Leadership Coaching as an Implementation Strategy to Enhance Adoption of a Relational Playbook and Team Well-Being: A Pilot Randomized Clinical Trial In Cardiology

Leadership Coaching as an Implementation Strategy to Enhance Adoption of a Relational Playbook and Team Well-Being: A Pilot Randomized Clinical Trial In Cardiology | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Leadership Coaching as an Implementation Strategy to Enhance Adoption of a Relational Playbook and Team Well-Being: A Pilot Randomized Clinical Trial In Cardiology Heather Gilmartin, Robert Klocko, Edward Hess, Marguerite Daus, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9612173/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Supportive learning environments are foundational to clinician well-being, workforce retention, and delivery of high-quality care. Prior evidence suggests that the Relational Playbook, an evidence-based leadership development program, can cultivate these environments. Leadership coaching may further enhance Playbook implementation, but its effectiveness has not been tested. The objective of this study was to assess the acceptability, appropriateness, and feasibility (AAF) of the Playbook and determine whether leadership coaching improves Playbook adoption and cardiology team well-being. Methods A pilot site-randomized trial was conducted from July 2024 to January 2025 in six Veterans Health Administration (VA) cardiac catheterization labs. Nine clinical managers enrolled; six managers from six labs completed the study. Labs were stratified by 2022 percutaneous coronary intervention volume. Within each tier, one lab was randomized to receive coaching (intervention) and one to no coaching (control). All labs implemented the Playbook. Intervention managers received six months of individualized virtual coaching from an International Coaching Federation-certified coach and nurse practitioner. The primary outcome was AAF, measured using validated implementation instruments (Weiner, 2017) across 12 Likert-type subscales (range 1–5; higher scores reflect greater AAF). Secondary outcomes included team perceptions of the learning environment and well-being: burnout, intent to leave and job satisfaction measured with the Learning Environment Survey (LES). A difference-in-difference (DID) analysis assessed pre-post changes between intervention and control groups; confidence intervals and statistical tests were omitted due to small sample size. Adoption of Playbook practices, coaching experience, and implementation perceptions were assessed through surveys and qualitative interviews. Results Participants’ mean (SD) age was 50 (6.5) years; all identified as White, most as nurse managers. AAF ratings for the Playbook were high with median scores exceeding 4 across domains. After six months, the coaching intervention teams showed a relative reduction in burnout (DID = -0.6) and intent to leave (DID = -0.7) as well as a relative increase in job satisfaction (DID = + 1.1). compared with control teams. Interviews indicated that coaching offered real-time feedback, facilitated Playbook adoption, and supported team professional development and well-being. Conclusions Leadership coaching enhanced Playbook implementation and improved markers of cardiology team well-being. These findings support further testing and scale-up of the combined approache to strengthen learning environments and workforce resilience in high-intensity clinical settings. Trial Registration: ClinicalTrials.gov Identifier: NCT06456021 Leadership and Ethics Leadership Coaching Supportive Learning Environments Healthcare Workforce Implementation Figures Figure 1 Contributions to the Literature Advances the implementation of learning environment interventions by evaluating leadership coaching as a discrete implementation strategy to support adoption and enactment of an evidence-based Relational Playbook in cardiology teams. Extends evidence on implementation–workforce outcome pathways by linking high acceptability, appropriateness, and feasibility of a leadership development intervention with improvements in burnout, intent to leave, and job satisfaction. Provides mixed-methods insight into implementation mechanisms , illustrating how leadership coaching enables real-time feedback, adaptation, and sensemaking that facilitate sustained use of Relational Playbook practices. BACKGROUND Clinician burnout and turnover have reached crisis levels across U.S. healthcare and within the Veterans Health Administration (VA), threatening care quality, patient safety, and organizational performance.( 1 , 2 ) High burnout is associated with lower patient safety, reduced reliability of clinical operations, and increased costs linked to staffing instability.( 3 – 5 ) In response, the VA has prioritized employee well-being while advancing high quality and safe care through Learning Health System and High Reliability Organization principles.( 6 ) The National Academy of Medicine has similarly highlighted the need for organizations to cultivate supportive learning environments that strengthen teamwork, psychological safety, and relational capacity, which are key determinants of workforce well-being and patient outcomes.( 7 ) Despite substantial system-level investment, frontline clinical teams often lack practical tools and guidance to create supportive learning environments.( 8 ) These environments enable teams to experiment with and adopt innovations while using highly reliable work practices.( 9 , 10 ) They intentionally cultivate positive moments, joy in work, relational connection and high-quality communication.( 11 ) Supportive learning environments are associated with higher job satisfaction and lower burnout and turnover, which are core indicators of employee well-being.( 12 ) Yet, supportive learning environments remain uncommon across the VA.( 12 , 13 ) Organizational constraints include staffing pressures, high workload and limited time for learning. These factors impede a leaders ability to create supportive learning environments.( 7 ) To address this gap, The Relational Playbook, (henceforth Playbook) a team-focused intervention developed in VA cardiac catheterization laboratory (CCL) teams, was developed.( 13 ) CCLs were a strategic starting point because they are high cost and high value team-based settings, making them ideal for observing team learning processes with potential generalizability to other clinical settings.( 11 ) The Playbook includes five chapters of research-based content and more than 50 evidence-based practices presented in brief, accessible formats to help leaders and teams cultivate supportive learning environments. Although promising, the Playbook has not been rigorously implemented or evaluated in diverse VA environments, and optimal implementation strategies to support its adoption are unknown. Leadership coaching is an evidence-based implementation strategy that promotes proactive and supportive leadership behaviors which are critical for successful implementation of innovations in complex environments. Although coaching is well-established for patients and executive leaders, no studies have examined its role in supporting innovation implementation among clinical managers.( 14 ) By examining intervention implementation and leadership coaching, this study will generate new insights into mechanisms that support both effective adoption of interventions and leadership development. METHODS Aim This pilot study aimed to implement the Playbook, assess its acceptability, appropriateness, and feasibility, and test coaching as an implementation strategy to enhance Playbook adoption and team well-being. Study Design, Setting, and Participants We piloted a site randomized trial with a convergent mixed method process evaluation of the Playbook and coaching with six VA CCL nurse or technician clinical managers and assistant managers. Managers from the 84 VA CCLs were recruited through email and VA listservs. Sample size was set pragmatically to six sites to fit the study budget. Participation was voluntary, and all participants provided written consent. The intervention occurred from July 2024 to January 2025, followed the Consolidated Standards of Reporting Trials (CONSORT) guideline for trial studies,( 15 ) and was approved as an exempt human research study by the Colorado Multiple Institutional Review Board (COMIRB 17-1153). Qualitative reporting followed the Standards for Reporting Qualitative Research.( 16 ) The study protocol is available in eSupplement 1 . Randomization, Allocation Concealment, and Follow-up CCLs were stratified into low, medium, and high tiers based on 2022 percutaneous coronary intervention volume. Within each tier, one site was randomized to the coaching group (intervention) and the other to the control group and were provided no coaching or advisement. Both groups received the Playbook Program. Post-randomization data collection was conducted by the evaluation team. Data were not shared with the leadership coach until study conclusion. (Fig. 1). Description of Intervention Relational Playbook Leadership Program The Playbook is an intervention carried out by frontline managers in the clinical setting. Playbook concepts are grounded in the fields of positive psychology, team science, servant leadership, Whole Health, and Clinical Team Training models. These concepts informed the development of the Playbook chapters: 1) Creating a positive culture; 2) Teamwork; 3) Leading teams; 4) Creating joy in work; and 5) Communication and high reliability.( 8 , 12 , 13 ) Each chapter includes brief asynchronous modules and 2–3 required interventions that managers incrementally implement into meetings and interactions to create supportive learning environments. The Playbook’s Introduction and Chap. 1 are presented in eSupplement 2. Leadership Coaching Implementation Strategy Leadership coaching aims to transform managers’ behaviors and mindsets, with the potential to impact work environments. Coaching uses solution-focused approaches to support managers in deepening self-awareness.( 17 ) Coaching is grounded in adult learning theory which describes how learning is most effective when self-directed, problem-centered, and immediately relevant.( 18 ) Most healthcare coaching programs focus on executive leadership, academic faculty, or trainees.( 19 , 20 ) Two literature reviews have reported positive impacts of coaching on physician wellness( 21 ) and nurse leader performance and role effectiveness.( 22 ) A review by Bisbey et al( 23 ) identified leadership coaching as one of eight core principles for transforming teams of experts into expert teams, underscoring its potential value for healthcare settings. Leadership coaching may be a scalable strategy to strengthen adoption of innovations. However, few studies have examined coaching specifically among clinical managers and research is needed to understand how coaching influences team-level innovation adoption.( 24 ) We hypothesized that leadership coaching delivered for six months by an International Coaching Federation-certified coach and nurse practitioner would enhance Playbook adoption and improve team well-being. Coaching sessions followed the VA National Center for Organization Development (NCOD) GROW framework (Goal, Reality, Options, What) and were conducted as structured 60-minute virtual meetings ( eSupplement 2) . Study Groups CCLs randomly assigned to the intervention group were offered the Playbook and coaching program. They were not given protected time to participate and carried the same responsibilities as participants assigned to the control group. Control group participants were offered coaching after the study conclusion. Study Outcomes Baseline and post-intervention surveys were administered electronically. The surveys contained demographic questions and validated instruments studying the acceptability, appropriateness, and feasibility (AAF)( 25 ) of the Playbook and the learning environment.( 8 ) Process outcomes were assessed through intention and reflection surveys, coaching notes, and interviews to assess Playbook implementation and coaching perceptions and experiences. Primary Outcomes: Acceptability, Appropriateness and Feasibility The primary outcomes assessed were the AAF of the Playbook intervention, as perceived by all participants at trial completion based on measures developed by Weiner et al ( eSupplement 2 ).