Transcript Communication

Communication
For Nursing Professionals
Today’s Objectives
 Increase awareness of the risks surrounding poor
communication, specifically targeting exposure to
negligence and malpractice claims
 Enhance the quality and effectiveness of
communication by expanding awareness in order to
provide quality patient care and avoid malpractice
incidents
 To address specific communication methods and
recommendations to protect your patient from harm
and minimize your liability exposure
Agenda
 Introduction to Communication
 Section I: Communication with Patients
 Section 2: Communication with Other Healthcare
Providers
 Section 3: External Communication
 Case Study
What is Communication?
 The exchange of information, ideas, or opinions
 Interactive or one-way
 Often complex and affected by a variety of elements,
which can affect patient safety and quality of care
provided
Importance of Communication
The Joint Commission, which accredits the majority of
hospitals in this country and some nursing homes and
other facilities, analyzes the root causes of sentinel,
or critical, events.
Miscommunication is the most common cause of
patient injury or death.
Importance of Communication

Breakdowns in communication can cause:
–
Medical errors
–
Patient injury or death
–
Malpractice lawsuits
–
Delays in treatment
–
HIPAA violations
–
A culture of intimidation
–
And more…
Four C’s of Communication
 Clear
 Concise
 Correct
 Complete
Communication Channels
Patient &
Patient’s
Family
Internal
Nurse
Physicians
Colleagues
Technicians
Supervisors
Office Staff
Patient
External
Legal team
Social
Media
HIPAA
Section I
Communication with Patients
 The Human Connection
 Phone and E-mail Communication
 Informed Consent and Duty to Disclose
 Workplace Violence
The Human Connection:
Nonverbal Communication to the Patient
 Nonverbal dynamics have great impact on:
– Rapport
– Trust
– Mutual respect
 Remember:
– People pick up on your nonverbal messages
– Respond to the patients’ negative nonverbal signals with empathy
– Be culturally sensitive to nonverbal communication differences
Nonverbal communication has an enormous impact!
Your posture, tone, pace, and face all give away your real
meaning.
The Human Connection:
Nonverbal Communication from the Patient

Pay attention to your patients’ nonverbal signs

Nonverbal behavior may not always support what is said

–
Posture
–
Tone of voice
–
Facial expression
–
Nodding and smiling
–
Eye contact
Resist responding to the content of what patients are saying,
when the nonverbal behaviors communicate a different
message
The Human Connection:
Communicating with Patients and Families
Nurses may deal with difficult situations involving
language barriers, disagreements, or complaints
about delivery of care.
Remember to:
 Deal with the situation honestly and treat all
participants with respect
 Utilize appropriate therapeutic and listening skills
 Establish rapport
 Avoid medical jargon
 Provide a private neutral place
 Use interpreter services
Phone and E-mail Communication
While telephone and e-mail facilitate contact with
patients, they also may jeopardize privacy.
It is important to follow written policies addressing
appropriate and secure use to safeguard patients’
protected health information (PHI).
Phone and E-mail Communication:
Parameters of Use

