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Policies, procedures, and plans—defining the language of your organization

12.06.17

Good Practices Are Not Enough

When it comes to IT security, more than one CEO running a small organization has told me they have really good people taking care of “all that.” These CEOs choose to believe their people perform good practices. That may be true, but who defines good practices and how they administer them? And when? If “security is everyone’s job,” then nobody is responsible for getting specific things done. Good practices require consistency, and consistency requires structure.

From an audit perspective, a control not written down does not exist. Why? Because it can’t be tested, measured, or validated. An IT Auditor can’t assess controls if they were never defined. Verbal instruction carries by far the most risk. “I told him to do that,” doesn’t pass the smell test in court.

Why Does it Matter?

Because it’s not IT’s job to write policies. Their job is to implement IT decisions made by management. They’re not at the right level to make decisions that impact the entire organization. Why should small organizations concern themselves with developing policies and procedures? Here are two very good reasons:

1. Regulatory Requirements
2. Lawsuits

No matter how small your organization, if you have a corporate network (even cloud-based) and you store credit card transactions, personal health information, client financial information or valuable intellectual property, being aware of state and federal regulatory requirements for protecting that information is vital. It is the responsibility of management to research and develop a management framework for addressing risk.

Lawsuits happen when information is stolen and/or employees are terminated for inappropriate activities. If you have no policies that mandate what is and isn’t acceptable, and what the penalties are for violations, your terminated employee has grounds for a wrongful termination lawsuit: policy should not be written by the IT Department.

If confidential data you are responsible for is stolen and clients sue you, standing up in court and saying “We don’t have any written policies or procedures,” is a sure way to have both significant financial losses and a negative impact on your reputation. For a small organization, that could mean going out of business.

Even if data is stolen from a third-party vendor who stores your data, your organization owns the data and is responsible for ensuring the data is secure with the vendor and meets organizational requirements. Do you have a vendor management policy? If you work with vendors, you need one.

Consider, too, that every organization expects to grow its business. The longer management doesn’t pay attention to policies and procedures, the more difficult it becomes to develop and implement them.

Medium and Large Organizations Need to Pay Attention, too

A policy document provides a framework for defining activities and decision-making by everyone in the organization. A policy contains standards for the organization, and outlines penalties for non-performance. The organization’s management team or board of directors must drive their creation.
Policies also maintain accountability in the eyes of internal and external stakeholders. Even the smallest organization wants their customers and employees to have confidence the organization is protecting important information. By defining the necessary controls for running business operations that address risk and compliance requirements (and reviewing them annually), your management team demonstrates a commitment to good practices.

Procedures are the “How”

Procedures don’t belong in a policy. Departments need to be able to design their own procedures to meet policy requirements and definitions. HR will have procedures for employee privacy and financial information, finance must manage credit card, student, banking or client financial documentation, and IT will need to develop specific technical procedures to document their compliance with policy.

If all those procedures are in a policy, it makes for unwieldy policy documents that management must review and approve. Departments need to change and update their procedures quickly in order to remain effective. For example, a policy may mandate the minimum number of characters in a password, but IT needs to develop the procedures to implement that requirement on many platforms and devices.

What is a “Plan” Used For?

Consider that organizations commonly have a Business Continuity Plan as well as an Incident Response Plan. How is a “plan” different from a policy or procedure?

A plan (for example, an Information Security Plan, or Privacy Plan, etc.) is a collection of related procedures with a specific focus. I have seen these collections called “programs,” but most organizations use “plan” (plus, the Federal government uses that term). The term “program” implies a beginning and an end, as well as tending to be a little too generic (think “School Lunch Program”).

Three Ways Not to Develop Policies, Procedures and Plans

1.

Getting templates from the Internet. Doing a Google search delivers an overwhelming number of approaches, examples and material. Policy templates found online may not be applicable to your organization’s purpose, or require so much editing they defeat the template’s purpose. 

2.

Alternatively, going to organizational peers can endlessly replicate one poorly developed approach to documentation.

3.

Writing policies and procedures totally focused on meeting one regulatory requirement frequently necessitates a total re-write as soon as the next regulation comes along.

Consider the Unique Aspects of Your Organization

What electronic information does your organization consider valuable? During an assessment with a state university, we discovered that the farm research the agriculture school was performing was extremely valuable. While we started out with questions about student health and financial information, the university realized the research data was equally critical. The information might not have federal or state regulations attached to it, but if it is valuable to your organization, you need to protect it. By not taking a one-size fits all approach to our assessment, we were able to meet their specific needs.

Multiple Departments or Locations? Standardize.

