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TELER

The concepts on which TELER is based (the TELER Concept), the TELER Copyright, and an overview of the TELER Method for Nurses and Therapists are given below.

THE TELER^® CONCEPT

TELER is the acronym for Treatment Evaluation by the LE Roux method. This acronym is similar to the word teller, which means a person who counts or narrates. While TELER is a method of clinical note making, it can readily be used by other professionals such as social workers and business managers.

The concepts on which TELER is based (the TELER concept), is described below in the answers to the following ten questions:-

1. What is TELER?
2. What is different about TELER?
3. Why is TELER different?
4. How is TELER different?
5. What is a TELER indicator?
6. Why does a TELER indicator have six points?
7. What is TELER evaluation?
8. What is TELER attribution?
9. What is The TELER Index?
10. What are the givens of TELER?

The answer to a question consists of a set of discrete statements. The statements which answer the first nine questions identify the purpose, characteristics and uses of TELER. The statements which answer the last question give the assumptions on which TELER is based.

1. What is TELER?

TELER is a unique method for recording or making notes about the care of or dealings with a client or customer.

TELER is a unique method for facilitating the care of or dealings with a client or customer.

TELER is a unique method for evaluating the effectiveness of the care of or dealings with a client or customer.

TELER is a unique method for providing statistics which show the characteristics of a service.

TELER is a unique method for providing statistics which show the effectiveness of a service.

TELER is a unique method for auditing the structure, process and outcome of a service.

2. What is different about TELER?

TELER requires the use of a data collection form with a structure based on a two-way table.

TELER requires the use of a unique ordinal outcome measuring scale, the TELER indicator.

TELER requires the explicit use of knowledge. The effective use of a TELER indicator is possible only when the user possesses the appropriate knowledge.

TELER is not prescriptive. It specifies what must be done. It does not specify how it must be done.

TELER is not an "off the shelf" method. TELER must be adapted for use in the existing structure and process. Normally it should not be necessary to change the existing structure and process to incorporate TELER.

TELER traces the changes that occur during the care of or dealings with a client or customer. TELER does not measure the absolute amount of change that has occurred.

TELER shows when recorded changes are statistically significant.

TELER can be used by any profession, in any situation, for any purpose.

TELER can be used in multi-disciplinary care of or dealings with clients or customers.

TELER can be used in collaborative care of or dealings with clients or customers.

TELER can be used with care pathways.

TELER can be used to manage a service.

TELER can be used to audit the system, process and outcome of a service.

3. Why is TELER different?

TELER shows at a glance how the care of or dealings with a client or customer is developing.

TELER shows at a glance the changes experienced by a client or customer during care or while being dealt with.

TELER shows the association between the development of the care of or dealings with a client or customer and the changes being experienced by the client or customer (TELER evaluation).

TELER shows the effectiveness with which a client or customer was cared for or dealt with (The TELER Index).

TELER shows whether the changes experienced by a client or customer while receiving care or being dealt with is attributable to a cause (TELER attribution).

4. How is TELER different?

TELER provides evidence based practice. A TELER indicator is the expression of existing knowledge. In the absence of knowledge it is impossible to define a TELER indicator.

TELER provides practice based evidence. The TELER form readily shows the effects of using specified knowledge in practice.

TELER provides job-satisfaction. The TELER form enables its user to readily identify and recognise the changes experienced by a client or customer.

TELER provides a foundation for advancement. The TELER form enables colleagues to readily recognise and acknowledge the changes experienced by clients or customers.

TELER provides protection. It provides a quality of service readily recognised and appreciated by clients or customers.

TELER provides peace of mind, and the experience of freedom that this engenders.

5. What is a TELER indicator?

A TELER indicator is an ordinal measuring scale for tracing change, and lack of change, in a functional deficit.

A TELER indicator is an ordinal measuring scale for tracing change, and lack of change, in a non-functional deficit.

A TELER indicator is an ordinal measuring scale for tracing change, and lack of change, in a physical deficit.

A TELER indicator is an ordinal measuring scale for tracing change, and lack of change, in a non-physical deficit.

A TELER indicator is an ordinal measuring scale for tracing change, and lack of change, in an environment.

A TELER indicator is an ordinal measuring scale for tracing change, and lack of change, in a management activity.

A TELER indicator is an ordinal measuring scale for tracing change, and lack of change, in the need for a management activity.

A TELER indicator is an ordinal measuring scale for tracing change, and lack of change, in the effects of management activities.

A TELER indicator is an ordinal measuring scale for tracing change, and lack of change, in the quality of a service.

