Penanganan kasus gawat janin dengan sistem code green bertujuan mempercepat response time evakuasi janin ke luar rahim. Sistem code green telah dilaksanakan sejak tahun 2007 di Instalasi Rawat Darurat RSUP Sanglah Denpasar. Namun demikian belum pernah dilakukan evaluasi untuk mengukur keberhasilan penerapan sistem tersebut. Penelitian ini bertujuan untuk mengevaluasi penerapan sistem code green dengan pendekatan kualitatif dan disain studi kasus. Pengumpulan data primer dan sekunder didapat melalui wawancara mendalam dan observasi partisipatif. Dasar teori yang digunakan dalam penelitian ini adalah Theory of Constraints yang memandang sistem sebagai kesatuan mata rantai. Evaluasi juga dilakukan dengan menganalisis enam variabel pada diagram Ishikawa (fishbone diagram) meliputi man, method, material, machine, management dan milieu. Penelitian ini menemukan pemanjangan response time dalam sistem code green pada tahap penegakan diagnosis sampai menghubungi announcer sebagai the weakest link dari penerapan sistem. Variabel yang menyebabkan the weakest link dari sistem ini adalah sumber daya manusia yakni ketiadaan dokter penanggungjawab pelayanan (DPJP) di tempat kerja Ketiadaan DPJP (tidak on site) dalam penerapan sistem code green, terutama pada tahap pelayanan pertama yaitu penegakan diagnosis sampai menghubungi announcer berakibat fatal mengingat adanya keharusan bagi dokter residen kebidanan melaporkan dan meminta ijin terlebih dahulu kepada DPJP. Penelitian ini menyarankan agar pihak manajemen RSUP Sanglah Denpasar mengupayakan keberadaan DPJP di tempat tugas (on site), melakukan kajian standard opersional prosedur, dan melaksanakan monitoring penerapan sistem code green secara berkesinambungan.

 Code green system in management of fetal distress cases have purposes to improve response time on unborn baby evacuation process. Code green system have been implemented since 2007 in Emergency Department of Denpasar Sanglah General Hospital. However, there was no any evaluation process which was performed to assess the successes of implementation of code green system. The aim of this study is to evaluate the implementation of code green system with qualitative approach and case study design. Primary and secondary data were collected by a numbers efforts (by a few methods) such as in-depth interview, and observation participative. The theory of constraints (TOC) which postulate system as a chain was used as a based theory in this study. This study analyzed six variables of Ishikawa's diagram (Fishbone diagram) such as man, method, material, machine, management, and milieu. This study found delay response time in code green system at the step of process from diagnosis to contact the announcer as a weakest link on the implementation of code green system. The cause of this weakest link was human resources. Obstetrician who in charge was not present during implementation of the code green system especially in the first step which the services was started from diagnosis until announcer informed when obstetric and gynecology resident reported and request approval from obstetrician who in charge in that critical moment. This study give recommendation such as to present an obstetrician who in-charge in field of services, to conduct a regular standard operational procedure review, and to perform continuing monitors and evaluations of code green system was needed.