Whistleblowers, Incident Reporting and Incident Management…Is your Health Care Organization Ready?
Posted In Incident Reporting, Legal, Regulatory Compliance, Risk Management on August 31st, 2010 Tags: dodd-frank wall street reform, Health Care, Incident Reporting, whistleblower
A previous Lessons Learned Blog mentioned the Dodd-Frank Wall Street Reform and Consumer Protection Act and a special bounty program within the Act for whistleblowers. Did you see it?
An attorney at the Healthcare Financial Management Association’s Annual National Institute legal update says healthcare providers may be heading into a storm of whistleblower suits that could cause serious problems for the unprepared.
The attorney predicts the new Patient Protection and Affordable Care Act could lead to an explosion of whistleblower lawsuits because the new law does not require the plaintiff to have direct knowledge of alleged fraud to file a suit.
So if you are involved with healthcare industry…are you ready?
Healthcare organizations to make sure they are ready for whistleblower related challenges:
- Do employees have access to trusted tools to report suspicious actions?
- Do third-parties/business associates have access to trusted tools to report suspicious actions?
- Do patients have access to trusted tools to report suspicious actions?
- Are assessment teams defined and trained on how to respond to incident reports?
- Do assessment teams have tools to access, track and document their actions and decisions?
- Do organizations have a customized compliance program implemented and documented?
The short list above represents some but not all of the challenges healthcare leadership should be targeting as soon as possible to ensure legal defensibility for your leadership and your organization…are you ready?
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Veterans Affairs: Why Not Implement Data Breach Lessons Learned?
Posted In Human Resources, Incident Reporting, Information Privacy, Information Security, Legal, Regulatory Compliance, Risk Management on August 26th, 2010 Tags: Awareness Training, Data Breach, Information Security, lost laptops, Veterans Affairs
Dissemination vs. Implementation
The Veterans Affairs Department recently announced they will be publishing monthly online accounts of data breaches and lost BlackBerrys and laptops in order to improve accountability and increase transparency.
What was shocking to me was that from April through July of this year, the VA has lost 72 BlackBerrys and 34 laptops. Patient information has been sent to the wrong address or mailed incorrectly 441 times. There were 9,746 breach incidents involving notifications to patients and 2,501 incidents in which credit reporting was required.
Almost 10,000 breach incidents in 3 months! What is wrong with this picture? Instead of just disseminating data breaches after the fact, what if the VA actually explained and implemented lessons learned and took proactive steps towards prevention?
I think the VA needs to ask a couple of questions:
1) Why are so many handheld devices and laptops being lost? Are there ways we can educate our employees on best practices for protecting devices? Are there consequences?
2) With so many devices and laptops lost each month, how do we ensure these devices are protected with encryption? Are employees taking home sensitive information that should not be placed on personal devices? Do employees know what information is sensitive?
3) What should be done to improve efficiencies in the mail room and prevent mailing errors with patient information? How do we know there were only 441 errors; were these just the mistakes that were caught?
4) How can we implement ongoing awareness and educate our employees (and third-parties) on protecting sensitive information?
Breach notifications are expensive. Credit reporting is expensive. Replacing BlackBerrys and laptops is expensive. Correcting errors and re-mailing information is expensive.
Prevention is a lot less expensive for the Veterans Affairs and a lot less expensive for us tax payers too… is anyone interested in implementing lessons learned?
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SEC Creates Bounty for Whistleblowers?
Posted In Incident Reporting, Legal, Regulatory Compliance, Risk Management on August 24th, 2010
According to a recent Washington Post headline, law firms are gearing up for new whistleblower reward program.
The new program was included in the Dodd-Frank Wall Street Reform and Consumer Protection Act signed by President Obama in July 2009 has created a bounty program that rewards individuals who provide “original information” to the SEC. The SEC can then award the individual with up to 30 percent of any successful enforcement action that exceeds $1 million.
There is no doubt that federal agencies are publicly ramping up to police illegal corporate activity… future Lessons Learned Blogs will discuss healthcare, education and others.
Here are some questions your organization’s leaders should be asking:
- Are your existing compliance programs working as you want them to?