( 25 ) The AAF survey consists of twelve items. All items were rated using a 1–5 ascending Likert scale. Secondary Outcomes : Learning Environment and Team Well-being Learning Environment Survey Pre to post intervention, survey responses relating to learning environment and job satisfaction, burnout, turnover intention, CCL turnover, and safety climate were collected from participants and their self-identified team members (e.g., nurse, technician, physician) through the validated Learning Environment Survey (LES) [ eSupplement 2 ].( 12 ) The survey consists of 64 items related to CCL learning environments and use of reliability enhancing work practice factors rated using 1–5 and 1–7 Likert scale formats. Team well-being was assessed using five validated questions from the 2023 VA All Employee Survey item dictionary.( 26 ) The following were rated on a 1–5 Likert scale using a single item question: job satisfaction (Considering everything, how satisfied are you with your job?) , turnover intention ( If I were able, I would leave my current job ), and perception of safety climate ( I would feel perfectly safe being treated in this CCL ). Burnout was measured using a single item (I feel burned out from my work) and rated on a 7-item scale ranging from “Never” to “ Everyday”. CCL turnover was measured by a single item ( We have had __ staff leave our team in the last 12 months ) with numerical response options ranging from zero to seven or more. Process Outcomes: Evaluation of Adoption and Implementation Bi-weekly Intention Setting and Reflection Surveys Surveys were descriptively analyzed. The Intention Setting survey was sent every other Monday to remind participants of the assigned chapter and to encourage goal setting. The Reflection Survey was sent every other Friday to document intervention and implementation stories ( eSupplement 2 ). Coaching Notes Coaching sessions were summarized by the coach immediately after each session using the NCOD Framework, stored in a secure VA folder, and de-identified prior to reporting. Post-Intervention Interviews Nine CCL managers were invited to participate. Recruitment emails included the informed consent statement. Interviews were scheduled at the participants’ convenience, conducted by an experienced interviewer over Microsoft Teams, recorded, and transcribed. The interview guide included questions on their experience participating in the Playbook trial and impacts on participants and teams ( eSupplement 2 ). Statistical Analysis Outcomes were calculated using the average of available items within each factor. For example, if a respondent answered three of four items for a given factor, the mean of those three responses was used as the factor score. To provide a preliminary estimate of relative pre-post changes in LES outcomes between the intervention and control group, we fit mixed-effects models with each outcome specified as a function of time (pre vs. post), intervention group, and their interaction, including a random intercept for respondent. The parameter of interest for each model was the difference-in-difference estimate (DiD), representing the relative change in mean scores from pre to post between groups. Statistical tests were not performed due to the small sample size. All data analysis and summary statistics were conducted using R version 4.3.1 and SAS version 9.4. Qualitative Analysis Open-text survey responses, coaching notes and interview transcripts were analyzed using a deductive rapid matrix analysis approach.( 27 , 28 ) This method was selected to generate timely insights for the study team while retaining sufficient detail to identify emergent concepts. A structured summary was developed for each data source, organized into domains and reviewed by two analysts.( 29 ) Themes were developed iteratively, refined through repeated engagement with the data, supported with illustrative quotations and incorporated into a table. The quantitative and qualitative findings were triangulated to identify areas of convergence and divergence.( 30 ) RESULTS Participants Of the 84 VA CCLs invited to participate, 28 expressed interest (21% response rate) and six sites submitted enrollment forms by the deadline. All clinical managers completed a demographic survey, and three of the six sites were randomly assigned to the intervention group. Participants included six CCL managers and three assistant managers with nursing or technician backgrounds. The mean (SD) age of participants was 50 (6.5) years, all participants identified as White and female and mean (SD) VA tenure was 11.6 (9.6) years. Baseline characteristics did not differ meaningfully between groups. Of the nine individuals who initially enrolled, six completed the study. One intervention participant and two control participants withdrew because of time constraints. Each of these sites had two enrolled participants, so affected sites remained in the study (Table 1 ). Table 1 Site and Participant Characteristics Site Characteristics Coaching Group Cath Lab Volume (high/low) Location Number of Participants Number of Team Members Intervention High North Central 1 12 Intervention Low Southwest 1 24 Intervention Medium Mountain West 2* 20 Control High South 2* 28 Control Medium Southeast 2* 34 Control Low Northeast 1 20 Participant Characteristics Overall N (%) Intervention (n = 4) Control (n = 5) Role Registered Nurse 8 (89) 3 ( 38 ) 5(62) Technician 1 ( 11 ) 1 ( 25 ) 0 (0) Supervisor 9 (100) 4 (44) 5 (56) Age years Mean (SD) 50.0 (6.5) 48.8 (8.5) 51.2 (4.8) Gender: Female 9 (100) 4 (100) 5 (100) Race: White 9 (100) 4 (100) 5 (100) Ethnicity: Not of Hispanic Origin 9 (100) 4 (100) 5 (100) Years in VA Mean (SD) 11.6 (9.6) 11.2 (12.8) 11.8 (7.8) Key High Cath Lab Volume = greater than 140 procedures annually, Medium Cath Lab Volume = 60–139 procedures annually, Low Cath Lab Volume = less than 59 procedures annually. Team members = nurse, technicians, physician staff. * indicates sites that had a cath lab manager and assistant manager participate. AAF surveys were completed by all six clinical managers across the six participating sites (100% response rate). Baseline LES surveys (n = 41) were received from all six sites (intervention: n = 16; control: n = 25; response rate = 30%). Post-intervention, 20 surveys were received from five sites (intervention: n = 9; control n = 11; response rate = 14.5%). Twelve respondents across the six sites completed both pre- and post-intervention surveys, including the six study participants. Engagement Overall adoption of the required Playbook interventions was 73%: 100% for Chap. 1 (2 of 2 interventions), 100% for Chap. 2 (2 of 2), 50% for Chap. 3 (1 of 2), 67% for Chap. 4 (2 of 3), and 50% for Chap. 5 (1 of 2). Participants completed a total of 39 coaching sessions. The mean number of sessions per participant was 5.6, with a range of 5–6 sessions. Primary Outcome: Acceptability, Appropriateness, Feasibility Both groups rated the Playbook as highly acceptable (median = 5.0), appropriate (median = 4.6), and feasible (median 5.0) (Table 2 ). Table 2 Primary Outcome: Acceptability, Appropriateness, Feasibility Acceptability Subscale Control (N = 3) Intervention (N = 3) Total (N = 6) Median; Range ( 1 – 5 ) 4.5 (4.2–4.8) 5.0 (5.0–5.0) 5.0 (4.6-5.0) Appropriateness Subscale Median; Range ( 1 – 5 ) 4.5 (4.4–4.6) 5.0 (4.8-5) 4.6 (4.5–4.9) Feasibility Subscale Median; Range ( 1 – 5 ) 5.0 (4.8-5.0) 5.0 (5.0–5.0) 5.0 (5.0–5.0) Secondary Outcomes: Learning Environment and Team Well-being After six months of Playbook implementation, LES factor scores showed greater improvement in the intervention group (11 of 12 factors) than in the control group (5 of 12). For example, the intervention group’s supportive learning environment factor increased from a baseline score of 4.5 to 6.2, whereas the control group declined from 4.4 to 4.1 on a 1–7 Likert scale ( eTable 1; Supplement 3 ). Team well-being outcomes also favored the intervention group. Compared with controls, intervention CCLs demonstrated a relative reduction in burnout (DID = -0.64) and intent to leave (DID = -0.6.5) with a relative increase in job satisfaction (DID = + 1.10). Perceptions of safety climate showed minimal difference between groups (DID = -0.06). Both intervention and control CCLs reported no staff turnover post-intervention (Table 3 ). Table 3 Team Well-being Pre-Post Playbook and Coaching Job satisfaction Pre Control (N = 25) Post Control (N = 11) Pre Intervention (N = 16) Post Intervention (N = 9) Total (N = 61) DiD Estimate Mean (SD) 3.9 (1.1) 3.6 (1.1) 3.6 (1.2) 4.5 (0.8) 3.8 (1.1) 1.10 Burnout Mean (SD) 4.0 (1.7) 4.0 (1.8) 3.9 (1.7) 3.0 (1.2) 3.8 (1.6) -0.64 Intent to leave Mean (SD) 2.4 (1.4) 2.7 (1.3) 2.6 (1.4) 2.2 (1.4) 2.5 (1.4) -0.65 Feel safe as patient Mean (SD) 3.6 (1.3) 3.5 (1.3) 4.0 (1.0) 4.5 (1.1) 3.8 (1.2) -0.06 Staff turnover last 12 months Turnover: 0 8 (100%) 2 (100%) 8 (100%) 6 (100%) 24 (100%) Turnover: 1–3 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) Turnover: 4–6 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) Turnover: 7 + 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) Note. Unadjusted mean (SD) LES outcome scores stratified by intervention status + timepoint (i.e. pre vs post intervention). The far-right column provides the difference in difference (Did) estimate for intervention vs control. Qualitative Results Interviews were conducted from January 17 to 31st, 2025, with six managers representing the six sites. Interviews lasted from 12 to 37 minutes (mean, 23.5). Participant demographics are provided in eTable 2; eSupplement 3. Theme 1: Effectiveness Participants reported the Playbook Program enhanced their understanding of what motivates different team members, fostered positivity and strengthened collaboration, “people [started] talking and break(ing) the ice a little bit ” [Control 1],and “ OK, today may have been a hard challenge, but what three things made it better? ” [Intervention 2]” and that teams found “ communication and flow” [Intervention 3]. Managers who received coaching noted coaching helped them “ think and come up with answers on [their] own” [Intervention 1], provided space for feedback, helped them understand their strengths and weaknesses, and prepared them for difficult conversations. One leader stated that “c oaching was one of the most valuable features of the entire Playbook experience” [Intervention 2]. Theme 2: Adoption Participants reported that Playbook interventions were easy to adopt and “ if I did it consistently for two weeks, it would have a better chance” [Intervention 1]. Ice breaker questions, staff check-ins, and celebrating wins were the most frequently adopted interventions that boosted team morale and increased playfulness, where previously staff “ dragged themselves to attend (huddles and meetings).” [Intervention 2]. Theme 3: Implementation Participants reported spending an average of 2.4 hours per week on the Playbook program (range, 1–6 hours). The Playbook was “ user friendly” [Intervention 1], interventions took only a couple minutes, and the “(Playbook) examples make it easy to understand how you can implement them with the least amount of effort ” [Intervention 2]. Facilitators included integrating the practices into existing team meetings and leadership coaching. Barriers included skepticism that the Playbook was “ the next flavor of the month” [Intervention 3], staff burnout, staffing shortages and competing priorities. However, participants emphasized that even partial engagement was valuable (Table 4 ). Table 4 Mixed Methods Results Outcome of Interest Quantitative Result Illustrative Quotes Acceptable, Appropriate, Feasible Intervention and control groups rated the Playbook as acceptable, appropriate, and feasible “The real-time feedback [provided with coaching] with ideas or things I was trying to implement helped with personal growth and development” [Intervention 3] “Examples within the Playbook make it extremely easy to understand how you can implement them with the least amount of effort because they give you real world scenarios” [Intervention 2] “I think a lot of new leaders especially will find [the Playbook] very valuable and even your seasoned leaders may find some use” [Intervention 2] Job Satisfaction Intervention groups demonstrated an increase in job satisfaction “[The Playbook] started engaging staff… and start laughing and bringing more joy into the work environment” [Intervention 2] “Make it a priority to invest in your team and grow your team… if I can get them engaged and some type of positive foundation to help them grow, that’s literally what I’m here for” [Control 3] Playbook practices impacted the team by having them “be more focused” and having them “thinking about the things that can work versus can’t work” [Intervention 1] Burnout Intervention CCLs demonstrated a decrease in burnout It was noted that staff are more playful, and “the zombies have come alive” [Intervention 2] “People used to drag themselves to attend [regular team meetings], now they show up on time, there is laughter. Staff volunteer for assignments or offer to be extra help” [Intervention 2] “I do see that there is some changes in behavior with some of my staff… positive changes” [Intervention 1] Note : Intent to leave, staff turnover, and safety climate outcomes were assessed quantitively and were not part of the interview guide questions. DISCUSSION In this pilot site randomized trial in VA CCLs, the Playbook was acceptable, appropriate and feasible for implementation. Cardiology managers reported that Playbook practices were readily integrated into existing workflows with a modest time commitment, and that uptake was facilitated by coaching. Teams in the intervention group (Playbook plus coaching) described improvements in their local learning environment and use of high-reliability practices, along with favorable trends in burnout, job satisfaction, and intent to leave, compared to the control group. Although these signals are preliminary, they suggest that a brief, team-focused program paired with a coaching implementation strategy may help strengthen team culture and well-being. No differences were observed in turnover or safety climate during the study period. Given the short follow-up and small sample, these null findings may reflect limited power and the time required for unit level behaviors to translate into organizational outcomes.