Tag: compliance
How to survive an IT Management Audit
This is a test. Which of the following are common occurrences during IT Management Audits?
1. Staff members quit.
2. Staff members break down in tears in front of the consultants.
3. Staff members fly into a screaming rage at the consultants.
4. Staff members lie to the consultants.
5. Staff members refuse to cooperate.
6. All of the above.
If you selected item 6, you get a gold star! There is no reason for any of these behaviors but they occur all too often, especially in organizations in which audits are not routine events. The consultants are there to identify problems and help improve operations. They wouldn’t have been hired if everything was peachy keen, but Information Technology management and staff members rarely see it from this perspective. Identifying the problem is the first step to recovery. All Information Technology organizations should be managed as if an audit is imminent. How would you fare if auditors walked in the door tomorrow morning?
Why are you being audited?
There are many reasons for conducting audits, but following are the four I encounter most often.
Regulatory compliance audits
In market sectors such as Financial, Behavioral Health, Medical, and Pharmaceutical, periodic audits are the norm and the guidelines are clear. In any given year, a Behavioral Health clinic in NY State, for instance may be required to undergo 4 separate audits including Medicaid, HIPAA, OMH (Office of Mental Health), and OASAS (Office of Alcohol and Substance Abuse Services). In many of these cases, the auditors show up unannounced or on very short notice.
Compliance audits aren’t technically management audits, but the scores on such audits are certainly a direct reflection of management’s performance. Would your policies, practices, procedures, and documentation measure up to the scrutiny to which a Behavioral Health clinic is subjected?
Performance audits or ‘What’s wrong with our IT operation?’
Often, members of the IT management and staff think they are doing a spectacular job but the customers and executive management disagree vehemently. In the worst cases, end users are preparing their pitchforks and torches in case the audit doesn’t bring about some positive performance outcomes. These audits are tough; the IT staff is defensive and they all assume that the consultants are there to fire them. Sometimes, the hostility reaches levels that make me feel like Patrick Swayze’s character, Dalton in the 1989 movie Road House. I have been accused of cherry-picking information, interrogation, and cross examination and I have been screamed at in front of a large audience. The truth is, I am simply researching a complex problem and I will work diligently to provide answers to the people who are paying me to do so.
During these audits, employees sometimes resign even before the final report is released. This is unfortunate because poor performance is a reflection of management rather than staff. At other times, excellent employees leave because they have had their fill of ineffective management. Frustrations become bitter tears dripping on the conference room table, even from managers.
New management
Sometimes, incoming executives want an X-Ray of organizational performance and requesting an audit is an intelligent professional move. They want a clear distinction between the previous management’s practices and their own and they use the final report to establish a program of organizational change.
IT is too expensive
Occasionally, IT audits are conducted because executive management considers the IT operation too expensive. They want an independent audit and a strategic plan that shows all the viable options.
4 tips for a lower stress audit
If the auditors are coming next week, there probably isn’t much you can do to improve the outcome, but there is plenty you can do to make the process more comfortable for everyone involved.
Answer binary questions with binary answers
When questions requiring a Yes or No answer are met with lengthy explanations, it is a clear indication of a problem. When I ask if you have documentation of your daily security log validation, just say yes or no! If you don’t have the required documentation, no amount of explanation is going the help. Also, I am not really interested that you are going to begin implementing your security program next month. Good for you, but I only care about what your actual practices are at the time I ask.
Don’t lie, embellish, or bury information
I always walk into audits and assessments taking a neutral, objective stance and I appreciate clients who don’t try to pre-program me. I will selectively ask for evidence or documentation for every statement you make and false statements will certainly damage your credibility. When subjects provide evasive or ambiguous answers, my inner Columbo puts on his trench coat. Equivocation and rationalization drive me to keep searching until I get the answer. Just tell the truth.
Instruct your staff to cooperate politely
I recall one compliance audit where a staff member served up every document request with a plate full of anger and hostility. The odd thing about it was that all her ducks were in a row, which is pretty unusual. So, why the anger? Don’t unleash it on the consultants.
I remember several engagements where the IT staff tried to tell me that their IP addressing schemes and Visio diagrams were secret. Huh? As soon as I retrieved my jaw from the floor, I went over their heads and arranged for delivery of the requested information. These events created suspicion and hostility that weren’t required.