Most suitable for brief exchanges of minimally
sensitive information

Consent form at initial patient visit should outline
the expectations, risks and limitations
Phone and E-mail Communication:
Security Guidelines
Two key risk management principles:
 Ensure security of transmitted information
 Ensure privacy of content
Phone and E-mail Communication:
Security Guidelines
E-mail Risk Reduction Tips:
 Avoid patient identifiers in the subject heading
 Include a privacy notice with all e-mails
 Limit unsecured messaging to notification of services
 Never send blind copies or group e-mails where other
names are visible to recipients
 Rely on a centralized patient e-mail database
 Retain the original e-mail message
 Transmit through an approved and secure serve
Phone and E-mail Communication:
Security Guidelines
Telephone Risk Reduction Tips:
 Designate a separate telephone conversation area
 Use landlines when possible
 Never leave sensitive information on an answering
machine, in a voicemail message or with an
answering service.
 Update patient telephone numbers on a regular basis
Phone and E-mail Communication:
Advice Protocols
Safeguards to help limit liability:
 Advise callers to seek emergency medical attention if symptoms worsen or fail to
improve
 Establish protocols for which telephone calls must be immediately referred to a
physician, nurse practitioner, physician assistant or other licensed independent
practitioner
 Establish telephone advice protocol parameters for specific symptoms
 Make a physician/practitioner available for nurse staff consultation during any
form of telephone or electronic assessment
 Require physicians/practitioners to sign off on all telephone advice protocols
 Review telephone advice protocols annually and maintain discontinued ones in a
secure location
 Securely fax or e-mail patients an approved health information sheet following
any protocol-based telephone advice discussion
 Use a checklist format for telephone advice protocols
Phone and E-mail Communication:
Documentation
 Same documentation and retention requirements as
other forms of documentation
 Attach e-mails to electronic medical records
 Telephone messages must be written down - use
preprinted telephone logs
Phone and E-mail Communication:
Special Situations
 Prescription requests
 Laboratory results
 Urgent and non-urgent requests
 Out-of-office communication
Informed Consent
Informed Consent: the voluntary permission that a
patient or patient’s legal representative gives to the
physician or authorized healthcare provider to do
something to or for that patient after having been
apprised of the risks, benefits and alternatives to
the proposed test, medication or treatment.
Patient Autonomy: process of giving the power of
choice to patients by respecting their decisions
about their own health care.
The Law of Informed Consent: varies from state to
state. Refer to the specific statues of your state.
Informed Consent - Documentation
Regarding strictly nursing procedures, the nurse
SHALL verify that the patient’s informed consent
was obtained, and SHALL document the information
given.
Regarding medical informed consent, if the
patient/legal representative is unclear or has
questions regarding their consent, the nurse should
contact the involved practitioner to personally meet
with the patient or their legal representative to be
certain they understand the risks, benefits and
alternatives to the treatment, medication or
procedure proposed.
Informed Consent
The nurse should be knowledgeable as to the protocol
for obtaining informed consent, from the patient…as
established in organizational policies and
procedures.*
When organizational policies fail to ensure informed
consent, discuss additional strategies with your risk
manager and/or legal counsel.
*Ibid.
Capacity to Consent
Decision-making capacity is based on the
patient’s ability to:
 Understand his or her condition
 Use relevant information presented
 Communicate his or her preference
Types of Consent:
Expressed Consent
The practitioner obtaining the informed consent is
responsible for documenting the consent.
Documenting written and oral consent includes:
 High quality documentation
 Date and time of the discussion
 Nature of the discussion
 Statement that patient gave consent
Types of Consent:
Implied Consent
 Applies in an emergency situation combined
with the inability to seek consent.
 Appropriate for:
–
Unconscious or delusional patient
–
Patient under the influence of alcohol or drugs
–
Patient incapable of giving expressed consent
Treatment Without Consent
Treatment or attempts to treat without consent may
result in a lawsuit based on the following claims:
– Assault or battery
– Lack of informed consent
– Negligently obtaining informed consent
Workplace Violence

Violence at work is the leading cause of death
among all workers and the #1 killer of women in
the workplace

More assaults occur in healthcare and social
services industries than in any other.

Range of attack types

Range of perpetrators

Emotional toll potential
Workplace Violence:
Key Indicator Signs

History of aggression

Problematic behavior

Changes in body language

Dull, unresponsive, blank affect

Confusion and agitation in an older patient
Workplace Violence:
Managing an Angry Patient
1.
Look for the signs
2.
Act fast
3.
Don’t hesitate to contact security or the police if
you feel threatened
4.
Document
Workplace Violence:
Managing an Angry Patient

Help them vent

Spend extra time

Maintain eye contact and
listen
 Identify the underlying
reason
 Explain consequences
 Keep your cool

Show empathy
 Ask for the patient’s solution

Respond calmly

Treat them with respect
 Find some point of
agreement
Section II
Communication with Other Healthcare Providers
 General Information
 Culture of Intimidation
 Teamwork and Collaboration
 Handoff Process
Behaviors That Show Respect