( 31 ) Participants described substantial contextual challenges, including staff burnout and shortages, yet still reported positive changes in teamwork and morale. Together, these findings suggest that simple, low-burden relational practices, reinforced with an evidence-based leadership coaching implementation strategy, may be implementable even amid operational strain.( 32 ) Leadership coaching functioned as an effective implementation strategy by offering real-time feedback, accountability, and problem-solving as managers translated Playbook practices into local context. Our study adds to the growing body of literature that reports on the impact of coaching on clinician well-being, professional development,( 33 , 34 ) and adoption of evidence-based practices.( 35 , 36 ) Qualitative findings suggested that the Playbook interventions allowed for quick wins and coaching provided individualized support which translated to leader and team behavior change. Importantly, several teams reported benefit even when there was moderate engagement, underscoring that small efforts can have positive impacts. The Playbook program aligns with the VA’s emphasis on high-reliability and learning health system principles( 6 ) and addresses engagement, joy at work, and psychological safety that are linked to patient safety and reliability of operations.( 37 ) The program’s micro-learning, self-driven education and interventions fit the realities of clinical managers workflow and adult learning best practices. Coaching delivered by a clinically experienced, certified leadership coach likely enhanced relevance compared to programs that hire external, non-clinical consultants or rely on peer coaches with varying degrees of training.( 38 , 39 ) The individualized approach does limit reach. Partnering with existing VA coaching resources and group coaching models will be important next steps for scalability. Limitations This pilot included six sites and nine clinical managers and had lower-than-anticipated post-intervention survey response, increasing the risk of nonresponse bias. We therefore did not report inferential statistics. Voluntary participation may have favored managers interested in professional development, and observed improvements may be attributable to either component alone (Playbook or coaching). Future trials will consider an active control (e.g., noncoaching support), stratified randomization, longer follow-up, and objective implementation outcomes (e.g., fidelity, reach) alongside staff outcomes. The sample was demographically homogeneous and focused on VA CCLs; generalizability to other specialties, systems, and demographic groups is uncertain. Lower completion of post-intervention surveys may reflect survey burden or concerns about anonymity during a period of organizational change. CONCLUSIONS The Playbook, supported by leadership coaching, was feasible to implement, required limited time, and suggested improvements in the perceived learning environment and markers of staff well-being. These early signals justify a larger, adequately powered trial to test effectiveness, mechanisms (e.g., consistency of use, coaching dose), and scalability. In an increasingly volatile and capacity-constrained clinical environment, a low-burden, team-based evidenced-based program to create supportive learning environments, paired with focused implementation support, warrants further evaluation for broader adoption and sustainment. Abbreviations AAF Acceptability, Appropriateness, Feasibility VA Veterans Health Administration LES Learning Environment Survey DiD Difference in difference SD Standard deviation CCL Cardiac catheterization laboratory COMIRB Colorado Multiple Institutional Review Board CONSORT Consolidated Standards of Reporting Trials ( GROW Goal, reality, options, what NCOD National Center for Organization Development Declarations Ethics approval and consent to participate: The trial was approved as an exempt human research study by the Colorado Multiple Institutional Review Board (COMIRB 17-1153). Participation was voluntary, and all participants provided written consent. Consent for publication : Not applicable Data Availability Statement : A de-identified, anonymized dataset will be created meeting VA standards for disclosure, upon request. Prior to distribution, a local privacy officer will certify that all datasets contains no personal health information. Those requesting data will be asked to sign a data use agreement. The principal investigator will maintain a crosswalk between the analytical dataset(s) and the public release datasets so that a VA-approved auditor or the principal investigator could conduct or facilitate validation if needed. Some loss of information might occur given the need to remove personal health information. Competing Interests: All authors receive salary support from the Department of Veterans Affairs. Disclaimer: 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 or the United States government Funding information: This material is based upon work supported (or supported in part) by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research and Development Award number 1I21HX003811-01A1. Dr. Gilmartin was supported by Career Development Award number 1IK2HX002567-01A1 from the VA Office of Research and Development. The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Author Contributions: Dr. Gilmartin had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: Gilmartin, Leonard Acquisition, analysis, or interpretation of data: Gilmartin, Daus, Hess, Klocko, Leonard Drafting of the manuscript: Gilmartin, Daus, Hess, Klocko, Leonard Critical review of the manuscript for important intellectual content: Gilmartin, Daus, Hess, Klocko, Leonard Statistical analysis : Hess Obtained funding: Gilmartin Administrative, technical, or material support: Gilmartin, Daus, Hess, Klocko, Leonard Supervision: Gilmartin, Leonard Acknowledgements: Not applicable Reporting Checklists: Consolidated Standards of Reporting Trials 2025; Standards for Reporting Qualitative Research 2023 References Addressing Health Worker Burnout: The U.S. Surgeon General’s Advisory on Building a Thriving Health Workforce Washington, D.C.: U.S. Surgeon General’s Office; 2022 [Available from: https://www.hhs.gov/surgeongeneral/priorities/health-worker-burnout/index.html. Gilmartin HM, Plomondon ME, Mueller C, Connelly B, Battaglia C, Waldo SW, et al. The Impacts of COVID-19 on Veterans Affairs Catheterization Laboratory Staff During the First Months of the US Response. The Journal of Cardiovascular Nursing. 2021. Oh RC, Mohr DC, Schult TM. VA physicians intent to leave and correlations to drivers of burnout: a cross-sectional study. BMC Health Serv Res. 2025;25(1):125. Li LZ, Yang P, Singer SJ, Pfeffer J, Mathur MB, Shanafelt T. Nurse Burnout and Patient Safety, Satisfaction, and Quality of Care: A Systematic Review and Meta-Analysis. JAMA Network Open. 2024;7(11):e2443059–e. Rinne ST, Mohr DC, Swamy L, Blok AC, Wong ES, Charns MP. National burnout trends among physicians working in the Department of Veterans Affairs. Journal of General Internal Medicine. 2020;35:1382–8. Atkins D, Kilbourne AM, Shulkin D. Moving from discovery to system-wide change: The role of research in a learning health care system: Experience from three decades of health systems research in the Veterans Health Administration. Annual Review of Public Health. 2017(0). National Plan for Health Workforce Well-Being. Washington, D.C: National Academy of Medicine; 2022. Gilmartin HM, Connelly B, Hess E, Mueller C, Plomondon ME, Waldo SW, et al. Developing a relational playbook for cardiology teams to cultivate supportive learning environments, enhance clinician well‐being, and veteran care. Learning Health Systems. 2023;e10383:1–7. Singer SJ, Moore SC, Meterko M, Williams S. Development of a short-form learning organization survey: The LOS-27. Medical Care Research and Review. 2012;69(4):432–59. Vogus TJ, Iacobucci D. Creating highly reliable health care: How reliability-enhancing work practices affect patient safety in hospitals. ILR Review. 2016;69(4):911–38. Gilmartin H, Connelly B, Hess E, Mueller C, Plomondon ME, Waldo S, et al. Developing the Relational Playbook for Cardiology Teams to Enhance Employee Well-being and Veteran Care. Academic Medicine. Under Review. Gilmartin HM, Hess E, Mueller C, Connelly B, Plomondon ME, Waldo SW, et al. Learning environments, reliability enhancing work practices, employee engagement, and safety climate in VA cardiac catheterization laboratories. Health Services Research. 2022;57(2):385–91. Gilmartin HM, Hess E, Mueller C, Plomondon ME, Waldo SW, Battaglia C. A pilot study to assess the learning environment and use of reliability enhancing work practices in VHA cardiac catheterization laboratories. Learning Health Systems. 2020;March:1–6. Williams NJ, Wolk CB, Becker-Haimes EM, Beidas RS. Testing a theory of strategic implementation leadership, implementation climate, and clinicians’ use of evidence-based practice: a 5-year panel analysis. Implementation Science. 2020;15(1):1–15. Hopewell S, Chan A-W, Collins GS, Hróbjartsson A, Moher D, Schulz KF, et al. CONSORT 2025 explanation and elaboration: updated guideline for reporting randomised trials. bmj. 2025;389. O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Academic medicine. 2014;89(9):1245–51. Wolever RQ, Moore MA, Jordan M. Coaching in healthcare. The Sage handbook of coaching. 2017:521–43. Knowles MS, Holton III EF, Swanson RA. The adult learner: The definitive classic in adult education and human resource development: Routledge; 2014. Lovell B. What do we know about coaching in medical education? A literature review. Medical education. 2018;52(4):376–90. Horvath Z, Wilder RS, Guthmiller JM. The power of coaching: Developing leaders and beyond. J Dent Educ. 2024;88:671–7. Boet S, Etherington C, Dion P-M, Desjardins C, Kaur M, Ly V, et al. Impact of coaching on physician wellness: A systematic review. PLoS One. 2023;18(2):e0281406. Richardson C, Wicking K, Biedermann N, Langtree T. Coaching in nursing: An integrative literature review. Nursing open. 2023;10(10):6635–49. Bisbey TM, Allison M, Salas E. Transforming Teams of Experts into Expert Teams: Eight Principles of Expert Team Performance. Journal of Expertise. 2021;4(2):190–207. Hu S, Välimäki M, Liu S, Li X, Shumaila B, Huang W, et al. Coaching to develop leadership of healthcare managers: a mixed-methods systematic review. BMC medical education. 2024;24(1):1083. Weiner BJ, Lewis CC, Stanick C, Powell BJ, Dorsey CN, Clary AS, et al. Psychometric assessment of three newly developed implementation outcome measures. Implementation Science. 