Debriefing Beyond Simulation: Using Plus-Delta-Plus to Debrief Real Patient Events


Christopher Roussin
Posted on March 16, 2017

“Simulation educators, especially novices, can be overwhelmed by the
complexity of facilitating debriefings, and practical guidance is needed.”
-Adam Cheng and Walter Eppich

Your colleagues are gathered in a circle after experiencing a difficult clinical care event. You try to read their faces. Some show confusion, others frustration or concern and others hope and enthusiasm. You feel your face flush as you shuffle your papers and take a deep breath…


The value of facilitated debriefing, after both simulations and real patient events, is now clearly established in the academic literature. Most clinicians have had one or several positive debriefing experiences. Still, leading a debriefing session can be intimidating, even for those with advanced “people skills,” and skilled facilitators can seem almost magical in their ability to lead complex conversations. Many would-be facilitators worry about appearing to “judge” valued colleagues or causing more damage than benefit.


How can debriefing be made easier, so that more facilitators feel confident enough to lead positive, developmental conversations? One answer is to use a simpler debriefing approach so that facilitation is easier to learn and practice. Another answer is to rethink feelings of “judgment;” to take the focus off worrying about offending colleagues and instead embracing the role of positive, developmental guide. But these approaches put the onus on the sole facilitator. There is still a need for an easily executed, replicable, flexible, trainable method of debriefing.


Enter Plus-Delta-Plus, a refinement and repackaging of existing debriefing methods that makes debriefing easier and less worrisome for both novice and experienced facilitators. Using a series of structured steps, Plus-Delta-Plus clearly shifts responsibility for identifying performance gaps (and achievements) from the facilitator to the team of debriefing participants.

After welcoming the team and introducing the debriefing process, the facilitator invites the team to produce a “Plus/Delta” chart describing “what went well” (Plus) and “what could be improved” (Delta). Next, the facilitator guides the team through a review of the chart, followed by a deeper exploration of two to three salient items. This deeper dive includes development of solution-based “next steps” to encourage positive behaviors and develop new ones.


Plus-Delta-Plus is currently being used by multi-disciplinary teams in Boston Children’s NICU after both simulations and real patient events. It has already strengthened the culture of safety and collaboration in the NICU.


“This simple, efficient framework helps teams focus on crisis event review in an effective way,” reports Dr. Kristen Leeman, the NICU’s associate medical director. “Systems changes, individual personal development and improved team dynamics have all resulted from our Plus-Delta-Plus debriefing sessions.”




In FY16, the Simulator Program ran 603 course meetings. The majority were in the Boston Children’s Residency Program, Department of Medicine, Emergency Medicine, Anesthesia, Cardiology, Nursing and Surgery. There there were 37 courses at network hospitals. Another 14 programs are being developed for FY17.



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