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  • Developing an Information Technology Risk Management ProgramTraining for DHHS Information Security Officials and Backup Security Officials
  • What this training covers . . What Risk Management means What NIST says you should do What ISO 17799 says you should do What COBIT says you should do What Microsoft says you should do What HIPAA says you should do What NC ITS says you should do What DHHS says you should do What you should do and when to do it
  • Risk“Take calculated risks. That is quite different from being rash.” General George S. Patton“Only those who risk going too far can possibly find out how far they can go” T.S. Elliot“Of course you have to go out on a limb sometimes; that’s where the fruit is” Unknown
  • Information Security the protection of data against unauthorizedaccess or modification
  • What is “Risk”? Risk is the net mission impact considering both the likelihood that a particular threat-source will exercise (accidentally trigger or intentionally exploit) a particular information system vulnerability, and the resulting impact on the organization if this should occur (NIST) Risk is the probability of a vulnerability being exploited in the current environment, leading to a degree of loss of confidentiality, integrity, or availability, of an asset. (Microsoft)
  • What is Risk Management? The total process of identifying, controlling, and minimizing information system related risks to a level commensurate with the value of the assets protected The goal of a risk management program is to protect the organization and its ability to perform its mission from IT-related risk
  • Risk Management is theKeystone of Information Security
  • Golden and Silver Rules of RM All risk is owned!Risk that is not assigned is owned by theorganization’s Director
  • Why are we doing this? Why do we do risk management? Why does a car have brakes?An organization that can take advantage ofopportunities (and the inherent risks) willoutlast an organization which cannot
  • Reactive Risk Management1) Protect human life and people’s safety2) Contain the damage3) Assess the damage4) Determine the cause of the damage5) Repair the damage6) Review response, and update policies
  • Proactive Risk Management Owners wish to to reduce minimize impose Controls that may be value reduced by that may possess Vulnerabilities may be aware ofThreat Sources that leading to exploit Risk to give rise that increase to Threats to Assets wish to abuse and/or may damage
  • Proactive Risk Management Owners Controls VulnerabilitiesThreat Sources Risk Threats Assets
  • What Assets are we Protecting? Servers  Email Desktop Computers  Data Integrity Laptops and PDAs  All Files on the Server Switches and Routers  Consumer Information Application software  Network Infrastructure Development Tools  DHCP Source Code  Web Site Availability VPN Access  Reputation Backup Tapes  Employee Morale
  • Proactive Risk Management Owners Controls VulnerabilitiesThreat Sources Risk Threats Assets
  • Protecting From What Threats? Human Threats – Carelessness, Shoulder Surfing, User Abuse, Sabotage, Arson, Data Entry Errors, Intentional and Unintentional Procedure Violations Technical Threats – Takeover of authorized session, Intrusion, Keystroke Eavesdropping, System Failure, Saturation of Resources Environmental Threats – Fire, Earthquake, Hurricane, Tornado, Cable Cuts, Power Fluctuation, Hazardous Material Accident, Overheating
  • Proactive Risk Management Owners Controls VulnerabilitiesThreat Sources Risk Threats Assets
  • Threats to What Vulnerabilities? Unlocked doors  Software Configuration Unlocked windows  Systems not monitored Misconfigured systems  Unnecessary protocols Missing patches  Poorly defined procedures Antivirus out-of-date  Stolen credentials Poorly written apps  Poor password protection Vendor backdoors  Poor Disaster Recovery Spyware  Violations not reported
  • Proactive Risk Management Owners Controls VulnerabilitiesThreat Sources Risk Threats Assets
  • Vulnerabilities Protected by What Security Controls? Controls Physical Technical AdministrativePreventive Key-card access System & Network Security Awareness to enter area Monitoring Training for staffDetective Seals on archive Admin message on Audit of employee file cabinets 3 incorrect logins exit proceduresDeterrent Closed-circuit Account lockout Data owner camera monitor after 3 attempts approval of rightsCorrective Physical Isolation Firewall changes Arranging for day of servers from past events time cleaningRecovery Electronic records Netware’s file Contact police after recreate physical “Salvage” option security breach
  • Proactive Risk Management Owners wish to to reduce minimize impose Controls that may be value reduced by that may possess Vulnerabilities may be aware ofThreat Sources that leading to exploit Risk to give rise that increase to Threats to Assets wish to abuse and/or may damage
  • Two Approaches to Risk Assessment1) Quantitative Risk Assessment Value your assets Determine the SLE (total amount lost from a single occurrence of the risk) Single Loss Expectancy Determine the ARO (number of times you expect the risk to occur during one year) Annual Rate of Occurrence Determine the ALE (amount you will lose in one year if the risk is not mitigated) Annual Loss Expectancy Determine the ROSI (ALE before control) – (ALE after control) – (annual cost of control) = ROSI Return On Security Investment
  • Two Approaches to Risk Assessment2) Qualitative Risk Assessment Estimate relative values Determine what threats each asset may be facing Determine what vulnerabilities those threats might exploit in the future Determine controls which will mitigate the risks, and the approximate cost of each control Management performs a cost-benefit analysis on the results