In two organizations I contracted with, staff members claimed their Security Policies were secret! How does that work? These sorts of behaviors are indicators of significant departmental and organizational problems.
Prepare documentation in advance
All documentation including policies, procedures, infrastructure documentation, logs, hardware and software inventories, PSA system reports, etc. should be readily available for the consultants. They will ask to see it. I generally ask for all this information before I go on site for the first time and I am always appalled by the number of organizations that have none of the documents that are generally accepted to be components of a solid Information Technology Governance program. Sometimes these data dumps include reams of irrelevant information in the hope that I won’t find the smoking gun.
Auditing for organizational culture
I include a frank assessment of departmental and organizational culture in my reports and it is sometimes less than flattering. Delivering this information to executives and managers generally creates a tense silence while they try to chew and swallow that particularly tough piece of meat. They rarely argue because they know it’s true, but few have dared to state the obvious out loud. A realistic and objective assessment of company culture is required to address the root causes of problems. Bad management, inefficiency, malfeasance and incompetence have often been enabled for years before an audit is finally initiated. Interdepartmental politics, turf wars, jealousy, meddling and backstabbing all contribute to the problems at hand and managers throughout the organization are responsible.
In many cases, executives and managers have worked in large, bureaucratic organizations for their entire careers and they can’t see the signs of broken company culture. They think bad behavior and dysfunction are the norm.
The final report
If the final report is not a testimonial of glowing praise for your IT operation, I urge you to sit back and reflect carefully before lashing out. The report is a mixture of data, facts, and input from your coworkers and end users. I always base part of my conclusions on both formal and informal interviews with end users and managers from every department in an organization. What ends up in the report is a reflection of what your colleagues really think about your operation. My career started with a four-year stint in army intelligence and I actually do cross examine and interrogate. The natural inclination of some IT Directors is to argue and pick apart every statement and conclusion in the report, but this is definitely the wrong approach.
A nearby local government entity with which I am familiar recently received a failing audit from a state regulatory agency. It wasn’t a first-time fail and the endemic problems have been simmering for decades. Several executives from this entity made statements to the press that the audit “was a gotcha audit. It’s all about paperwork and there is nothing real here. We’re providing excellent services.” Talk about denial! I believe they will come to regret those statements since the infractions were extremely serious and they will likely have to return millions of dollars to Medicaid. They may call a missing signature “a gotcha,” but Medicaid calls it fraud. Their culture is so broken that they really need a turnaround expert and complete replacement of the management, but they haven’t reached rock bottom yet, apparently.
In recovery
The correct response to a failing audit is to contemplate the report carefully and develop a proactive remediation plan immediately. Humility may save your job, but you can’t step off onto the recovery road until you admit you have a problem.
Ask for help. Operations that have been dysfunctional for years can’t be turned around overnight. Organizational culture may inhibit a turnaround and objective, external assistance may be required.
Listen to what your colleagues and objective auditors had to say and take it seriously. Don’t go swimmin’ in denial.
If you would like to discuss an audit for your organization’s IT operation, e-mail me at jmorgan@e-volvellc.com.
This article was first published on CIO.COM at: http://www.cio.com/article/3082124/leadership-management/surviving-a-management-audit.html
© Copyright Jeffrey Morgan, 2016
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Information Security Basics for Executives – The First Steps
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Is your information secure?
Are your organization’s information assets absolutely secure? Do your staff and contractors assure you that everything is safe? How do they know? And how about all those paper files? Is confidential data appropriately labeled and stored in a secure, locked and monitored facility? How do you know? How would anyone even know if there was a breach?
The role of IT Staff
I have sat in meetings with IT Staff who have sworn up and down that the network is secure without any facts or data to support that assertion. What are your IT staff and contractors doing every day to ensure that your information is secure? And what about staff that maintain other types of physical instruments and records?
The role of vendors
I have also sat in many meetings with security vendors who have made outrageous and patently false statements, like “our product is HIPAA compliant.” (There is no such thing. The HIPAA Security Rule is a federal regulation that describes the framework for developing a security policy for certain types of information and organizations. HIPAA is purposely technology and vendor-neutral). Every security vendor wants you to believe that they are selling a magical product that will keep your organization secure from all the evils that result from being connected to the entire world through the Internet.
