In 2006, the Agency for Healthcare Research and Quality (AHRQ) funded a project to develop, test, and disseminate a package of tools to facilitate the effective and financially viable implementation of the Chronic Care Model (CCM) in safety net organizations. The RAND Corporation, Group Health's MacColl Institute for Healthcare Innovation, and the California Health Care Safety Net Institute participated in the project. A key premise of our effort was that primary care practices may need more help than a toolkit alone can provide, yet they may be unable to attend a year-long Breakthrough Series style collaborative. This intervention was designed to provide low-intensity in-person, hands-on guidance to successfully implement the CCM. We conceptualized such assistance as helping, advising, and enabling and used terms such as "coaching" and "facilitation" when talking about it.
To better understand how such help might be structured, we looked at the literature on coaching and facilitation and talked with nine practice coaching leaders from a variety of organizations. In this chapter, we summarize key lessons learned from the literature and our interviews with coaching practitioners, as well as our own experience with practice coaching.
There are a number of reasons that primary care organizations might want to look to coaches when embarking on a program of practice improvement:
- Primary care practices often lack in-house expertise or experience to successfully identify and initiate needed changes. Coaches can bring expertise on specific topics and approaches, and tools to facilitate implementation.
- Practice transformation is a complex undertaking, involving fundamental change to how a practice operates. Coaches have experience in how to help practices sequence and manage change.
- Primary care practices have difficulty making time for quality improvement in the face of the competing demands of day-to-day practice. The presence of a coach lends structure, dedicated time, and focus to quality improvement efforts.
"External initiatives like pay-for-performance and public reporting may help to generate interest in improving care, but in the crush of the current practice environment, mounting an initiative to redesign care is almost impossible without support."
—Northwest Physicians Network
What Roles Do Practice Coaches Play?
Coaches perform multiple functions.9 Coaches can serve as:
- Facilitators who help practices achieve their improvement goals.
- Conveners who bring groups of staff members together to work through an issue.
- Agenda setters and task masters who help practices prioritize their change activities and keep them on track.
- Skill builders who train practices in quality improvement processes and assist them in developing proficiency in the techniques used in the CCM.
- Knowledge brokers who know about external resources and tools and save practices from engaging in extensive searches for information or reinventing the wheel.
- Sounding boards who give practices a reality check and provide feedback.
- Problem-solvers who can help practices identify and surmount a stumbling block.
- Change agents who promote adoption of specific evidence-based practices.
"Coaches offer a structure, time, and place for practices to solve their own problems."
—Humboldt Del Norte Foundation, a Robert Wood Jonson Aligning Forces for Quality participant
Coaches can play a role in setting the stage at the outset of the transformation process. For example, coaches can:
- Help to prepare the organizational infrastructure for quality improvement implementation through such activities as advising on team-building, improving communication,10 facilitating meetings,11 and helping to develop leadership skills.12
- Communicate the vision for change through activities such as presenting best practices13-15 and sharing what other organizations have done.
- Help people to better understand how their practice compares to the ideal and where there is room for improvement by observing and delineating practice operations, assessing needs, and gathering baseline data, as well as guiding discussions of the current practice and opportunities for change.16,17
Coaches can also engage in very concrete tasks during the implementation period. Coaches can:
- Help practitioners to plan change by encouraging them to set goals,18 suggesting ideas or providing menus of possible strategies or innovations,16,17 and helping them choose among such options and create a plan.15-17
- Enable practitioners to execute changes by providing tools,13, 14, 16,17,19 guiding them through rapid-cycle tests of change,11,13,14,18 and assisting when obstacles arise.11
- Aid practices in customizing processes to fit their own situation and incorporating the changes into their day-to-day routines, so as to increase the likelihood that the changes will be sustained.20,21
- Provide direct technical support with health information technology (HIT) implementation and development of registries and reminders systems.15
- Help practitioners to collect and use measurement data,22 assess the effectiveness of changes made16,17 and sometimes even undertake activities such as conducting chart audits.15-17
Motivation, education, and consultation are at the core of coaching.
- Motivational coaching addresses the amount of effort that group members collectively put into the task, especially by enhancing the conviction and confidence they bring to the work23 through encouragement, reassurance, permission, and nudges.24
- Educational coaching addresses the knowledge and skills that members bring to bear on the group's work.23 Educational coaching can take the form of information sharing, skills training, and role feedback.24
- Consultative coaching fosters use of performance strategies that are especially well-aligned with and appropriate to the task.23 Consultative coaching may include rapid response to needs and requests; interactive problem solving,17, 24 and suggestions for change concepts or resources.