  • Comparing the Two Approaches – the Benefits Quantitative Qualitative1) Risks and assets are 1) Enables visibility and prioritized by financial understanding of risk values ranking2) Results facilitate 2) Easier to reach consensus management of risk by 3) Not necessary to quantify Return on Security threat frequency or Investment determine financial value of3) Results expressed in terms assets management understands ($) 4) Easier to involve people4) Accuracy tends to increase who are not experts on over time security or computers
  • Comparing the Two Approaches – the Drawbacks Quantitative Qualitative1) Impact values assigned to 1) Insufficient differentiation risks are based on subjective between important risks opinion 2) Difficult to justify investing2) Very time-consuming in control implementation3) Calculations can be very when there is no basis for a complex cost-benefit analysis4) Results are presented only in 3) Results are dependent on the monetary terms, and can be quality of the Risk difficult for non-technical Management Team that is people to interpret created5) Process requires expertise
  • Effective Risk Management Attempts to Malicious Natural Sabotage access private attacks disasters information Threats User Fraud Pranks error Sensitive Services and Integrity of data Assets lost information benefits and reports disclosed interrupted compromised :Public’s Potential Damage Critical Failure to Loss of operations meet contractual confidence halted obligations
  • Know what to do now?
  • Who Wants to Help You?
  • NIST - The National Institute of Standards and Technology NIST is a non-regulatory Federal agency with the mission of developing and promoting measurement, standards and technology to enhance productivity and improve quality of life They invent – an atomic clock; a cement-like substance that promotes bone regrowth They develop - software for the 170 VA hospitals; complex computational models The set standards – weights and measures, cholesterol testing, and . . . Information Security
  • Pertinent NIST Publications SP 800-12 An Introduction to Computer Security: The NIST Handbook SP 800-18 Guide for Developing Security Plans for Information Technology Systems SP 800-26 Security Self-Assessment Guide for Information Technology Systems SP 800-30 Risk Management Guide for Information Technology Systems
  • NIST Says It’s a Management Function The goal of Risk Management is to protect the organization and its ability to perform its mission The focus is the mission; not IT assets Risk Management, therefore, is an essential management function of the organization
  • NIST Says Risk Management has Three Parts Risk Assessment - Determining where risks lie, and how big they are Risk Mitigation - Prioritizing, evaluating, and implementing appropriate risk-reducing controls Evaluation and Assessment – Since Risk Management is continuous and evolving, the past year’s Risk Management efforts should be assessed and evaluated prior to beginning the cycle again
  • Risk Management Process Risk Risk RMAssessment Mitigation Evaluation
  • National Institute of Standards and Technology SP 800-30The Ten Steps of Risk Assessment1) System Characterization2) Threat Identification3) Vulnerability Identification4) Control Analysis5) Identify Threat-source/Vulnerability Pairs6) Likelihood Determination7) Impact Analysis8) Risk Determination9) Control Recommendations10) Results Documentation
  • Risk Management Process Risk RiskAssessment Mitigation
  • Risk Mitigation Risk Mitigation is the process of identifying areas of risk that are unacceptable; and estimating countermeasures, costs and resources to be implemented as a measure to reduce the level of risk Determining “appropriate risk-reducing controls” is a job for your Risk Management Committee
  • What is “Acceptable” Risk? Setting your agency’s “risk appetite” is up to your Director and Senior Management Because elimination of all risk is impossible, we must use the least-cost approach and implement the most appropriate controls to decrease mission risk to an acceptable level, with minimal adverse impact on the organization’s resources and mission
  • Risk Mitigation Options Assume the Risk – Accept the risk and continue operating (how big is your appetite?) Avoid the Risk – Stop running the program or sharing the data Transfer the Risk – Use options to compensate for the loss, such as insurance Lessen the Risk – Implement controls that lessen the impact or lower the likelihood
  • Risk Mitigation Methodology1) Prioritize based on risk levels presented2) Evaluate recommended control options3) Conduct a cost-benefit analysis4) Select additional controls, as necessary5) Assign responsibility6) Develop an action plan, if necessary7) Implement the selected controls
  • Cost-Benefit Analysis If control reduces risk more than needed, see if a less expensive alternative exists If control would cost more than the risk reduction provided, then find something else If control does not reduce risk sufficiently, look for more controls or a different control If control provides enough risk reduction and is cost-effective, then use it
  • Residual Risk The risk remaining after the implementation of new or enhanced controls is the residual risk If the residual risk has not been reduced to an acceptable level, the risk management cycle must be repeated to identify a way of lowering the residual risk to an acceptable level Understand that no IT system can be risk-free
  • Risk Management Process Risk Risk RMAssessment Mitigation Evaluation
  • Evaluation and Assessment People, systems, and networks change, so risk management must be ongoing Federal agencies must conduct risk management at least every three years Stay flexible to allow changes when warranted
  • NIST SaysGood Risk Management Depends Upon1) Senior management’s commitment2) Support of the IT Team3) Competence of the Risk Management Committee4) Cooperation and education of the users5) Ongoing assessment of IT-related mission risks
  • Who Wants to Help You?
