Breaking the Wall of Silence: Carolyn McCulley on Patient Safety, Transparency, and Hopeful Change

My guest for episode #168 is Carolyn McCulley, from CityGate Films, and  she is a co-director and producer of the upcoming documentary called “Breaking the Wall of Silence,” which sheds light on patient safety challenges in healthcare — but more importantly, highlights hopeful examples of cultural transformation.

Rather than focusing only on the devastating consequences of medical errors, the film follows leaders at MedStar Health (a ten-hospital system in the Washington, D.C., and Baltimore region) as they adopt approaches like the Seven Pillars framework for transparency and accountability. MedStar's efforts include involving patients and families immediately after harm occurs, waiving related medical costs, and fostering a non-punitive culture where caregivers can speak up and improve the system.

In our conversation, Carolyn shares:

• Why she and her team wanted to make a hopeful film that encourages action instead of resignation
• How patient advocates like Patty Skolnik and Sorrel King inspired the project
• The role of human factors engineering in preventing repeated errors
• Why transparency and respect for patients (and staff) are essential to rebuilding trust in healthcare
• How crowdfunding (via Kickstarter) was used to launch the project

This episode is not just about a film — it's about the cultural shift needed in healthcare to honor the principle of “first, do no harm.”

Show notes and links:

• The book upon which the title of the film is based (as a homage, not a direct translation of the book into film): Wall of Silence: The Untold Story of the Medical Mistakes That Kill and Injure Millions of Americans
• The book by Dr. Marty Makary she mentions: Unaccountable: What Hospitals Won't Tell You and How Transparency Can Revolutionize Health Care
• Statistics on patent safety and quality problems
• Past episode with Sorrel King
• Earlier podcast with Clare Crawford-Mason that includes a discussion of her film “Good News…How Hospitals Heal Themselves“
• Episode with Dr. Richard Shannon talking about Lean and infection reduction
• The “seven pillars” approach to improving patient safety

For a link to this episode, refer people to www.leanblog.org/168.

For earlier episodes, visit the main Podcast page, which includes information on how to subscribe via RSS or via Apple Podcasts.

Transcript

Mark Graban: Hi, this is Mark Graban. Welcome to episode 168 of my podcast. It's March 18, 2013. My guest today is Carolyn McCulley from Citygate Films and she is a co-director and producer of the upcoming documentary due out next year called Breaking the Wall of Silence.¹ And through March 31, you can sponsor their project through the website Kickstarter, and I hope you'll join me as a supporter of this important work.

If you go to leanblog.org/168, you'll find a link to learn more and view a video preview of their project on Kickstarter. As Carolyn discusses with me, their film doesn't just focus on the problems of patient safety and poor healthcare quality. It focuses on the positive steps that MedStar Health, a large health system in the Washington, D.C. area, is taking to transform its culture to reduce systemic patient harm.² And those efforts include the Lean improvement methodology. And this focus is why Carolyn calls this a hopeful film as opposed to being just alarmist. So I hope you enjoy the conversation. Again, go to leanblog.org/168. There's a bunch of show notes and links to different books and articles and things that are mentioned in podcasts, a link to the Kickstarter page, and there's links to previous podcasts of mine on patient safety that you might be interested in as well. Carolyn, thanks so much for being a guest on the podcast and talking about your project today.

Carolyn McCulley: Mark, it's my pleasure. Thank you for having us on.

Mark Graban: Well, sure. So tell us the story of Breaking the Wall of Silence, the documentary, how it came to be, why you're working on this.