Whether your organization is a university, non-profit organization, government agency, medical center or business, you frequently have sub-entities. Each sub-entity or location may have different terms for different functions. For example, at a recent engagement for another university, Information Security “Programs,” “Plans” and “Policies” meant different things on different campuses. This caused confusion on the part of all stakeholders. It also showed a lack of cohesion in the approach to security of the university as a whole. Standardizing language is one of the best ways to have everyone in the organization on the same page, even if the documents are unique to a location, agency or site. This makes planning, implementation, and system upgrade projects run more effectively.

Demonstrate Competence

No matter what terms your organization chooses, using consistent terms is a good way to demonstrate a thoughtful approach. Everyone needs to be talking the same language. Having documents that specify management decisions provides assurance to internal and external stakeholders. Good policies, procedures and plans can mean the difference between a manageable crisis and a business failure.

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Topics: IT management

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Read this if you are a police executive, city/county administrator, or elected government official responsible for a law enforcement agency. 

Who you gonna call? 

Law enforcement agencies provide essential services to our communities vital to maintaining order and public safety. These critical organizations always answer the call, and they are prepared for every type of disaster imaginable: floods, hurricanes, tornadoes, blizzards, train derailments, and even... a pandemic?

Police agencies plan, prepare, and train for disasters, and are particularly adept and agile in their response to them. As an industry, law enforcement agencies are also very good at helping one another in times of need. When there is a major disaster in your community, your agency can always count on neighboring departments sending you some much needed resources―that is, unless everyone has the same problem. Then what do you do?

Although law enforcement agencies are very capable, their strength is in sprinting, not running marathons. Even the best and most-qualified police agencies struggle with the strain of long-lasting disasters, particularly when there are no other resources to help. That is when having the right patrol-schedule design can be critical. If your patrol schedule is inefficient in the first place, managing a lengthy disaster or critical event will magnify those inefficiencies, exhausting your personnel and fiscal resources at the same time.

Flaws in patrol schedule design = reduced efficiency

Flaws in the patrol schedule design often contribute to reduced efficiency and suboptimal performance, and design issues may work against your ability to maintain operational staffing during critical times of need. So, how do you know if your patrol schedule is serving you well? 

To help agencies evaluate their patrol schedules, BerryDunn has developed at free tool. Click here to measure your patrol schedule against key design components and considerations. If your agency scores low in this self-assessment, it may be time to consider making some adjustments. 

The path to resolving inefficiencies in your patrol work schedule and optimizing the effective deployment of patrol personnel requires thoughtful consideration of several overarching goals:

  • Reducing or eliminating predictable overtime
  • Eliminating peaks and valleys in staffing due to scheduled leave
  • Ensuring appropriate staffing levels in all patrol zones or beats
  • Providing sufficient staff to manage multiple and priority Calls for Service  in patrol zones or beats
  • Satisfying both operational and staff needs, including helping to ensure a proper work/life balance and equitable workloads for patrol staff

Accomplishing these goals requires an intentional approach, customized to your agency’s characteristics (e.g., staffing levels, geographic factors, crime rates, zone/beat design, contract/labor rules). BerryDunn can help your agency assess the patrol schedule, and if necessary, provide guidance and assistance on implementation of a more effective model. 

If you are interested in a patrol work-schedule assessment or redesign or a patrol staffing study, our dedicated Justice & Public Safety consultants are available to discuss your organization’s needs.

Article
Continuity of patrol operations in a COVID-19 environment

Read this if you are a CIO, CFO, Provost, or President at a higher education institution.

In my conversations with CIO friends over the past weeks, it is obvious that the COVID-19 pandemic has forced a lot of change for institutions. Information technology is the underlying foundation for supporting much of this change, and as such, IT leaders face a variety of new demands now and into the future. Here are important considerations going forward.

Swift impact to IT and rapid response

The COVID-19 pandemic has had a significant impact on higher education. At the onset of this pandemic, institutions found themselves quickly pivoting to work from home (WFH), moving to remote campus operations, remote instruction within a few weeks, and in some cases, a few days. Most CIOs I spoke with indicated that they were prepared, to some extent, thanks to Cloud services and online class offerings already in place—it was mostly a matter of scaling the services across the entire campus and being prepared for returning students and faculty on the heels of an extended spring break.

Services that were not in place required creative and rapid deployment to meet the new demand. For example, one CIO mentioned the capability to have staff accept calls from home. The need for softphones to accommodate student service and helpdesk calls at staff homes required rapid purchase, deployment, and training.

Most institutions have laptop loan programs in place but not scaled to the size needed during this pandemic. Students who choose to attend college on campus are now forced to attend school from home and may not have the technology they need. The need for laptop loans increased significantly. Some institutions purchased and shipped laptops directly to students’ homes. 