  • ISO - International Organization of Standardization In the late 1990s, the British Standard Institute (BSI) developed a program to accredit auditing firms, called “BS 7799” When demand grew quickly for an information security standard, the ISO (International Organization for Standardization) adapted 7799 and released Part 1 in 2000 as “ISO 17799” ISO 17799 defines a set of recommended information security management practices
  • On-line Purchases of ISO 177999% 35 % 18% 9% 6% Others 9%
  • ISO 17799 – A Set of Recommendations ISO does not expect you to apply every piece of the standard Instead ISO suggests that you consider each recommendation as you try to improve your information security program If a particular recommendation helps you address an important security need, then accept it – otherwise, ignore it
  • ISO 17799 Says “First, Understand”Perfect security may be achievable only for networkless serverslocated in rooms without doors in stone buildings without peopleon high ground with no earth faults in areas with very little rain
  • 10 Key Contexts of ISO 17799 Security policy Organizational Compliance securityBusiness continuity Asset classification Integrity Confidentiality management and control Information Systems development & Personnel security maintenance Availability Physical and Access control environmental Communications security and operations management
  • ISO 17799 Deliverables
  • ISO 17799’s Information Security Management Process1) Obtain Upper Management Support2) Define Security Perimeter3) Create Information Security Policy4) Create Info Security Management System5) Perform Risk Assessment6) Select and Implement Controls7) Document in Statement of Accountability8) Audit
  • ISO 17799 Risk Assessment Steps 1) Identify assets within the security perimeter 2) Identify threats to the assets 3) Identify vulnerabilities to the assets 4) Determine realistic probability
  • ISO’s Probability of Event ScaleProbability Frequency Rating of EventNegligible Unlikely to Occur 0Very Low 2 to 3 times every 5 years 1Low Less than or equal to once per year 2Medium Once every 6 months or less 3High Once every month or less 4Very High More than once every month 5Extreme Once per day or more 6
  • ISO 17799 Risk Assessment Steps 1) Identify assets within the security perimeter 2) Identify threats to the assets 3) Identify vulnerabilities to the assets 4) Determine realistic probability 5) Calculate harm
  • ISO’s Harm of Event ScaleHarm of Event Degree of Harm RatingInsignificant Minimal to no impact 0Minor No extra effort required to repair 1Significant Tangible harm, extra effort required to repair 2Damaging Significant expenditure of resources required; 3 Damage to reputation and confidenceSerious Extended outage and/or loss of connectivity; 4 Compromise of large amounts of data or servicesGrave Permanent Shutdown; Complete compromise 5
  • ISO 17799 Risk Assessment Steps 1) Identify assets within the security perimeter 2) Identify threats to the assets 3) Identify vulnerabilities to the assets 4) Determine realistic probability 5) Calculate harm 6) Calculate risk (probability x harm)
  • ISO’s Risk ScaleRisk Calculation Rating(Probability times harm) 0 None 1–3 Low 4–7 Medium 8 – 14 High 15 – 19 Critical 20 – 30 Extreme
  • ISO 17799’s Information Security Management Process1) Obtain Upper Management Support2) Define Security Perimeter3) Create Information Security Policy4) Create Info Security Management System5) Perform Risk Assessment6) Select and Implement Controls7) Document in Statement of Accountability8) Audit
  • Who Wants to Help You?