2017;12(1):108. VA All Employee Survey (AES) 2023-2024- Item Dictionary 2024 [Internet]. U.S. Department of Veterans Affairs. 2024 [cited February 13, 2026]. Available from: https://www.data.va.gov/dataset/All-Employee-Survey-AES-2023-2024/hevq-e649/about_data. Averill JB. Matrix analysis as a complementary analytic strategy in qualitative inquiry. Qualitative Health Research. 2002;12(6):855–66. Pope C, Ziebland S, Mays N. Analysing qualitative data. Bmj. 2000;320(7227):114–6. Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC medical research methodology. 2013;13(1):117. Tashakkori A, Johnson RB, Teddlie C. Foundations of mixed methods research: Integrating quantitative and qualitative approaches in the social and behavioral sciences. 2 ed. Thousand Oaks, California: SAGE Publications; 2020. Pinheiro M, Rebelo T, Lourenço PR, de Sousa B, Dimas I. Dynamics of team learning behaviours: The effect of time and team culture. Behavioral Sciences. 2022;12(11):449. Maddox TM, Biesbrock, G., Downey, W., Lohr, N., Price, A., Thakker, P., Wan, L.S. Workforce in Crisis: Charting the Path Forward. Cardiology Magazine. 2023 June 2, 2023. Maini A, Saravanan Y, Singh TA, Fyfe M. Coaching skills for medical education in a VUCA world. Med Teach. 2020;42(11):1308–9. Burtson KM, Wilson KR, Kiger ME, Jung E, Hartzell JD, Meyer H. Academic Coaching to Promote Self-Directed Learning in Graduate Medical Education: Burtson et al. Journal of General Internal Medicine. 2025;40(14):3311–9. Snyder PA, Hemmeter ML, Fox L. Supporting implementation of evidence-based practices through practice-based coaching. Topics in early childhood special education. 2015;35(3):133–43. Ashcraft LE, Goodrich DE, Hero J, Phares A, Bachrach RL, Quinn DA, et al. A systematic review of experimentally tested implementation strategies across health and human service settings: evidence from 2010-2022. Implementation Science. 2024;19(1):43. Janes G, Mills T, Budworth L, Johnson J, Lawton R. The association between health care staff engagement and patient safety outcomes: a systematic review and meta-analysis. Journal of patient safety. 2021;17(3):207–16. Dyrbye LN, Shanafelt TD, Gill PR, Satele DV, West CP. Effect of a professional coaching intervention on the well-being and distress of physicians: a pilot randomized clinical trial. JAMA internal medicine. 2019;179(10):1406–14. Palamara K, Chu JT, Chang Y, Yu L, Cosco D, Higgins S, et al. Who benefits most? A multisite study of coaching and resident well-being. Journal of general internal medicine. 2022;37(3):539–47. Additional Declarations The authors declare no competing interests. Supplementary Files CONSORT2025editablechecklist.docx srqrchecklistreplaymanuscript.docx eSupplement1.TrialProtocol.doc eSupplement 1: Trial Protocol eSupplement23.19.docx eSupplement 2: 13-item Learning Environment Assessment Tool; Relational Playbook Components; Introduction and Chapter 1; The NCOD Coaching Curriculum GROW Coaching Framework, Question List & Fidelity Assessment Guide; Acceptability, Appropriateness, and Feasibility Survey; Learning Environment Survey; Intention and Reflection Survey; Interview Guide. eSupplement3.docx eSupplement 3: Pre Post Learning Environment Survey Table; Qualitative Interview Demographic Table. 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Gilmartin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEklEQVRIiWNgGAWjYBACAyBmBrOYmRtAFA8DewNBLYzNEC2MIKUGPAw8B4jVwgDRwsAgkYBfizl78/PHBRX3GOTdGVs3/NzzR8Zc8o3hB4ZfNom43GfZc8ywecaZYgbDw4xtN3ueGfBYzs4xlmDsS8OpxeBGgmEzb1sCg2EzY9sNngMGPAa30xIkGHsOG+P0y/3nH5t5/0G03PwD0nLzWPIPvFpu8ABtaUhgkGdmbLsNtuUG8zEJhh+H5XBqOZNTOJvnWAKPAUiLzAFjHoMzyccsEhvScGs5fnzDZ56aBDn5/sPHbr45IGdvcPxg840Pf2x4cGmBAR6DA8jcxDZCGoBAvgGF+4cILaNgFIyCUTBSAABP6VqhbnTO/gAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0002-0264-4059","institution":"Department of Veterans Affairs","correspondingAuthor":true,"prefix":"","firstName":"Heather","middleName":"","lastName":"Gilmartin","suffix":""},{"id":634395609,"identity":"5720a469-6af4-40e4-8aa0-b470a622b46d","order_by":1,"name":"Robert Klocko","email":"","orcid":"https://orcid.org/0009-0002-6695-4934","institution":"Department of Veterans 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16:52:27","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":34453,"visible":true,"origin":"","legend":"","description":"","filename":"CONSORT2025editablechecklist.docx","url":"https://assets-eu.researchsquare.com/files/rs-9612173/v1/a905b0bf9d3b7a3c182f1be9.docx"},{"id":108823232,"identity":"fe31c014-8fe8-429b-9f50-576bce88ca48","added_by":"auto","created_at":"2026-05-08 16:52:50","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":145701,"visible":true,"origin":"","legend":"","description":"","filename":"srqrchecklistreplaymanuscript.docx","url":"https://assets-eu.researchsquare.com/files/rs-9612173/v1/d45e2bb3bb3b844aa7abd758.docx"},{"id":108822985,"identity":"c8553f16-420b-4e7d-85e8-710e285a1458","added_by":"auto","created_at":"2026-05-08 16:51:43","extension":"doc","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":209920,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eeSupplement 1:\u003c/strong\u003e Trial Protocol\u003c/p\u003e","description":"","filename":"eSupplement1.TrialProtocol.doc","url":"https://assets-eu.researchsquare.com/files/rs-9612173/v1/0522489c6b374acc49d9732c.doc"},{"id":108822986,"identity":"63712b53-db9e-420d-9343-c967aebe94be","added_by":"auto","created_at":"2026-05-08 16:51:43","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":50940,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eeSupplement 2:\u003c/strong\u003e 13-item Learning Environment Assessment Tool; Relational Playbook Components; Introduction and Chapter 1; The NCOD Coaching Curriculum GROW Coaching Framework, Question List \u0026amp; Fidelity Assessment Guide;\u003cstrong\u003e \u003c/strong\u003eAcceptability, Appropriateness, and Feasibility Survey; Learning Environment Survey; Intention and Reflection Survey; Interview Guide.\u003c/p\u003e","description":"","filename":"eSupplement23.19.docx","url":"https://assets-eu.researchsquare.com/files/rs-9612173/v1/06367e7268c147cf56231980.docx"},{"id":108823300,"identity":"4e48b4c9-bb9f-4981-afea-05944971f1ef","added_by":"auto","created_at":"2026-05-08 16:53:04","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":22043,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eeSupplement 3: \u003c/strong\u003ePre Post Learning Environment Survey Table; Qualitative Interview Demographic Table.\u003c/p\u003e","description":"","filename":"eSupplement3.docx","url":"https://assets-eu.researchsquare.com/files/rs-9612173/v1/c4fe26c713eeb7caa83775a7.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eLeadership Coaching as an Implementation Strategy to Enhance Adoption of a Relational Playbook and Team Well-Being: A Pilot Randomized Clinical Trial In Cardiology\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Contributions to the Literature","content":"\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eAdvances the implementation of learning environment interventions\u003c/strong\u003e by evaluating leadership coaching as a discrete implementation strategy to support adoption and enactment of an evidence-based Relational Playbook in cardiology teams.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eExtends evidence on implementation–workforce outcome pathways\u003c/strong\u003e by linking high acceptability, appropriateness, and feasibility of a leadership development intervention with improvements in burnout, intent to leave, and job satisfaction.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eProvides mixed-methods insight into implementation mechanisms\u003c/strong\u003e, illustrating how leadership coaching enables real-time feedback, adaptation, and sensemaking that facilitate sustained use of Relational Playbook practices.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"BACKGROUND","content":"\u003cp\u003eClinician burnout and turnover have reached crisis levels across U.S. healthcare and within the Veterans Health Administration (VA), threatening care quality, patient safety, and organizational performance.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) High burnout is associated with lower patient safety, reduced reliability of clinical operations, and increased costs linked to staffing instability.(\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) In response, the VA has prioritized employee well-being while advancing high quality and safe care through Learning Health System and High Reliability Organization principles.(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) The National Academy of Medicine has similarly highlighted the need for organizations to cultivate supportive learning environments that strengthen teamwork, psychological safety, and relational capacity, which are key determinants of workforce well-being and patient outcomes.(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eDespite substantial system-level investment, frontline clinical teams often lack practical tools and guidance to create supportive learning environments.(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) These environments enable teams to experiment with and adopt innovations while using highly reliable work practices.(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) They intentionally cultivate positive moments, joy in work, relational connection and high-quality communication.(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) Supportive learning environments are associated with higher job satisfaction and lower burnout and turnover, which are core indicators of employee well-being.(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) Yet, supportive learning environments remain uncommon across the VA.(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) Organizational constraints include staffing pressures, high workload and limited time for learning. These factors impede a leaders ability to create supportive learning environments.(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eTo address this gap, The Relational Playbook, (henceforth Playbook) a team-focused intervention developed in VA cardiac catheterization laboratory (CCL) teams, was developed.(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) CCLs were a strategic starting point because they are high cost and high value team-based settings, making them ideal for observing team learning processes with potential generalizability to other clinical settings.(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) The Playbook includes five chapters of research-based content and more than 50 evidence-based practices presented in brief, accessible formats to help leaders and teams cultivate supportive learning environments. Although promising, the Playbook has not been rigorously implemented or evaluated in diverse VA environments, and optimal implementation strategies to support its adoption are unknown.\u003c/p\u003e \u003cp\u003eLeadership coaching is an evidence-based implementation strategy that promotes proactive and supportive leadership behaviors which are critical for successful implementation of innovations in complex environments. Although coaching is well-established for patients and executive leaders, no studies have examined its role in supporting innovation implementation among clinical managers.(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) By examining intervention implementation and leadership coaching, this study will generate new insights into mechanisms that support both effective adoption of interventions and leadership development.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eAim\u003c/h2\u003e \u003cp\u003eThis pilot study aimed to implement the Playbook, assess its acceptability, appropriateness, and feasibility, and test coaching as an implementation strategy to enhance Playbook adoption and team well-being.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Design, Setting, and Participants\u003c/h3\u003e\n\u003cp\u003eWe piloted a site randomized trial with a convergent mixed method process evaluation of the Playbook and coaching with six VA CCL nurse or technician clinical managers and assistant managers. Managers from the 84 VA CCLs were recruited through email and VA listservs. Sample size was set pragmatically to six sites to fit the study budget. Participation was voluntary, and all participants provided written consent. The intervention occurred from July 2024 to January 2025, followed the Consolidated Standards of Reporting Trials (CONSORT) guideline for trial studies,(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) and was approved as an exempt human research study by the Colorado Multiple Institutional Review Board (COMIRB 17-1153). Qualitative reporting followed the Standards for Reporting Qualitative Research.