Carolyn McCulley: We actually got started on this topic because we had the opportunity to film a project for another author who was writing a book on transparency and accountability. So we created a book trailer for him, and that's how we got immersed in the subject as filmmakers. We were focusing on other topics. We're doing a documentary on aviation and on jazz music. We do client projects.³ But we weren't well versed on this topic until we did the book trailer. And that's when we had the opportunity to interview some of the leading figures in patient safety. And as we got immersed into it, we thought, “Okay, this really begs for a follow-on documentary.” But when we showed people the trailer for this project, we saw the reaction that a lot of people had, which was, “I'm alarmed. I didn't know this, and now I want to stick my fingers in my ears, Lalala, because there's nothing I can do about it.” I saw the reaction of outrage followed by immediate resignation. And I have a friend who's having surgery on Monday, and she's been proactive on this topic, but I saw that as soon as I wanted to talk to her about the particular risks, she just said, “I don't want to hear about this. There's nothing I can do. I need this surgery for my health, and I don't want to be scared when I go in.” And that really shaped the direction of the documentary we wanted to make. There are a lot of documentaries that are alarmist, and for good reason. There's a lot of things to alarm you in this world, but that's not always what draws people to wanting to watch a documentary. You know, it's great that we have access to things like Netflix and iTunes, but if you're going to kick back on a Friday night, are you going to want to watch an alarmist documentary or an escapist entertainment film? We all know it's going to be the latter. So we wanted to make a hopeful film. And so we were looking for a cast of characters who were on a quest to change the system rather than just put together something with a lot of scare stories.

Mark Graban: Yeah. And I'm curious, the author of that book on transparency and accountability, who was that author? What was that book?

Carolyn McCulley: The author was Dr. Marty Makary, and the book was Unaccountable.

Mark Graban: Yeah, that's been a really recent best-seller, fairly recent book that's out there. So it's great that you're able to work with him. For listeners, I'll post a link to that book in the show notes as well. So it's great. I mean, I appreciate the tact you're taking of trying to make a hopeful film. I'm sure the film will break down some of the data and some of the risks. But on that hopeful front, talk about who you're working with to illustrate some of the good things that are happening in healthcare, trying to improve patient safety and protect patients.

Carolyn McCulley: It was actually one of the characters in that book trailer, Patty Skolnick, who's a patient safety advocate.⁴ It was meeting Patty that led us through to the MedStar folks that we ended up meeting. She was telling us about her good friend Dave Mayer, a doctor in Chicago who had just gotten a new position in the area where we are. We're based in Washington, D.C. region. So I called him and I said, “I hear that you've gotten a new position in patient safety and that you might be interested in working with us.” Well, it turns out that he had already produced two documentaries of his own, educational documentaries for doctors and nurses and those in the healthcare industry. And he had made one about Patti and the incident that had happened with her son, who unfortunately passed away. And in fact, today, as we're recording, it's her son's birthday. So I've been thinking of Patti and her family today and knowing that every time, you know, this year, every time during the year that they think of their son, Patti is thinking of them every day because of the work that she does.

Anyway, through Patti, we met Dave Mayer. And so when we walked in and said, “We hear that you're on a quest… on a quest to bring some of the things that you have developed in terms of patient safety now to this entire large hospital system in this region. And we'd like to follow you.” Well, when you show up as a film team to a hospital, you know, people are kind of suspicious and for good reason. You know, it's hard to differentiate between those who are making films, those who are doing gotcha television shows, and you have to earn the trust. But what I appreciated right away about Dave Mayer was the fact that he knew what we were talking about. Having produced films before, he understood the process. And two, he was so committed to the transparency that he was going to bring into this hospital system, which had already been practicing a lot of it anyway. It wasn't like they were completely unfamiliar with it, but they wanted to see his entire program transformation brought in. And he welcomed us to come in and be part of that process. And that was really compelling to us just to see that as he began his journey. He was just a few months into the job, as I recall, when we met last fall, that he welcomed us to start following the story.