A TELER indicator has six reference points, coded 0, 1, 2, 3 ,4 and 5 for convenience.

Code 0 denotes a deficit, while Code 5 denotes a resolution of the deficit. The remaining codes are intermediate outcomes which mark progress towards the resolution of a deficit.

Alternatively, Code 0 denotes a deficit to be avoided or delayed, while Code 5 denotes the current deficit. The remaining codes are intermediate outcomes which mark progress towards preventing or delaying the undesired deficit.

The title of a TELER indicator defines the outcome which shows that a deficit has been resolved or maintained.

The title of a TELER indicator is written in language the client or customer and others can understand.

The definitions of the codes of a TELER indicator are written in language the client or customer and others can understand.

6. Why does a TELER indicator have six points?

The codes of a TELER indicator trace change over the continuum between a deficit and a resolution of the deficit.

The codes of a TELER indicator trace change over the continuum between the current deficit and the deficit to be avoided or delayed.

A series of six changes, for example, is obtained from a series of seven measurements. When the measurements consist of the codes 0, 1, 2, 2, 1, 2 and 3, the changes are improvement, improvement, no change, deterioration, improvement and improvement, respectively.

With the six codes of a TELER indicator the shortest series of improvements between a deficit and a resolution of the deficit is five improvements. Four successive improvements is the minimum number of improvements that could not have occurred by chance. Four successive improvements therefore are statistically significant.

With the six codes of a TELER indicator the shortest series of deteriorations to a deficit is five deteriorations. Four successive deteriorations is the minimum number of deteriorations that could not have occurred by chance. Four successive deteriorations therefore are statistically significant.

The TELER indicator has six codes because they give the minimum number of successive improvements or deteriorations needed for the purposes of TELER attribution.

7. What is TELER evaluation?

TELER evaluation is a method for using TELER notes to maximise the effectiveness of the ongoing care of or dealings with a client or customer.

In TELER evaluation the guiding principle is belief in the effectiveness of the care to be provided or the dealings to be undertaken.

In TELER evaluation it is accepted that the care of or dealings with a client or customer produced the change, or lack of change, experienced by the client or customer.

In TELER evaluation observed patterns of change, or lack of change, are compared with expected patterns of change, or lack of change.

In TELER evaluation a correspondence between an observed and an expected pattern of change, or lack of change, is taken as evidence that the care provided or the dealings undertaken is or are effective.

In TELER evaluation a lack of correspondence between an observed and an expected pattern of change, or lack of change, is taken as evidence that the care provided or the dealings undertaken is not or are not as effective as desired and should be altered or replaced.

8. What is TELER attribution?

TELER attribution is a method for determining whether an observed pattern of change, or lack of change, is unlikely to have occurred by chance. An observed pattern of change, or lack of change, is unlikely to have occurred by chance when it is statistically significant.

In TELER attribution the guiding principle is uncertainty about the cause of an observed pattern of change, or lack of change.

In TELER attribution an observed pattern of change, or lack of change, which is unlikely to have occurred by chance is regarded as attributable to a cause.

In the normal situation of caring for or dealing with a client or customer TELER attribution does not and cannot identify the cause of an observed pattern of change, or lack of change, which is unlikely to have occurred by chance.

When used in an appropriate research design TELER attribution does identify the cause of an observed pattern of change, or lack of change, which is unlikely to have occurred by chance.

9. What is The TELER Index?

The TELER Index is a method for combining into a single measurement the changes in a group of deficits.

The TELER Index is a method for combining into a single measurement the improvements in a group of deficits. An improvement from a deficit is not necessarily the same as a change in a deficit.

The TELER Index is a method for combining the changes in a group of deficits into a health or status gain measurement. Health or status gain is not necessarily the same as improvement.

The TELER Index is a method for showing the extent to which the treatment or care delivered to and accepted by a patient or client had been effective.

The TELER Index is a method for showing whether the objectives for improvement or maintenance had been achieved.

The TELER Index is a method for showing whether any unnecessary care of or dealings with clients or customers had occurred.

10. What are the givens of TELER?

TELER is based on the assumption that the essential purpose of caring for or dealing with a client or customer is to induce or prevent change.

TELER is based on the assumption that for maximum effectiveness the care being provided or the dealings being undertaken must be client or customer specific.

TELER is based on the assumption that for maximum effectiveness the care being provided or the dealings being undertaken must be grounded in theory.

TELER is based on the assumption that change, or lack of change, occurs in steps that are of clinical or incremental significance.