Most coaching involves a mix of these functions, but the emphasis placed on any one function changes over the course of the coaching process.9,23 A motivational focus, for example, may be needed before education or consultation can be effective.
A frequent challenge for coaches is to maintain clarity about what they do and do not do. Coaching leaders have observed that there is a danger of "scope creep," whereby coaches are pulled into work unrelated to the project at hand. In most cases this occurred because the coaches themselves were not clear on their role or because they wanted to be perceived as a helpful and valuable resource. "Scope creep" was best managed through clarification of roles at the outset of the project, frequent reevaluations of project status and open, clear communication with both the practice team and their leadership about the role of the coach and the expectations of the teams.
"Presenting accurate, timely data on a provider's panel of patients is a powerful way to create a willingness to change."
—Colorado Clinical Guidelines Collaborative
Coaching approaches and methods vary in many respects, including:
- Duration (e.g., from a few months to a number of years).
- Intensity, ranging from time-intensive, comprehensive practice management and clinical quality improvement efforts involving frequent communication with sites (e.g., ongoing facilitation provided through practice-based research networks) to brief and narrowly focused efforts (e.g., a preventive care effort launched with one group meeting and minimal follow-up).
- Proximity, ranging from onsite coaching, with a coach dedicated to a single site or set of sites (e.g., academic research institute coaches integrated into university-affiliated practices) to long-distance coaching, using telephone and E-mail to continue work between in-person meetings (e.g., coaches in large systems such as the Veterans Affairs (VA) health system).
Coaching also can be:
- A team activity, whereby two or more coaches bring complementary skills to interactions with the practice (e.g., specialized expertise in improvement methods versus the clinical problem area).
- Scripted, using a consistent curriculum for practice coaches to use with sites (e.g., Improving Performance in Practice).
- Prescriptive of the changes that the practices should make (e.g., top-down promotion of highly defined best practices).
- Practice driven, allowing the structure—and to some degree the content—of the program to be decided largely by the site (e.g., STEP-UP16).
Most coaching leaders acknowledged a tension between wanting to be reliable and consistent in their approach to teams while recognizing that one key advantage of coaching is the ability to tailor the implementation of a quality improvement initiative to needs and strengths of each practice. Learning which elements of an intervention work and are generalizable and which can and should be customized at the site level is an area where much more needs to be known.
Who Serves as a Practice Coach?
While coaching can be done by a member of the practice, the predominant model found in the literature is to use a coach external to the practice. In the coaching interventions that we studied, an entity outside the practice arranged and paid for the coaching. Practice coaching is a service available for purchase. A variety of different types of individuals have served as coaches. These include:
- Researchers with expertise on evidence-based practice and implementation (e.g., practice facilitators for the VA Quality Enhancement Research Initiative (QUERI) program).24-27
- Professional improvement advisors, broadly trained in quality improvement methods (e.g., faculty at the Institute for Healthcare Improvement).
- Specially trained individuals with bachelor's or master's degrees and some previous health care experience or training (e.g., practice enhancement assistants trained by practice-based research networks).
Which Practices Benefit From Coaching?
It is difficult to predict which practices will be most likely to succeed. Coaches generally see that practices with engaged leaders and long-term quality improvement goals are more likely to embrace the changes coaches nurture. On the other hand, programs using coaches may want to target practices unlikely to be able to engage in quality improvement on their own. These include practices that:
- Are not part of or supported by a larger system.
- Cannot attend quality improvement collaboratives.
- Require additional motivation or contain pockets of resistance or inertia that block spread of the CCM.
"You don't always know which practices are going to do well. There may be practices that you think are least likely to change, but if you can crack the nut, they are often the ones that make transformational change."
Does Practice Coaching Work?
Although there are few evaluations of practice coaching, it is perceived to be valuable. Many have come to view primary care practices as complex adaptive systems, each with unique histories, people, relationships, values, rules, influences, and problems.28,29 Since one predefined approach cannot possibly fit all these unique systems, quality improvement implementation requires extensive customization. This customization, in turn, necessitates understanding the context and opportunities for change30 and facilitating a process of learning and reflection that helps practices adapt to and plan change.31 Coaching is key to this process.
Emerging evidence suggests that this tailoring to the practice's unique context may increase the likelihood of sustainability by helping to better incorporate quality improvement changes into the day-to-day routines of the practice.20,21 Studies have shown that coaching has led to increases in evidence-based care of diabetics, preventive services, and screenings.15,32,33
Evaluation of our practice coaching intervention, which was designed to foster adoption of the CCM and use of the "Integrating Chronic Care and Business Strategies in the Safety Net" toolkit, has led to the following conclusions:
- Coaching is a necessary bridge to the toolkit. The coaches help providers and staff navigate the toolkit. By answering questions and helping people locate specific tools, the coaches save staff and provider time.
