Disadvantages of Spreadsheets – Obstacles to Compliance in the Healthcare Industry

Most of the regulatory compliance issues we talked about concerning spreadsheets have been related to financial data. But there are other kinds of data that are stored in spreadsheets which may also cause regulatory problems in the future.

In the US, a legislation known as HIPAA or Health Insurance Portability and Accountability Act is changing the way health care establishments and practitioners handle patient records. The HIPAA Privacy Rule is aimed at protecting the privacy of individually identifiable health information a.k.a. protected health information (PHI).

Examples of PHI include common identifiers like a patient’s name, address, Social Security Number, and so on, which can be used to identify the patient. HIPAA covers a wide range of health care organisations and service providers, including: health plan payers, health care clearing houses, hospitals, doctors, dentists, etc.

To protect the confidentiality, integrity, and availability of PHI, covered entities are required to implement technical policies such as access controls, authentication, and audit controls. These can easily be implemented on server-based systems.

Sad to say, many health care organisations who have started storing data electronically still rely on spreadsheet-based systems. Those policies are hard to implement in spreadsheet-based systems, where files are handled by end-users who are overloaded with their main line of work (i.e. health care) and have very little concern for data security.

In some of these systems, spreadsheet files containing PHI may have multiple versions in different workstations. Chances are, none of these files have any access control or user authentication mechanism whatsoever. Thus, changes can easily be made without proper documentation as to who carried out the changes.

And because the files are normally easily accessible, unauthorised disclosures – whether done intentionally or accidentally – will always be a lingering threat. Remember that HIPAA covered entities who are caught disclosing PHI can be fined from $50,000 up to $500,000 plus jail time.

But that’s not all. Through the HITECH Act of 2009, business associates of covered entities will now have to comply with HIPAA standards as well. Business associates are those companies who are performing functions and services for covered entities.

Examples of business associates are accounting firms, law firms, consultants, and so on. They automatically need to comply with the standards the moment they too deal with PHI.

More Spreadsheet Blogs

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Disadvantages of Spreadsheets – obstacles to compliance in the Healthcare Industry

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Spreadsheet Reporting – No Room in your company in an age of Business Intelligence

Still looking for a Way to Consolidate Excel Spreadsheets?

Disadvantages of Spreadsheets

Spreadsheet woes – ill equipped for an Agile Business Environment

Spreadsheet Fraud

Spreadsheet Woes – Limited features for easy adoption of a control framework

Spreadsheet woes – Burden in SOX Compliance and other Regulations

Spreadsheet Risk Issues

Server Application Solutions – Don’t let Spreadsheets hold your Business back

Why Spreadsheets can send the pillars of Solvency II crashing down

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2015 ESOS Guidelines Chapter 6 – Role of Lead Assessor

The primary role of the lead assessor is to make sure the enterprise?s assessment meets ESOS requirements. Their contribution is mandatory, with the only exception being where 100% of energy consumption received attention in an ISO 50001 that forms the basis of the ESOS report.

How to Find a Lead Assessor

An enterprise subject to ESOS must negotiate with a lead assessor with the necessary specialisms from one of the panels approved by the UK government. This can be a person within the organisation or an third party. If independent, then only one director of the enterprise need countersign the assessment report. If an employee, then two signatures are necessary. Before reaching a decision, consider

Whether the person has auditing experience in the sector
Whether they are familiar with the technology and the processes
Whether they have experience of auditing against a standard

The choice rests on the enterprise itself. The lead assessor performs the appointed role.

The Lead Assessor?s Role

The Lead Assessor?s main job is reviewing an ESOS assessment prepared by others against the standard, and deciding whether it meets the requirements. They may also contribute towards it. Typically their role includes:

Checking the calculation for total energy consumption across the entire enterprise
Reviewing the process whereby the 90% areas of significant consumption were identified
Confirming that certifications are in place for all alternate routes to compliance chosen
Checking that the audit reports meet the minimum criteria laid down by the ESOS system

Note: A lead assessor may partly prepare the assessment themselves, or simply verify that others did it correctly.