TELER is based on the assumption that change, or lack of change, occurs over periods of time that are of clinical or incremental significance.

TELER is based on the assumption that change, or lack of change, can occur naturally or spontaneously.

TELER is based on the assumption that change, or lack of change, can occur by chance.

TELER is based on the assumption that the appropriate model for change, or lack of change, that occurs by chance is a constrained random walk.

TELER is based on the assumption that change, or lack of change, can also be induced or prevented.

TELER is based on the assumption that change, or lack of change, which is unlikely to have occurred by chance was induced.

TELER is based on the assumption that the effects of clinically or incrementally significant change or lack of change are not necessarily measurable on a ratio or interval measuring scale.

TELER is based on the assumption that the effects of clinically or incrementally significant change are observable.

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THE TELER^® COPYRIGHT

The TELER copyright identifies the holder of the copyright as the legal owner of the intellectual property known as TELER, and makes it illegal under international copyright law to use TELER or any part of TELER without the permission of the copyright holder. That permission is granted through a Licence to use TELER.

The intellectual property embodied in TELER consists of ten ideas which have been used to define TELER. TELER has three components: the TELER form, the TELER indicator, and the method for interpreting the data obtained with the TELER form and the TELER indicator (TELER data). All three components are needed to achieve the objectives of TELER.

The Objectives of TELER

TELER is based on ten ideas which are used singly or in combination to achieve one or more of seven objectives. These objectives are

1. To provide a simple and effective record of the delivery of care to or of dealings with a named client or customer.
2. To provide a simple and effective record of the outcomes observed when caring for or dealing with a named client or customer.
3. To provide an easy to follow display of the relationship between the delivery of care to or dealings with a named client or customer and the outcomes observed when doing so.
4. To provide information which facilitates effective care of or dealings with a named client or customer.
5. To provide information which facilitates effective attribution of the outcomes observed when caring for or dealing with a named client or customer.
6. To provide information which facilitates effective management of a service which cares for or deals with clients or customers.
7. To provide information which facilitates effective audit of the structure, process and outcome of a service which cares for or deals with clients or customers.

The Ideas of TELER

Three of the ten ideas on which TELER is based are presentational ideas, and are put into effect on the TELER form. Another three are measurement ideas, which are used to define the scale of the TELER measuring instrument. This scale is a six point ordinal scale called the TELER indicator. The remaining four ideas are ideas for interpreting the outcomes observed when caring for or dealing with clients or customers, and recorded as TELER indicator codes.

The three TELER form ideas are

1.1 To present in the form of a two-way table the implementation of the plan for caring for or dealing with a named client or customer.

1.2 To present in the form of a two-way table the outcomes that occur during the implementation of the plan for caring for or dealing with a named client or customer.

1.3 To combine these two forms of two-way table in a way that shows the relationship between the implementation of the plan for caring for or dealing with a named client or customer and the outcomes that occur during that implementation.

The three measurement ideas are

2.1 To use outcome as a measurement.

2.2 To use the concept of clinical significance to maximise the reliability of a measuring scale.

2.3 To use the concept of consensus to maximise the validity of the calibration of a measuring scale.

The four interpretation ideas are

3.1 To use clinically significant change as a measure of effect.

3.2 To use the fact that a plan for caring for or dealing with a client or customer is implemented in the belief that it will work as the basis for determining whether the implementation had been effective.

3.3 To use the multinomial distribution function to determine whether a series of changes could have occurred by chance.

3.4 To use clinical significance to minimise, if not eliminate the possibility that a change, or lack of change, could have occurred by chance.

The interpretation of TELER data has two components: TELER evaluation and TELER attribution. TELER evaluation is concerned with the association between the plan for caring for or dealing with a named client or customer, as implemented, and the runs of outcomes recorded during the implementation. TELER evaluation is also concerned with the interpretation of the outcomes. The interpretation uses The TELER Index.

TELER attribution is concerned with the interpretation of the patterns of change shown by runs of outcomes. The outcomes are those recorded during the implementation of the plan for caring for or dealing with a named client or customer. The interpretation is based on the results obtained from tests of statistical significance.

TELER evaluation and TELER attribution are performed for a named deficit, a named client or customer, and a named group of clients or customers.

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OVERVIEW OF TELER^® FOR NURSES AND THERAPISTS

TELER is a unique method for making clinical notes. The method requires the use of a version of a particular data collection form, the TELER form, and one or more versions of a particular outcome measure, the TELER indicator. An example of a completed TELER form is given further down. An example of a TELER indicator is given below.