  • COBIT – Control Objectives for Information and related Technology Created by the Information Systems Audit and Control Association (ISACA) and the IT Governance Institute (ITGI) The first edition was published in 1996, the second in 1998, the third in 2000, and the on- line edition became available in 2003 Recently found favor due to Enron scandal and the subsequent passage of the Sarbanes- Oxley Act
  • What COBIT Says You Should Do COBIT looks at information that is needed to support business requirements and the associated IT resources and processes COBIT has 34 high level objectives that cover 318 control objectives, categorized in four domains: 1) Planning and Organization 2) Acquisition and Implementation 3) Delivery and Support 4) Monitor
  • High Level ObjectivesCOBIT – Planning and OrganizationP01 Define a Strategic IT PlanP02 Define the Information ArchitectureP03 Determine Technological DirectionP04 Define the IT Organization and RelationshipsP05 Manage the IT InvestmentP06 Communicate Management Aims and DirectionP07 Manage Human ResourcesP08 Ensure Compliance with External RequirementsP09 Assess RisksP10 Manage ProjectsP11 Manage Quality
  • High Level ObjectivesCOBIT – Acquisition & Implementation AI1 Identify Automated Solutions AI2 Acquire and Maintain Application Software AI3 Acquire and Maintain Technology Infrastructure AI4 Develop and Maintain Procedures AI5 Install and Accredit Systems AI6 Manage Changes
  • High Level Objectives COBIT – Delivery and SupportDS1 Define and Manage Service DS8 Assist and Advise Levels CustomersDS2 Manage Third-Party Services DS9 Manage the ConfigurationDS3 Manage Performance and DS10 Manage Projects CapacityDS4 Ensure Continuous Service DS11 Manage DataDS5 Ensure Systems Security DS12 Manage FacilitiesDS6 Identify and Allocate Costs DS13 Manage OperationsDS7 Educate and Train Users
  • High Level Objectives COBIT – MonitorM1 Monitor the ProcessesM2 Assess Internal Control AdequacyM3 Obtain Independent AssurancesM4 Provide for Independent Audit
  • Who Wants to Help You?
  • Microsoft Says . .Successful Risk Management Requires: Executive sponsorship A well-defined list of RM stakeholders Organizational maturity in terms of RM An atmosphere of open communication A spirit of teamwork A holistic view of the organization Security Risk Management Team authority
  • Microsoft Says . . Risk Management Has Four Phases1) Assessing Risk – Triage an entire list of security risks, identifying the most important2) Conducting Decision Support – Potential control solutions are evaluated, and the best are recommended for mitigating top risks3) Implementing Controls – Control solutions are put in place4) Measuring Program Effectiveness – Checking to make sure that the controls are providing the expected protection
  • FromMicrosoft’s Security Ris
  • Microsoft Says . . Assessing Risk Phase has Three Steps1) Planning – Align your annual process with your budget; Specify your scope; Identify and pre-sell stakeholders; embrace subjectivity2) Facilitated Data Gathering – Identify tangible and intangible assets, threats, vulnerabilities, existing controls, probable impact3) Risk Prioritization – Determine probabilities, and combine impact with probability to produce a risk statement
  • Microsoft Says . . Conducting Decision Support Phase1) Determine functional requirements2) Identify combinations of controls (Organizational, Operational, Technological)3) Compare proposed controls to functional requirements4) Calculate the probable overall risk reduction to the organization5) Estimate the cost of teach proposed control6) Select which controls to implement
  • Microsoft Says . .Implementing Controls Phase Solid Building Structure Good Network Design Secure Wireless Segment Disable LAN Services Remove User Rights Good Firewall Settings Least Privilege Necessary Small attack surface Frequent Backups Encryption
  • Microsoft Says . .Measuring Program Effectiveness Phase1) Ongoing – continues until next assessment phase2) Should catch changes in the information systems environment, and in applications3) Includes creating and maintaining a security risk scorecard that demonstrates the organization’s current risk profile
  • FromMicrosoft’s Security Ris
  • Who Wants to Help You?
  • The Health Insurance Portabilityand Accountability Act of 1996
  • Final Rule, “Administrative Safeguards” – 45 CFR Part 164.306 HIPAA Says Covered Entities Must  Ensure the confidentiality, integrity and availability of all protected health information the covered entity creates, receives, maintains or transmits  Protect against any reasonably anticipated threats or hazards to the security or integrity of such information
  • Final Rule, “Administrative Safeguards” – 45 CFR Part 164.308 HIPAA Security Specifications 1) Security Management Process – “Implement policies and procedures to prevent, detect, contain and correct security violations” Standard: (a)(1)(i) 2) Train workforce – “Implement a security awareness and training program for all members of its workforce (including management)” Standard: (a)(5)(i)
  • Final Rule, “Administrative Safeguards” – 45 CFR Part 164.308 HIPAA Security Specifications 3) Information Systems Activity Review – “Implement procedures to regularly review records of information system activity, such as audit logs, access reports, and security incident tracking reports” Standard: (a)(1)(D) 4) Security Incidence Procedures – “Mitigate, to the extent practicable, harmful effects of security incidents that are known to the covered entity” Standard: (a)(6)(2)
  • Final Rule, “Administrative Safeguards” – 45 CFR Part 164.308 HIPAA Security Specifications 5) Risk Analysis – A covered entity “must conduct an actual and thorough assessment of the potential risks and vulnerabilities of the confidentiality, integrity, and availability of electronic PHI held by the covered entity” Standard (a)(1)(2)(A) 6) Risk Management – A covered entity “must implement security measures sufficient to reduce risks and vulnerabilities to a reasonable and appropriate level” Standard (a)(1)(ii)(D)
  • . . And Why You Should Do It Civil Monetary Penalties for Non-Compliance $100/person/violation, up to $25,000 per person per year per violation (Section 1176) Knowingly Misusing PHI - $50,000, 1 year Misuse of PHI under False Pretenses - $100,000 and up to 5 years Misuse of PHI with Intent to Sell - $250,000 and up to 10 years (Section 1777)
  • Because it’s the Law!
