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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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.

ESOS What is the Truth?

When the UK administration introduced its ESOS Energy Savings Opportunity Scheme reactions from business people followed a familiar theme.

Do nothing it will go away
The next Westminster will drop this
Another stealth tax. I don’t have time for this
Give the problem to admin and tell them to fix it

ecovaro decided to share three facts with you. These are

(1) ESOS is not a government money spinner

(2) all major political parties support it, and

(3) it is a cost-effective way to put money back in your pocket while feeling better about what business pumps into the environment.

Four More ESOS Facts

1. You Cannot Give the Problem to Admin ? Energy is technical. The lead belongs with your operations staff because they understand how your systems work. Some things are best outsourced though. ecovaro is here to help.

2. ESOS is Not Going to Go Away ? A company inside the regulation net must submit its first report by 6 December 2015. Non-compliance risks the following penalties:

?5,000 for not maintaining adequate records
?50,000 for not completing the assessment

?50,000 for making a false or misleading statement

3. The Employee Count is the Annual Average – The employment criteria (unlike balance sheet and turnover) is the monthly average of full and part-time employees taken across the full financial year. The fact you have <250 employees in December 2015 when the first report is due does not necessarily let you off the hook.

4. The 6 December 2014 Report is No Big Deal ? When you think about it the administration is hardly likely to spend years wading through 9,000 detailed company energy plans. It has no authority to comment in any case. All that is required is for a senior director to confirm reading the document, and a lead assessor to agree it complies with the law.

Does this mean that ESOS is a damp squib? We do not think so, although some firms may take the low road. ecovaro believes the financial benefits will carry the process forward, and that the imperative to make the world a better place will do the rest.

Six Sigma

Six Sigma has received much attention worldwide as a management strategy that is said to have brought about huge improvements and financial gains for such big-name companies as Allied Signal, General Electric (GE) and Motorola.

If you want to give your business the chance to attain the same resounding success, Six Sigma could be the method that will steer you towards that direction.

What is Six Sigma?

So what really is it? Six Sigma is a business management tool that was developed using the most effective quality improvement techniques from the last six decades. Basing its approach on discipline, verifiable data, and statistical calculations, Six Sigma aims to identify the causes of defects and eliminate them, thereby resulting in near-perfect products that meet or exceed customer’s satisfaction.

The core concept behind the Six Sigma method is that if an organisation can quantify the number of “defects” there are in a particular process, improvement activities can be implemented to eliminate them, and get as close to a “zero defects” scenario as possible. Defect here is defined as any process output that fails to meet customer specifications.

Six Sigma is also unique from other programs in that it calls for the creation of a special infrastructure of people within the organisation (“Champions“, “Black Belts“, “Green Belts“) who are to be expert in the methods.

Six Sigma Methodologies

When implementing Six Sigma projects, two methodologies are often employed. Although each method uses five phases each, these two are distinguished from each other using 5-letter acronyms and their specific uses.

DMAIC ? is the project methodology used to improve processes and maximise productivity of current business practices. The 5 letters stand for:

D ? Define (the problem)
M ? Measure (the main factors of the existing process)
A ??Analyse?(the information gathered to deter mine the causes of defects)
I ? Improve (the current process based on the analysis)
C ? Control (all succeeding processes so as to minimise additional defects)

DMADV – is the method most suitable if your business is looking to create new products or designs. The acronym stands for:

D ? Define (product goals as the consumer market demands)
M ? Measure (and identify product capabilities and risks)
A ??Analyse?(to create the best possible design)
D ? Design (the product or process details)
V ? Verify (the design)

How does Six Sigma differ from other quality programs?

If you think that Six Sigma is just another one of those business strategies that produce more hype than actual results, think again. Six Sigma uses three key concepts that sets it apart from other business management methods.

It is strictly a data-driven approach, where assumptions and guesswork do not figure in the decision making.
It focuses on achieving quantifiable financial results ? the bottom line ($) ? as much as giving emphasis on customer satisfaction.
It requires strong management leadership, while at the same time creating a role for every individual in the organisation.

Is Six Sigma right for your business?

While many other organisations such as Sony, Nokia, American Express, Xerox, Boeing, Kodak, Sun Micro-systems and many other blue chip companies have followed suit in adopting Six Sigma, the truth is, any company — whether you have a large manufacturing corporation, or a small business specialising in customer service.

Certainly, there is a lot more to Six Sigma than what you can probably absorb in one sitting or reading.

With our wide range of business management consultancy services, we can help you understand the Six Sigma method in the context of your business. We can also help you establish your improvement goals, set up your program, and train your own team of “champions” who can lead in implementing your Six Sigma goals.

Find out more about our Quality Assurance services in the following pages: