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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Top 10 Disadvantages of Spreadsheets

Disadvantages of Spreadsheets – obstacles to compliance in the Healthcare Industry

How Internal Auditors can win the War against Spreadsheet Fraud

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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Benefits Realisation Frameworks – A Useful Handle

One of the greatest challenges of project management is maintaining top-down support in the face of fluctuating priorities. If you elect to take on the role yourself and are peppered by other priorities, it can be a challenge to exactly remember why you are changing things and what your goals are. Sometimes you may not even notice you have reached your goal.

The Benefits Realisation Chart-room

The Benefits Realisation Model is a framework on which to hang key elements of any project. These traditionally include the following, although yours may not necessarily be the same:

Definition of the project goal
Quantification of intended benefits
Project plan versus actual progress
How you know you reached your goal
Quantification of actual benefits

Another way of describing Benefits Realisation Frameworks is they answer four fundamental questions that every project manager should know by heart:

What am I going to do?
How am I going to do it?
When will I know it’s done?
What exactly did I achieve?

The Benefits Realisation Promise

An astounding number of projects fail to reach completion, or miss their targets. It’s not for nothing that the expression ?after the project failed the non-participants were awarded medals? is often used in project rooms. We’re not saying that it is a panacea for success. However it can alert you to warnings that your project is beginning to falter in terms of delivering the over-arching benefits that justify the effort.

When Projects Wander Off-Target

Pinning blame on participants is pointless when project goals are flawed. For example, the goals may be entirely savings-focused and not follow through on what to do with the windfall. At other times realisation targets may be in place, but nobody appointed to recycle the benefits back into the organisation. This is why a Benefits Realisation Framework needs to look beyond the project manager?s role.

Realisation Management in Practice

If the project framework does not look beyond the project manager?s role, then it is over when it reaches its own targets ? and can even run the risk of being an event that feeds entirely off itself. In order to avoid a project being a means to its own end, this first phase must culminate with handover to a benefits realisation custodian.

An example of this might be a project to centralise facilities that is justified in terms of labour savings. The project manager?s job is to build the structure. Someone else needs to rationalise the organisation.

In conclusion, the Benefits Realisation Framework is a useful way of ensuring a project does not only achieve its internal goals, but also remains a focus of management attention because of its extended, tangible benefits.

Competencies, Roles and Responsibilities of Lead Assessors

Any organisation that opts for energy audits, Display of Energy Certificates and Green Deal Assessments needs a lead assessor to review the chosen ESOS compliance routes. The Derivative provides that energy audits should be carried out independently by qualified and accredited experts. Additionally, these audits should be implemented as well as supervised by independent authorities under the national legislation.

Lead assessors undertake several roles in ESOS assessments. He or she is the one responsible to take the lead of the entire assessment team, prepare the plan, conduct the meetings and submit the formal report to governing authorities. Nevertheless, selecting an appropriate lead assessor is an important element that every organisation should carefully consider.

Competencies Requirements of Lead Assessors

Lead assessors should be knowledgeable enough with in-depth expertise in carrying out energy efficiency assessment. They should also possess foundational, functional and technical competencies to deliver the task effectively. Likewise, consider the assessors? sector experiences, familiarity with your business? technologies and properties, and accreditation with prescribed standards.

As you choose your lead assessor, contemplate on the skills and qualifications that would give your organisation benefits.

Roles and Responsibilities of Lead Assessors

The business organisation is responsible for the overall legal ESOS compliance. Moreover, here are some of the roles and responsibilities that lead assessors should assume in ESOS assessments.

The lead assessor agrees on the audit methodologies that the organisation would undergo in new audits. He or she agrees with the ESOS participant regarding the audit timetable, sampling approach and visits required. It is also the lead assessor?s role to identify the opportunities on energy saving and assist in calculating the cost savings from the measures taken. During the ESOS audits, the lead assessor determines the energy use profiles, presents the recommendations and reviews the entire assessment as a whole. Furthermore, he or she should maintain the evidence pack of the ESOS to uphold the audit’s credibility, its findings and recommendations.

Finding Lead Assessors

Energy and environment professionals would only be able to demonstrate their expertise as lead assessors upon registering in a professional body accredited by the Environment Agency. Any business that needs a lead assessor is advised to check on the EA?s website to see the details of approved registers.

Lead assessors can either be in-house experts or external professionals. However, they should be able to provide proof of membership as an approved register to take the role of a lead assessor. If the organisation has an internal lead assessor, the company should then take the final ESOS assessment to two board-level directors that would sign the formal report.

Indeed, the lead assessor is an organisation’s partner when it comes to delivering great results. With good professional conduct and excellent management of an assessment team, the lead assessor can help achieve breakthrough energy efficiency strategies. More than anything else, the organisation will benefit from maximum energy savings opportunities ahead. Thus, every qualified business enterprise should invest in finding the best lead assessor to guide them towards success.

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Can you do away with the Project Initiation Meeting?

Project initiation meetings are often skipped to fast-track projects. Once a sponsor is found, organisations go straight to project planning and execution. But based on our own experience, holding a project initiation meeting can actually eliminate many issues that may crop up in the future and hence may speed things up instead in the long run.

It is in the project initiation meeting where your project objectives and scope are clarified and all stakeholders are brought to the same page. Project sponsors and stakeholders will have to know in a nutshell what is needed from them, what the possible risks are, what different resources are required, and so on. So that, when it’s time to proceed to the next phase, everyone is already in-sync.

So what are taken up in such a meeting? Perhaps an actual example can help. Sometime in the past, we set out to work on an eCommerce website project. After conducting the project initiation meeting, these were some of the things we were able to accomplish:

Identified deliverables e.g. site design, interface to payment system, etc.
Come up with the project phases
Agreed what should be in and out of scope
Defined the acceptance test criteria
Identified possible risks
Identified the possible training and documentation work needed
Established whether any analysis was required, e.g. as with regards to payment interfaces
Formulated disaster recovery plans
Defined roles and responsibilities
Drafted timelines and due dates

Aren’t these covered in project planning? If the project is a big one, the answer is no. In a large project, project planning is a much more exhaustive activity. In a project initiation meeting, only the basic framework is defined.

Some questions may still remain unanswered after a project initiation meeting, but at least you already know what answers you need to look for. In the example we gave earlier, we left the meeting knowing that we needed:

a list of all necessary hardware to estimate the costs
to identify possible dependencies we might have with third parties
to identify what software had to be bought and what skills we needed to hire

When it was time to proceed to project planning, everyone involved already knew what direction we were taking. In effect, by not skipping the project initiation meeting, we were able to avoid many potential obstacles.