Listen and be fully attentive

Acknowledge and express appreciation

Exhibit empathy and understanding

Display courtesy and consideration

Be accountable and professional
Disruptive Behaviors
 Definition: any behavior which either overtly or
covertly compromises safe and quality patient care
 Examples include:
– Verbal outbursts
– Physical outbursts
– Uncooperative attitudes
– Condescending voice or tone intonations
– Culture of intimidation
Disruptive Behaviors
Chain of Command = The Line of Authority
 The chain of command in its simplest definition is the
line of authority and responsibility along which orders
are passed within the nursing department, the
hospital, and between different units.
 Every hospital, indeed, nearly every organization, has
a chain of command.
 Nurses who ignore the chain of command may lose
their jobs, and in some cases their licenses.
Invoking the Chain of Command
 Invoke the chain of command when necessary to
obtain attention to the patient’s condition and/or
change in condition.
 Nurses are responsible to obtain the care and
services necessary for the treatment of patients under
their care.
 This responsibility continues to the point of resolution.
Invoking the Chain of Command – 4 steps
 (1) Call on your head nurse or charge nurse, who can use their position
to accelerate a response or get the necessary authorization.
 (2) Should this fail or if for some reason there is no head nurse or
charge nurse available look to the Unit or Department Director of
Nursing (DON).
 (3) If your scenario involves a physician and a patient is in jeopardy,
remember that the Chief Nursing Officer (CNO) is your top advocate.
–
the CNO is usually directly beneath the hospital administrator, and therefore, has a
great deal of authority to assist in finding a positive solution to the problem. If the CNO
is not responsive, then the next step is to contact the medical director or the hospital
administrator or CEO depending on the issue.
 (4) Always remember to document. If you are having trouble getting the
appropriate authorization to administer medication or perform a
procedure, be sure to notate this in the chart. If necessary and
appropriate, you can also complete an incident report as defined by
your hospital’s policies and procedures.
Chain of Command - Communication Deterrents
 Nurses must use both nursing and medical chains of command
if a patient service is not made available or if interventions
performed are inadequate or ineffective.
 Discomfort with invoking the medical staff chain of command
cannot be allowed to inhibit the nurse from seeking assistance
when a physician or other licensed independent provider does
not respond to calls.
 Even more challenging are events where the licensed
independent provider has responded, but the nurse believes he
or she has failed to appreciate the seriousness of the patient’s
condition or where the appropriate treatment, medication, or
clinical intervention were not initiated.
Communication and “just culture”
 Nurses should report communication issues between
nursing and medical staffs to identify and report
instances of intimidation, bullying or other deterrents
to invoking the chain of command.
 Nurses should notify leadership of situations, clinical
services or individuals who prevent nursing staff from
invoking the chain of command.
 Nurses can initiate discussions regarding “just
culture” if the organization’s current culture does not
support invoking the chain of command.
 Asking for help is not a sign of weakness.
Culture of Intimidation
 Definition: Any intimidating or condescending
behavior, usually by a superior
 Affects:
– Nurses
– Patients
– Management
– Other healthcare providers
Culture of Intimidation:
Statistics
 According to an Institute for Safe Medication
Practices (ISMP) survey:
– 88% of respondents encountered condescending language or voice
intonation
– 87% encountered impatience with questions
– 79% encountered a reluctance or refusal to answer questions or
phone calls
– The Impact: 7% reported that they had been involved in a
medication error during the past year in which intimidation played a
role
Culture of Intimidation:
Tools and Strategies
 Advocate for the patient
 Be assertive
 Be firm and respectful to authority
 Use CUS words: Concerned, Uncomfortable, Safety
 Voice your concern at least two times
 If necessary, go up the chain of command
Teamwork and Collaboration:
Barriers to Effective Communication

Gender

Education

Generational differences

Large team size

Instability of the workforce and assignments

Absence of a common purpose

Nurse-Physician relationship
Teamwork and Collaboration:
Overcoming Barriers
Collegial Relationships
Sharing Knowledge
Understanding differences
Increased effectiveness
Improved quality of care
Reduced Turnover rates
Increased patient safety
Improved group cohesion
Improved nurse satisfaction
Overcoming Communication Barriers
Using the SBAR method of Communication
 SBAR, used in many hospitals, is a formalized
method of communicating with other healthcare
practitioners
 SBAR = Situation, Background, Assessment,
Recommendation
 Purpose:
– To report to a healthcare provider a situation that requires
immediate action
– To define the elements of a handoff
– To provide a specific structure for communication
Overcoming Communication Barriers
Recommendations

Use a a direct, honest, and respectful manner

Remain cool, calm, and collected

Appropriately set limits

Seek third-party assistance

Do not take things personally
Handoff Process
 Defining the Process: Process of passing complete
and accurate patient-specific information from one
caregiver to another.
 Information should include:
– patient’s condition
– care, treatment, and anticipated changes
– services delivered to the patient
Handoff Process
 Identify critical hand-off points
 Importance of effective handoffs
– Confirm responsibility for patient care
– Provide critical shift change updates
– Enhance continuity of care
Handoffs:
Strategies
 Use face-to-face communication
 Allocate enough time to the process
 Use standardized reporting methods
 Use precise language
 Read back critical information
 Smooth hand-offs between settings
 Get full use of information technology
 Confirm receipt of patient charts
Joint Commission’s National Patient Safety
Goals - 2006
 Goal: Improve the effectiveness of communication
among caregivers.
Improve Communication
 Requirement: For verbal or telephone orders or for
telephonic reporting of critical test results, verify the
complete order or test result by having the person
receiving the order or test result "read-back" the
complete order or test result.
Improve Communication
 Requirement: Standardize a list of abbreviations,
acronyms and symbols that are not to be used
throughout the organization.
Improve Communication
 Requirement: Measure, assess and, if appropriate,
take action to improve the timeliness of reporting,
and the timeliness of receipt by the responsible
licensed caregiver, of critical test results and
values.
Improve Communication
 Requirement: All values defined as critical by the
laboratory are reported to a responsible licensed
caregiver within time frames established by the
laboratory (defined in cooperation with nursing and
medical staff). When the patient’s responsible
licensed caregiver is not available within the time
frames, there is a mechanism to report the critical
information to an alternative responsible caregiver.
Section III
External Communication
 HIPAA
 Social Media
Health Insurance Portability and Accountability
Act (HIPAA)
 Protects a patient's rights to the confidentiality of
his/her medical information
 Hospitals and providers may use this information
only for:
– Treatment,
– Obtaining payment for care
– Specified operational purposes like improving quality of care
 Must inform patients in writing of how their health
data will be used; establish systems to track
disclosure; and allow patients to review, obtain
copies, and amend their own health information
HIPAA:
Protected Health Information (PHI)
 PHI - all individually identifiable health information
held or transmitted by or to the covered entity in any
form or media
– Can be electronic, paper, or verbal
 Examples of PHI:
– Name
– Date of birth
– Social security number
– Device identifiers/serial numbers
– Full-face photos
 Who can you disclose information to?
HIPAA:
Standards for Electronic Transactions Security
 When communicating with another clinician, remember this:
– Others besides the addressee may process messages during addressee's
usual business hours or during addressee's vacation or illness
– Electronic messages can occasionally go to the wrong party
– Electronic communication can be accessed from various locations
– Information written by one clinician may be sent electronically to other care
providers
– The Internet does not typically provide a secure media for transporting
confidential information unless both parties are using encryption
technologies.
HIPAA:
Be Compliant
 Keep confidential all patient information.
 Share patient information on a "need- to-know" basis.
 Be mindful of your surroundings when discussing patient information.
Avoid discussing patients in public places
 Keep confidential papers, reports, computer disks, and data in a
secure place.
 Retrieve confidential papers from fax machines, copiers, mailboxes,
conference rooms, and other publicly accessible locations as quickly
as possible.
 Use technology such as fax machines and e-mail only to support
patient care activities. Do not fax information to attorneys, employers,
or patients.
 Always tear or shred paper copies of documents containing patient
information.
HIPAA:
Be Compliant
 Don't share computer log-ins or passwords to systems containing
PHI.
 Never leave medical records unattended in public areas.
 Dispose of items containing PHI appropriately.
 Be sure to log out of computer or data systems containing PHI.
 Follow security systems requirements for remote accessing of PHI.
 Activate the security settings of PDAs if they contain PHI.
 Avoid discussing patients in public places.
HIPAA – An Example
A nurse is participating in a research project and needs
access to PHI to make clinical comparisons of
response to treatment. Is this okay?
HIPAA – Keep up to date
Recommended websites for HIPAA:
 ANA Code of Ethics
– http://www.nursingworld.org/ethics/ecode.htm
