MM: Waiting times and delays are ubiquitous in health care, and until a few years ago most people thought that they were an inevitable part of the system. We now know that we can change the system and we can eliminate waiting times. There is an improvement process and a set of principles that we can use to accomplish this. We can learn to to see differently, and when we are able to see differently we are able to do differently. It is now possible to build systems in health care where waits are minimal.

QHC: What is your vision for how IHI.org can accelerate improvement in access? How do you see people using the site?

MM: I think different people will use it in different ways; there are many different needs. Some groups are well on their way to seeing the world differently and doing the world differently. IHI.org can be a forum for them to share with other groups or to pick up key pointers to help them refine their improvement. For other groups that are just getting started, IHI.org offers an opportunity to see what’s possible and to get some idea of the magnitude of the change that’s necessary, as well as some hints about how to begin.

QHC: As an Expert Host, what are you curious about achieving on the website?

MM: One of the things that I am most interested in is, where is the point where we reach a critical mass in health care? Where is the point at which, if you tolerate waiting times, you become the outlier? I don’t think we have quite reached that yet. There is a competitive advantage and an operational advantage and certainly it is more pleasing to work in an environment where there is either far less waste or no waiting times. This forum will help me start to see where’s the tipping point — the point at which, if you don’t see the world differently, you’ll be an outlier. I believe that at some point, for example, organizations or practices will be considered negligent if they tolerate unnecessary waits and delays.

QHC: What are the biggest points of skepticism you hear about improving access?

MM: The biggest source of skepticism is the feeling that "we are different," "this doesn’t apply to me," or "it doesn’t work." Well, there isn’t any "this" and there isn’t any "it." To reduce waiting times in a health care system, there’s a process and a set of principles. There is not a specific product or answer. Using a proven improvement process and a time-tested set of changes can reduce waits in any setting.

Often practices or organizations will look at what another group has accomplished and they will be very skeptical because they are convinced something is different: either we are different from them or they are different from us. However, when people look at what another group or organization did, in essence what they are looking at is their solution — and then they measure themselves against those other solutions. I think that’s a big mistake. The key is to look at the principles. The principles are going to work in any environment. The solutions are going be specific to each environment. Solutions don’t spread; principles do. The particular solution might not fit or might not look like it fits, but the principles always fit.

In my view, we really are not different. Every day, all day long, one patient at a time, one service at a time, one appointment at time, one "demand" at a time, we’re matching that demand to a supply. We are in the supply-and-demand-matching business — whether we are in an academic environment, a specialty environment, a military environment, an international environment — and we can either acknowledge it or understand it or recognize it, but that’s what we do. And we can either do it well or we can do it poorly.

This is where outside expertise and guidance can help. For example, in my own experience and in my own organization, it took years to refine some of these principles. Others can streamline that process by being exposed to expertise that can cut through some of the potential mistakes.

QHC: How did you come to work on access?

MM: I trained as a family medicine doctor, and I was working in a large HMO in California. One of my responsibilities was to build a scheduling system. I recognized that I had two problems to solve: continuity — I needed patients to get into their own doctor — and capacity. I needed space or capacity in the system so that the patients could see their own doctor at the time that they chose. What I recognized, over a long period of time, was that the distinction between urgent and routine (urgent and non-urgent) appointments actually became a barrier to solving the capacity and continuity problems. It just created a whole other set of variables and it created inevitable waiting times and delays. Urgent and non-urgent were just different forms of demand — arbitrarily different demand streams.

I also looked at other businesses and other industries, anybody else that matched supply to demand to see how these groups have addressed the issues. And I discovered that all those other businesses and organizations had practices could be successful. They had a process for improvement and they had a set of principles that they used to address waits and delays in their businesses. And over the last four years, I’ve devoted my professional life to consulting with groups all over the country and all over the world to help guide them through these changes.