The report is a product of the VA/HSR Evidence Synthesis Program.

Transformational Coaching: Effect on Process of Care Outcomes and Determinants of Uptake

Quality improvement (QI) activities seek to promote high-quality healthcare by applying innovations, rapid-cycle testing, and spreading best practices that produce meaningful improvements. However, healthcare teams often need dedicated support to incorporate QI activities into busy clinical practice. One method for providing support for QI activities is through longitudinal coaching from an expert trained in QI and related methods (e.g., Lean, Six Sigma, system redesign). Within VA, transformational coaching is one commonly used strategy for the provision of long-term expert support to interdisciplinary clinical teams seeking to engage in QI processes.

This systematic review sought to support the future development of transformational coaching by addressing several knowledge gaps: 

• How impacts of transformational coaching-like interventions have been measured;
• What the effects of coaching are on practice or clinical team-level behaviors (or process outcomes); and
• What the barriers and facilitators are to the uptake of transformational coaching.

Investigators from the VA’s Evidence Synthesis Program (ESP) Center in Durham, NC searched the literature, including Ovid MEDLINE, MEDLINE®, and CINAHL from inception through October 7, 2019. Investigators identified 3,620 citations, of which 271 received a full text review; of these, 19 cluster-randomized trials addressed the effects of transformational coaching-like interventions on process of care outcomes of interest and 16 qualitative and mixed or multi-methods studies that evaluated facilitators and barriers to the implementation of coaching-like interventions. All but one trial was conducted within the primary care setting, and only one study was conducted in the VA.

Summary of Findings

Transformational coaching is a complex intervention that has the potential to support access to – and use of data and technical resources for QI activities at the team and practice level. While Transformational coaching is a type of expert QI support developed in the VA, there are several fields of study (i.e., quality improvement, improvement science, implementation science) that have developed similar interventions (i.e., facilitation, outreach visitors), so we took a broad approach to looking for relevant literature. Transformational coaching-like interventions may have an effect on certain process-of-care activities, including: composite process of care outcomes, ordering of labs and vital signs, and, possibly, on changes in organizational process-of-care and delivery of appropriate counseling. Differences among studies in the description and dosing of implementation strategies employed by coaches, as well as outcome measurement, precluded a more definitive estimate of effects. Specific strategies like adapting coaching techniques to team needs and preferences appears to be better received than other strategies.

Process of Care Activities

This review identified 19 studies relevant to the effect of transformational coaching-like interventions on process of care activities. Across outcomes related to the uptake of targeted process-of-care activities, there was very low to low certainty of evidence that coaching probably has an effect on collections of process-of-care outcomes considered as one composite score (i.e., proportion of 9 recommended actions of care for patients with diabetes) and ordering of labs and vital signs, and possibly has an effect on changes in organizational process of care and delivery of appropriate counseling. It is uncertain if coaching has an effect on the conduct of specific exams and procedures; coaching likely does not have an effect on prescription of diagnosis-appropriate medications.

Barriers and Facilitators of Coaching Implementation

Investigators identified 16 studies relevant to barriers and facilitators of coaching implementation. Findings support the interdependent nature of the complex components of the coaching intervention—the role of the coach, the QI project, and the team. All of these components are also influenced by context or environment in which the coach is facilitating change. The nature of coaching requires that the coach be able to recognize both the  big picture and the smaller details to overcome barriers and maximize facilitators. Additionally since every environment, project and team is unique coaching requires a flexibile approach to implement change. The coach may need to provide one or more of the following: education, support, accountablity, task completion or finding work arounds as examples to facilitate change. The coach must consider the project through multiple phases from planning to evaluation. Working with the team to set expectations early in the process for both the QI project and the coaching process is a key for success.

Implications for VA

VA has a longstanding and ongoing commitment to providing high-quality patient-centered care—and continues to seek effective strategies that can accelerate the speed and impact of improvement efforts. Results from this review suggest that transformational coaching could play an important role in VA’s overall commitment to QI. For example, VA is currently planning a national transition of its electronic health record from the VA-created Computerized Patient Record System (CPRS) to a new system developed by Cerner. This will create a significant learning curve for QI teams related to the gathering of electronic health record (EHR) data to measure and evaluate the success of their improvement projects. Transformational coaching could support teams during this technological transition.  

Research Gaps/Future Research

Few coaching interventions employed the strategies identified in this review as being most helpful in combination (i.e., stakeholder/leadership engagement and technical support). Most coaching interventions focused on pre-determined quality improvement projects rather than the capacity for QI more generally. In addition, all but one of the included interventions were conducted in primary care settings, so the effect of coaching in other clinical settings (e.g., inpatient, sub-specialty clinics) is unknown. In addition, there were gaps in the qualitative literature, including: primary data collection from all individuals involved with coaching (i.e., team members, coaches, and peripheral leadership); information on how coaches make strategic decisions; and barriers and facilitators in the context of coaching for general QI capacity development. Future research that standardizes and provides more detail about how coaching interventions are used will better support future comparisons and implementation efforts.

Policy Implications/Guidance for the Field 

VA’s Transformational Coaching Program resides in the Office of Veterans Access to Care, which synchronizes access activities and operations across VACO, VISNs and VAMCs. T-Coaching focuses on individualizing coaching processes to the needs of specific teams. T-coaches have provided flexible facilitative approaches to strengthen teams in programs and initiatives such as Systems Redesign, Behavioral Health Integration Program, Clinical Pharmacy Program Office-Substance Abuse Disorder, Referral Coordination Initiative, and Patient Aligned Care Teams (PACTs). This approach has assisted project teams toward implementation of change. Strategies identified in this review as being most helpful in combination (i.e., stakeholder/leadership engagement and technical support) are built into the T-Coaching Program. Future opportunities include collaborations with program offices for implementation science research about T-Coaching to facilitate and strengthen spread and sustainment of respective program office initiatives.  A standardization of VISN and site T-Coach capacity is in the beginning phases, for example, VISN and facility POCs for T-Coaching have been identified.

Support from the Networks and medical facilities would be the next step toward building their capacity to maximize the success of national change management and improvement efforts.

Ballengee LA, Rushton S, Lewinski AA, Hwang S, Zullig LL, Ball Ricks KA, Brahmajothi MV, Moore TS, Blalock DV, Ramos K, Cantrell S, Kosinski AS, Gordon AM, Ear B, Williams JW, Gierisch JM, Goldstein KM. Transformational Coaching: Effect on Process of Care Outcomes and Determinants of Uptake. VA ESP Project 09-010; 2020.

To view the full report, go to the intranet at vaww.hsrd.research.va.gov/publications/esp/transformational-coaching.cfm (Copy and paste the URL into your browser if you have intranet access.)

ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.

This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.

This report is a product of VA/HSR&D's Evidence Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers –; and to disseminate these reports throughout VA.

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