wastage of scarce resources and widespread health hazards

Corruption Access to and quality of treatments

Measures taken to avoid corruption in the following processes: provision of services by medical personnel, human resources management, drug selection and use, procurement of drugs and medical equipment, distribution and storage of drugs, regulatory systems, and budgeting and pricing Because of the complexity of health care systems and services, and the significant amount of money involved, the risk of corruption is high, that can result in the inequality of access to and quality of treatments.

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Healthcare systems and services

Corruption in hospitals, informal payments for health care, in pharmaceutical sector and HIV/AIDS Fighting corruption in the health sector is a complex challenge. At one end of the scale are doctors and nurses who charge small informal payments to patients to supplement inadequate incomes. At the other end, and far more pernicious, are the corrupt suppliers who offer bribes, and the health ministers and hospital administrators who accept bribes, or siphon millions of dollars from health budgets, skewing health policy and depleting funds that should be spent building hospitals, buying medicines or employing staff.

Other Corporate governance

Gender participation on governance bodies

GOVERNANCE / EUROPE: boardroom lady boom: is it possible without quotas? On 22 June, the CapitalCom agency published its 2011 survey into the boardroom gender mix of CAC 40 companies, with fairly encouraging results: the proportion of women on the board has doubled in recent years, from 10.5% in 2009 to 20.8% in 2011. In January, the French parliament adopted legislation imposing quotas for the proportion of women on the board of major companies. Under the measures, the development of female board membership is mandatory and gradual: 20% for listed groups, public companies of an administrative, industrial and commercial nature by January 2014, rising to 40% by January 2017. The law also stipulates that companies with no women present on their board must appoint at least one within six

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months of it being on the statute books (voted on 13 January 2011). In France, some 2,000 companies are affected (the 650 largest listed firms and companies with more than 500 employees and those generating sales in excess of €50bn). In terms of sanctions for noncompliance, appointments that run counter to the parity principles are to be declared null and void and attendance fees are to be temporarily suspended. At the European level and at the instigation of the Vice-president of the European Commission, Viviane Reding, the European parliament will decide in March 2012 on whether to adopt common legislation on this matter (a mandatory proportion of women in decision-making positions of 30% in 2015 and 40% in 2020). This will depend on the level of improvement seen based on the selfregulation of European companies, in accordance with the equality initiative adopted by the European Commission in December 2010 and the European parliament resolution of 17 January 2008 calling for the Commission and member states to promote a balance between women and men on company boards, particularly where member states are shareholders. Europe as a whole illustrates the degree of hesitation between a soft-law approach and conventional legislation (quotas in this instance), but it is clear from the experience at national level that the second method tends to get much better results.

Political accountability

There are various measures of political accountability that can be measured (contributions, disclosure, board oversight). Note that this topic is applicable to more than the three industries noted. Essentially the political accountability practices of any company that is owned by public stockholders. Political contributions, the amount of disclosure and board oversight are among the data items that would be helpful in a sustainability report. In making investment decisions (especially for investors interested in socially responsible investing) is would be helpful to understand how a given company is exposed to political risk (i.e. are they backing the winning candidate, are they subject to potential retribution, why do they find it necessary to make political contributions, etc.). I have found the information I reference to be helpful in constructing investment portfolios that take into account this attribute of sustainability. Since it is not currently an established parameter in the socially responsible investment industry (www.ussif.org), adoption by the Global Reporting Initiative would go a long way in moving the topic of political accountability forward.

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Public health service effectiveness

Laboratory readiness - Outbreaks of novel, emerging and dangerous pathogens

Laboratories readiness and response for rapid detection and containment of outbreaks of emerging and dangerous pathogens Outbreaks of emerging and dangerous pathogens are a great risk for public health

1 All references can be found at https://www.globalreporting.org/reporting/sector-guidance/Topics-Research/Pages/default.aspx

References

All references can be found at https://www.globalreporting.org/reporting/sector-guidance/Topics-Research/Pages/default.aspx

34 Baghdadi-Sabeti, G. & Serhan, F., 2010. WHO Good Governance for Medicines Programme: An Innovative Approach to Prevent Corruption in the Pharmaceutical Sector, Geneva: World Health Organization (WHO).

44 Becker, J., 2010. Minding the Gap: Research Priorities to Address Pharmaceuticals in the Environment, Arlington: Health Care Without Harm.

66 Castan Centre for Human Rights Law; International Business Leaders Forum; Office of the United Nations High Commissioner for Human Rights, 2008. Human Rights Translated, A Business Reference Guide, New York: United Nations Global Compact.

102 Davis, S. C., 2002. 10 Ways to reduce regulated medical wastes (RMW), Arlington: Healthcare without Harm.

123 Emmanuel, J. & Stringer, R., 2007. For Proper Disposal: A global inventory of alternative medical waste treatment technologies, Arlington: Health Care without harm.