- Coaching motivates and prompts people to make changes. The coaches encourage providers and staff to test small changes in their work routines, which providers and staff may not have been able to do on their own. The participants believed these changes would not have happened without coaching.
- Coaching extends the horizons of the teams. The coaches provided outside experience and shared information from other clinics. These examples allowed the providers and staff to learn from changes that have been effective elsewhere, resulting in greater motivation in implementing the CCM.
- Coaching has a positive effect on team building. Although some physicians and their supporting staff worked well together prior to the project, others commented that coaching helped them to build a better team through regular meetings and staff empowerment.
- Coaching is an emotional bond. The coaches' commitment and positive attitudes in motivating and encouraging participants were appreciated. This emotional bond was noted to be a key factor in the success of the coaching intervention.
What Makes a Good Practice Coach?
For those practices interested in hiring their own practice coach, below are some characteristics to consider, including a list of core competencies and a proposed scope of work. Because this area has not been empirically examined in the context of ambulatory care, we rely on our own experience and our conversations with national leaders to suggest what makes a good practice coach.
In our experience and that of others in the coaching world, certain characteristics and personality traits of the coach are tremendously important. Because of the interpersonal nature of the coaching relationship, respect for others, superior communication skills, and open-mindedness are characteristics deemed most crucial. Other characteristics mentioned by experienced program leaders as important for a potential coach include empathy, creativity, passion for the job, and respect for the real-life barriers in practice. They also need to have a thick skin and avoid internalizing things. Being a "people-person" was considered very important (e.g., being able to get along well with people and being good at reading people and understanding who is in power). Teaching skills also were emphasized, as was the ability to read between the lines and elicit underlying issues in a nonthreatening way.
Those quality improvement leaders who have experience serving as practice coaches spoke about some of the challenges of working with different types of people on different teams. The executive director of one quality improvement effort said, "Coaches must have a variety of approaches at their fingertips to connect with different teams. And, you need lots of different tools in your toolbox to connect with different types of staff—from those with a high school education to highly trained providers. A coach has to work well with all of them."
In many cases, the coach is the face of the quality improvement program for the practice teams. Being able to keep teams engaged in what is often very challenging improvement work is not easy. As one coach put it, "You have to have a thick skin. There is no way around it. You'll be treated like dirt, and you can't take it personally." Sometimes the frustration of the team gets directed at the coach, so being able to maintain good relationships while continuing to promote improvement is key.
In addition to the interpersonal skills and emotional intelligence of coaches that may enable them to function well in a practice, some skills and content knowledge are needed. Although all our interviewees agreed that these skills were important, there was some debate as to which were essential and which were nice to have. If you are fortunate enough to have a number of coaches that will work together on your initiative, then the group as a whole could possess these skills. Each coach individually may be able to provide specialized knowledge in areas where they are more familiar. If you only are able to hire one coach, seeking out external sources of support in areas where that person may not be as strong would be helpful.
Skills and knowledge a coach should possess or be able to connect with include:
- Familiarity with data systems, including registries.
- Ability to understand and explain data reports in different ways to different stakeholders.
- Some clinical understanding and credibility.
- Knowledge of, and experience with, the Chronic Care Model.
- Knowledge of, and experience with, the Model for Improvement.
- Understanding of performance reporting and measurement.
- General quality improvement methods.
- Group facilitation skills.
- Project management skills.
- Knowledge of practice management and/or financial aspects of the practice.
- Experience with and understanding of the outpatient clinical setting.
There was considerable debate about how important it is for the coach to be clinically trained, such as a registered nurse, physician assistant, nurse practitioner, medical doctor, or doctor of osteopathy. Some thought it was essential that the coach be a clinician to provide credibility and to act as a resource with whom the practicing physician could discuss clinical issues in improvement. Others thought having a clinician coach may be a detriment because of an overemphasis on the clinical aspects of care. These respondents stressed the wide variety of skill sets needed to care for patients and emphasized how a coach needs to be able to value and speak to each role. In the end there are pros and cons to having a clinician coach. Likely it is important for the coach to have some clinical credibility and to be able to access a provider to come in and talk to the clinicians on an "as-needed" basis.
How Much Does Coaching Cost?