- Are your policies and procedures updated, communicated, acknowledged and documented?
- Are employees and third-parties aware of how to report incidents?
- Are you encouraging employees to report internally before going to the government?
- Are you confident in how employee complaints will be handled?
- Do you have the right tools in place to connect the dots?
If law firms are gearing up…it is probably a good idea to pay attention to headlines and this Lessons Learned Blog too.
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Whistleblowers, Incident Reporting, Incident Management…Are You Ready?
Posted In Incident Reporting, Information Security, Legal, Regulatory Compliance, Risk Management, Workplace Violence on August 19th, 2010 Tags: bank fraud, CYA, financial reform, Incident Reporting, online safety, SEC, whistleblower, Workplace Violence
Have you been paying attention to recent headlines?
“New whistleblower reward program has law firms gearing up”
“Attorney tells audience to brace for a storm of whistleblower lawsuits”
“Financial reforms up retaliation risk”
“Preventing violence in health care setting”
“Banks seek customers’ help to stop online thieves”
Lessons learned and headlines are mounting and organizational leaders from nearly every sector should be paying close attention if they want to prevent their name and their organization’s name from being featured in unwanted headlines and lawsuits.
In a few of our next blog posts, I will be sharing lessons learned on how incident reporting, incident management, threat assessment teams, prevention, intervention, documentation and CYA will play a critical role for the foreseeable future….are you ready?
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Rite Aid – HIPAA Violation – Lessons Learned Not Implemented
Posted In Incident Reporting, Information Privacy, Information Security, Legal, Regulatory Compliance, Risk Management on August 12th, 2010 Tags: CVS, FTC, HIPAA, HITECH, Rite Aid, Security Awareness
Did everyone see this ultimate lesson regarding lessons learned but not implemented?
Remember back in February 2009 when the Federal Trade Commission (FTC) issued a settlement against CVS Caremark? According to the settlement, CVS Caremark violated the HIPAA privacy rule and the FTC Act when some of its stores improperly disposed of prescription information and pill bottles that had patient information on them. The settlement resulted in a $2.25 million fine and they must ensure their security program meets the standards of the settlement [including ongoing audits] for the next 20 years.
Now roll the clock ahead to July 2010 and another pharmacy chain – Rite Aid Corp. – has agreed to pay a $1 million fine because they violated the HIPAA privacy rule and the FTC Act when some if its stores improperly disposed of prescription information in dumpsters.
The HHS settlement against Rite Aid requires their pharmacies to:
- Establish policies and procedures for disposing protected health information and sanctioning workers who do not follow them;
- Create a training program for disposing of patient information;
- Conduct internal monitoring;
- Obtain an independent assessment of its compliance for three years.
The FTC settlement against Rite Aid requires the company to:
- Establish a comprehensive information security program designed to protect the security, confidentiality and integrity of the personal information it collects from consumers and employees;
- Obtain, every two years for the next 20 years, an audit from a qualified independent third-party professional to ensure that its security program meets the standards of the settlement.
For lessons learned to become lessons implemented, organizations must ensure that their program [security, privacy, compliance, risk management, etc.] is clearly defined, communicated, acknowledged by all appropriate personnel, documented, updated and maintained on an ongoing basis.
Unfortunately most programs are just pushed out on portals, intranets and shared drives or blasted out in binders, e-mails and memorandums.
Albert Einstein said it best:
“Insanity is doing the same thing over and over again and expecting different results.”
Are you and your organization doing the same thing over and over again and expecting different results?
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Blueprints Do Not Build Skyscrapers
Posted In Business Continuity, Human Resources, Regulatory Compliance, Risk Management, School Safety, Workplace Violence on August 11th, 2010 Tags: Anti-Bullying, policy and procedure management, preparedness program
In my previous blog I suggested that building a successful preparedness campaign is like building a skyscraper…and in some cases it seems like building a skyscraper may actually be easier than building a successful campus-wide or organization-wide preparedness effort.
I mentioned that building a skyscraper and building a campus-wide or organization-wide preparedness effort have a lot in common and one of those common items is blueprints.