So what MedStar is doing, MedStar's a healthcare system with 10 hospitals and a number of other facilities in the Washington, Baltimore region, and they have well-known hospitals like Georgetown, Washington Hospital Center that sit right in the nation's capital and a number of other hospitals that would be more community-based hospitals throughout the region.⁵ But it's a large system, but not a well-known system. So what he wanted to do was to bring in a number of programs and also work with MedStar's innovative human factors engineering department. Their innovations systems. These are things we're still learning about, but kind of excited that there are people who are looking at the factors that contribute to errors in hospitals that are beyond just a “bad doctor.” You know, we all can get alarmed, but there actually are factors that other high-risk industries have already tackled. Looking at like, “People are going to repeatedly make this error if this button is red when it needs to be green, because we always think green means go.” And so they have this whole collection of people looking at the factors for medical errors. But mostly I was impressed by what he and Dr. Tim McDonald had already developed in Chicago which was this concept called Seven Pillars. And the idea was we're going to bring immediate transparency when patient harm occurs. So immediate reporting to the patient, including the patient and the patient's family in how they were going to fix the error, waiving the medical costs of that surgery and any follow-up or related medical care that was needed. What a concept, customer service, right? Any other industry, if they mess up, they don't charge you for it. And so, it was these wonderful ideas of being accountable, making change and creating a non-punitive culture for those who are working in the hospital system. I mean, everyone knows in every industry there are bad apples in a sense, but as we've come to see it, there are just a lot more people who are affected by the culture, the system and the crazy hours and the expectation of all that you're going to juggle. And more often than not, these are preventable mistakes, which is the reason why he is passionate about getting in and creating a system that would fix what is preventable.

Mark Graban: Right. And I think that's a message I'm sure is resonating with the listeners. People listening, whether they work in healthcare, whether they work in other industries, people who use this Lean Management System, as it's called, it's based on Toyota. A lot of it's based on the work of Dr. W. Edwards Deming, who was one of the quality gurus of the last century, who would focus on… Dr. Deming would say something on the order of 94% of problems or defects are caused by the system. He never said 100% because you're right, sometimes there are people who make willful choices that they shouldn't have. But more often than not, it's the system. It's people being overly stressed. It's bad system design, lack of time, factors like that that do make things preventable, as you're saying. So it sounds like the focus at MedStar is around this culture.

Carolyn McCulley: And, you know, as filmmakers, every time we get on a subject, we are catching up to the knowledge that our own subjects have. And we're in the same position here in catching up on the issues of patient safety. But what you should have a skill for and an eye for as a filmmaker are those who are on really interesting quests, who have important and issues ahead of them and important narratives. And so we're learning and catching up on this subject. And one of the ways that we began this journey with MedStar was the fact that Dave had assembled a team of nationally known patient safety advocates. And Patty Skolnick is part of that. Helen Haskell, Carol Hemmelgarn, Michael Millenson, Victoria Nahum, Sorrel King, and Rosemary Gibson, who is the author of the seminal book The Wall of Silence. And she has been a huge supporter of us. Very grateful for her and very grateful for her allowing us to have the hat tip to her book with our film title, Breaking the Wall of Silence. So as they met with Dave and they started saying, “Here are the things that we think you should be doing. These are the areas we're passionate about in terms of change.” And they're not all on the same page themselves. They each have different agendas, but as they work together, they're kind of like the Greek chorus for this. They represent the patients who are their voices needing to be heard in this process. And so we've begun to film those meetings and as Dave is listening, as the MedStar team is listening, and we're beginning to learn each one of these characters and what they're doing. But we're at the very beginning of this journey and starting to film with them as they begin to change and bring several factors system-wide throughout the hospital. And there are risks. I mean, there are people who are listening in the hospital system saying, “I don't know, this could put my job at risk. What if I report this error? Won't somebody above me be punitive? Won't I be shut out? Could I lose my job?” And so, just the idea that somebody could come in and say, “Okay, we're going to have a non-punitive culture” doesn't mean that everybody believes that. And you know, there are those risks.