Pain
0  Painful at rest without footwear
1  Painful at rest with footwear
2  Painful when weight bearing with footwear
3  Tender when weight bearing with footwear
4  No pain when weight bearing with footwear unless subject to mild trauma
5  Pain free

The indicator shows the limiting effects of pain on a patient's use of footwear. These range from being unable to use footwear due to pain, denoted by Code 0, to being able to use footwear pain free, denoted by Code 5. The intermediate codes denote clinically significant reductions in pain and its limiting effects on the patient's use of footwear. This indicator, like all TELER indicators, is patient specific and measures change in effect, rather than amount of effect.

The TELER form shows

• the patient made 7 visits;
• the patient presented two severe problems on the first visit on 2 August, giving a deficit index of 60;
• the clinician expected the patient to make a full recovery, shown by the 5 entered against each indicator in the short column under "Indicators";
• nail surgery was performed on the second visit on 6 August, when there had been some compensating change (deficit index still at 60, improvement index at 0 and effectiveness index at 50)
• the patient presented severe post-surgery infection on the third visit on 13 August, which increased the deficit index to 67, reduced the improvement index to -11, and reduced the effectiveness index to 40;
• treatment was wholly effective, and the patient had recovered fully by the seventh visit on 4 September (deficit index at 0, and improvement index at 100);
• delivery of treatment was less than wholly effective (effectiveness index at 80);
• statistically significant improvements on every indicator by discharge; and
• a health gain index of 60 on discharge.

TELER^®    The Bluebell NHS Trust    Year: 2002

Unit: Multi-disciplinary Team    Patient: A N Other

The two severe problems presented on the first visit were

• "severe pain", shown by the 0 in the column for 2 August against the indicator Pain; and
• "very little mobility", shown by the 1 in the column for 2 August against the indicator Mobility.

Infection was not a problem on the first visit. That there was "no infection" is shown by the 5 in the column for 2 August against the indicator Infection.

Pre-surgery assessment on the second visit found

• "some relief of pain", shown by the 1 (previously 0) in the column for 6 August against the indicator Pain;
• "no improvement in mobility", shown by the 1 (previously also 1) in the column for 6 August against the indicator Mobility; and
• "some infection", shown by the 4 (previously 5) in the column for 6 August against the indicator Infection.

The severe post-surgery infection on the third visit is shown by the 2 (previously 4) in the column for 13 August against the indicator Infection.

That the patient made a full recovery is shown by

• the 5 (0 on admission) in the column for 4 September against the indicator Pain;
• the 5 (1 on admission) in the column for 4 September against the indicator Mobility; and
• the 5 (2 on 13 August) in the column for 4 September against the indicator Infection.

The evidence provided by the form suggests that the patient's treatment would have been delivered more efficiently

• if the increase in infection post-surgery had been avoided, or minimised; and
• if the discharge visit had been replaced by another method of discharge, such as follow up by telephone.

The effectiveness index of 80 at discharge suggests that the patient's treatment cost 20 percent more than it should have done. If there had been no increase in infection post-surgery this additional cost would not have been incurred.

The TELER Method for Nurses and Therapists provides ....

This example of a completed TELER form shows that the TELER method of clinical note making provides clinical notes in a form that is specific to the method. The notes are in the form of entries in a table. The treatment or care plan and the treatment or care objectives, in the form of indicator titles, are listed in the table, and the entries are made by referring to them. The entries show when and how the activities were carried out and what the effect was. As little effort is needed to make the entries, and as they are made in date order, TELER clinical notes are

• quick to write;
• easy to keep up-to-date; and
• easy to read.

The example of a completed TELER form also shows that the TELER method of clinical note making provides clinical information specific to the method. The information is provided routinely by the indicators used with a patient or client under treatment or care, and consists of

• clearly defined objectives;
• clinical outcomes;
• measurements of change; and
• measurements of the effectiveness of treatment or care.

The information enables a clinician to deliver high quality treatment or care consistently. It does so by facilitating

• self-auditing of the treatment or care being delivered;
• routine review of practice; and
• evidence based practice.

When carried out routinely these activities ensure that the patient or client receives

• cost effective treatment or care.

The use by clinicians of the TELER method of clinical note making provides managers with the advantages of

• cost effective service delivery;
• high quality treatment or care;
• efficient use of resources; and
• good legal protection.

