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.

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Spreadsheet woes – Burden in SOX Compliance and other Regulations

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Succeed at Transformation

Despite the pomp and fanfare associated with launching corporate transformation programs, in reality very few of them succeed. According to a recent report by McKinsey the success rate is pegged below 40%. In addition, the same research indicates that defensive transformations – those undertaken as part of crisis management – have lower chances of success than progressive ones – those launched to streamline operations and foster growth. However, adopting certain strategies, like setting clear and high goals, and maintaining energy and engagement throughout the implementation phase, can really boost the project’s success rate. A key aspect of business transformation is IT transformation. This can be attributed to the fact that significant business change is either driven or influenced by technological change.

So what is IT Transformation?

IT transformation is basically a holistic reorganisation of the existing technological infrastructure that supports the company’s mission critical functions. In essence, IT transformation is not all about effecting change for the sake of change but involves systematic steps that align IT systems to business functions. To appreciate this approach, it is important to explore current trends in the business world where human resource, finance and IT transformations are being carried out in unison. This is being done to develop strong corporate centres that are leaner, agile and more productive that enhance greater synergies across all business functions.

IT transformation inevitably results in major changes of the information system’s technology, involving both hardware and software components of the system, the architecture of the system, the manner in which data is structured or accessed, IT control and command governance, and the components supporting the system. From this scope of works it is evident that IT transformation is a huge project that requires proper planning and implementation in order to succeed.

Tips to Improve Success in IT transformations Projects

1. Focus on Benefits not Functionality

The project plan should be more focused on benefits that can be accrued if the system is implemented successfully rather than system functionality. The benefits should be in line with business goals, for instance cost reduction and value addition. The emphasis should be on the envisaged benefits which are defined and outlined during the project authorisation. The business benefits outlined should be clear, feasible, compelling and quantifiable. Measures should be put in place to ensure that the benefits are clearly linked to the new system functionality.

2. Adopt a Multiple Release Approach

Typically most IT projects are planned with focus on a big launch date set in years to come. This approach is highly favoured because it simplifies stakeholder expectation management and avoids the complexity associated with multiple incremental releases. However, this approach misses the benefit of getting early critical feedback on functioning of the system. In addition, the long lead times often result in changes in project scope and loss of critical team members and stakeholders. IT transformation projects should be planned to deliver discrete portions of functionality in several releases. The benefit of multiple release approach is that it reduces project risks and most importantly allows earlier lessons learnt to be incorporated in future releases.

3. Capacity of the Organisation to confront Change

As pointed out, IT transformations result in significant changes in business operations and functions. Hence it is important that all business stakeholders should be reading from the same script in regards to changes expected. In addition, key stakeholders should be involved in crucial project stages and their feedback incorporated to ensure that the system is not only functional but business focused.

Introduction to Matrix Management

A leader is responsible to empower his people and get the best out of them. Yet an organisational structure can either help or hamper performance. Worst, it can make or break success.

Looking at the fast-changing world of the global economy, whatsoever slows up and obstructs decision-making is a challenge. Hierarchical management is rather unattractive and functional silos are unlikable. Instead, employees desire to create teams equipped with flexibility, cooperation and coordination.

Recognising that companies have both vertical and horizontal chains of command, the matrix model is created. The concept of this principle lies in the ability to manage the collaboration of people across various functions and achieve strategic objectives through key projects.

Consider this scenario:

Ian is a sales executive of a company. His role is to sell a new product under the supervision of a product manager. The manager is expert about the product and she is accountable to coordinate the people across the organisation, making sure the product is achieved.

Moreover, Ian also reports to the sales manager who oversees his overall performance, monitors his pay and benefits and guides his personal development.

Complicated it may seem but this set-up is common to companies that seek to maximise the effect of expert product managers, without compromising the function of the staffing overhead in control of the organisation. This is a successful approach to management known as Matrix Management.

Matrix Management Defined

Matrix management is a type of organisational management wherein employees of similar skills are shared for work assignments. Simply stated, it is a structure in which the workforce reports to multiple managers of different roles.

For example, a team of engineers work under the supervision of their department head, which is the engineering manager. However, the same people from the engineering department may be assigned to other projects where they report to the project manager. Thus, while working on a designated project, each engineer has to work under various managers to accomplish the job.

Historical Background

Although some critics say that matrix management was first adopted in the Second World War, its origins can be traced more reliably to the US space programme of the 1960’s when President Kennedy has drawn his vision of putting a man on the moon. In order to accomplish the objective, NASA revolutionised its approach on the project leading to the consequent birth of ?matrix organisation?. This strategic method facilitated the energy, creativity and decision-making to triumph the grand vision.

In the 1970’s, matrix organisation received huge attention as the only new form of organisation in the twentieth century. In fact it was applied by Digital Equipment, Xerox, and Citibank. Despite its initial success, the enthusiasm of corporations with regards to matrix organisation declined in the 1980’s, largely because it was complex.

Furthermore, the drive for motivating people to work creatively and flexibly has only strengthened. And by the 1990’s, the evolution of matrix management geared towards creation and empowerment of virtual teams that focused on customer service and speedy delivery.

Although all forms of matrix has loopholes and flaws, research says that until today, matrix management is still the leading approach used by companies to achieve organisational goals.

2015 ESOS Guidelines Chapter 3 to 5 ? The ESOS Assessment

ESOS operates in tandem with the ISO 50001 (Energy Management) system that encourages continual improvement in the efficient use of energy. Any UK enterprise qualifying for ESOS that has current ISO 50001 certification on the compliance date by an approved body (and that covers the entire UK corporate group) may present this as evidence of having completed its ESOS assessment. It does however still require board-level certification, following which it must notify the Environment Agency accordingly.

The Alternate ESOS Route

In the absence of an ISO 50001 energy management certificate addressing comprehensive energy use, a qualifying UK enterprise must:

Measure Total Energy Consumption in either kWh or energy spend in pounds sterling, and across the entire operation including buildings, industrial processes and transport.
Identify Areas of Significant Energy Consumption that account for at least 90% of the total. The balance falls into a de minimis group that is officially too trivial to merit consideration.

Consider Available Routes to Compliance. These could include ISO 500001 part-certification, display energy certificates, green deal assessments, ESOS compliant energy audits, self-audits and independent assessments

Do an Internal Review to make sure that you have covered every area of significant consumption. This is an important strategic step to avoid the possibility of failing to comply completely.

Appoint an Approved Lead Assessor who may be internal or external to your enterprise, but must have ESOS approval. This person confirms you have met all ESOS requirements (unless you have no de minimis exceptions).

Obtain Internal Certification by one of more board-level directors. They must certify they are satisfied with the veracity of the reports. They must also confirm that the enterprise is compliant with the scheme.

Notify the Environment Agency of Compliance within the deadline using the online notification system as soon as the enterprise believes is fully compliant.

Assemble your ESOS Evidential Pack and back it up in a safe place. Remember, it is your responsibility to provide proof of the above. Unearthing evidence a year later it not something to look forward to.

The ESOS assessment process is largely self-regulatory, although there are checks and balances in place including lead assessor and board-level certifications. As you work through what may seem to be a nuisance remember the primary objectives. These are saving money and reducing carbon emissions. Contact ecoVaro if we can assist in any way.