  • Who Wants to Help You?
  • What NC ITS Says You Should Do* They say you should focus on four things:1) Identification of Risks2) Analysis of Risks3) Mitigation Planning4) Tracking and Controlling Risks* Based on November 2004 Risk Management policy issued
  • NC ITS’s Risk Management Program Consists of two components: Pre-Risk Assessment, and Risk Assessment (three phases), explained in a Risk Management Guide Phase I – Identify Risks Phase II – Analyze Risks Phase III – Manage Risks Heavily uses the NIST rating scale: Low – Limited adverse effect on agency Moderate – Serious adverse effect High – Severe or catastrophic adverse effect
  • NC ITS’s RM – Pre-Risk Assessment Review lines of business service that have automated systems that support the business service Determine if critical infrastructures are involved, or if there are critical infrastructure dependencies Complete the Pre-Risk Assessment form
  • NC ITS’s RM – Phase I A Facilitator leads a team of people responsible for delivery of a particular line of business through completing the Phase I Questions of the ITS Risk Assessment Questionnaire If the final score is “Low”, the risk assessment process ends If the final score is “Moderate” or “High”, proceed to Phase II for additional analysis
  • NC ITS’s RM – Phase II A Facilitator leads a team of people knowledgeable in the particular line of business through the Phase II Questions of the ITS Risk Assessment Questionnaire If the final score is “Low”, the risk assessment process ends If the final score is “Moderate” or “High”, proceed to Phase III for mitigation
  • NC ITS’s RM – Phase III A Facilitator leads appropriate managers and staff through an analysis that focuses on mitigation The team identifies options to mitigate the risk, analyzes the cost implications, determines the benefits, and balances the cost of implementing each option against the benefits derived from it The result is completion of the Risk Analysis Results & Mitigation Plans form found in the ITS Risk Assessment Questionnaire
  • NC ITS’s Risk Management Training On March 31, 2004, ITS and its vendor partner, Strohl Systems, presented a two hour agency training session (introduced by Ann Garrett) which covered both Business Impact Analysis and Risk Management Let’s fast forward and view the Risk Management part of the PowerPoint slide show presented there Let’s try working through an example
  • Pre-Risk Assessment Form Line of Business – Pharmacy Business Process Owner – Pharmacy Director Automated System Supporting – MCPlus Critical Infrastructure – Linux Server Critical Dependencies – Vendor
  • Risk Assessment Questionnaire 20 Phase I Questions (Q1 – Q19) If one or more questions is answered as “Moderate” or “High”, then proceed to Phase II questions 65 Phase II Questions (Q1 – Q25) If one or more questions (except for Q3) is answered as “Moderate” or “High”, then proceed to Phase III Let’s try to fill out the Mitigation Plan now
  • Who Wants to Help You?
  • (Based on June 15, 2005 DHHS Risk Management Policy)What DHHS Says You Should Do Assign responsibility for managing risk to senior management Provide a mechanism for tracking and reporting risks Identify system threats in the environment Identify system vulnerabilities the threats could attack Identify current security controls Identify current security gaps
  • More DHHS Risk Management Policy, June 15, 2005 Things DHHS Says to Do Ensure that every risk has at least one owner Develop the responses or controls necessary to mitigate identified and reported risks Assess the probability of risks occurring and their potential impact Identify the risks associated with critical processes in the workflow Identify security controls currently implemented Provide an analysis of risks
  • DHHS Risk Management Policy, June 15, 2005 Even More Things DHHS Says to Do Ensure that Risk Management is an intrinsic part of operations Keep Risk Management policies and procedures current Perform an analysis to evaluate risk mitigation actions taken, and to determine further steps Respond to changes in risks, and take corrective action as needed
  • DHHS Information Security Management Policy, June 15, 2005 Even More Things DHHS Says to Do Implement a systematic, analytical and continuous risk management program for information systems Ensure that risk identification, analysis and mitigation activities are performed Ensure that risk assessments are performed periodically to evaluate effectiveness of existing controls Define strategies and mitigate risks to acceptable levels
  • DHHS Says to Address Risks by: Risk Reduction – Implement measures to alter the risk position of an asset Risk Transference – Assign or transfer the potential cost of the loss to another party Risk Acceptance – Accept the level of loss that will occur and be prepared to absorb the loss
  • Confused Yet? HIPAA ISO 17799DHHS NIST What you thoughtMicrosoft you knew COBIT
  • Who Provides Us with the Most Help?