CIO insights about people

CIOs shared seeing positive outcomes with their staff. Almost all of the CIOs I spoke with mentioned how the pandemic has spawned creativity and problem solving across their organizations. In some cases, past staffing challenges were put on hold as managers and staff have stepped up and engaged constructively. Some other positive changes shared by CIOs:

  • Communication has improved—a more intentional exchange, a greater sense of urgency, and problem solving have created opportunities for staff to get engaged during video calls.
  • Teams focusing on high priority initiatives and fewer projects have yielded successful results. 
  • People feel a stronger connection with each other because they are uniting behind a common purpose.

Perhaps this has reduced the noise that most staff seem to hear daily about competing priorities and incoming requests that seem to never end.

Key considerations and a framework for IT leaders 

It is too early to fully understand the impact on IT during this phase of the pandemic. However, we are beginning to see budgetary concerns that will impact all institutions in some way. As campuses work to get their budgets settled, cuts could affect most departments—IT included. In light of the increased demand for technology, cuts could be less than anticipated to help ensure critical services and support are uninterrupted. Other future impacts to IT will likely include:

  • Support for a longer term WFH model and hybrid options
  • Opportunities for greater efficiencies and possible collaborative agreements between institutions to reduce costs
  • Increased budgets for online services, licenses, and technologies
  • Need for remote helpdesk support, library services, and staffing
  • Increased training needs for collaborative and instructional software
  • Increased need for change management to help support and engage staff in the new ways of providing services and support
  • Re-evaluation of organizational structure and roles to right-size and refocus positions in a more virtual environment
  • Security and risk management implications with remote workers
    • Accessibility to systems and classes 

IT leaders should examine these potential changes over the next three to nine months using a phased approach. The diagram below describes two phases of impact and areas of focus for consideration. 

Higher Education IT Leadership Phases

As IT leaders continue to support their institutions through these phases, focusing on meeting the needs of faculty, staff, and students will be key in the success of their institutions. Over time, as IT leaders move from surviving to thriving, they will have opportunities to be strategic and create new ways of supporting teaching and learning. While it remains to be seen what the future holds, change is here. 

How prepared are you to support your institution? 

If we can help you navigate through these phases, have perspective to share, or any questions, please contact us. We’re here to help.

Article
COVID-19: Key considerations for IT leaders in Higher Ed

Editor’s note: Please read this if you are a not-for-profit board member, CFO, or any other decision maker within a not-for-profit.

In a time where not-for-profit (NFP) organizations struggle with limited resources and a small back office, it is important not to overlook internal audit procedures. Over the years, internal audit departments have been one of the first to be cut when budgets are tight. However, limited resources make these procedures all the more important in safeguarding the organization’s assets. Taking the time to perform strategic internal audit procedures can identify fraud, promote ethical behavior, help to monitor compliance, and identify inefficiencies. All of these lead to a more sustainable, ethical, and efficient organization. 

Internal audit approaches

The internal audit function can take on many different forms, depending on the size of the organization. There are options between the dedicated internal audit department and doing nothing whatsoever. For example:

  • A hybrid approach, where specific procedures are performed by an internal team, with other procedures outsourced. 
  • An ad hoc approach, where the board or management directs the work of a staff member.

The hybrid approach will allow the organization to hire specialists for more technical tasks, such as an in-depth financial analysis or IT risk assessment. It also recognizes internal staff may be best suited to handle certain internal audit functions within their scope of work or breadth of knowledge. This may add costs but allows you to perform these functions otherwise outside of your capacity without adding significant burden to staff. 

The ad hoc approach allows you to begin the work of internal audit, even on a small scale, without the startup time required in outsourcing the work. This approach utilizes internal staff for all functions directed by the board or management. This leads to the ad-hoc approach being more budget friendly as external consultants don’t need to be hired, though you will have to be wary of over burdening your staff.

With proper objectivity and oversight, you can perform these functions internally. To bring the process to your organization, first find a champion for the project (CFO, controller, compliance officer, etc.) to free up staff time and resources in order to perform these tasks and to see the work through to the end. Other steps to take include:

  1. Get the audit/finance committee on board to help communicate the value of the internal audit and review results of the work
  2. Identify specific times of year when these processes are less intrusive and won’t tax staff 
  3. Get involved in the risk management process to help identify where internal audit can best address the most significant risks at the organization
  4. Leverage others who have had success with these processes to improve process and implementation
  5. Create a timeline and maintain accountability for reporting and follow up of corrective actions

Once you have taken these steps, the next thing to look at (for your internal audit process) is a thoughtful and thorough risk assessment. This is key, as the risk assessment will help guide and focus the internal audit work of the organization in regard to what functions to prioritize. Even a targeted risk assessment can help, and an organization of any size can walk through a few transaction cycles (gift receipts or payroll, for example) and identify a step or two in the process that can be strengthened to prevent fraud, waste, and abuse.  