The information for managers specific to the TELER method of clinical note making is provided by the TELER Patient Outcome Index and the TELER Quaility of Care Index. The TELER Patient Outcome Index has six components: the deficit index; the improvement index; the maintenance index; the effectiveness index; the health gain index; and the quality of care index. A TELER index number gives a quantitative summary of the treatment received by a named patient or client. TELER index numbers provide sound evidence on which to base management decisions that affect the service which supplies the treatment or care.

The TELER Method for Nurses and Therapists facilitates ....

The TELER method of clinical note making facilitates evaluation by the clinician, of the effectiveness with which he or she is delivering the treatment or care of a named patient or client. The TELER form is designed to reflect the treatment or care process, and when a form is completed properly, it facilitates the evaluation of a named patient's or clients's treatment or care. The TELER indicator is designed to describe in clinically significant terms what happens to a named patient or client during treatment or care, and when the indicators used are appropriate and used properly, they facilitates the evaluation of a patient's or clients's treatment or care.

Clinical knowledge, and the explicit use of that knowledge, is an essential requirement for completing a TELER form properly. Clinical knowledge, and the explicit use of that knowledge, is also an essential requirement for selecting indicators appropriate for a named patient or client, and using the indicators properly. The clinical knowledge needed to use TELER properly may be formal knowledge obtained from textbooks and journals or informal knowledge obtained from experience.

When the indicators selected for a named patient or client are used properly, they provide the information that enables the clinician to accommodate the changing needs of a named patient or client as the clinician develops the treatment or care of the patient or client. The indicators provide that information because a TELER indicator satisfies the requirements of measurement theory, thereby ensuring that TELER measurements are valid descriptions of the clinical deficits suffered by a named patient or client. These descriptions show which treatment or care objectives for the named patient or client have been achieved.

To ensure that its use is knowledge based the TELER method of clinical note making prescribes how clinical knowledge is to be used, but it does not suggest what clinical knowledge is to be used. Those decisions are left to the clinician, allowing total control of the treatment or care process. The design of the TELER form ensures that the decisions are recorded in a manner which makes it easy to identify the evidence on which they are based.

The TELER method of clinical note making facilitates effective delivery of treatment or care. The method is dynamic, and avoids a major cause of ineffective treatment or care, namely, delay in detecting lack of effect. A TELER form shows at a glance when lack of effect is developing, thus alerting the clinician to the need to examine the treatment or care plan, the method of delivery, and the indicators used, with a view to effecting improvements. In responding to the data provided by the TELER form the clinician is completing the audit cycle, and ensuring that the most effective treatment or care is delivered over the shortest period of time.

The TELER method of clinical note making facilitates effective management of a service providing treatment or care. The method requires that each clinician sets treatment or care objectives for each patient or client. The TELER form shows the extent to which an objective is achieved; it shows the action taken by a clinician in response to an unexpected deterioration or an unexpected lack of improvement, and it shows the appropriateness of that action. The clinician's response in either situation is a measure of her or his experience in delivering treatment or care, and can show if the clinician is in need of a mentor, training or retraining to enhance that knowledge. This need is shown by the Improvement Index.

Effectiveness in the delivery of treatment or care is dependent on the acceptance by the patient or client of that treatment or care. The Effectiveness Index shows the extent to which the treatment or care that had been accepted had been effective.

Requirements for Using TELER by Nurses and Therapists

A Licence to do so is a prerequisite for using the TELER method of clinical note making. The Licence authorises the use of the method upon payment of an annual registration fee, and entitles the Licensee to user support without additional payment. The support includes a workshop in using the TELER method, a starter pack and an annual support visit.

The TELER form is an essential component of the TELER method. The characteristics of the form are prescribed, as is the type of data to be collected as a minimum data set. The overall design of the form is not prescribed, and clinicians are expected to adapt it to their work practices. The content of the data to be collected is not prescribed, and decisions about what that content should be are left to the clinicians who use the TELER method. The evidence on which they base their decisions should be obtained by analysing and justifying existing clinical practice.

Effective use of the TELER method of clinical note making requires a change in mind set. The method is based on the self-evident truth that treatment or care cannot be effective if it is not planned, and requires of clinicians who do not routinely plan their treatment or care that they develop the practice.

The TELER method is based on the assumption that effective treatment or care is dynamic rather than static. A feature of dynamic treatment or care is continuous appraisal of its effects on the patient or client. This requires of clinicians who do not routinely appraise the effects of their treatment or care that they develop the practice.

Another "given" underpinning the TELER method of clinical note making is that treatment or care cannot be effective if it is not explicitly based on clinical or other appropriate knowledge. This assumption requires of clinicians who do not use clinical or other appropriate knowledge explicitly that they develop the practice.

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