  • NIST Says Risk Management has Three Parts Risk Assessment - Determining where risks lie, and how big they are Risk Mitigation - Prioritizing, evaluating, and implementing appropriate risk-reducing controls Evaluation and Assessment – Since Risk Management is continuous and evolving, the past year’s Risk Management efforts should be assessed and evaluated prior to beginning the cycle again
  • Risk Management Process Risk Risk RMAssessment Mitigation Evaluation
  • National Institute of Standards and Technology SP 800-30The Ten Steps of Risk Assessment1) System Characterization2) Threat Identification3) Vulnerability Identification4) Control Analysis5) Identify Threat-source/Vulnerability Pairs6) Likelihood Determination7) Impact Analysis8) Risk Determination9) Control Recommendations10) Results Documentation
  • 1) System Characterization Define the boundaries of the IT system you are addressing, along with the resources and the information that constitute the system, setting the scope of the assessment effort Methods of gathering system characterization information include the use of questionnaires, interviews, and automatic scanning tools Output #1: A system characterization paragraph
  • 2) Threat Identification A threat is the potential for a particular threat-source to successfully exercise a particular vulnerability A threat-source is any circumstance or event with the potential to cause harm to an IT system A vulnerability is a weakness that can be accidentally triggered or intentionally exploited
  • Two Types of Threat-Sources1) Intent and method targeted at the intentional exploitation of a vulnerability2) A situation and method that may accidentally trigger a vulnerability
  • Common Threat-Sources Natural Threats – Floods, earthquakes, tornadoes, electrical storms, landslides, avalanches, etc. Human Threats – Events either enabled or caused by human beings, including both unintentional acts (inadvertent data entry) and deliberate actions (unauthorized access) Environmental Threats – Long-term power failure, pollution, chemicals, liquid leakage
  • Threat-Source Identification Humans are the most dangerous threat-source For each type of human threat-source, estimate the motivation, resources, and capabilities that may be required to carry out a successful attack (to be used during the Likelihood Determination phase) Output #2: A list of threats Output #3: A chart showing motivation and necessary threat actions for human threats
  • 3) Vulnerability Identification A vulnerability is a flaw or weakness in system security procedures, design, implementation, or controls that could be exercised (accidentally triggered or intentionally exploited) and result in a security breach or a violation of an information security policy Output #4: A list of vulnerabilities that could be exploited by the potential threat-sources
  • Where Vulnerabilities are Found1) Hardware Configuration – Servers, Workstations, Routers, Switches, Firewalls2) Software Applications – How installed, Where installed, Rights granted3) IS Policies and Procedures – How complete, How up-to-date, How well known4) Humans – Procedures not being followed, Staff not being trained
  • How We Find Vulnerabilities1) Hardware Configuration – Complete a System Risk Analysis form for each network component, arrange for penetration testing2) Software Applications – Complete an Application Criticality and Risk Analysis form for each application3) IS Policies and Procedures – Complete a review of the quality of your Information Security Policies and Procedures every year4) Humans – Review log files, training records, and incident reports
  • 4) Control Analysis The goal of this step is to analyze the controls that have been implemented to minimize the likelihood of a threat exercising a vulnerability Output #5: A list of controls currently in use by network hardware components Output #6: A list of controls currently in use by applications
  • 5) Threat-Source/Vulnerability Pairs  Considering the controls in place, what are the Threat-source/Vulnerability pairs which are of most concern?  A vulnerability with no threat-source is not a risk  A threat-source with no vulnerability is not a risk  Output #7: A list of Threat-source and Vulnerability pairs of concern
  • 6) Likelihood Determination A determination of the probability that a potential vulnerability will be exercised When determining likelihood, consider:1) Threat-source motivation and capability2) The nature of the vulnerability3) The existence and effectiveness of current controls
  • Likelihood Determination Results Output #8: For each identified vulnerability, a determination of likelihood (H, M, or L)High – The threat-source is highly motivated and sufficiently capable, and controls to prevent the vulnerability from being exercised are ineffectiveMedium – The threat-source is motivated and capable, but controls are in place that may impede successful exercise of the vulnerabilityLow – The threat-source lacks motivation or capability, or controls are in place to prevent or significantly impede exercising the vulnerability
  • 7) Impact Analysis Determine the adverse impact resulting from a successful threat exercise of each threat- source/vulnerability pair of concern
  • Adverse Impact Comes From: Loss of Integrity - Improper modification Loss of Availability - System cannot be accessed or data cannot be located Loss of Confidentiality - Information classified as sensitive is disclosed without authorization