Here are a few examples of internal audit projects we have helped clients with:

  • Payroll analysis—in-depth process mapping of the payroll cycle to identify areas for improvement
  • Health and education facilities performance audit—analysis of various program policies and procedures to optimize for compliance
  • Agreed upon procedures engagement—contract and invoice/timesheet information review to ensure proper contractor selection and compliant billing and invoicing procedures 

Internal audits for companies of all sizes

Regardless of size, your organization can benefit from internal audit functions. Embracing internal audit will help increase organizational resilience and the ability to adapt to change, whether your organization performs internal audit functions internally, outsources them, or a combination of the two. For more information about how your company can benefit from an internal audit, or if you have questions, contact us

Article
Internal audit potential for not-for-profit organizations

Read this if you are a police executive, city/county administrator, or elected government official, responsible for a law enforcement agency. 

“We need more cops!”  

Do your patrol officers complain about being short-staffed or too busy, or that they are constantly running from call to call? Does your agency struggle with backed-up calls for service (CFS) or lengthy response times? Do patrol staff regularly find themselves responding to another patrol area to handle a CFS because the assigned officer is busy on another call? Are patrol officers denied leave time or training opportunities because of staffing issues? Does the agency routinely use overtime to cover predictable shift vacancies for vacations, holidays, or training? 

If one or more of these concerns sound familiar, you may need additional patrol resources, as staffing levels are often a key factor in personnel deployment challenges. Flaws in the patrol schedule design may also be responsible, as they commonly contribute to reduced efficiency and optimal performance, and design issues may be partially responsible for some of these challenges, regardless of authorized staffing levels.
 
With community expectations at an all-time high, and resource allocations remaining relatively flat, many agencies have growing concerns about managing increasing service volumes while controlling quality and building/maintaining public trust and confidence. Amid these concerns, agencies struggle with designing work schedules that efficiently and optimally deploy available patrol resources, as patrol staff become increasingly frustrated at what they consider a lack of staff.

The path to resolving inefficiencies in your patrol work schedule and optimizing the effective deployment of patrol personnel requires thoughtful consideration of several overarching goals:

  • Reducing or eliminating predictable overtime
  • Eliminating peaks and valleys in staffing due to scheduled leave
  • Ensuring appropriate staffing levels in all patrol zones or beats
  • Providing sufficient staff to manage multiple and priority CFS in patrol zones or beats
  • Satisfying both operational and staff needs, including helping to ensure a proper work/life balance and equitable workloads for patrol staff

Scheduling alternatives

One common design issue that presents an ongoing challenge for agencies is the continued use of traditional, balanced work schedules, which spread officer work hours equally over the year. Balanced schedules rely on over-scheduling and overtime to manage personnel allocation and leave needs and, by design, are very rigid. Balanced work schedules have been used for a very long time, not because they’re most efficient, but because they’re common, familiar, and easily understood―and because patrol staff are comfortable with them (and typically reluctant to change). However, short schedules offer a proven alternative to balanced patrol work schedules, and when presented with the benefits of an alternative work schedule design (e.g., increased access to back-up, ease of receiving time off or training, consistency in staffing, less mandatory overtime), many patrol staff are eager to change.

Short schedules

Short schedules involve a more contemporary design that includes a flexible approach that focuses on a more adaptive process of allocating personnel where and when they are needed. They are significantly more efficient than balanced schedules and, when functioning properly, they can dramatically improve personnel deployments, bring continuity to daily staffing, and reduce overtime, among other operational benefits. Given the current climate, most agencies are unlikely to receive substantial increases in personnel allocations. If that is true of your agency, it may be time to explore the benefits of alternative patrol work schedules.

A tool you can use

Finding scheduling strategies that work in this climate requires an intentional approach, customized to your agency’s characteristics (e.g., staffing levels, geographic factors, crime rates, zone/beat design, contract/labor rules). To help guide you through this process, BerryDunn has developed a free tool for evaluating patrol schedules. Click here to measure your patrol schedule against key design components and considerations.

If you are curious about alternative patrol work schedules, our dedicated justice and public Safety consultants are available to discuss your organization’s needs.

Article
Efficient police patrol work schedules―By design

Read this if you are a state Medicaid Director, State Medicaid Chief Information Officer, State Medicaid Project Manager, State Procurement Officer, or work in a State Medicaid Program Integrity Unit.

The Centers for Medicare & Medicaid Services (CMS) issued a Payment Error Rate Measurement (PERM) Final Rule on July 5, 2017, that made several changes to the PERM requirements. One important change was the updates to the Medicaid Eligibility Quality Control (MEQC) requirement. 