Mark Graban: Well, it takes time to build up that trust with people when you're trying to kind of reshape that culture. There is that traditional fear of punishment. That's why people don't speak up when there's risks or near misses. And unfortunately then because those systemic issues don't get addressed, you have often quite serious patient harm. You mentioned Sorrel King. I've been able to meet Sorrel before. She was actually a guest of mine back on episode 78 of my podcast talking about the tragedy with her daughter at Johns Hopkins and how she's channeled what was originally a lot of anger, of course, about what had happened into working with Johns Hopkins, people like Peter Pronovost and others who are really trying to do great things to help change the culture and improve systems within healthcare. And I think it's great you talk about catching up to what the experts know, the people you're working with at MedStar. But there can be the trap an expert in an area falls into of being unable to communicate it clearly in a way that can resonate with the public. And so I'm sure that's the skill that you and your team are bringing to the project. Being able to actually explain something in, like you said, in an engaging way that makes them want to actually watch and learn and hopefully take action. So on that point, what do you hope the film will accomplish in terms of the way you envision the film, people's reactions? What would you like to see come out of it other than having the film out there?

Carolyn McCulley: We want the general viewership to understand the issue of patient safety. Most people are probably a lot like me, you know, you find out about this in the beginning that there's a risk that you could be harmed in a clinical setting, and that's not well known because of the traditional “deny and defend” principles. So when patient harm did occur, there would be a settlement or an award, and then there were terms to that in terms of what you were willing and could talk about. So not as many people are aware of this. And so we want the educational component to be in there. We want people to understand this. But then we want to be able to turn around and offer them a picture of those who are breaking the wall of silence. I mean, in the sense of the risks that they're taking, while the rest of the industry watches. And we hope that there will be, that this film will inspire change.

Now, Dave Mayer and everybody else on this project is very quick to point out that they're not really coming up with anything new, that they're taking the best practices, many of which different ideas have been developed around the country, and putting them together in a comprehensive change. That's really the point to emphasize, is that as far as any of us are aware, no hospital system of this size has tried to do such a comprehensive change. And that is really the quest that we want to follow. And whether it'll be successful or not is really the arc of the film. Now, in doing this project, even though we're at the very beginning of it, we've already heard many heartbreaking stories from patients. Many people have already contacted us, sent pictures, told us their stories. And that's, to me, it breaks my heart to see the suffering that's out there. And those are very real and valid stories in and of themselves. But what we really want to show is the fact that it is possible to own your mistakes and change the system. I've heard this both inside and outside of the medical industry. I've heard this from lawyers. I've heard this from various counselors. The main reason that people sue is because nobody has said, “I'm sorry,” nobody has owned their mistake, and nobody's given them the information. And so what fascinated me about the Seven Pillars Project and the articles I was reading about it was how when this procedure was used in Chicago and this process was used, that the number of claims went down, the number of malpractice claims went down, the number of lawsuits went down, and their premiums went down. And so you're able to see that the fear that a lot of people have of the financial risk is not always merited, and that more often than not, what people want are answers. And when they don't get answers, then they sue because they're angry. It's the only way to find out what happened to them or their loved one.

Mark Graban: And so I hope the film accomplishes all of those goals and more of creating awareness, helping, I think, maybe even other hospital systems see what's possible through the good work that MedStar is doing. And maybe the final thing we can talk about here, we've jumped ahead to talk about when the film is done. Let's talk about Kickstarter and the process that you're going through. People listening might not be familiar, might not have heard of Kickstarter, or might not know how it works and the role people can take in helping fund the project. So can you talk about, I think we've covered maybe why this is an important film and why people should go and support this. I was happy to go and make a pledge to support the project, but can you talk about how others can help and how this works?