 U.S. Department of Health & Human Services
– http://www.hhs.gov
 Centers for Medicare & Medicaid Services
– http://www.cms.hhs.gov
 American Medical Association
– http://www.ama-assn.org
 American Hospital Association
– http://www.hospitalconnect.com/aha/key_issues/hipaa
Social Media
Opportunities
 Examples: Facebook, Twitter, MySpace, LinkedIn,
personal blogs
 The three P’s of digital ethics: privacy, protection, and
policy
 Many healthcare organizations have established a
social media presence
– Nurses can discuss issues related to Nursing: best practices,
safety, clinical trials
– Important teaching tool
– YouTube and Twitter updates
– Dedicated pages to keep up on the latest news and research
Social Media
Pitfalls
Do not:
– Share your work experiences on any social media sites
– Reveal any information that can identify a patient
– Give any medical advice
– Share any experiences on challenging patients
– Share any experiences on an interesting medical problem
– Post any patient information
• Five nurses were fired for allegedly discussing patient cases on
Facebook
• Two Wisconsin nurses were fired for posting a patient’s x-ray on
Facebook page
Proceed with Caution!
Social Media
Recommendations
 Use common sense
 Protect patient privacy
 Adhere to the legal and regulatory requirements such
as those of Health Insurance Portability and
Accountability Act (HIPAA)
– Even if you don’t identify the patient, the HIPAA violation still exists
– you don’t have the patient’s permission
– Should you become a patient’s “friend” ?
– Violating HIPAA regulations can lead to fines as high as $250,000
and time in jail.
Social Media
Recommendations
 Always remember to follow your facility’s guidelines
regarding e-mail and other electronic communication
when using social media
– If your facility doesn’t have a policy regarding social media, assume
e-mail and electronic policies, by extension, apply to social media
sites.
– Mayo Clinic’s guidelines around social media
– Good rule of thumb: Would I be comfortable with this item being
shared in a public forum with my employer, patients and
colleagues?
Social Media
Safeguards
 Ask your employer for policies and procedures regarding these
sites
 Participate in or request staff training – sessions should cover
key concerns such as:
– Rules and etiquette
– Parameters for use during working and non-working hours
– Potential legal perils
– Patient confidentiality issues
– Disciplinary consequences fpr misuse
– Training session content and attendance should be documented.
Nurse Claim Scenario
Case Summary
 A 23-year-old woman with no significant medical
history presented to the emergency room
complaining of generalized body ache, with a fever of
102.6.
 CT Scan of the chest was abnormal, resulting in ED
MD admitting the Pt to the intensive care unit.
 Pt was started on oxygen and antibiotic therapy.
Blood cultures were drawn, indicating Streptococcus
Pneumoniae, and antibiotics were appropriately
adjusted.
Nurse Claim Scenario
Case Summary
 The attending MD noted that while the Pt was not in
acute distress, her blood chemistry was abnormal
with a potassium level of 2.9.
 MD ordered 30mEq of potassium to be added to
each bag of the Pt’s intravenous fluid, infused at 80
milliliters per hour.
 Two days later, the Pt’s potassium level was noted to
be 3.0, and the attending MD ordered 80 mEq of
potassium to be administered by mouth.
Nurse Claim Scenario
Case Summary
 The Pt vomited the medication.
 The attending MD then ordered two doses of 40 mEq
of intravenous potassium to infuse over a four-hour
time period with the plan of increasing the potassium
level between 4 and 4.5.
 Throughout the day, the defendant intensive care unit
nurse documented the Pt’s heart rate in the Pt care
record.
Nurse Claim Scenario
Case Summary
 The nurse did not notify MD of the pattern of rising
heart rate. When the MD saw the Pt that day, he
ordered the Pt to be transferred to the telemetry unit.
 According to hospital records, the attending MD was
called at approximately 10:00 p.m. and was advised
that the Pt had gone into cardiac arrest.
 The on-call emergency MD attempted to resuscitate,
but was unable to obtain a heartbeat, and the Pt was
pronounced dead.
Nurse Claim Scenario
Was the Nurse Deemed Negligent?
• Do you think this nurse was negligent?
• Do you think any other practitioners were negligent?
• Do you think indemnity and/or expense payment was
made on behalf of the nurse? If yes, how much?
Nurse Claim Scenario
Was the Nurse Deemed Negligent?
The nurse was deemed negligent in the following areas:
• Failure to notify the MD of the Pt’s increasing heart rate
• Failure to clarify the potassium order, and the nurse
administered an incorrect dosage of potassium at an
incorrect rate
• Failure to fully document her actions and the Pt’s
condition during the transfer of the plaintiff to the
telemetry unit
• Lack of documentation of time of transfer
• Lack of documentation of Pt’s condition at time of transfer
Nurse Claim Scenario
