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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Matrix Management: Benefits and Pitfalls

Matrix management brings together managers and employees from different departments to collaborate with each other towards the accomplishment of the organizational goals. As much as it is beneficial, matrix management also has limitations. Hence, companies should understand its benefits and pitfalls before implementing this management technique.

Benefits

The following are some of the advantages of matrix management:

Effective Communication of Information

Because of the hybrid nature of the matrix structure, it enables different departments to closely work together and communicate frequently in order to solve project issues. This leads to a proficient information exchange among leaders and subordinates. Consequently, it results to developed strategies, enhanced performance and quick productivity.

Efficient Use of Resources

Resources can be used efficiently in the organisation since it can be shared among functions and projects. As the communication line is more open, the valuable knowledge and highly skilled resources are easily distributed within the organisation.

Increased Motivation

The matrix structure promotes democracy. And with the employees working on a team, they are motivated to perform their duties better. The opinions and expertise of the employees are brought to the table and considered by the managers before they make decisions. This leads to employee satisfaction, empowerment and improved performance.

Flexibility

Since the employees communicate with each other more frequently, decision making becomes speedy and response is adaptive. They can easily adjust with diverse situations that the company encounters.

Skills Development

Matrix employees are pooled out for work assignments, even to projects that are not necessarily in line with their skill background. With this approach to management, employees have the chance to widen their skills and expertise.

Discipline Retention

One significant advantage of matrix management is that it enables the employees to maintain their skills in functional areas while working with multidisciplinary projects. Once the project is completed and the team wraps up, the members remain sharp in their discipline technically and return to their home functions.

Pitfalls

Here are some disadvantages of matrix management:

Power Struggle

In the matrix structure, there is always tension between the functional and project manager. Although their intent is polite, their conflicting demands and competition for control over the same resources make it more difficult.

Internal Complexity

Having more than one manager, the employees might become confused to who their immediate leader is. The dual authority can lead to internal complexity and possible communication problems. Worst, employee dissatisfaction and high employee turnover.

Heightened Conflict

In any given situation where people and resources are shared across projects, there would always be competition and conflict. When these issues are prolonged, conflicts will heightened and will lead to more internal problems.

Increased Stress

For the employees, being part of a matrix structure can be stressful. Their commitment is divided among the projects and their relationship with multiple managers requires various adjustments. Increased stress can negatively affect their performance in the long run.

Excessive Overhead Expenses

Overhead administrative costs, such as salaries, increase in a matrix structure. More expenses, more burden to the organisation. This is a challenge to matrix management that leaders should consider carefully.

These are just some of the advantages and disadvantages of matrix management. The list could go on, depending on the unique circumstances that organisations have. The key is that when you decide to implement matrix management, you should recognise how to take full advantage of its benefits and understand how to lessen, if not eradicate, the pitfalls of this approach to management.

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.

Energy Audit – clearly clear?

An energy audit is an examination of an energy system to ensure that energy is being used efficiently. It is the inspection, survey and analysis of energy flows for energy conservation in a building. Energy audits can be conducted by building managers who examine the energy account of an energy system, checks the way energy is used in its various components, checks for areas of inefficiency or where less energy can be used, and identifies the means for improvement.

An energy audit is often used to identify cost effective ways to improve the comfort and efficiency of buildings. In addition, homes/ enterprises may qualify for energy efficiency grants from central government. Energy audits seek to prioritise the energy uses from the greatest to least cost effective opportunities for energy savings.

An energy audit is an effective energy management tool. By identifying and implementing improvements as identified, savings can be achieved not only on energy bills, but also equipment will be able to attain a longer life under efficient operation. All these mean actual dollar savings.

An energy audit has to be conducted by a competent person with adequate technical knowledge on building services installations, after which he/she comes up with a report recommending plans on the Energy Management Opportunities (EMO) for energy saving.

An energy audit culminates to a written report. This could show energy use for a given time period (for example a year) and the impact of any suggested improvements per year. Energy audit reports are then used to identify cost effective ways to improve the comfort and efficiency of buildings. The energy audit report therefore gives management an understanding of the energy consumption scenario and energy saving plans formulation.
Energy audit reports should always translate into action. No matter how well articulated, the energy management objectives are afterall, an energy audit (EMOs), all the effort will be futile if no action is taken. The link between the audit and action is the audit report. It is therefore important for the audit reports to be understandable for all the target audiences/ readers, all of whom may have diverse needs, hence the reason why they should be clear, concise and comprehensible.

What are the do?s and don’ts when writing energy audit reports?

Avoid technical jargon as much as possible; present information graphically; use different graphics such as pie charts, data tables. Schematics of equipment layouts and digital photos tend to make EMO reports less dry. Some of the energy audit software?s come in handy in the generation of such graphs and charts.
The climax of it all is the recommendations, which should be made very fascinating.

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