  • Impact Analysis Needs For an Impact Analysis we must know:1) The organization’s mission2) The criticality of the data3) The sensitivity of the dataSensitivity is the sum of the potential injury froma breakdown in confidentialityCriticality is the sum of the potential injury froma breakdown in integrity and/or availability
  • Impacts are High, Medium, or Low Output #9: For each identified vulnerability, an estimation of the magnitude of probable impactHigh – Exercise of the vulnerability may result in a highly costly loss or may significantly impede an organization’s mission or reputationMedium – Exercise of the vulnerability may result in a costly loss or may harm an organization’s mission or reputationLow – Exercise of the vulnerability may result in the loss of some assets, or may noticeably affect an organization’s mission or reputation
  • 8) Risk Determination NIST says risk is the net mission impact considering both the likelihood that a particular threat-source will exercise (accidentally trigger or intentionally exploit) a particular information system vulnerability, and the resulting impact on the organization if this should occur Likelihood x Impact = Risk
  • Use a Risk-Level Matrix Impact Threat Low Medium High Likelihood (10) (50) (100) High (1.0) Low Medium High 10 x 1.0 = 10 50 x 1.0 = 50 100 x 1.0 = 100Medium (0.5) Low Medium Medium 10 x 0.5 = 5 50 X 0.5 = 25 100 x 0.5 = 50 Low (0.1) Low Low Low 10 x 0.1 = 1 50 x 0.1 = 5 100 x 0.1 = 10Risk Scale: High (>50 to 100); Medium (>10 to 50); Low (1 to 10)
  • Risk Scale and Necessary ActionsRisk Level Risk Description and Necessary Actions High There is a strong need for corrective measures, the system may continue to operate, but a corrective action plan should be put in place as soon as possibleMedium Corrective actions are needed, and a plan incorporating these actions should be developed in a reasonable period of time Low Additional controls may be implemented, or management may decide to accept this risk
  • Assessing the Risk Level Final determination of mission risk is derived by multiplying the threat likelihood and the threat impact scores Output #10: A numeric risk score for each identified vulnerability/threat-source pair The Vulnerability Analysis form can be used to capture this information
  • 9) Control Recommendations Finish your risk assessment by thinking of controls which could help minimize the risk of the vulnerability/threat-source combinations you are most concerned about To determine which controls are appropriate to add, perform a cost-benefit analysis Output #11: Recommendation of additional controls based on risk assessment
  • 10) Results Documentation The Risk Assessment report should be of sufficient detail to allow the organization’s management to make informed decision on appropriate actions in response to the risks identified Unlike an audit or investigative report that looks for “wrong-doing”, the Risk Assessment report should be not be presented in an accusatory manner
  • Risk Assessment Report Your Risk Assessment report should have: A) An Introduction B) A description of your Risk Assessment approach C) A system characterization summary D) A list of Threat-Sources E) Vulnerability/Threat-Source analysis results F) A summary of risk levels and recommendations Output #12: Risk Assessment Report that measures risk and provides recommendations
  • Report - Introduction Purpose Scope Describe * System Controls * Elements * Users * Site Locations * Other Details as necessary
  • Report – Risk Assessment Approach Describe Approach Used Risk Assessment Team members Techniques used to gather information (use of tools, questionnaires, etc.) Development and description of risk scale (3x3, 4x4, or 5x5 risk level matrix)
  • Report – System Characterization Describe the system - Hardware (server, router, switch) - Software (application, operating system) - System Interfaces (communication link) - Data - Users Provide connectivity diagram or system input and output flowchart
  • Report - Threat Statement  Compile potential threat sources  List associated threat actions  Review Human Motivations
  • Report – Risk Assessment Results List observations (vulnerability/threat pairs) Observations contain - Observation number and brief description - Discussion of threat-source and vulnerability - Identification of existing security controls - Likelihood discussion and evaluation - Risk rating - Recommended controls or alternative options
  • Report - Summary Total number of threat-source/vulnerabilities pairs identified (“observations”) Summarize - Observations - Associated risk levels - Recommendations - Any comments Organize into a table to facilitate implementation
  • The Ten Steps of Risk Assessment1) System Characterization2) Threat Identification3) Vulnerability Identification4) Control Analysis5) Identify Threat-source/Vulnerability Pairs6) Likelihood Determination7) Impact Analysis8) Risk Determination9) Control Recommendations10) Results Documentation
  • Reviewing NIST’s RA Output1) System Characterization 7) List Threat-Source and2) List of Threats Vulnerability pairs3) Human Motivation 8) Likelihood determination for Review each pair of concern4) List of Vulnerabilities 9) Estimation of probable5) Review Network impact Hardware Controls 10) Identify risk scores6) Review Application 11) Recommendations, if any, for Controls additional controls 12) Risk Assessment Report
  • Risk Management Process Risk RiskAssessment Mitigation
  • Risk Mitigation Risk Mitigation is the process of identifying areas of risk that are unacceptable; and estimating countermeasures, costs and resources to be implemented as a measure to reduce the level of risk Determining “appropriate risk-reducing controls” is a job for your Risk Management Committee