Was the Nurse Deemed Negligent (Cont.) ?
• Failure to document that the Pt was on a monitor and
receiving oxygen when transferred
• Failure to notify the MD that the telemetry unit was in an
overflow situation and verify whether the transfer should
be completed
Nurse Claim Scenario
Payments made on Behalf of the Nurse?
 Indemnity payment – 6 figures
 Expense payment - < $10,000
(Often, the payments made on behalf of co-defendants is
not available. In this case, it is known that payments
made on behalf of multiple co-defendants totaled
$1,400,000.)
Nurse Claim Scenario
Risk Management Recommendations
• When assigned to a clinical area, the nurse’s
training and experience should provide the skills
necessary to demonstrate competencies required for
performing the nursing role specific to the clinical
specialty or area.
Nurse Claim Scenario
Risk Management Recommendations
• If not, it is the responsibility of the nurse to:
– Notify the charge nurse and/or supervisor that the
assigned clinical area transcends the nurse’s training
and experience.
– Request close supervision and/or the assistance
of an experienced nurse and also request that all
treatments and medications be checked prior to
administration.
Nurse Claim Scenario
Risk Management Recommendations
– Obtain assistance for lack of complete
understanding of any aspect of the patient’s
condition, plan of care, progress notes,
physician orders and/or medication orders.
– Utilize the chain of command, including the
director of nursing and/or hospital administrator,
until provided with an assignment appropriate to
his/her level of training and experience or until
appropriate support and supervision by an
experienced nurse is provided.
Nurse Claim Scenario
Risk Management Recommendations
• Monitor and document the patient’s vital signs,
symptoms, response to treatment and changes in
condition in the patient care record.
• Timely report all significant findings to the patient’s
physician.
• Adhere to physician medication orders, including the
correct drug, dosage, route and administration times.
• Contact the physician and/or pharmacist with
questions, concerns or to obtain clarification regarding
the medication(s) ordered for the patient. If the physician
does not respond in a timely manner, follow the chain of
command to the point of resolution.
Nurse Claim Scenario
Risk Management Recommendations
• Manage any deviation from the physician’s order
regarding administration of a medication as a
medication error, including reporting, investigating
and developing a plan of correction to prevent
subsequent recurrences.
• Perform and document formal handoff procedures
when transferring a patient and report all significant
patient information regarding the patient’s treatment,
including a review of treatments, tests, medications and
outstanding orders, to the accepting nurse.
Nurse Claim Scenario
Risk Management Recommendations
• Manage any deviation from the physician’s order
regarding administration of a medication as a
medication error, including reporting, investigating
and developing a plan of correction to prevent
subsequent recurrences.
• Perform and document formal handoff procedures
when transferring a patient and report all significant
patient information regarding the patient’s treatment,
including a review of treatments, tests, medications and
outstanding orders, to the accepting nurse.
Resources
 Navigate Nursing. “Five Behaviors that Show Respect.”
 ADVANCE for Nurses. “Building Blocks of Teamwork.”
 Nursezone.com. “SBAR Improves Communication in
Patient Handoffs.”
 Medleaugue.com. “SBAR.”
 Joint Commission Guide to Improving Staff
Communication, Second Edition. 2009.
Disclaimer

The purpose of this presentation is to provide general information, rather than advice or opinion. It
is accurate to the best of the speakers’ knowledge as of the date of the presentation. Accordingly,
this presentation should not be viewed as a substitute for the guidance and recommendations of a
retained professional and legal counsel. In addition, Aon, Affinity Insurance Services, Inc. (AIS),
Nurses Service Organization (NSO) or Healthcare Provider Service Organization (HPSO) do not
endorse any coverage, systems, processes or protocols addressed herein unless they are
produced or created by AON, AIS, NSO, or HPSO, nor do they assume any liability for how this
information is applied in practice or for the accuracy of this information.

Any references to non-Aon, AIS, NSO, HPSO websites are provided solely for convenience, and
AON, AIS, NSO and HPSO disclaims any responsibility with respect to such websites. To the
extent this presentation contains any descriptions of CNA products, please note that all products
and services may not be available in all states and may be subject to change without notice. Actual
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Corporation. © CNA Financial Corporation, 2012.

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Corporation. Copyright © 2012, by Affinity Insurance Services, Inc. All rights reserved.