In the former instance a lead assessor might

Determine energy use profiles
Identify savings opportunities
Calculate savings measures
Present audit findings
Determine future methodology
Define sampling methods
Develop audit timetables
Establish site visit programs
Assemble ESOS information pack

Core Enterprise Responsibilities

The enterprise cannot absolve itself from responsibility for good governance. Accordingly, it remains liable for

Ensuring compliance with ESOS requirements
Selecting and appointing the lead assessor
Drawing attention to previous audit work
Agreeing with what the lead assessor does
Requesting directors to sign the assessment

The Environment Agency does not provide assessment templates as it believes this reduces the administrative burden on the enterprises it serves.

2015 ESOS Guidelines Chapter 2 – Deadlines and Status Changes

The ESOS process is deadline driven and meeting key dates is a non-negotiable. The penalties for not complying / providing false or misleading information are ?50,000 each. Simply not maintaining adequate records could cost you ?5,000. The carrot on the end of the stick is the financial benefits you stand to gain.

Qualifying for inclusion under the ESOS umbrella depends on the status of your company in terms of employee numbers, turnover and balance sheet on 31 December 2014. Regardless of whether you meet the 2014 threshold or not, you must reconsider your situation on 31 December 2018, 2022 and 2026.

Compliance Period	Qualification Date	Compliance Period	Compliance Date
1	31 December 2014	From 17 July 2014* to 5 December 2015	5 December 2015
2	31 December 2018	From 6 December 2015 to 5 December 2019	5 December 2019
3	31 December 2022	From 6 December 2019 to 5 December 2023	5 December 2023
4	31 December 2026	From 6 December 2023 to 5 December 2027	5 December 2027

Notes:

1. The first compliance period begins on the date the regulations became effective

2. Energy audits from 6 December 2011 onward may go towards the first compliance report

Changes in Organisation Status

If your organisation status changes after a qualification date when you met compliance thresholds, you are still bound to complete your ESOS assessment for that compliance period. This is regardless of any change in size or structure. Your qualification status then remains in force until the next qualification date when you must reconsider it.

The Connection Between Six Sigma and CRM

Six Sigma is an industrial business strategy directed at improving the quality of process outputs by eliminating errors and system variables. The end objective is to achieve a state where 99.99966% of events are likely to be defect free. This would yield a statistical rating of Sigma 6 hence the name.

The process itself is thankfully more user-friendly. It presents a model for evaluating and improving customer relationships based on data provided by an automated customer relations management (CRM) system. However in the nature of human interaction we doubt the 99.99966% is practically achievable.

Six Sigma Fundamentals

The basic tenets of the business doctrine and the features that set off are generally accepted to be the following:

Continuous improvement is essential for success

Business processes can be measured and improved

Top down commitment is fundamental to sustained improvement

Claims of progress must be quantifiable and yield financial benefits

Management must lead with enthusiasm and passion

Verifiable data is a non-negotiable (no guessing)

Steps Towards the Goal

The five basic steps in Six Sigma are define the system, measure key aspects, analyse the relevant data, improve the method, and control the process to sustain improvements. There are a number of variations to this DMAIC model, however it serves the purpose of this article. To create a bridge across to customer relationships management let us assume our CRM data has thrown out a report that average service times in our fast food chicken outlets are as follows.

<2 Minutes	3 to 8 Minutes	9 to 10 Minutes	>10 Minutes
45%	30%	20%	5%
Table: Servicing Tickets in Chippy?s Chicken Caf?s

Using DMAIC to unravel the reasons behind this might proceed as follows

Define the system in order to understand the process. How are customers prioritised up front, and does the back of store follow suit?

Break the system up into manageable process chunks. How long should each take on average? Where are bottlenecks most likely to occur?

Analyse the ticket servicing data by store, by time of day, by time of week and by season. Does the type of food ordered have a bearing?

Examine all these variables carefully. Should there for example be separate queues for fast and slower orders, are there some recipes needing rejigging

Set a goal of 90% of tickets serviced within 8 minutes. Monitor progress carefully. Relate this to individual store profitability. Provide recognition.

Conclusion

A symbiotic relation between CRM and a process improvement system can provide a powerful vehicle for evidencing customer care and providing feedback through measurable results. Denizon has contributed to many strategically important systems.?

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