The Final Rule restructures the MEQC program into a pilot program that requires states to conduct eligibility reviews during the two years between PERM cycles. CMS has also introduced the potential for imposing disallowances or reductions in federal funding percentage (FFP) as a result of PERM eligibility error rates that do not meet the national standard. One measure states can use to lessen the chance of this happening is by successfully carrying out the requirements of the MEQC pilot. 

What states should know―important points to keep in mind regarding MEQC reviews:

  • Each state must have a team in place to conduct MEQC reviews. The individuals responsible for the MEQC reviews and associated activities must be separate from the state agencies and personnel responsible for Medicaid and Children’s Health Insurance Program (CHIP) policy and operations, including eligibility determinations.
  • States can apply for federal funding to help cover the costs of the MEQC activities. CMS encourages states to partner with a contractor in conducting the MEQC reviews.
  • The deadline to submit the state planning document to CMS is November 1 following the end of your state’s PERM cycle. If you are a Cycle 2 state, your MEQC planning document is due by November 1, 2019. 
  • If you are a Cycle 1 state, you are (or should be) currently undergoing the MEQC reviews.
  • There are minimum sample size requirements for the MEQC review period: 400 negative cases and 400 active cases (consisting of both Medicaid and CHIP cases) over a period of 12 months.
  • Upon conclusion of all MEQC reviews, states must submit a final findings report along with a corrective action plan that addresses all error findings identified during the MEQC review period.

CMS encourages states to utilize federal funding to carry out and fulfill MEQC requirements. BerryDunn has staff with experience in preparing Advanced Planning Documents (APD) and can assist your state in submitting an APD request to CMS for these MEQC activities. 

Check out the previously released blog, “PERM: Prepared or Not Prepared?” and stay tuned for upcoming blogs about specific PERM topics, including the financial impacts of PERM, and how each review phase will affect your state.   

For questions or to find out more, contact the team

Article
PERM: Does MEQC affect states?

Federal contractors with the Centers for Medicare & Medicaid Services (CMS) have begun performing Payment Error Rate Measurement (PERM) reviews under the Final Rule issued in July 2017—a rule that many states may not realize could negatively impact their Medicaid budgets.

PERM is a complex process—states must focus on several activities over a recurring three-year period of time—and states may not have the resources needed to make PERM requirements a priority. However, with the Final Rule, this PERM eligibility review could have financial implications. 

After freezing the eligibility measurement for four years while undergoing pilot review, CMS has established new requirements for the eligibility review component and made significant changes to the data processing and medical record review components. As part of the Final Rule, CMS may implement reductions in the amount of federal funding provided to a state’s Medicaid and Children’s Health Insurance Program (CHIP) programs based on the error rates identified from the eligibility reviews. 

Since the issuance of the Final Rule in July 2017, Cycle 1 states are the first group of states to undergo a PERM cycle, including reviews of the data processing, medical record, and eligibility components. These states are wrapping up the final review activities, and Cycle 2 states are in the early stages of their PERM reviews.

How can your state prepare?

Whether your state is a Cycle 1, Cycle 2, or Cycle 3 state, there are multiple activities your Medicaid departments should engage in throughout each three-year period of time during and between PERM cycles: 

  • Analyzing prior errors cited or known issues, along with the root cause of the error
  • Identifying remedies to reduce future errors
  • Preparing and submitting required questionnaires and documents to the federal contractors for an upcoming review cycle
  • Assisting federal contractors with current reviews and findings
  • Preparing for and undergoing Medicaid Eligibility Quality Control (MEQC) planning and required reviews
  • Corrective action planning

Is your state ready?

We’ve compiled a few basic questions to gauge your state’s readiness for the PERM review cycle:

  • Do you have measures in place to ensure all eligibility factors under review are identifiable and that all federal and state regulations are being met? The eligibility review contractor (ERC) will reestablish eligibility for all beneficiaries sampled for review. This process involves confirming all verification requirements are in the case file, income requirements are met, placement in an accurate eligibility category has taken place, and the timeframe for processing all determinations meets federal and state regulations. 
  • Do you have up-to-date policy and procedures in place for determining and processing Medicaid or CHIP eligibility of an individual? Ensuring eligibility policies and procedures meet federal requirements is just as important as ensuring the processing of applications, including both system and manual actions, meet the regulations. 
  • Do you have up-to-date policy, procedures, and system requirements in place to ensure accurate processing of all Medicaid/CHIP claims? Reviewers will confirm the accuracy of all claim payments based on state and federal regulations. Errors are often cited due to the claims processing system allowing claims to pay that do not meet regulations.
  • Do you have a dedicated team in place to address all PERM requirements to ensure a successful review cycle? This includes staff to answer questions, address review findings, and respond to requests for additional information. During a review cycle, the federal contractors will cite errors based on their best understanding of policies and/or ability to locate required documentation. Responding to requests for information or reviewing and responding to findings in a timely manner should be a priority to ensure accurate findings. 
  • Have you communicated all PERM requirements and updates to policy changes to all Medicaid/CHIP providers? Providers play two integral roles in the success of a PERM review cycle. Providers must understand all claims submission requirements in order to accurately submit claims. Additionally, the medical record review component relies on providers responding to the request for the medical records on a sampled claim. Failure to respond will result in an error. Therefore, states must maintain communication with providers to stress the importance of responding to these requests.
  • Have you begun planning for the MEQC requirement? Following basic requirements identified by CMS during your state’s MEQC period, your state must submit a case planning document to CMS for approval prior to the MEQC review period. After the MEQC review, your state should be prepared to issue findings reports, including a corrective action plan as it relates to MEQC findings.