(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) The study protocol is available in \u003cb\u003eeSupplement 1\u003c/b\u003e.\u003c/p\u003e\n\u003ch3\u003eRandomization, Allocation Concealment, and Follow-up\u003c/h3\u003e\n\u003cp\u003eCCLs were stratified into low, medium, and high tiers based on 2022 percutaneous coronary intervention volume. Within each tier, one site was randomized to the coaching group (intervention) and the other to the control group and were provided no coaching or advisement. Both groups received the Playbook Program. Post-randomization data collection was conducted by the evaluation team. Data were not shared with the leadership coach until study conclusion. (Fig.\u0026nbsp;1).\u003c/p\u003e\n\u003ch3\u003eDescription of Intervention\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eRelational Playbook Leadership Program\u003c/h2\u003e \u003cp\u003eThe Playbook is an intervention carried out by frontline managers in the clinical setting. Playbook concepts are grounded in the fields of positive psychology, team science, servant leadership, Whole Health, and Clinical Team Training models. These concepts informed the development of the Playbook chapters: 1) Creating a positive culture; 2) Teamwork; 3) Leading teams; 4) Creating joy in work; and 5) Communication and high reliability.(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) Each chapter includes brief asynchronous modules and 2\u0026ndash;3 required interventions that managers incrementally implement into meetings and interactions to create supportive learning environments. The Playbook\u0026rsquo;s Introduction and Chap.\u0026nbsp;1 are presented in \u003cb\u003eeSupplement 2.\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eLeadership Coaching Implementation Strategy\u003c/h2\u003e \u003cp\u003eLeadership coaching aims to transform managers\u0026rsquo; behaviors and mindsets, with the potential to impact work environments. Coaching uses solution-focused approaches to support managers in deepening self-awareness.(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) Coaching is grounded in adult learning theory which describes how learning is most effective when self-directed, problem-centered, and immediately relevant.(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) Most healthcare coaching programs focus on executive leadership, academic faculty, or trainees.(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) Two literature reviews have reported positive impacts of coaching on physician wellness(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) and nurse leader performance and role effectiveness.(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) A review by Bisbey et al(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) identified leadership coaching as one of eight core principles for transforming teams of experts into expert teams, underscoring its potential value for healthcare settings. Leadership coaching may be a scalable strategy to strengthen adoption of innovations. However, few studies have examined coaching specifically among clinical managers and research is needed to understand how coaching influences team-level innovation adoption.(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eWe hypothesized that leadership coaching delivered for six months by an International Coaching Federation-certified coach and nurse practitioner would enhance Playbook adoption and improve team well-being. Coaching sessions followed the VA National Center for Organization Development (NCOD) GROW framework (Goal, Reality, Options, What) and were conducted as structured 60-minute virtual meetings (\u003cb\u003eeSupplement 2)\u003c/b\u003e.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Groups\u003c/h3\u003e\n\u003cp\u003eCCLs randomly assigned to the intervention group were offered the Playbook and coaching program. They were not given protected time to participate and carried the same responsibilities as participants assigned to the control group. Control group participants were offered coaching after the study conclusion.\u003c/p\u003e\n\u003ch3\u003eStudy Outcomes\u003c/h3\u003e\n\u003cp\u003eBaseline and post-intervention surveys were administered electronically. The surveys contained demographic questions and validated instruments studying the acceptability, appropriateness, and feasibility (AAF)(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) of the Playbook and the learning environment.(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) Process outcomes were assessed through intention and reflection surveys, coaching notes, and interviews to assess Playbook implementation and coaching perceptions and experiences.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e\u003cb\u003ePrimary Outcomes: Acceptability, Appropriateness and Feasibility\u003c/b\u003e\u003c/h2\u003e \u003cp\u003eThe primary outcomes assessed were the AAF of the Playbook intervention, as perceived by all participants at trial completion based on measures developed by Weiner et al (\u003cb\u003eeSupplement 2\u003c/b\u003e).(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) The AAF survey consists of twelve items. All items were rated using a 1\u0026ndash;5 ascending Likert scale.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSecondary Outcomes\u003c/b\u003e: \u003cb\u003eLearning Environment and Team Well-being\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eLearning Environment Survey\u003c/h2\u003e \u003cp\u003ePre to post intervention, survey responses relating to learning environment and job satisfaction, burnout, turnover intention, CCL turnover, and safety climate were collected from participants and their self-identified team members (e.g., nurse, technician, physician) through the validated Learning Environment Survey (LES) [\u003cb\u003eeSupplement 2\u003c/b\u003e].(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) The survey consists of 64 items related to CCL learning environments and use of reliability enhancing work practice factors rated using 1\u0026ndash;5 and 1\u0026ndash;7 Likert scale formats.\u003c/p\u003e \u003cp\u003eTeam well-being was assessed using five validated questions from the 2023 VA All Employee Survey item dictionary.(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) The following were rated on a 1\u0026ndash;5 Likert scale using a single item question: job satisfaction \u003cem\u003e(Considering everything, how satisfied are you with your job?)\u003c/em\u003e, turnover intention (\u003cem\u003eIf I were able, I would leave my current job\u003c/em\u003e), and perception of safety climate (\u003cem\u003eI would feel perfectly safe being treated in this CCL\u003c/em\u003e). Burnout was measured using a single item \u003cem\u003e(I feel burned out from my work)\u003c/em\u003e and rated on a 7-item scale ranging from \u003cem\u003e\u0026ldquo;Never\u0026rdquo;\u003c/em\u003e to \u0026ldquo;\u003cem\u003eEveryday\u0026rdquo;.\u003c/em\u003e CCL turnover was measured by a single item (\u003cem\u003eWe have had __ staff leave our team in the last 12 months\u003c/em\u003e) with numerical response options ranging from zero to seven or more.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eProcess Outcomes: Evaluation of Adoption and Implementation\u003c/h2\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003eBi-weekly Intention Setting and Reflection Surveys\u003c/h2\u003e \u003cp\u003eSurveys were descriptively analyzed. The Intention Setting survey was sent every other Monday to remind participants of the assigned chapter and to encourage goal setting. The Reflection Survey was sent every other Friday to document intervention and implementation stories (\u003cb\u003eeSupplement 2\u003c/b\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eCoaching Notes\u003c/h2\u003e \u003cp\u003eCoaching sessions were summarized by the coach immediately after each session using the NCOD Framework, stored in a secure VA folder, and de-identified prior to reporting.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003ePost-Intervention Interviews\u003c/h2\u003e \u003cp\u003eNine CCL managers were invited to participate. Recruitment emails included the informed consent statement. Interviews were scheduled at the participants\u0026rsquo; convenience, conducted by an experienced interviewer over Microsoft Teams, recorded, and transcribed. The interview guide included questions on their experience participating in the Playbook trial and impacts on participants and teams (\u003cb\u003eeSupplement 2\u003c/b\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eOutcomes were calculated using the average of available items within each factor. For example, if a respondent answered three of four items for a given factor, the mean of those three responses was used as the factor score. To provide a preliminary estimate of relative pre-post changes in LES outcomes between the intervention and control group, we fit mixed-effects models with each outcome specified as a function of time (pre vs. post), intervention group, and their interaction, including a random intercept for respondent. The parameter of interest for each model was the difference-in-difference estimate (DiD), representing the relative change in mean scores from pre to post between groups. Statistical tests were not performed due to the small sample size. All data analysis and summary statistics were conducted using R version 4.3.1 and SAS version 9.4.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eQualitative Analysis\u003c/h2\u003e \u003cp\u003eOpen-text survey responses, coaching notes and interview transcripts were analyzed using a deductive rapid matrix analysis approach.(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) This method was selected to generate timely insights for the study team while retaining sufficient detail to identify emergent concepts. A structured summary was developed for each data source, organized into domains and reviewed by two analysts.(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) Themes were developed iteratively, refined through repeated engagement with the data, supported with illustrative quotations and incorporated into a table. The quantitative and qualitative findings were triangulated to identify areas of convergence and divergence.(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eOf the 84 VA CCLs invited to participate, 28 expressed interest (21% response rate) and six sites submitted enrollment forms by the deadline. All clinical managers completed a demographic survey, and three of the six sites were randomly assigned to the intervention group. Participants included six CCL managers and three assistant managers with nursing or technician backgrounds. The mean (SD) age of participants was 50 (6.5) years, all participants identified as White and female and mean (SD) VA tenure was 11.6 (9.6) years. Baseline characteristics did not differ meaningfully between groups. Of the nine individuals who initially enrolled, six completed the study. One intervention participant and two control participants withdrew because of time constraints. Each of these sites had two enrolled participants, so affected sites remained in the study (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSite and Participant Characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eSite Characteristics\u003c/span\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCoaching Group\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eCath Lab Volume (high/low)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eLocation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eNumber of Participants\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eNumber of Team Members\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNorth Central\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSouthwest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMountain West\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSouth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSoutheast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNortheast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParticipant Characteristics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eOverall\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eN (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eIntervention\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;4)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cb\u003eControl\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;5)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRole\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegistered Nurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e5(62)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTechnician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSupervisor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e5 (56)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50.0 (6.