G.r.e.e.n.

Operation Theatre -
(Green OT )
 PREVIEW – Green OT

01 Introduction 02 Assessment Pillars 03 Certification Process

Background Information on Assessment Pillars for Certification and training
Operation Theatres and to deliver continual
Patient Safety Green OT
improvement
01
Green OT
Early intervention and zero delay in the initiation of treatment
are very much essential to stabilize a critically ill patient and
diminishes the anguish and apprehension of the relatives of
the patients attending Emergency.
The development of Green OT protocol is done to help the
Hospitals enhance their patient care practices, mitigate risks
and optimum use of resources.
 Certifications for Hospital Operation Theaters
 Worldwide , Certifications are increasingly being utilized as a key driver for
implementation of patient safety efforts

 Certifications demonstrate to stakeholders that the hospital has maintained

compliance with a set of criteria that provides them with reassurance that
quality, environment, and safety standards are being met.

 Patients , from both within and outside the country feel confident about the
hospitals , which are certified.

 The core messaging around impressive lists of doctors , state-of-the art

infrastructure & accreditations helps reinforce confidence in the target group.

 A “Centre of Excellence” approach with department specific accreditation

provides reassurance to the patients and their relatives.
Critical processes contributing to the success in Operation Theaters

 Management Commitment;
 Competence Management;
 Infrastructure Management;
 Environmental conservation
 Bio-medical Waste Management
 Legal, Statutes and Regulatory Compliance
 Patient Privacy and Access Control
 Infection Control, Patient Safety and Risk Management
Salient Features:

 The Green OT standard covers the concept of practicing operation theatre

activities in environmental friendly & safe manner

 This standard requirement will be a value addition to the hospitals who are
already following NABH & JCI requirements.

 The evaluation is based on the criteria based rating system covering key
elements from the day to day activities of the OT

 The certification approach is through self assessment & through independent

certification body Bureau Veritas.
 Benefits:

• Promotion of Green & Safe working practices by the hospital management to the stakeholders

• The implementation of the standard will increase the overall utilization & optimization of the OT activities

 Green OT procedures & practices will improve the ot processes & evaluation of regulatory compliance can be
monitored.

• The Green OT certification will enhance the reputation & commitment towards environment and safe
practices related to anesthetic agents use among the patients, staff & investor communities
02
Green OT Assessment Pillars
Green OT assessment:
• Promotes evidence based planned care at every visit.
• Potential to address compliance, significantly impact health
care delivery, enhance outcomes and reduce health
disparities.
• Enhances the shift to predictive, personalized and
preemptive medicine.
GREEN OT PILLARS

Resource &
Leadership &
Competency
Commitment
Management

Process
Optimization Infrastructure
& Analysis Management

Operational Legal
Control Compliance
 Leadership & Commitment
Leadership &
Commitment

• Management Commitment

• Environmental and Safety Policies and Procedures

• Risk Assessment

• Incident Management

• Management Objectives
Resource & Resource & Competency Management
Competency
Management

