This chapter analyzes the process of developing a health services innovation. It describes the strategy and tactics of reform within the framework of institutional change, beginning with problem definition and continuing through the operationalization of change. The chapter explains the goals of the Neighborhood Health Center (NHC) program as well as those of the local health institutions which sponsored specific projects, contending that significant differences in orientation existed. It argues that the initial NHC program emphasized activities which served goal-oriented functions. As the program expanded, increasing emphasis was placed on system maintenance functions, which became an overriding concern after 1969 because of changes in the social and political milieu. The importance of the factor was apparent after the NHC's became operational. At Tufts, as with other projects, the degree of cooperation between the various units of the medical school and the NHC project was highest among those departments which were interested "in putting students in the centers."