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48.8 (8.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e51.2 (4.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender: Female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e5 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRace: White\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e5 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEthnicity:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot of Hispanic Origin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e5 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears in VA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.6 (9.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.2 (12.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e11.8 (7.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eKey\u003c/strong\u003e \u003cp\u003eHigh Cath Lab Volume\u0026thinsp;=\u0026thinsp;greater than 140 procedures annually, Medium Cath Lab Volume\u0026thinsp;=\u0026thinsp;60\u0026ndash;139 procedures annually, Low Cath Lab Volume\u0026thinsp;=\u0026thinsp;less than 59 procedures annually. Team members\u0026thinsp;=\u0026thinsp;nurse, technicians, physician staff. * indicates sites that had a cath lab manager and assistant manager participate.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eAAF surveys were completed by all six clinical managers across the six participating sites (100% response rate). Baseline LES surveys (n\u0026thinsp;=\u0026thinsp;41) were received from all six sites (intervention: n\u0026thinsp;=\u0026thinsp;16; control: n\u0026thinsp;=\u0026thinsp;25; response rate\u0026thinsp;=\u0026thinsp;30%). Post-intervention, 20 surveys were received from five sites (intervention: n\u0026thinsp;=\u0026thinsp;9; control n\u0026thinsp;=\u0026thinsp;11; response rate\u0026thinsp;=\u0026thinsp;14.5%). Twelve respondents across the six sites completed both pre- and post-intervention surveys, including the six study participants.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eEngagement\u003c/h2\u003e \u003cp\u003eOverall adoption of the required Playbook interventions was 73%: 100% for Chap.\u0026nbsp;1 (2 of 2 interventions), 100% for Chap.\u0026nbsp;2 (2 of 2), 50% for Chap.\u0026nbsp;3 (1 of 2), 67% for Chap.\u0026nbsp;4 (2 of 3), and 50% for Chap.\u0026nbsp;5 (1 of 2). Participants completed a total of 39 coaching sessions. The mean number of sessions per participant was 5.6, with a range of 5\u0026ndash;6 sessions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003ePrimary Outcome: Acceptability, Appropriateness, Feasibility\u003c/h2\u003e \u003cp\u003eBoth groups rated the Playbook as highly acceptable (median\u0026thinsp;=\u0026thinsp;5.0), appropriate (median\u0026thinsp;=\u0026thinsp;4.6), and feasible (median 5.0) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePrimary Outcome: Acceptability, Appropriateness, Feasibility\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAcceptability Subscale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl (N\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntervention (N\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal (N\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian; Range (\u003cspan additionalcitationids=\"CR2 CR3 CR4\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.5 (4.2\u0026ndash;4.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.0 (5.0\u0026ndash;5.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.0 (4.6-5.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAppropriateness Subscale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian; Range (\u003cspan additionalcitationids=\"CR2 CR3 CR4\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.5 (4.4\u0026ndash;4.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.0 (4.8-5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.6 (4.5\u0026ndash;4.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFeasibility Subscale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian; Range (\u003cspan additionalcitationids=\"CR2 CR3 CR4\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.0 (4.8-5.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.0 (5.0\u0026ndash;5.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.0 (5.0\u0026ndash;5.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eSecondary Outcomes: Learning Environment and Team Well-being\u003c/h2\u003e \u003cp\u003eAfter six months of Playbook implementation, LES factor scores showed greater improvement in the intervention group (11 of 12 factors) than in the control group (5 of 12). For example, the intervention group\u0026rsquo;s supportive learning environment factor increased from a baseline score of 4.5 to 6.2, whereas the control group declined from 4.4 to 4.1 on a 1\u0026ndash;7 Likert scale (\u003cb\u003eeTable 1; Supplement 3\u003c/b\u003e). Team well-being outcomes also favored the intervention group. Compared with controls, intervention CCLs demonstrated a relative reduction in burnout (DID = -0.64) and intent to leave (DID = -0.6.5) with a relative increase in job satisfaction (DID\u0026thinsp;=\u0026thinsp;+\u0026thinsp;1.10). Perceptions of safety climate showed minimal difference between groups (DID = -0.06). Both intervention and control CCLs reported no staff turnover post-intervention (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTeam Well-being Pre-Post Playbook and Coaching\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eJob satisfaction\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre Control\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;25)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost\u003c/p\u003e \u003cp\u003eControl (N\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePre Intervention\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePost\u003c/p\u003e \u003cp\u003eIntervention (N\u0026thinsp;=\u0026thinsp;9)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTotal (N\u0026thinsp;=\u0026thinsp;61)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eDiD Estimate\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.9 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.6 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.6 (1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.5 (0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.8 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBurnout\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.0 (1.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.0 (1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.9 (1.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.0 (1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.8 (1.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIntent to leave\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.4 (1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.7 (1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.6 (1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.2 (1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.5 (1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFeel safe as patient\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.6 (1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.5 (1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.0 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.5 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.8 (1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStaff turnover last 12 months\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTurnover: 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e24 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTurnover: 1\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTurnover: 4\u0026ndash;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTurnover: 7 +\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003cb\u003eNote.\u003c/b\u003e Unadjusted mean (SD) LES outcome scores stratified by intervention status\u0026thinsp;+\u0026thinsp;timepoint (i.e. pre vs post intervention). The far-right column provides the difference in difference (Did) estimate for intervention vs control.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eQualitative Results\u003c/h2\u003e \u003cp\u003eInterviews were conducted from January 17 to 31st, 2025, with six managers representing the six sites. Interviews lasted from 12 to 37 minutes (mean, 23.5). Participant demographics are provided in \u003cb\u003eeTable 2; eSupplement 3.\u003c/b\u003e\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eTheme 1: Effectiveness\u003c/h2\u003e \u003cp\u003eParticipants reported the Playbook Program enhanced their understanding of what motivates different team members, fostered positivity and strengthened collaboration, \u003cem\u003e\u0026ldquo;people [started] talking and break(ing) the ice a little bit\u003c/em\u003e\u0026rdquo; [Control 1],and \u0026ldquo;\u003cem\u003eOK, today may have been a hard challenge, but what three things made it better?\u003c/em\u003e\u0026rdquo; [Intervention 2]\u0026rdquo; and that teams found \u0026ldquo;\u003cem\u003ecommunication and flow\u0026rdquo;\u003c/em\u003e [Intervention 3]. Managers who received coaching noted coaching helped them \u0026ldquo;\u003cem\u003ethink and come up with answers on [their] own\u0026rdquo;\u003c/em\u003e [Intervention 1], provided space for feedback, helped them understand their strengths and weaknesses, and prepared them for difficult conversations. One leader stated that \u0026ldquo;c\u003cem\u003eoaching was one of the most valuable features of the entire Playbook experience\u0026rdquo;\u003c/em\u003e [Intervention 2].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eTheme 2: Adoption\u003c/h2\u003e \u003cp\u003eParticipants reported that Playbook interventions were easy to adopt and \u0026ldquo;\u003cem\u003eif I did it consistently for two weeks, it would have a better chance\u0026rdquo;\u003c/em\u003e [Intervention 1]. Ice breaker questions, staff check-ins, and celebrating wins were the most frequently adopted interventions that boosted team morale and increased playfulness, where previously staff \u0026ldquo;\u003cem\u003edragged themselves to attend (huddles and meetings).\u0026rdquo;\u003c/em\u003e [Intervention 2].