High-quality health care is a priority for patients and clinicians alike. In 2001, the Institute of Medicine (now the National Academy of Medicine) outlined a strategy to improve the quality of health care in the United States anchored on 6 aims: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.¹ The pursuit of these aims is the process of quality improvement (QI), which can be defined as “a framework we use to systematically improve the ways care is delivered to patients.”² QI is one aspect of the science of improvement, or “an applied science that emphasizes innovation, rapid cycle testing … and spread in order to generate learning about what changes, in which context, produce results.”³ Improvement science offers rigorous approaches to the attainment of high-quality care through clinic-level care delivery process refinement and the uptake of evidence-based practices.^4,5 One approach to promote the pursuit of high-quality health care is the provision of longitudinal, expert support to help individuals and health care teams identify and implement areas of practice change.^6–8 Within the VA, transformational coaching is one commonly used strategy for the provision of longitudinal, expert support to clinical teams seeking to engage in QI processes.

Transformational coaching is a team-centered approach to bolster QI in which an individual (ie, the coach) supports an interdisciplinary health care delivery team in their pursuit of achieving sustained change and the improvement of clinical processes. Transformational coaches provide support by assisting with goal setting and attainment, connecting teams to system-level resources for change, and improving efficiency and team dynamics around improvement processes. The coach is not part of the particular health care practice or team receiving the coaching, but can be from the larger health care system in which the team or practice sits. The coach role is agnostic to the clinical content area and does not require topical expertise. The effects of the coaching intervention can be measured at multiple levels including the level of care delivery such as provider behaviors or practice activities and policies (process outcomes) or at the level of patient care (clinical outcomes). Beginning in 2012, the VA utilized transformational coaches in numerous collaboratives to integrate VHA transformational improvement initiatives, including the Patient Aligned Care Team (PACT) Collaborative, Patient Flow Collaborative, Specialty and Surgical Collaborative, and Transitioning Levels of Care Collaborative.^9,10

Transformational coaching is similar to other approaches that encourage the systematic adoption of high-quality, evidence-based practices. One well-studied approach with overlapping characteristics is facilitation.¹¹ Facilitation has been defined multiple ways but can generally be thought of as a “process of working with groups to support participatory ways of doing things.”¹² Those who provide the facilitation, or facilitators, typically are experts in the process of helping groups make changes and solve problems. Specific organizations and health care systems offer variations on the concept and use of facilitation, with VA QUERI and the Agency for Healthcare Research and Quality (AHRQ) being 2 prime examples.^2,12 VA QUERI defines facilitators as “experts in the process of helping groups make decisions and identify and solve problems,”¹² whereas AHRQ defines practice facilitators as specially trained individuals who work with clinical care practices “to make meaningful changes designed to improve patients’ outcomes.”² Because there are multiple scholarly fields which seek to promote the optimal improvement of clinical care delivery, there are multiple terms used to describe coaching-like processes and many examples of how these terms have been operationalized. Table 1 defines relevant scholarly fields and describes some examples of clinical care improvement approaches similar to transformational coaching.

Table 1

Clinical Care Improvement Approaches.

This report seeks to support future development of transformational coaching by addressing the following knowledge gaps. First, little is known about the variety of ways that the effects of transformational coaching have been measured. Second, the effect of coaching specifically on practice or clinical team-level behaviors (or process outcomes) is unknown. A better understanding of process outcomes could improve the selection of clinical QI projects/teams for the application of transformational coaching. Finally, we seek to explore barriers and facilitators to the uptake of transformational coaching. Experiential evidence suggests that transformational coaching interventions is not embraced equally across clinical settings and teams. Clarity on contributors could improve local fit, increasing intervention impact, and ultimately boost sustainability of transformational coaching in varied health care system settings.

In recognition that transformational coaching is not explicitly defined outside of the VA nor studied in the peer-reviewed literature, we used a broad search strategy to identify interventions that shared the essential ingredients that must be maintained to ensure fidelity to the transformational coaching intervention as defined within the VA. Specifically, we took a holistic approach to identifying evidence for this review drawing from QI, improvement science, and implementation science literatures which themselves employ overlapping terms and methods pertaining to the support of clinical teams and practices in the uptake and improvement of evidence-based clinical processes. While necessarily introducing heterogeneity, this approach offered the depth and richness of the larger spectrum of work seeking to optimize the support provided to health care teams and systems trying to improve the quality of their health care delivery.

The Key Questions (KQs) for this report were:

KQ 1a.

What outcomes have been used to assess the effects of transformational coaching across practice, provider, and patient levels?

KQ 1b.

What are the effects of transformational coaching for team-based health care improvement and practice change efforts on process outcomes, specifically:

• Adoption of targeted process of care activities (eg, more appropriate documentation of screening)
• Quality improvement process goal attainment (eg, the number of quality improvement projects reaching completion)
• Team member knowledge
• Team member self-efficacy

KQ 2.

What are the identified barriers and facilitators that impact the uptake of transformational coaching in a large health care system such as the VA?