Need help piloting your state’s PERM review process?

BerryDunn has subject matter experts experienced in conducting PERM reviews, including a thorough understanding of all three PERM review components—eligibility, data processing, and medical record reviews. 

We would love to work with your state to see that measures are in place that will help ensure the lowest possible improper payment error rate. Stay tuned for upcoming blogs where we will discuss other PERM topics, including MEQC requirements, the financial impacts of PERM, and additional details related to each phase of PERM. For questions or to find out more, please email me
 

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PERM: Prepared or not prepared?

Best practices for financial institution contracts with technology providers

As the financial services sector moves in an increasingly digital direction, you cannot overstate the need for robust and relevant information security programs. Financial institutions place more reliance than ever on third-party technology vendors to support core aspects of their business, and in turn place more reliance on those vendors to meet the industry’s high standards for information security. These include those in the Gramm-Leach-Bliley Act, Sarbanes Oxley 404, and regulations established by the Federal Financial Institutions Examination Council (FFIEC).

On April 2, 2019, the FDIC issued Financial Institution Letter (FIL) 19-2019, which outlines important requirements and considerations for financial institutions regarding their contracts with third-party technology service providers. In particular, FIL-19-2019 urges financial institutions to address how their business continuity and incident response processes integrate with those of their providers, and what that could mean for customers.

Common gaps in technology service provider contracts

As auditors of IT controls, we review lots of contracts between financial institutions and their technology service providers. When it comes to recommending areas for improvement, our top observations include:

  • No right-to-audit clause
    Including a right-to-audit clause encourages transparency and provides greater assurance that vendors are providing services, and charging for them, in accordance with their contract.
  • Unclear and/or inadequate rights and responsibilities around service disruptions
    In the event of a service incident, time and transparency are vital. Contracts that lack clear and comprehensive standards, both for the vendor and financial institution, regarding business continuity and incident response expose institutions to otherwise avoidable risk, including slow or substandard communications.
  • No defined recovery standards
    Explicitly defined recovery standards are essential to ensuring both parties know their role in responding and recovering from a disaster or other technology outage.

FIL-19-2019 also reminds financial institutions that they need to properly inform regulators when they undertake contracts or relationships with technology service providers. The Bank Service Company Act requires financial institutions to inform regulators in writing when receiving third-party services like sorting and posting of checks and deposits, computation and posting of interest, preparation and mailing of statements, and other functions involving data processing, Internet banking, and mobile banking services.

Writing clearer contracts that strengthen your institution

Financial institutions should review their contracts, especially those that are longstanding, and make necessary updates in accordance with FDIC guidelines. As operating environments continue to evolve, older contracts, often renewed automatically, are particularly easy to overlook. You also need to review business continuity and incident response procedures to ensure they address all services provided by third-parties.

Senior management and the Board of Directors hold ultimate responsibility for managing a financial institution’s relationship with its technology service providers. Management should inform board members of any and all services that the institution receives from third-parties to help them better understand your operating environment and information security needs.

Not sure what to look for when reviewing contracts? Some places to start include:

  • Establish your right-to-audit
    All contracts should include a right-to-audit clause, which preserves your ability to access and audit vendor records relating to their performance under contract. Most vendors will provide documentation of due diligence upon request, such as System and Organization Control (SOC) 1 or 2 reports detailing their financial and IT security controls.

    Many right-to-audit clauses also include a provision allowing your institution to conduct its own audit procedures. At a minimum, don’t hesitate to perform occasional walk-throughs of your vendor’s facilities to confirm that your contract’s provisions are being met.
  • Ensure connectivity with outsourced data centers
    If you outsource some or all of your core banking systems to a hosted data center, place added emphasis on your institution’s business continuity plan to ensure connectivity, such as through the use of multiple internet or dedicated telecommunications circuits. Data vendors should, by contract, be prepared to assist with alternative connectivity.
  • Set standards for incident response communications 
    Clear expectations for incident response are crucial  to helping you quickly and confidently manage the impact of a service incident on your customers and information systems. Vendor contracts should include explicit requirements for how and when vendors will communicate in the event of any issue or incident that affects your ability to serve your customers. You should also review and update contracts after each incident to address any areas of dissatisfaction with vendor communications.
  • Ensure regular testing of defined disaster recovery standards
    While vendor contracts don’t need to detail every aspect of a service provider’s recovery standards, they should ensure those standards will meet your institution’s needs. Contracts should guarantee that the vendor periodically tests, reviews, and updates their recovery standards, with input from your financial institution.

