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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Maturing Into CMMI

In all likelihood, the reason why you landed on this page was because you were seeking CMMI experts to help you meet the demands of a growing number of potential clients who require CMMI compliance.

Whether or not you’re here for that reason, you might want to know why CMMI or Capability Maturity Model Integration is steadily becoming a common denominator among highly successful software and engineering development companies. If you stay for a while, we can show you how CMMI can substantially increase your organisation’s chances of:

reducing development costs;
acquiring new customers and retaining old ones;
beating deadlines;
bringing down development time;
increasing the overall quality of your products and services; and
improving the level of satisfaction of customers, employees, and all other stakeholders.

Surely, no organisation can be too small or too big to aspire for such benefits of attaining high levels of maturity and capability.

If you want to look beyond Maturity Level ratings, then you’ve come to the right place. We focus on introducing CMMI principles and blending them into your organisation’s culture to achieve a truly superior and sustainable business advantage. Compliance will then be an inevitable offshoot of the actions you make.

Likewise, if you simply want to obtain a deeper understanding of CMMI and learn how it can be applied either to your entire organisation or to specific projects, we’d be happy to assist you in that regard as well.

Finally, when you’re ready, we can also conduct CMMI appraisals either for benchmarking purposes or simply for determining how well your process improvement initiatives are going.

CMMI Consulting

Are you worried that implementing CMMI might entail an overhaul of your current processes? Don’t be.

CMMI is all about improving current processes, not replacing them. Ideally, the final result of all process improvement activities should be hinged on your own business objectives and context, so we’ll make sure it remains that way when we work with you.

We rely on our extensive knowledge and experience in CMMI, engineering, software development, and technologies as well as in change and project management in providing model-based process improvement services. Whether you’re gearing up for an appraisal or simply want to employ CMMI-based practices, these are the things we can do for you.

Help you interpret how CMMI can be implemented in relation to your business.
Assist in convincing sponsors and stakeholders to support your CMMI implementation initiatives.
Introduce the necessary training to all individuals who need to undertake them.
Conduct a Gap Analysis to find out where your company’s current processes stand relative to their CMMI specifications.
Assemble a process group that will champion your process improvement initiatives. We’ll facilitate effective collaboration among its team members, transforming them into a cohesive force designed to carry out plans and motivate everyone else down the line.
Introduce tools and practices that will improve the efficiency of our process improvement initiatives.
Carry out periodic evaluations and produce reports to provide sponsors and stakeholders a clear picture of our progress.

CMMI Training

Still not convinced CMMI is right for you? There’s only one way to fully grasp the benefits of implementing CMMI – take the Introduction to CMMI course. Although what happens next is entirely up to you, we’re pretty sure you’ll make the right decision after passing it.

Do you need to include people from your organisation in a SCAMPI (Standard CMMI Appraisal Method for Process Improvement) team? They’ll have to undergo this course too. The Introduction to CMMI is for systems and software engineering managers and practitioners, appraisal team members, process group members, and basically anyone who want to grasp CMMI fundamentals.

This is what you’ll be able to do after going through 3 days of lectures and exercises:

Gain a deeper understanding of the various components of CMMI-DEV models and their relationships.
Discuss the process areas in CMMI-DEV models.
Extract and interpret aspects in the model relevant to your own organisation’s processes.

We also offer highly specialised training and workshops such as those for:

Achieving High Maturity Levels
Top Executives
Team Building in Preparation for Appraisals

CMMI Appraisal

An organisation new to CMMI will want to know first how far their current processes are relative to the implementation of model-based improvements in order to determine the resources and time that have to be spent to get there.

Similarly, an organisation already well acquainted with CMMI and has begun taking steps in improving processes, will eventually want to know how close it has come to the Maturity Level it has aimed for.

In both cases, these organisations will have to be assessed by a qualified CMMI appraiser to obtain an accurate picture of their current status. We can perform appraisals on either your entire organisation or on specific projects/practices within a process area. Our appraisers can conduct the following SCAMPI (Standard CMMI Appraisal Method for Process Improvement) appraisals:

SCAMPI Class A – This is what you’ll need if you’re aiming for a level rating.
SCAMPI Class B – You may want to use this for process reviews or for preparing for a SCAMPI Class A.
SCAMPI Class C or Gap Analysis – We typically conduct this for organisations who have yet to implement CMMI-based initiatives so that they can design the most cost-effective road map for the implementation proper.