Blueprints can be a technical drawing, a mechanical drawing, an architectural plan, a model, a prototype, a detailed plan of action and etc. Blueprints can also include programs, policies, procedures, processes, guidelines, checklists and etc.
But blueprints are not skyscrapers.
Lessons learned continue to reveal that many organizations are extremely vulnerable because they purchase blueprints (emergency plans, anti-bullying programs, checklists, and etc.) and schedule a meeting or training session and post their blueprints on an intranet/portal and think they have built their “skyscraper”.
More and more organizations are learning the hard way that having blueprints is not enough.
Even though financial organizations have policies, government entities have plans, schools have procedures, healthcare organizations have checklists and organizations have been offering general training on an annual basis for years… tragedies, failures, bullying and lawsuits continue to escalate.
Do your organization’s leaders understand that building organization-wide preparedness efforts or a culture of safety or an anti-bullying environment requires more than disseminating blueprints?
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Building A Preparedness Program…like Building a Skyscraper?
Posted In Business Continuity, Emergency Management, Human Resources, Regulatory Compliance, School Safety, Workplace Violence on August 9th, 2010 Tags: campus preparedness conference, Compliance, Ethics, safety, Security
I attended the Virginia Governor’s Campus Preparedness conference last week and had an interesting discussion with one of the attendees. We were talking about how building preparedness across an organization or an entire campus is becoming more complex and more difficult due to escalating challenges, regulations, obligations, liabilities and much more.
As our discussion continued, we started talking about how important tools can be when building campus-wide preparedness programs. In reference to whether tools can make a difference, I offered the following analogy:
Could a skyscraper be built using a hammer, a saw and some nails?
The attendee responded quickly, yes the skyscraper could be built but she wouldn’t go inside it!
Next we discussed how building a skyscraper and building a campus-wide or organization-wide preparedness program have a lot in common:
- Both require blueprints
- Both are complex and require planning
- Both require specialized tools to build
- Both have a lot of parts or “dots to connect”
- Both require specialized tools to maintain
- People will not trust poorly built skyscrapers or preparedness programs
Are you building your __________ program [preparedness, compliance, business continuity, safety, security, ethics, etc.] with old outdated tools such as binders, intranets, shared drives and general training?
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CFOs Have Responsibility To Break Down Risk Management Silos
Posted In Business Continuity, Information Security, Regulatory Compliance, Risk Management on July 12th, 2010 Tags: CFOs, Cybercrime, Cybersecurity, DHS
Last week financial executives received some valuable advice on ways to significantly reduce costs associated with an expensive non-budgeted item – cybercrime.
Greg Schaffer heads up DHS’s Office of Cybersecurity and Communications and his comments on cybercrime included:
“Cybercrime is not a problem that is growing, or coming, or off in the future. This is a problem right now.”
Mr. Schaffer also cited some statistics from reports and surveys:
- A single cyber breach costs companies an average of $6.75 million
- 27 countries have claimed to have experienced financial losses related to cybercrime
- In 2009, 30 million examples of new malicious software were released
Mr. Schaffer shared that there is a “disconnect” between corporate risk managers and information technology professionals. Mr. Schaffer also pointed out that most companies have kept risk management related to cybercrime in “a silo” within the IT department, rather than treating cybercrime as a risk the entire organization must address.
Mr. Schaffer had this advice too… because CFOs play an important role in enterprise risk management; CFOs have a responsibility to break down “silos” within an organization.
Do you have “silos” in your organization?
Of course you do! CFOs (along with CEOs, COOs, CROs, etc.) must become more proactive and prevention focused. CFOs must find better ways to break down silos and connect the dots before a cybercrime incident creates a huge hit on their bottom line.
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Prevention is Key to Escalating Costs for Banks and Customers…
Posted In Information Privacy, Information Security, Legal, Regulatory Compliance on June 4th, 2010 Tags: ACH Fraud, Awareness Training, Financial Security, Hillary Machinery, PlainsCapital, Security Awareness
Did you see this lesson learned involving a bank and their customer?
We all know that famous quote from Benjamin Franklin – “An ounce of prevention is worth a pound of cure”….but knowing it and implementing it are two entirely different efforts.
