About this Presentation
Patient falls continue to pose persistent and costly challenges to healthcare systems worldwide, contributing to adverse patient outcomes, prolonged hospital stays, and increased resource use. Despite decades of effort, the frequency of falls highlights the need for a more focused and systemic approach. This study applies Constraints Management and High Reliability Organization (HRO) principles to reduce inpatient falls in collaboration with the Ministry of Health of Türkiye at Ankara Etlik City Hospital—a state-of-the-art facility with over 4,050 beds. Using the Theory of Constraints (TOC) Five Focusing Steps, the team identified key system constraints and implemented targeted interventions. In this pilot study, three-month control period following implementation showed measurable reductions in falls and related harm. Nevertheless, sustaining and scaling these improvements has proven to be challenging, largely due to factors such as heterogeneous patient risk profiles, fluctuating staff practices, inconsistent data quality, and the operational complexity inherent to
large hospital systems. To address ongoing challenges with sustaining and replicating improvements, the Cynefin Framework is being considered to guide decision-making that reflects the varying levels of complexity in fall-related scenarios. The Cynefin framework distinguishes ordered from unordered domains; in complex and chaotic contexts, patterns must be sensed, and solutions emerge through experimentation. This differentiation supports more effective governance by aligning interventions with the nature of the situation—avoiding over-standardization in complex domains and enabling rapid response in chaotic ones. Concurrently, the initiative reinforces the core principles of High Reliability Organization (HRO), particularly preoccupation with failure, sensitivity to frontline operations, and commitment to resilience. Teams were encouraged to anticipate failure modes, respond to weak signals, an engage subject matter experts closest to the work to shape realistic, sustainable solutions. These behaviors were essential I reducing variation in fall prevention practices across departments and shifts. However, sustaining gains requires more than behavioral discipline. It depends on robust data quality and sufficiency—including timely, narrative-rich, and context-aware reporting that goes beyond binary metrics. Data sufficiency also includes the presence of both leading and lagging indicators that can inform learning from both success and failure. By combining Constraints Management, HRO behaviors, and Cynefin’s situational awareness lens, this integrated approach offers a practical, adaptive model for improving patient safety and operational reliability in dynamic healthcare environments, while building the foundations for long-term learning and system-level resilience.
What Will You Learn
To help you get the most value from this session, we’ve highlighted a few key points. These takeaways capture the main ideas and practical insights from the presentation, making it easier for you to review, reflect, and apply what you’ve learned.
Learn how applying Theory of Constraints and High Reliability principles reduced inpatient falls by 50% in a large, complex hospital environment.
Understand how identifying systemic constraints—such as staffing, awareness, and environmental factors—enabled focused, coordinated fall-prevention actions.
See how TOC logic tools like SIPOC and the Ambitious Target Tree aligned bedside practices with leadership decision-making.
Gain insight into sustaining patient safety improvements through training, feedback loops, and cultural commitment across the organization.
Instructor(s)
Bahadir Inozu, Ph.D
Dr. Baha Inozu is the cofounder and CEO of Sharp Focus, Inc., and a faculty member at the University of Southern California. He has collaborated with more than forty organizations to improve performance and reliability across a range of sectors. Internationally recognized for his expertise in system reliability and performance improvement, Dr. Inozu specializes in integrating leading methodologies to achieve high-impact outcomes. He currently supports the SafeMTS project as a Subject Matter Expert and contributes to the Shipyard Infrastructure Optimization Program (SIOP) for the U.S. Navy.
His research centers on identifying and applying best practices from high-risk industries to advance safety and reliability. He is the co-author of High Reliability for a Highly Unreliable World. Previously, he served as CEO of NOVACES and as Chairman of the School of Naval Architecture and Marine Engineering at the University of New Orleans.