There are no magic products
The truth of the matter is that there are no products or services that will inherently ensure and maintain the confidentiality, integrity and availability (CIA) of your information. Information Security is about process, policy, procedure, and training rather than about installing products. A successful security program comes as a result of looking closely at both the macro view and the micro details and taking appropriate, thoughtful actions using a cycle of continuous improvement. Security products might be a part of your overall security strategy, but without sensible policies. procedures, and training the products themselves are unlikely to produce the desired, advertised result.
Do you have a Comprehensive Information Security Policy?
If you are larger than a Mom and Pop operation, you should have a Comprehensive Information Security Policy. If you are running a municipality or corporation with dozens or hundreds of employees, the lack of such a policy probably constitutes organizational malpractice or malfeasance at some level. Moreover, your policy shouldn’t be just a dusty book on the shelf – all your employees should have had training on and understand the policy.
You can wait for a catastrophic security event to wake your organization up, or you can take action now to prevent an embarrassing and costly revelation. For instance, if your organization is required to comply with HIPAA, the wake up call could come in the form of a multi-million dollar fine from HHS or civil litigation. Or you might end up paying ransom to buy back your data from data pirates. These risks are real and well documented.
How do I get started with a Security Policy?
There are many options for developing a comprehensive information security policy. You can purchase kits, buy books, hire consultants, etc. You can do it yourself, or contract it out, but the process will be largely the same either way. I will give you a 40,000 foot view and you can decide how to proceed. Other than time, the initial costs should not be high, but securing your information infrastructure will definitely have some impact on your budget, albeit less than the eventual cost of not addressing security. Even if this is a DIY project, outsourcing some aspects is probably appropriate unless you have staff members who have been extensively trained in information security domains and disciplines.
Make sure the right people are at the table!
This is NOT an Information Technology project. It is a critical enterprise business, policy and security project, so you want to make sure you have the appropriate stakeholders at the table. Establish a multi-disciplinary committee to participate in the process. Managers and Department Heads from different departments may provide illuminating perspectives and the group must also include rank and file members of your staff who actually do the work (AKA the minions). Staff members with security and military backgrounds may have much to contribute. People who may have had experience in highly regulated industries, such as Pharmaceutical, Insurance, Medical, Public and Mental Health, and Law Enforcement may also have much to contribute to the process. HR and Legal must be at the table. I am certain that your organization has untapped, expert resources, so find them and use them.
Inventory your Assets
Once your Information Security Committee is assembled, its time to get to work. The first step is going to be a Risk Assessment. Since you have already established your Information Security committee, begin the Risk Assessment process by cataloging and categorizing all your information resources. Information in this catalog may include paper files, network and computer files including backups, archival and historical records, microfilm, tax records, specifications, etc. There are payroll records, health insurance records, possibly protected medical information, HR information, meeting records, AR and AP records. All of these records may contain information protected by local, state or federal statute. There may be proprietary information related to manufacturing or other information such as videos, films, sound recordings that you may want or need to protect in some way. Use an interrogative process to identify, catalog, and categorize all this information. The output of this process should be a detailed document that clearly identifies all of these assets.
It may be appropriate to contract a qualified consultant for the Risk Assessment process. Why? Regardless of how intelligent and qualified the members of your staff are, they are probably immersed in your organizational culture. They may have biases and make assumptions because “we have always done it this way.” Outsiders may be able to see past the assumptions and biases that your staff members can’t
Once you have completed this process, you will almost certainly have found information that you didn’t even know you had. If you found sensitive information without any plan for protecting it, you might have trouble sleeping until your committee comes up with a plan.
Once you know what types of information for which you are responsible, ask yourself and the Subject Matter Experts on your committee what statutes apply. There are at least a handful of regulations that always apply, and there may be dozens of regulations dealing with information-specific data you have to consider. You probably also found information not protected by statute that needs to be addressed. Do your current policies cover all the information in your catalog? In a subsequent article, I will continue with the next steps for securing your information.
Thinking of your staff will not change overnight.
If you have a large catalog of unprotected, sensitive information, changing the thinking of your staff toward privacy and security may take a while – months or years. Also, this is a perfect time to do a Business Process Review of your information collection operations. Maybe your forms are decades old and no longer reflect current practices. For instance, do you really need to collect social security numbers from the public? If you are collecting this information, are you handing a Privacy Policy when you ask for information? Are the people providing information truly giving informed consent?
If you want to discuss Information Security in your organization, send me an e-mail at jmorgan@e-volvellc.com.
Copyright © Jeffrey Morgan 2015
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