2015 ESOS Guidelines Chapter 1 ? Who Qualifies

The base criteria are any UK undertaking that employs more than 250 people and/or has a turnover in excess of ?50 million and/or has a balance sheet total greater than ?43 million. There is little point in attempting to separate off high polluting areas. If one corporate group qualifies for ESOS, then all the others are obligated to take part too. The sterling equivalents of ?38,937,777 and ?33,486,489 were set on 31 December 2014 and apply to the first compliance period.

Representatives of Overseas Entities

UK registered branches of foreign entities are treated as if fully UK owned. They also have to sign up if any overseas corporate element meets the threshold no matter where in the world. The deciding factor is common ownership throughout the ESOS system. ecoVaro appreciates this. We have seen European companies dumping pollution in under-regulated countries for far too long.

Generic Undertakings that Could Comply

The common factor is energy consumption and the organisation’s type of work is irrelevant. The Environmental Agency has provided the following generic checklist of undertakings that could qualify:

Limited Companies	Public Companies	Trusts
Partnerships	Private Equity Companies	Limited Liability Partnerships
Unincorporated Associations	Not-for-Profit Bodies	Universities (Per Funding)

Organisations Close to Thresholds

Organisations that come close to, but do not quite meet the qualification threshold should cast their minds back to previous accounting periods, because ESOS considers current and previous years. The exact wording in the regulations states:

?Where, in any accounting period, an undertaking is a large undertaking (or a small or medium undertaking, as the case may be), it retains that status until it falls within the definition of a small or medium undertaking (or a large undertaking, as the case may be) for two consecutive accounting periods.?

Considering the ?50,000 penalty for not completing an assessment or making a false or misleading statement, it makes good sense for close misses to comply.

Joint Ventures and Participative Undertakings

If one element of a UK group qualifies for ESOS, then the others must follow suit with the highest one carrying responsibility. Franchisees are independent undertakings although they may collectively agree to participate. If trusts receive energy from a third party that must do an ESOS, then so must they. Private equity firms and private finance initiatives receive the same treatment as other enterprises. De-aggregations must be in writing following which separated ESOS accountability applies.

Total Quality Management

Total Quality Management (TQM) is another business management approach that focuses on the involvement of all members of the organisation to participate in improving processes, products, services, and the culture in which they work in. It is important that every team member realises how each individual and each activity affects, and in turn is affected by, others.

With the use of combined quality and management tools, TQM also aims to reduce losses brought about by wasteful practices, a common concern in most companies. Using the TQM strategy, business would also be able to identify the cause of a defect, thereby preventing it from entering the final product.

Deming’s 14 Points

At the core of the Total Quality Management concept and implementation is Deming’s 14 points, a set of guidelines on quality as conceptualised by W Edwards Deming, one of the pioneers of quality. Deming’s 14 points are as follows:

Create constancy of purpose for improving products and services.
Adopt the new philosophy.
Cease dependence on inspection to achieve quality.
End the practice of awarding business on price alone; instead, minimise total cost by working with a single supplier.
Improve constantly and forever every process for planning, production and service.
Institute training on the job.
Adopt and institute leadership.
Drive out fear.
Break down barriers between staff areas.
Eliminate slogans, exhortations and targets for the workforce.
Eliminate numerical quotas for the workforce and numerical goals for management.
Remove barriers that rob people of pride of workmanship, and eliminate the annual rating or merit system.
Institute a vigorous program of education and self-improvement for everyone.
Put everybody in the company to work accomplishing the transformation.

But if you were to reduce to bare bones the TQM philosophy from Deming’s 14 points, it would all come down to two simple goals:

To make things right the first time; and
To work for continuous improvement.

As with all other quality management process, the end goal is to be able to offer products and services that meet and even exceed customer’s expectations.

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