Carolyn McCulley: Yes, and thank you for your support, both in the financial support and in giving us this time on your podcast. My co-director, Brad Allgood, wasn't able to join us today, but we're both very grateful for your time and support. Kickstarter is part of what they call a crowdfunding effort. And crowdfunding simply allows you to build both audience awareness and financial support for a creative venture. It's used by a number of people, filmmakers, artists, writers, game developers. And the idea is that you share your pitch with people and they participate, they back. It's not usually a tax-deductible venture, not on Kickstarter. There are some crowdfunding, other crowdfunding elements that allow you to do a tax-deductible contribution. But with Kickstarter, it's much more of an innovative element. And so what they do is they vet us on our end pretty clearly. We have to be approved through Amazon payments. We have to be a financially viable company. We have to send in our bank account information. We have to do a lot of things so that they can represent you as not being a scam artist. And then there's this accountability for the milestones of delivering the rewards that backers receive. So when you go to Kickstarter, you're able to see the pitch for whatever the project is, read about it, see what the rewards are. The rewards can only be things that you create. You can't offer cars and other things for participating, but they're things that are part of your creative process. So most often for filmmakers it's, you know, the film credits, get to be a backer and see your name and the credits at the end of the film. So if you watch other films these days, you'll usually see a special thanks list with this ginormous number of names that follow. The crowdfunding campaign and access to behind-the-scenes information and film posters and these tiered rewards for backing.⁶ But mostly it's for the thrill of being part of an experience to be able to say, “I helped to support this and there's my name.” But more importantly, “I believe in the cause, the game, the film, the project.”

Mark Graban: The art, whatever, and looking at the page and I'll have a link again in the show notes. But if you go to Kickstarter and search for Breaking the Wall of Silence, there is, I guess, a deadline here, it's time-bounded by March 31, which is why I wanted to go ahead and get this out here. But if you go and find the page on Kickstarter, there are like, Carolyn, you were describing these different bonuses you can get of having your name listed in that list of credits. At higher levels of sponsorship, you can get a press kit or a movie poster or there's even some higher-level contribution levels where you can actually be listed as an associate producer and be involved in that way if somebody really believes in the project and wants to be a part of it. So anything else you would add about the Kickstarter process?

Carolyn McCulley: Kickstarter is actually different from a number of the other crowdfunding operations that are out there. Kickstarter believes that if you can't raise the amount that you need to get a project going or for the project stage you're in, then you can't guarantee success to your backers. So what they do is they've set a target, you decide what it is, whatever you're going to raise. But Kickstarter's system is if you don't meet your goal, you don't get any of what's been raised. And so that's a little nerve-wracking. We've done other crowdfunding, we've used other crowdfunding companies because of that risk. You know, you're like, “If I don't make it, I won't get any of it.” I understand from the backer's perspective why Kickstarter is a better system in some ways because you don't, your pledge is not collected unless that target is met. And so you can pledge and see how the campaign is going. You can change your pledge, you can raise it as it goes along if you want to. But for us from our side, you know, we have to work to build audience. We have to work to find people who are interested in it. And yeah, I mean, it's nerve-wracking. Every day we're going like back. You do feel like for 30 days you're a beggar with your hat in hand going back my film. But the point is that we believe in it and so we see the merit and we are hoping that other people would see the merit and see the importance of helping to get a feature film out that is going to inspire change because each local community helps to bring change to their local hospitals. It helps to create the conversation about patient safety. It's a process, but it's also an activist process and it requires collective change.

So we're actually working on a film right now, a little short update showing about the work that young doctors as residents are doing and why they are the ones most likely to pick up the mantle for patient safety. So we're getting ready to post a little update about that on our campaign. And so we continue to post updates and share information. But yeah, you know, you do kind of feel like you're back in high school with, “Hey, am I popular?” So, yeah, we appreciate the fact that you've shared your time on your podcast with us.

Mark Graban: Well, sure. And I'm happy to support the project. And I'll also be watching. We're recording this here on Friday, March 15, so we're halfway through and it says 16 days to go and it shows the stats. So as people are listening, you'll have about two weeks to learn more about the project. There's a video there on the Kickstarter site, a nice trailer that has a good overview and a lot of text and information that Carolyn and the team have provided there. So again, I hope people will go and check that out. So if you want to learn more, and a lot of people I know listen away from their computers, but use your computer, use your smartphone and go to leanblog.org/168. That's the episode page for our discussion. Here we'll have links to the specific Kickstarter page and you can take a look and hopefully join me as a supporter and contributor to this project. So, Carolyn, thanks so much for taking time to talk about the project and certainly wish you the best of luck, not just with the fundraising, but the filming of this really important story.

Carolyn McCulley: Great, thank you so much. I appreciated our conversation.

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