232 Greiner, T., Rossi, M., Thorpe, B. & Kerr, B., 2006. Healthy Business Strategies for Transforming the Toxic Chemical Economy, Spring Brook: Clean Production Action.

240 Health Care Without Harm Europe, 2007. Preventing damage to the environment from pharmaceuticals: a primer, Prague: Health Care Without Harm Europe.

241 Health Care Without Harm, 2001. Non-Incineration Medical Waste Treatment Facilities, Washington, D.C.: Health Care Without Harm.

242 Health Care Without Harm, 2001. Waste Minimization, Segregation and Recycling in Hospitals. [Online] Available at: http://www.noharm.org/lib/downloads/waste/Waste_Min_Seg_Recyc_in_Hosp.pdf, [Accessed 19 March 2013].

245 Heineman, B. J., 2011. We May Never Know Leaders' Responsibility in Gulf Disaster, Boston: Harvard Business Review.

253 Institute for Human Rights and Business (IHRB), 'The Dhaka Principles for Migration with Dignity', Dhaka, 2011.

353 Kershaw, P., Katsuhiko, S., Lee, S., Samseth, J., Woodring, D., & Smith, J., 2011. Plastic Debris in the Ocean. In United Nations Environment Programme (UNEP), UNEP Year Book 2011 (pp. 20-33). Nairobi: United Nations Early Warning and Assessment.

357 Kulick, M., Nathanson, A. & Sirois, E., 2011. Menu of Change: Healthy food in health care, Arlington: Health Care Without Harm.

362 Aiken, L.H., Clarke, S.P., Sloane, D.M., Sochalski, J., Silber, J.H., 20025. Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction. Journal of the American Medical Association, 288(16), pp. 1987-1993.

367 MacKerron, C., 2011. Unfinished Business: The Case for Extended Producer Responsibility for Post-Consumer Packaging, Oakland: As You Sow.

389° Natixis, 2011. Strategy Note Equity Research - Strategy/SRI: Monthly review June 2011, Paris: Natixis.

394 Nowak, T., 2012. Low Fee Socially Responsible Investing. 1st ed. Grayslake: Quantum Financial Planning LLC.

445 Prüss, A., Giroult, E. & Rushbrook, P., 1999. Safe Management of Wastes from Health-care Activities, Geneva: World Health Organization (WHO).

489 Sutherland, L., Easthope, T., Sattler, B., Welker-Hood, K., Wilburn, S., 2008. Guide to Choosing Safer Products and Chemicals, Arlington: Health Care Without Harm.

494 The American Hospital Association (AHA), 2012. Eliminating Racial and Ethnic Disparities. [Online] Available at: http://www.aha.org/advocacy-issues/disparities/index.shtml [Accessed 29 March 2013].

496 The Centers for Occupational and Environmental Health, University of California, 2008. Green Chemistry: Cornerstone to a Sustainable California, San Francisco: The Centers for Occupational and Environmental Health, University of California.

505 Transparency International, 2006. Global Corruption Report 2006, London: Transparency International.

506 Transparency International, 2006. Global Corruption Report 2006: Corruption and Health, London: Pluto Press.

527 United Nations Environment Programme (UNEP), 2012. Compendium of Technologies for Treatment/Destruction of Healthcare Waste, Nairobi: United Nations Environment Programme (UNEP).

555 Vian, T. & Nordberg, C., 2008. Corruption in the Health Sector, Bergen: U4 - Chr. Michelsen Institute.

583 World Health Organization (WHO), 2002. Prevention of Hospital-acquired Infections, Geneva: World Health Organization (WHO).

584 World Health Organization (WHO), 2003. WHO Guide to cost-effectiveness analysis, Geneva: World Health Organization (WHO).

586 World Health Organization (WHO), 2007. Infection Prevention and Control of Epidemic- and Pandemic-prone Acute Respiratory Diseases in Health Care, Geneva: World Health Organization (WHO).

590 World Health Organization (WHO), 2012. Pursuit of Responsible Use of Medicines: Sharing and Learning from Country Experiences, Geneva: World Health Organization (WHO).

591 World Health Organization (WHO), 2012. Rapid Risk Assessment of Acute Public Health Events, Geneva: World Health Organization (WHO).

593 World Health Organization (WHO), Department for Public Health and Environment Assessing and Managing Environmental Risks to Health, 'WHO Core Principles for Achieving Safe and Sustainable Management of Health-care Waste', 2007.

616 Zicklin Center for Business Ethics at the Wharton School of the University of Pennsylvania, 2012. CPA-Zicklin Index of Corporate Political Accountability and Disclosure, Washington, D.C.: Center for Political Accountability.

° Resource available on request and/or for a fee.

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