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003eTheme 3: Implementation\u003c/h2\u003e \u003cp\u003e Participants reported spending an average of 2.4 hours per week on the Playbook program (range, 1\u0026ndash;6 hours). The Playbook was \u0026ldquo;\u003cem\u003euser friendly\u0026rdquo;\u003c/em\u003e [Intervention 1], interventions took only a couple minutes, and the \u003cem\u003e\u0026ldquo;(Playbook) examples make it easy to understand how you can implement them with the least amount of effort\u003c/em\u003e\u0026rdquo; [Intervention 2]. Facilitators included integrating the practices into existing team meetings and leadership coaching. Barriers included skepticism that the Playbook was \u0026ldquo;\u003cem\u003ethe next flavor of the month\u0026rdquo;\u003c/em\u003e [Intervention 3], staff burnout, staffing shortages and competing priorities. However, participants emphasized that even partial engagement was valuable (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMixed Methods Results\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome of Interest\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuantitative Result\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIllustrative Quotes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcceptable, Appropriate, Feasible\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention and control groups rated the Playbook as acceptable, appropriate, and feasible\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;The real-time feedback [provided with coaching] with ideas or things I was trying to implement helped with personal growth and development\u0026rdquo; [Intervention 3]\u003c/p\u003e \u003cp\u003e\u0026ldquo;Examples within the Playbook make it extremely easy to understand how you can implement them with the least amount of effort because they give you real world scenarios\u0026rdquo; [Intervention 2]\u003c/p\u003e \u003cp\u003e\u0026ldquo;I think a lot of new leaders especially will find [the Playbook] very valuable and even your seasoned leaders may find some use\u0026rdquo; [Intervention 2]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJob Satisfaction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention groups demonstrated an increase in job satisfaction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;[The Playbook] started engaging staff\u0026hellip; and start laughing and bringing more joy into the work environment\u0026rdquo; [Intervention 2]\u003c/p\u003e \u003cp\u003e\u0026ldquo;Make it a priority to invest in your team and grow your team\u0026hellip; if I can get them engaged and some type of positive foundation to help them grow, that\u0026rsquo;s literally what I\u0026rsquo;m here for\u0026rdquo; [Control 3]\u003c/p\u003e \u003cp\u003ePlaybook practices impacted the team by having them \u0026ldquo;be more focused\u0026rdquo; and having them \u0026ldquo;thinking about the things that can work versus can\u0026rsquo;t work\u0026rdquo; [Intervention 1]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBurnout\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention CCLs demonstrated a decrease in burnout\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIt was noted that staff are more playful, and \u0026ldquo;the zombies have come alive\u0026rdquo; [Intervention 2]\u003c/p\u003e \u003cp\u003e\u0026ldquo;People used to drag themselves to attend [regular team meetings], now they show up on time, there is laughter. Staff volunteer for assignments or offer to be extra help\u0026rdquo; [Intervention 2]\u003c/p\u003e \u003cp\u003e\u0026ldquo;I do see that there is some changes in behavior with some of my staff\u0026hellip; positive changes\u0026rdquo; [Intervention 1]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cb\u003eNote\u003c/b\u003e: Intent to leave, staff turnover, and safety climate outcomes were assessed quantitively and were not part of the interview guide questions.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn this pilot site randomized trial in VA CCLs, the Playbook was acceptable, appropriate and feasible for implementation. Cardiology managers reported that Playbook practices were readily integrated into existing workflows with a modest time commitment, and that uptake was facilitated by coaching. Teams in the intervention group (Playbook plus coaching) described improvements in their local learning environment and use of high-reliability practices, along with favorable trends in burnout, job satisfaction, and intent to leave, compared to the control group. Although these signals are preliminary, they suggest that a brief, team-focused program paired with a coaching implementation strategy may help strengthen team culture and well-being. No differences were observed in turnover or safety climate during the study period. Given the short follow-up and small sample, these null findings may reflect limited power and the time required for unit level behaviors to translate into organizational outcomes.(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) Participants described substantial contextual challenges, including staff burnout and shortages, yet still reported positive changes in teamwork and morale. Together, these findings suggest that simple, low-burden relational practices, reinforced with an evidence-based leadership coaching implementation strategy, may be implementable even amid operational strain.(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e Leadership coaching functioned as an effective implementation strategy by offering real-time feedback, accountability, and problem-solving as managers translated Playbook practices into local context. Our study adds to the growing body of literature that reports on the impact of coaching on clinician well-being, professional development,(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) and adoption of evidence-based practices.(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) Qualitative findings suggested that the Playbook interventions allowed for quick wins and coaching provided individualized support which translated to leader and team behavior change. Importantly, several teams reported benefit even when there was moderate engagement, underscoring that small efforts can have positive impacts.\u003c/p\u003e \u003cp\u003eThe Playbook program aligns with the VA\u0026rsquo;s emphasis on high-reliability and learning health system principles(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) and addresses engagement, joy at work, and psychological safety that are linked to patient safety and reliability of operations.(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) The program\u0026rsquo;s micro-learning, self-driven education and interventions fit the realities of clinical managers workflow and adult learning best practices. Coaching delivered by a clinically experienced, certified leadership coach likely enhanced relevance compared to programs that hire external, non-clinical consultants or rely on peer coaches with varying degrees of training.(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e) The individualized approach does limit reach. Partnering with existing VA coaching resources and group coaching models will be important next steps for scalability.\u003c/p\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis pilot included six sites and nine clinical managers and had lower-than-anticipated post-intervention survey response, increasing the risk of nonresponse bias. We therefore did not report inferential statistics. Voluntary participation may have favored managers interested in professional development, and observed improvements may be attributable to either component alone (Playbook or coaching). Future trials will consider an active control (e.g., noncoaching support), stratified randomization, longer follow-up, and objective implementation outcomes (e.g., fidelity, reach) alongside staff outcomes. The sample was demographically homogeneous and focused on VA CCLs; generalizability to other specialties, systems, and demographic groups is uncertain. Lower completion of post-intervention surveys may reflect survey burden or concerns about anonymity during a period of organizational change.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eThe Playbook, supported by leadership coaching, was feasible to implement, required limited time, and suggested improvements in the perceived learning environment and markers of staff well-being. These early signals justify a larger, adequately powered trial to test effectiveness, mechanisms (e.g., consistency of use, coaching dose), and scalability. In an increasingly volatile and capacity-constrained clinical environment, a low-burden, team-based evidenced-based program to create supportive learning environments, paired with focused implementation support, warrants further evaluation for broader adoption and sustainment.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAAF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAcceptability, Appropriateness, Feasibility\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eVeterans Health Administration\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLES\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLearning Environment Survey\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDiD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDifference in difference\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStandard deviation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCCL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCardiac catheterization laboratory\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCOMIRB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eColorado Multiple Institutional Review Board\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCONSORT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConsolidated Standards of Reporting Trials (\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGROW\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGoal, reality, options, what\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNCOD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Center for Organization Development\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eThe trial was approved as an exempt human research study by the Colorado Multiple Institutional Review Board (COMIRB 17-1153). Participation was voluntary, and all participants provided written consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e: Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e:\u0026nbsp;A de-identified, anonymized dataset will be created meeting VA standards for disclosure, upon request. \u0026nbsp;Prior to distribution, a local privacy officer will certify that all datasets contains no personal health information. \u0026nbsp;Those requesting data will be asked to sign a data use agreement. The principal investigator will maintain a crosswalk between the analytical dataset(s) and the public release datasets so that a VA-approved auditor or the principal investigator could conduct or facilitate validation if needed. Some loss of information might occur given the need to remove personal health information.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e All authors receive salary support from the Department of Veterans Affairs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclaimer:\u003c/strong\u003e 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 or the United States government\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding information:\u0026nbsp;\u003c/strong\u003eThis material is based upon work supported (or supported in part) by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research and Development Award number\u0026nbsp;\u003cem\u003e1I21HX003811-01A1.\u0026nbsp;\u003c/em\u003eDr. Gilmartin was supported by Career Development Award number 1IK2HX002567-01A1 from the VA Office of Research and Development. The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e Dr. Gilmartin had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConcept and design:\u003c/strong\u003e Gilmartin, Leonard\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcquisition, analysis, or interpretation of data:\u003c/strong\u003e Gilmartin, Daus, Hess, Klocko, Leonard\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDrafting of the manuscript:\u003c/strong\u003e Gilmartin, Daus, Hess, Klocko, Leonard\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCritical review of the manuscript for important intellectual content:\u003c/strong\u003e Gilmartin, Daus, Hess, Klocko, Leonard\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e: Hess\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObtained funding:\u003c/strong\u003e Gilmartin\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdministrative, technical, or material support:\u0026nbsp;\u003c/strong\u003eGilmartin, Daus, Hess, Klocko, Leonard\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSupervision:\u003c/strong\u003e Gilmartin, Leonard\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReporting Checklists:\u0026nbsp;\u003c/strong\u003eConsolidated Standards of Reporting Trials 2025; Standards for Reporting Qualitative Research 2023\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAddressing Health Worker Burnout: The U.S. Surgeon General\u0026rsquo;s Advisory on Building a Thriving Health Workforce Washington, D.C.: U.S. Surgeon General\u0026rsquo;s Office; 2022 [Available from: https://www.hhs.gov/surgeongeneral/priorities/health-worker-burnout/index.html.\u003c/li\u003e\n\u003cli\u003eGilmartin HM, Plomondon ME, Mueller C, Connelly B, Battaglia C, Waldo SW, et al. The Impacts of COVID-19 on Veterans Affairs Catheterization Laboratory Staff During the First Months of the US Response. The Journal of Cardiovascular Nursing. 