    Your data center may also offer regular disaster recovery and failover testing. If they do, your institution should participate in it. If they don’t, work with the vendor to conduct annual testing of your ability to access your hosted resources from an alternate site.

As financial institutions increasingly look to third-party vendors to meet their evolving technology needs, it is critical that management and the board understand which benefits—and related risks—those vendors present. By taking time today to align your vendor contracts with the latest FFIEC, FDIC, and NCUA standards, your institution will be better prepared to manage risk tomorrow.

For more help gaining control over risk and cybersecurity, see our blog on sustainable solutions for educating your Board of Directors and creating a culture of cybersecurity awareness.
 

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Are your vendor contracts putting you at risk?

Who has the time or resources to keep tabs on everything that everyone in an organization does? No one. Therefore, you naturally need to trust (at least on a certain level) the actions and motives of various personnel. At the top of your “trust level” are privileged users—such as system and network administrators and developers—who keep vital systems, applications, and hardware up and running. Yet, according to the 2019 Centrify Privileged Access Management in the Modern Threatscape survey, 74% of data breaches occurred using privileged accounts. The survey also revealed that of the organizations responding:

  • 52% do not use password vaulting—password vaulting can help privileged users keep track of long, complex passwords for multiple accounts in an encrypted storage vault.
  • 65% still share the use of root and other privileged access—when the use of root accounts is required, users should invoke commands to inherent the privileges of the account (SUDO) without actually using the account. This ensures “who” used the account can be tracked.
  • Only 21% have implemented multi-factor authentication—the obvious benefit of multi-factor authentication is to enhance the security of authenticating users, but also in many sectors it is becoming a compliance requirement.
  • Only 47% have implemented complete auditing and monitoring—thorough auditing and monitoring is vital to securing privileged accounts.

So how does one even begin to trust privileged accounts in today’s environment? 

1. Start with an inventory

To best manage and monitor your privileged accounts, start by finding and cataloguing all assets (servers, applications, databases, network devices, etc.) within the organization. This will be beneficial in all areas of information security such as asset management, change control and software inventory tracking. Next, inventory all users of each asset and ensure that privileged user accounts:

  • Require privileges granted be based on roles and responsibilities
  • Require strong and complex passwords (exceeding those of normal users)
  • Have passwords that expire often (30 days recommended)
  • Implement multi-factor authentication
  • Are not shared with others and are not used for normal activity (the user of the privileged account should have a separate account for non-privileged or non-administrative activities)

If the account is only required for a service or application, disable the account’s ability to login from the server console and from across the network

2. Monitor—then monitor some more

The next step is to monitor the use of the identified privileged accounts. Enable event logging on all systems and aggregate to a log monitoring system or a Security Information and Event Management (SIEM) system that alerts in real time when privileged accounts are active. Configure the system to alert you when privileged accounts access sensitive data or alter database structure. Report any changes to device configurations, file structure, code, and executable programs. If these changes do not correlate to an approved change request, treat them as incidents and investigate.  

Consider software that analyzes user behavior and identifies deviations from normal activity. Privileged accounts that are accessing data or systems not part of their normal routine could be the indication of malicious activity or a database attack from a compromised privileged account. 

3. Secure the event logs

Finally, ensure that none of your privileged accounts have access to the logs being used for monitoring, nor have the ability to alter or delete those logs. In addition to real time monitoring and alerting, the log management system should have the ability to produce reports for periodic review by information security staff. The reports should also be archived for forensic purposes in the event of a breach or compromise.

Gain further assistance (and peace of mind) 

BerryDunn understands how privileged accounts should be monitored and audited. We can help your organization assess your current event management process and make recommendations if improvements are needed. Contact our team.

Article
Trusting privileged accounts in the age of data breaches

We humans have a complex attitude toward change. In one sense, we like finding it. For instance: “Now I can buy something from the vending machine!” In reality, we try to avoid change as much as possible. Why? Because it’s frightening. Consider this quote from Mary Shelley’s Frankenstein: “Nothing is so painful to the human mind as a great and sudden change.”

The key word in that quote is “sudden.” Because the more we prepare for change, the less painful it becomes. One crucial way to prepare for change is to assess how ready we are for something new.