• Workforce Planning

• Induction, Training and Capacity Building

• Communication and Participation

• Roles and Responsibilities

 Infrastructure Management
Infrastructure
Management

• Facility Design / Layout / Location

• Equipment Maintenance and Calibration

• OT Storage conditions

• Managing OT parameters and instrumentation

• Scavenging Systems and Effluent Management

 Legal
Legal Compliance
Compliance

• Statutory and Regulatory requirements

• Guidelines / Norms laid out by Apex body of healthcare association

• Bio-medical waste management

• Other legal requirements pertaining to Manpower / workforce as applicable

Operational
Operational Control
Control

• Identification of Aspects & Impacts

• Infection Control

• Sanitization and Hygiene Practice

• Patient Care and Anesthesia Practice

• Environmental Control

• Health and Safety

• Security and Access Control

 Process Process Optimization & Analysis
Optimization
& Analysis

• Internal Audits

• Management Reviews

• Implementing Improvement Programmes

• Monitoring, Measurement, and Control

03
Certification Process
Certification represents a third-party stamp of approval that a
product, service or system conforms to a specified standard.
It can improve reputation, open up new markets or simply
enable the company to operate.
Step by Step and steady approach to Certification ensures you
reach the goal within timelines.
Certification Process
A Hospital may perform Self assessment Based on the conditions defined in The GOT Programme Score certificate will The surveillance audits are planned on
effectively and efficiently to achieve “GOT assessment tool the percentage of maturity be issued to the Hospital management Annual basis to review the sustainance
Programme” Score by: will be calculated. Based on the calculations once all the criteria is complied to the and progress in the GOT Programme.
Understanding and satisfying the of the percentage (Qualifying score), scoring requirements. GOT Programme
requirements of the GOT Programme – Hospital’s “GOT Programme” Score will be score in all of the criteria will only entitle
Score. confirmed hospitals to get the certificate.
Monitoring the changes in OT Based on the assessment, the results will be The validity of the certificate is 3 year with
environment published in the form of radar chart as given Annual surveillance.
in the next figure.
Defining and deploying proper strategies Hospital may use this tool for their internal
Managing all required process and assessment to identify the maturity levels
relevant resources within the organisation.
Demonstrating confidence in its people,
leading to increased motivation,
commitment and involvement
This assessment tool uses Five maturity
levels. Hospital should review its
performance against specified criteria to
identify current maturity levels and
determine its strength and weaknesses.

Self Assessment On Site Audit Certification Surveillance

Certification Process
Steps to GOT Programme Certification
Wk. 10 Wk. 16
Wk. 7 - 8
Wk. 1 Wk. 2 Wk. 3/4
Wk. 9 Wk. 12 Wk. 18

HCP SAQ + Standard Self SAQ SAQ review Closure of

Onsite Issue of
Registration& Despatch to Training Assessment Submission to and Plan for Gaps & Final
Sign Off HCP by HCP BV onsite Auidt
Audit
Grading Certificate

1. Registration for assessment through BV Website / email.
2. Bureau Veritas Certification will send Technical Contract to Hospital.
3. Copy of GOT SAQ dispatched to Hospital post signing of Contract.
4. Onsite Training for Hospital GOT Programme team on requirements.
5. Hospital to complete Self Assessment and submit same to Bureau Veritas
certification.
6. BV will review SAQ and plan for onsite audit.
7. Post completion of onsite audits and closure of Gaps (if any) found final
grading will be announced and Certificate will be issued.
8. Surveillance Audit at annual frequency shall be conducted to review the
maintenance of GOT Programme Score.

18
© Copyright Bureau Veritas
Certification Process – Rating Criteria
Based on the conditions defined in above assessment tool the percentage of maturity will be calculated. Based on the calculations of the percentage
(Qualifying score), “GOT Programme” Score will be confirmed.

Rating Platinum Diamond Gold

Range >=90% >=80% - <90% >=70% - < 80%

(1) In order to be eligible for a particular category, apart from the overall score,
NOTE : there should be no criteria with Rating 1.
(2) An overall score of <70% would not be considered eligible for certification

CONDITIONS FOR CERTIFICATE ISSUANCE

The certificate shall be issued to the Hospital once all the criteria comply with the scoring requirements.
► A score of >=70% and a rating of 2 and above in all of the criteria will entitle the hospital to get the certificate as
per the category stated above (Refer rating criteria above).
► The validity of the certificate will be for 3 years with an annual surveillance audit at 12 & 24 month interval.
Inability to perform the surveillance within a tolerance of +1 month (max) shall result in suspension of the
certificate.
Certification Process – Rating Criteria
► This assessment tool uses three maturity levels. The typical sample of assessment tool matrix is as follows:

Rating 1 Rating 2 Rating 3 Comments

Requirements Requirements Requirements
GOT defined and implemented
not defined and not implemented but not
Elements
implemented defined and vice versa
Q1
Q2

Based on the assessment, the results will be published in the form of radar chart as given in the below figure
Green OT PROFILE
I. Leadership and
Commitment
100% 100.0%
80%
VI. Process Optimization
100.0% 60% II. Resource and
and Analysis 40% Competency Management
100.0%
20%
0%

III. Infrastructure
V. Operational Control 100.0%
Management
100.0%

IV. Legal Compliance

100.0%
W W W. B U R E AU V E R I TA S . C O M

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