2021.\u003c/li\u003e\n\u003cli\u003eOh RC, Mohr DC, Schult TM. VA physicians intent to leave and correlations to drivers of burnout: a cross-sectional study. BMC Health Serv Res. 2025;25(1):125.\u003c/li\u003e\n\u003cli\u003eLi LZ, Yang P, Singer SJ, Pfeffer J, Mathur MB, Shanafelt T. Nurse Burnout and Patient Safety, Satisfaction, and Quality of Care: A Systematic Review and Meta-Analysis. JAMA Network Open. 2024;7(11):e2443059\u0026ndash;e.\u003c/li\u003e\n\u003cli\u003eRinne ST, Mohr DC, Swamy L, Blok AC, Wong ES, Charns MP. National burnout trends among physicians working in the Department of Veterans Affairs. Journal of General Internal Medicine. 2020;35:1382\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eAtkins D, Kilbourne AM, Shulkin D. Moving from discovery to system-wide change: The role of research in a learning health care system: Experience from three decades of health systems research in the Veterans Health Administration. Annual Review of Public Health. 2017(0).\u003c/li\u003e\n\u003cli\u003eNational Plan for Health Workforce Well-Being. Washington, D.C: National Academy of Medicine; 2022.\u003c/li\u003e\n\u003cli\u003eGilmartin HM, Connelly B, Hess E, Mueller C, Plomondon ME, Waldo SW, et al. Developing a relational playbook for cardiology teams to cultivate supportive learning environments, enhance clinician well‐being, and veteran care. Learning Health Systems. 2023;e10383:1\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eSinger SJ, Moore SC, Meterko M, Williams S. Development of a short-form learning organization survey: The LOS-27. Medical Care Research and Review. 2012;69(4):432\u0026ndash;59.\u003c/li\u003e\n\u003cli\u003eVogus TJ, Iacobucci D. Creating highly reliable health care: How reliability-enhancing work practices affect patient safety in hospitals. ILR Review. 2016;69(4):911\u0026ndash;38.\u003c/li\u003e\n\u003cli\u003eGilmartin H, Connelly B, Hess E, Mueller C, Plomondon ME, Waldo S, et al. Developing the Relational Playbook for Cardiology Teams to Enhance Employee Well-being and Veteran Care. Academic Medicine. Under Review.\u003c/li\u003e\n\u003cli\u003eGilmartin HM, Hess E, Mueller C, Connelly B, Plomondon ME, Waldo SW, et al. Learning environments, reliability enhancing work practices, employee engagement, and safety climate in VA cardiac catheterization laboratories. Health Services Research. 2022;57(2):385\u0026ndash;91.\u003c/li\u003e\n\u003cli\u003eGilmartin HM, Hess E, Mueller C, Plomondon ME, Waldo SW, Battaglia C. A pilot study to assess the learning environment and use of reliability enhancing work practices in VHA cardiac catheterization laboratories. Learning Health Systems. 2020;March:1\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eWilliams NJ, Wolk CB, Becker-Haimes EM, Beidas RS. Testing a theory of strategic implementation leadership, implementation climate, and clinicians\u0026rsquo; use of evidence-based practice: a 5-year panel analysis. Implementation Science. 2020;15(1):1\u0026ndash;15.\u003c/li\u003e\n\u003cli\u003eHopewell S, Chan A-W, Collins GS, Hr\u0026oacute;bjartsson A, Moher D, Schulz KF, et al. CONSORT 2025 explanation and elaboration: updated guideline for reporting randomised trials. bmj. 2025;389.\u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Academic medicine. 2014;89(9):1245\u0026ndash;51.\u003c/li\u003e\n\u003cli\u003eWolever RQ, Moore MA, Jordan M. Coaching in healthcare. The Sage handbook of coaching. 2017:521\u0026ndash;43.\u003c/li\u003e\n\u003cli\u003eKnowles MS, Holton III EF, Swanson RA. The adult learner: The definitive classic in adult education and human resource development: Routledge; 2014.\u003c/li\u003e\n\u003cli\u003eLovell B. What do we know about coaching in medical education? A literature review. Medical education. 2018;52(4):376\u0026ndash;90.\u003c/li\u003e\n\u003cli\u003eHorvath Z, Wilder RS, Guthmiller JM. The power of coaching: Developing leaders and beyond. J Dent Educ. 2024;88:671\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eBoet S, Etherington C, Dion P-M, Desjardins C, Kaur M, Ly V, et al. Impact of coaching on physician wellness: A systematic review. PLoS One. 2023;18(2):e0281406.\u003c/li\u003e\n\u003cli\u003eRichardson C, Wicking K, Biedermann N, Langtree T. Coaching in nursing: An integrative literature review. Nursing open. 2023;10(10):6635\u0026ndash;49.\u003c/li\u003e\n\u003cli\u003eBisbey TM, Allison M, Salas E. Transforming Teams of Experts into Expert Teams: Eight Principles of Expert Team Performance. Journal of Expertise. 2021;4(2):190\u0026ndash;207.\u003c/li\u003e\n\u003cli\u003eHu S, V\u0026auml;lim\u0026auml;ki M, Liu S, Li X, Shumaila B, Huang W, et al. Coaching to develop leadership of healthcare managers: a mixed-methods systematic review. BMC medical education. 2024;24(1):1083.\u003c/li\u003e\n\u003cli\u003eWeiner BJ, Lewis CC, Stanick C, Powell BJ, Dorsey CN, Clary AS, et al. Psychometric assessment of three newly developed implementation outcome measures. Implementation Science. 2017;12(1):108.\u003c/li\u003e\n\u003cli\u003eVA All Employee Survey (AES) 2023-2024- Item Dictionary 2024 [Internet]. U.S. Department of Veterans Affairs. 2024 [cited February 13, 2026]. Available from: https://www.data.va.gov/dataset/All-Employee-Survey-AES-2023-2024/hevq-e649/about_data.\u003c/li\u003e\n\u003cli\u003eAverill JB. Matrix analysis as a complementary analytic strategy in qualitative inquiry. Qualitative Health Research. 2002;12(6):855\u0026ndash;66.\u003c/li\u003e\n\u003cli\u003ePope C, Ziebland S, Mays N. Analysing qualitative data. Bmj. 2000;320(7227):114\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eGale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC medical research methodology. 2013;13(1):117.\u003c/li\u003e\n\u003cli\u003eTashakkori A, Johnson RB, Teddlie C. Foundations of mixed methods research: Integrating quantitative and qualitative approaches in the social and behavioral sciences. 2 ed. Thousand Oaks, California: SAGE Publications; 2020.\u003c/li\u003e\n\u003cli\u003ePinheiro M, Rebelo T, Louren\u0026ccedil;o PR, de Sousa B, Dimas I. Dynamics of team learning behaviours: The effect of time and team culture. Behavioral Sciences. 2022;12(11):449.\u003c/li\u003e\n\u003cli\u003eMaddox TM, Biesbrock, G., Downey, W., Lohr, N., Price, A., Thakker, P., Wan, L.S. Workforce in Crisis: Charting the Path Forward. Cardiology Magazine. 2023 June 2, 2023.\u003c/li\u003e\n\u003cli\u003eMaini A, Saravanan Y, Singh TA, Fyfe M. Coaching skills for medical education in a VUCA world. Med Teach. 2020;42(11):1308\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eBurtson KM, Wilson KR, Kiger ME, Jung E, Hartzell JD, Meyer H. Academic Coaching to Promote Self-Directed Learning in Graduate Medical Education: Burtson et al. Journal of General Internal Medicine. 2025;40(14):3311\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eSnyder PA, Hemmeter ML, Fox L. Supporting implementation of evidence-based practices through practice-based coaching. Topics in early childhood special education. 2015;35(3):133\u0026ndash;43.\u003c/li\u003e\n\u003cli\u003eAshcraft LE, Goodrich DE, Hero J, Phares A, Bachrach RL, Quinn DA, et al. A systematic review of experimentally tested implementation strategies across health and human service settings: evidence from 2010-2022. Implementation Science. 2024;19(1):43.\u003c/li\u003e\n\u003cli\u003eJanes G, Mills T, Budworth L, Johnson J, Lawton R. The association between health care staff engagement and patient safety outcomes: a systematic review and meta-analysis. Journal of patient safety. 2021;17(3):207\u0026ndash;16.\u003c/li\u003e\n\u003cli\u003eDyrbye LN, Shanafelt TD, Gill PR, Satele DV, West CP. Effect of a professional coaching intervention on the well-being and distress of physicians: a pilot randomized clinical trial. JAMA internal medicine. 2019;179(10):1406\u0026ndash;14.\u003c/li\u003e\n\u003cli\u003ePalamara K, Chu JT, Chang Y, Yu L, Cosco D, Higgins S, et al. Who benefits most? A multisite study of coaching and resident well-being. Journal of general internal medicine. 2022;37(3):539\u0026ndash;47.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"United States Department of Veterans Affairs","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Leadership Coaching, Supportive Learning Environments, Healthcare Workforce, Implementation","lastPublishedDoi":"10.21203/rs.3.rs-9612173/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9612173/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSupportive learning environments are foundational to clinician well-being, workforce retention, and delivery of high-quality care. Prior evidence suggests that the Relational Playbook, an evidence-based leadership development program, can cultivate these environments. Leadership coaching may further enhance Playbook implementation, but its effectiveness has not been tested. The objective of this study was to assess the acceptability, appropriateness, and feasibility (AAF) of the Playbook and determine whether leadership coaching improves Playbook adoption and cardiology team well-being.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA pilot site-randomized trial was conducted from July 2024 to January 2025 in six Veterans Health Administration (VA) cardiac catheterization labs. Nine clinical managers enrolled; six managers from six labs completed the study. Labs were stratified by 2022 percutaneous coronary intervention volume. Within each tier, one lab was randomized to receive coaching (intervention) and one to no coaching (control). All labs implemented the Playbook. Intervention managers received six months of individualized virtual coaching from an International Coaching Federation-certified coach and nurse practitioner. The primary outcome was AAF, measured using validated implementation instruments (Weiner, 2017) across 12 Likert-type subscales (range 1\u0026ndash;5; higher scores reflect greater AAF). Secondary outcomes included team perceptions of the learning environment and well-being: burnout, intent to leave and job satisfaction measured with the Learning Environment Survey (LES). A difference-in-difference (DID) analysis assessed pre-post changes between intervention and control groups; confidence intervals and statistical tests were omitted due to small sample size. Adoption of Playbook practices, coaching experience, and implementation perceptions were assessed through surveys and qualitative interviews.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eParticipants\u0026rsquo; mean (SD) age was 50 (6.5) years; all identified as White, most as nurse managers. AAF ratings for the Playbook were high with median scores exceeding 4 across domains. After six months, the coaching intervention teams showed a relative reduction in burnout (DID = -0.6) and intent to leave (DID = -0.7) as well as a relative increase in job satisfaction (DID\u0026thinsp;=\u0026thinsp;+\u0026thinsp;1.1). compared with control teams. Interviews indicated that coaching offered real-time feedback, facilitated Playbook adoption, and supported team professional development and well-being.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eLeadership coaching enhanced Playbook implementation and improved markers of cardiology team well-being. These findings support further testing and scale-up of the combined approache to strengthen learning environments and workforce resilience in high-intensity clinical settings.\u003c/p\u003e\u003ch2\u003eTrial Registration:\u003c/h2\u003e \u003cp\u003eClinicalTrials.gov Identifier: NCT06456021\u003c/p\u003e","manuscriptTitle":"Leadership Coaching as an Implementation Strategy to Enhance Adoption of a Relational Playbook and Team Well-Being: A Pilot Randomized Clinical Trial In Cardiology","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-08 16:46:35","doi":"10.21203/rs.3.rs-9612173/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"522bd288-8eed-4a1f-8246-ce50785522ab","owner":[],"postedDate":"May 8th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":67514578,"name":"Leadership and Ethics"}],"tags":[],"updatedAt":"2026-05-08T16:46:39+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-08 16:46:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9612173","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9612173","identity":"rs-9612173","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}