The stipulation‐stimulation spiral: A model of system change

This paper proposes a general model, based on what is known about the nature of (complex) systems, of how systems—in particular, health care systems—respond to attempted change. Inferences are drawn from a critical literature review and reinterpretation of two primary studies. The two fundamental system‐change approaches are “stipulation” and “stimulation”: stip(ulation) attempts to elicit a specific response from the system; stim(ulation) encourages the system to generate diverse responses. Each has a unique strength: stip's is precision, the ability to directly impact the desired outcome and only that outcome; stim's is resonance, the ability to take advantage of behavior already present within the system. Each approach's inherent strength is its complement's inherent weakness; thus, stip and stim often clash if attempted simultaneously but can reinforce each other if applied in alternation. Opposite patterns (the “stip‐stim spiral” vs “stip‐stim stalemate”) are observed to underpin successful vs failed system change: The crucial difference is whether decision‐makers respond to a need for precision/resonance by strengthening the appropriate approach (stipulation/stimulation, respectively), or merely by weakening its complement. With further validation, the model has the potential to yield a more fundamental understanding of why system‐change efforts fail and how they can succeed.