There is little information about the costs of coaching, which of course varies with the intensity of coaching, the qualifications of the coach, and the duration of the coaching. Our 10-month practice coaching of two clinic sites cost approximately $41,000 (in 2007 dollars), which included time spent in coach training, coaching, and travel to sites. Practice coaching has been shown to be cost-effective by reducing inappropriate testing and treatment costs and increasing practice efficiency.34
More than 1,500 physician practices have participated in CCM collaboratives. Collaboratives can be thought of as group coaching sessions, where several practices are all trained in CCM implementation at the same time. There is real value in bringing together groups of practices. Teams benefit when they get together to interact, share lessons learned, feel some camaraderie with colleagues undergoing similar transformation, and develop ongoing networks.
Coaching, however, may be uniquely beneficial in these ways:
- Coaches can see and evaluate practice resources firsthand and tailor advice accordingly.
- Bringing coaches to the practice can enable more staff to participate in the practice improvement sessions.
- Through shorter educational sessions, conducted during a lunch break or after work hours, coaching can be delivered without requiring the closing of the practice.
Coaching has also been used as a supplement to collaborative learning sessions, blending the best that both methods have to offer.
"Some material is better presented in the collaboratives and some is better presented in the coaching framework. We're trying to capitalize on doing them both together."
—Prescription for Pennsylvania Coach
Clearly the field of practice coaching is still evolving, and it may be that even as our knowledge base grows, different models will work better in different settings. The next chapter provides a detailed description of the practice coaching intervention developed to be used in tandem with the "Integrating Chronic Care and Business Strategies in the Safety Net" toolkit, available at http://www.ahrq.gov and http://www.improvingchroniccare.org.
Coaching Preventive Care Improvement in Primary Care Practices34-36
Who was coached? Fifty-four physicians and allied health staff in 22 primary care practices in Ontario, Canada.
Who were the coaches? Three "prevention facilitators," all nurses with community nursing degrees and previous facilitation experience. They received 30 weeks of training in outpatient medical systems and management, preventive improvement, performance reporting, and facilitation techniques. Each coach was assigned to up to eight practices (with up to six physicians per practice) within a geographic area.
How was the coaching structured? The coaches worked out of their homes and traveled by car to the practice locations for onsite visits. During the 18 months of the intervention, they made 33 visits to each practice and spent 1 hour and 40 minutes per visit, on average. Between visits, they corresponded regularly with each practice through E-mail and telephone calls.
What roles did coaches play? The coaches served as educators, providing evidence on best preventive practices; motivators, using audit and feedback as well as opinion leader strategies; consultants, offering specific improvement tools and strategies such as reminder systems; team conveners and consensus builders; and chart auditors.
What did coaches do? They presented baseline performance data; facilitated the meetings in which the practices set performance goals, developed prevention plans, and developed and adapted strategies and tools to implement these plans; and conducted chart audits to provide performance data to monitor success.
Coaching Local Development of Interventions To Improve Depression Recognition and Treatment in Substance Abuse Clinics27
Who was coached? Clinicians and administrators at two outpatient substance abuse disorder clinics of the U.S. Department of Veterans Affairs (VA).
Who were the coaches? The facilitators, in this case, were researchers from the VA's Center for Mental Healthcare and Outcomes Research, including the project's principal investigator (PI), (a PhD with a background in sociology) and the project coordinator.
How was the coaching structured? This facilitation used onsite visits, conference calls, site-specific diagnostic data, expert consultation, and provision of implementation strategies and tools to help the local teams design and launch the site-specific interventions to further adoption of guideline-based practices for recognizing and treating depression. The PI spent 16 hours per week and the project coordinator 30 to 40 hours on these diagnostic and design guidance activities.
What roles did coaches play? The coaches acted as observers of local practice, collectors and providers of data and tools, educators on guideline-recommended practices, and builders of local expertise in quality improvement.
What did coaches do? They used formative evaluation and local teams (called "Development Panels") to facilitate the development of the interventions. In the formative evaluation, the coaches used clinic observation and key informant interviews to diagnose the key facilitators of, barriers to, and influences on depression recognition and treatment in these clinics. Specific diagnostic activities of the coaches included (1) an initial visit to each clinic by the PI to review materials on policies and procedures and to meet with clinical directors, (2) a three-day visit to each clinic three months later to conduct formal and informal observations of program operations and to interview program staff (10 to 14 staff members at each site) and patients (five or six), and (3) an analysis and presentation of this information in tables that summarized problems and offered potential solutions and tools. Over the next 5 months, the coaches used conference call meetings to guide the local Development Panels (consisting of the clinical director, a physician, a counselor, and a nurse or other staff member involved in depression screening) in designing the intervention specifics for their clinic.