If you’re in search of a tool that can be used for more effective employee feedback, better debriefing from real and simulated patient encounters, and individual and organizational performance improvement, that tool is called plus/delta. Those two words, plus (the sign for addition) and delta (the sign for change), are the key points of this simple yet effective and amazingly flexible quality improvement instrument.
Often discussed as a technique to provide structured debriefing in a learning environment, plus/delta can help EMS providers avoid the pitfalls of poor feedback techniques that have been taught for years.
The most basic form of feedback, simply providing a list of pros and cons or good and bad performances, is just not effective. While the person providing the feedback typically has good intentions, the listener often experiences this as “I’m right, and you’re wrong.” While the person giving the feedback is trying to help performance, using this technique makes it sound more like, “Here is a list of things that are wrong with you.” This can foster feelings of unfairness and resentment in the person receiving feedback.
Sometimes the pro/con approach can gain short-term compliance, but it is nearly always ineffective in the long run. Whether delivered in the form of a checklist, bullet points, or simply rattled off the top of a head, a simple list of good/bad observations is likely to hurt morale and kill enthusiasm for the learning and performance improvement processes.
Perhaps even worse is the dreaded “compliment sandwich.” This technique is widely used by people who provide feedback and widely hated by people who receive it. The intentions of the compliment sandwich are to ease the brunt of negative feedback and leave the receiver on a positive note, but the typical reaction is simply, “Just get it over with and tell me what I did wrong.” Thus, the compliment sandwich rarely achieves its desired effect and should be avoided by EMS leaders and educators in favor of more effective tools.
While plus/delta is a vast improvement over prior techniques, it is still only one tool in what should be part of a bigger framework of feedback. There are many variations of plus/delta that have been refined over the years, but those two words, plus/delta, remain the core concepts.
Plus = Positive
In this step we identify where the objectives, standards, or expectations have been met or exceeded. These are the things that fall into the range from “at least good enough” to “unexpected excellence.” Focus on what went so well that you would want exactly that to happen every time the situation occurs. Emphasize those things you’d want everyone to learn to do, especially new ideas and innovations.
When appropriate, identify the specific learning objective or performance standard met or exceeded. Then ask how these successes can be built on for even better results. Specify how the improved performance will result in improved outcome.
Delta = Change
This is not the step where we identify what went wrong; this is the step where we identify the parts of performance that need to be changed. This is a subtle but important difference. Identify the specific learning objective or performance standard that was not met and connect that with the consequences: “When you didn’t count your compressions out loud, the person ventilating didn’t know when you were going to pause. This hurt your ‘hands-off’ time. Changing to counting out loud can improve cerebral perfusion and the patient’s chance for successful resuscitation.” Be as specific as you can, but keep in mind that your aim is to help build improvements that can be applied to different situations.
Where appropriate, demonstrate or model the desired behavior, but know when to “teach with your hands behind your back.” Students need time to try it themselves more than they need to see you do it your way, even if that way meets expectations. You don’t want them to simply copy you. You want them to build on what you’ve shown them.
Sometimes through this step you will improve more than just student behavior. You may identify opportunities to improve processes or parts of your organization or system of care. For example, perhaps an individual performed in a certain way because they didn’t know or understand the expectations (education problem) or didn’t have what they needed (resource problem) or didn’t appreciate the need to perform differently (communication problem). Remember that you don’t always have to have the answer. Treat a delta question as a puzzle for the student(s) to figure out with your help.
Plus/Delta Dos and Don’ts
Don’t use the confusing and contradictory compliment sandwich;
Don’t allow people to assign blame;
Don’t get stuck on excuses;
Don’t let the discussion go off course;
Don’t just tell how you would have done it;
Don’t take over when you demonstrate.
Do be polite and respectful;
Do allow time for students to think before doing or answering;
Do use objective recording and data to review;
Do identify specific relevant performance standards and learning objectives;
Do provide “try it out” time;
Do focus on ways that systems can be developed to make it easier for people to succeed;
Do identify key take-home points;
Do be specific about next actions;
Do emphasize connections between actions and desired outcomes.
Rommie L. Duckworth, LP, is a dedicated emergency responder and award-winning educator with more than 25 years working in career and volunteer fire departments, hospital healthcare systems, and public and private emergency medical services. He is currently a career fire captain and paramedic EMS coordinator.