Which brings us to you. The fact you are reading a blog post with the words “Readiness for Enterprise Systems” in its title suggests that you have considered, or are considering, changing your institution’s Enterprise Resource Planning (ERP) system or other enterprise software, such as LMS, SIS, CRM, etc. This change is no minor adjustment.

Enterprise systems are complex, impacting institutional activities at many levels, from managing student records, finances, and human resources, to enabling student enrollment and registration. Is your institution prepared for transformation across the organization? To find out, assess your institution’s readiness for change. To help illustrate what an assessment might entail, I’ll outline BerryDunn’s method.

Step #1: Understanding Key Indicators for Readiness
When assisting a client to determine readiness, BerryDunn begins engaging stakeholders from across the institution (e.g., staff, faculty, and students) to understand the current environment. This allows us to address seven key indicators for change readiness:

  1. Stakeholder Buy-In. The key to success in changing an ERP platform is for users to understand the value that the change will bring. “Do stakeholders know how the new system will benefit them? Or, from their perspective, ‘What’s in it for me (aka, WIIFM)?’”
  2. Executive Sponsorship. In order to obtain stakeholder buy-in, leaders have to communicate effectively with various parties about change. They will be required to display strong and consistent leadership when stakeholders are faced with challenges with vendors, timing, scope creep, or other issues. “Are leaders prepared to lead the charge? Are they committed to change?”
     
  3. Vendor Ability. Each institution has specific operational needs and programmatic objectives. ERP vendors will highlight their strengths and may de-emphasize weaknesses that may exist in their products. “Are vendors actually able to meet the institution’s functional needs and align their software with strategic objectives?”
     
  4. Business Process Redesign. As mentioned above, it can be a struggle to align operational needs and programmatic objectives with vendor software. It’s even harder to achieve this while ensuring that, in implementing a new ERP system, an institution won’t lose valuable functionality that had been provided by the previous ERP. “Does the client fully understand the impact of a new ERP system on their processes?”
     
  5. Project Management. Proactive project management is critical when changing an ERP system. Project managers need to engage institutional stakeholders, project sponsors, and vendors to keep them apprised of progress. “Are project managers empowered to maintain strong communication with all stakeholders?”
     
  6. Data Governance. Another key indicator of ERP readiness is how well-defined data management is before implementation. ERP replacement projects are jeopardized when institutions don’t understand their data assets, or don’t know what level of data migration is necessary. “Is the institution prepared for data migration?”
     
  7. Software Change Management. As ERP vendors move their products to the cloud, the software they sell will become less customizable, but more configurable. In other words, customers won’t necessarily be able to modify the base software code, but they will have more options in regards to defined fields, workflow, and user interface. Although this sounds limiting, it is actually an opportunity to streamline operations, add discipline to software update timelines, and require organizations to consider how to best complete their administrative functions. It is critical that an institution adapt its software change management practices to meet this reality. “Do the institution’s software change management practices reflect how software is delivered by vendors today?”

Step #2: Establish Agreed-Upon Metrics
Based on our analysis from Step #1, we then score these indicators of readiness based on a maturity scale from 0 – 5, using the following parameters:

0  Non-existent
1  Aware, but not ready to change
2  Aware and open to change, but lack understanding of path forward
3  Accept that change is needed, but clear action plan is not in place
4  Accept that change is imminent and is being planned for
5  Readiness for change has broad understanding, is accepted, and is being executed 

Step #3: Score the Readiness of Your Organization
When you work with a consulting firm to assess your institution’s readiness for change, you should expect tangible takeaways that will inform stakeholders and provide a baseline metric. For example, we prepare a brief report that outlines a score for each of the seven maturity indicators of ERP readiness and provides supporting information for the basis of each score.

Here is an example of a Software Change Management section from a hypothetical ERP Readiness Report:

READINESS INDICATORS

BASIS FOR SCORE

SCORE (0 – 5)

Software Change Management

The University does have an effective software change management methodology, and a standard process for prioritizing requests to its current ERP system. This model may change significantly if a cloud system is chosen, and will require a new approach to configuration and asset management.

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Finally, based on the weighted aggregate score of the report, BerryDunn determines the institution’s readiness for change, and provides recommendations on how to remediate low scores, and sustain higher scores.

Now for the good news. By setting a baseline early in your readiness planning, the scoring can be revisited over time to measure progress and provide project leadership with a simple, but effective, approach to tracking change management within the organization.

Next Steps
As you can see, implementing a new ERP doesn’t have to be a monstrous experience. You simply need to determine your ERP readiness, and follow a common-sense plan for change management. If you’d like to talk more about this process, send me an email: dhoule@berrydunn.com. I look forward to learning about the great changes your institution has planned.

Article
Assessing organizational readiness for enterprise systems