I hope financial institution and business leaders are paying attention and realizing that COSTS related to implementing prevention are a whole lot less expensive than COSTS related to reaction and damage control?
What if PlainsCapital and Hillary Machinery had invested more in individual level awareness and tools that could have prevented this string of events?
- Cyber criminals transferred more than $800,000 out of Hillary Machinery’s bank account via ACH and wire transfers.
- Hillary Machinery and PlainsCapital bank were able to recover about $600,000 of the funds that were sent to eastern Europe.
- Hillary Machinery asked PlainsCapital to repay the remaining $229,000.
- PlainsCapital responded by filing a lawsuit against Hillary Machinery asking the judge to declare the bank’s security measures “reasonable”.
- Hillary Machinery filed a countersuit that charged that the bank did not catch the irregular wire transfers and ACH transactions made to Europe over a weekend.
- Hillary Machinery moved their business accounts to a different bank.
- PlainsCapital settled its lawsuit against Hillary Machinery.
Hillary Machinery is saying nothing and PlainsCapital is saying nothing.
Bottom line…the COSTS to both organizations were significant. When you add up the COSTS for legal fees and reputation management related to negative headlines along with each organization’s time, resources, marketing, damage control and lost business…you see that prevention would have been much less expensive.
Is your financial institution prepared to prevent this type of incident? Are customers prepared to do their part in preventing this type of incident? Are business leaders prepared to prevent sophisticated cyber attacks and risks?
One last thing…don’t you wonder what the settlement details were?
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What is a “Failure to Implement”?
Posted In Human Resources, Information Privacy, Information Security, Legal, Regulatory Compliance, Risk Management on April 19th, 2010 Tags: Assessments, CVS, documentation, FTC, HIPAA, Implementation, Infotec, legal due diligence, Omaha, Security Awareness
Recently, Awareity’s CEO, Rick Shaw, was asked to present at the Infotec conference in Omaha. During his presentation, “The Truths (and Myths) About Assessments, Planning and Implementing”, Rick discussed the three-legged stool each organization is sitting on, and the importance of all three legs (Assessments, Planning/Developing and Implementing).
Most organizations understand the importance of assessments and planning, but where many fail to deliver is in the implementation phase. As we have seen with numerous headlines and lessons learned, a failure to implement can lead to expensive fines, lawsuits, breaches and losses. Rick used a case study for CVS Caremark. Due to employees carelessly tossing old pill bottles into a store’s dumpster, CVS now has the FTC coming to audit their information security program for the next 20 years and was forced to pay a HIPAA violation fine of $2.25 M.
The FTC Complaint Docket No. C-4259 read:
“Among other things, respondent failed to: 1) implement policies and procedures to dispose securely of such information, including, but not limited to, policies and procedures to render the information unreadable in the course of disposal.”
During the presentation, one woman raised her hand and asked, “What do you mean by “implement”? How do you “implement” your policies and procedures once they are created?”
I thought this was a great question and one that should be expanded upon.
An organization can have the best security policy (or plan, program, etc.) in the world, but if the policy is not implemented down to the individual-level, how will individuals be able to help the organization achieve better results?
If your organization is just blasting your security policies out to your people in e-mails and memos…how do you know if anyone received the email or is reading the policies and understands them? Or perhaps you are sending out updated pages for the employee handbooks or manuals…how can you ensure your employees are actually reading these policies? Are the binders just sitting on a shelf untouched?
Implementing policies, procedures, plans and processes means organizations have documentation and proof that individuals have read, understood and acknowledged their roles and responsibilities. Regulations require proof of implementation. Legal due diligence requires proof of implementation. Lessons Learned continue to prove that organizations that lack implementation will continue to experience expensive and embarrassing results.
Organizations must ensure all appropriate individuals (employees, third-parties, etc.) are receiving updated policies and guidelines, reading the policies, understanding the policies, and acknowledging their individual roles and responsibilities. Providing employees with a once-a-year general training session is not good enough as we know risks, threats, best practices, etc. are constantly changing. The bad guys are not taking 364 days off, is your organization?
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