  • What is “Acceptable” Risk? Setting your agency’s “risk appetite” is up to your Director and Senior Management Because elimination of all risk is impossible, we must use the least-cost approach and implement the most appropriate controls to decrease mission risk to an acceptable level, with minimal adverse impact on the organization’s resources and mission
  • Risk Mitigation Options Assume the Risk – Accept the risk and continue operating (how big is your appetite?) Avoid the Risk – Stop running the program or sharing the data Transfer the Risk – Use options to compensate for the loss, such as insurance Lessen the Risk – Implement controls that lessen the impact or lower the likelihood
  • Risk Mitigation Methodology1) Prioritize based on risk levels presented2) Evaluate recommended control options3) Conduct a cost-benefit analysis4) Select additional controls, as necessary5) Assign responsibility6) Develop an action plan, if necessary7) Implement the selected controls
  • Possible Technical Controls User Identification Security Administration Authentication Authorization Nonrepudiation Transaction Privacy Restore Secure State Virus Detection and Eradication
  • Possible Management Controls Assign Security Responsibility Conduct Security Awareness Training Conduct end-user training for system users Implement personnel clearance procedures Perform periodic system audits Conduct ongoing risk management activities Establish incident response capability
  • Possible Operational Controls Control physical access Secure hub and cable wiring closets Establish off-site storage procedures Provide an uninterruptible power supply Control temperature and humidity Provide motion sensors or CCTV monitoring Ensure environmental security
  • Cost-Benefit Analysis If control reduces risk more than needed, see if a less expensive alternative exists If control would cost more than the risk reduction provided, then find something else If control does not reduce risk sufficiently, look for more controls or a different control If control provides enough risk reduction and is cost-effective, then use it
  • When Should Management Take Action? Threat Source Flaw or YES Can be YES Vulnerability & System Design weakness? exercised? Exists NO NO No Risk No Risk YES LossMission Risk Attacker’s YES Anticipated YES UnacceptableImpact? Exists Cost < Gain > Threshold Risk NO NO NONo Risk Risk Accept Risk Accept
  • Residual Risk The risk remaining after the implementation of new or enhanced controls is the residual risk If the residual risk has not been reduced to an acceptable level, the risk management cycle must be repeated to identify a way of lowering the residual risk to an acceptable level Understand that no IT system can be risk-free
  • Risk Management Process Risk Risk RMAssessment Mitigation Evaluation
  • Evaluation and Assessment People, systems, and networks change, so risk management must be ongoing Federal agencies must conduct risk management at least every three years Stay flexible to allow changes when warranted
  • NIST SaysGood Risk Management Depends Upon1) Senior management’s commitment2) Support of the IT Team3) Competence of the Risk Management Committee4) The cooperation of the users5) Ongoing assessment of IT-related mission risks
  • Risk Management ExamplesScenario #1 - The Grounds of My Home
  • #1) The Grounds of My Home1) System Characterization - the land my home sits on (risk owned by my wife)2) Threat Identification – Environmental? From people? From Nature?3) Vulnerability Identification – Looking for weaknesses which could be exercised by a threat-source; use eyes and knowledge4) Control Analysis – City Services, fire hydrant, Home Owner’s insurance, car insurance
  • The Grounds of My Home – Continued5) Identify Threat-Source/Vulnerability Pairs – Dead limb or whole tree could fall on my car6) Likelihood Determination – Has happened before; lots of storms; high likelihood7) Impact Analysis – Dents, broken glass, car not drivable, repair cost – medium impact8) Risk Determination – High (1.0) Likelihood x Medium (50) Impact = Medium (50) Risk
  • The Grounds of My Home – Continued9) Control Recommendation Options:o Have wife pull the limb downo Hire a tree surgeon to take off the limbo Take the tree downo Don’t park thereo Park my wife’s company car thereo Buy a bicycleo Lower amount of deductible
  • Completing Mitigation . . Assign Responsibility Taking down the limb - My wife (stronger) Parking differently - Me (get home first) Develop an Action Plan (if necessary) This weekend ------------------------------------------------------- -o Lessen the likelihood by removing the limbo Transfer some risk to my wife’s companyo
  • Risk Management ExamplesScenario #2 - The Agency File Servers
  • #2) The File Servers1) System Characterization - the File Servers in our Server Closet2) Threat Identification – Environmental? From people? From Nature?3) Vulnerability Identification – Looking for weaknesses which could be exercised by a threat-source; use eyes and knowledge4) Control Analysis – Firewall, Locks, Daily Observation, Separate Circuit, UPSs
  • The File Servers – Continued5) Identify Threat-Source/Vulnerability Pairs – Big Oak could fall on flat roof, break it6) Likelihood Determination – Tree appears strong, but lots of storms; low likelihood7) Impact Analysis – Damage from impact, water damage, repair cost – high impact8) Risk Determination – Low (0.1) Likelihood x High (100) Impact = Low (10) Risk
  • The File Servers – Continued9) Control Recommendation Options:o Have the tree removedo Weaken the tree on the other side to affect fallo Relocate the File Serverso Reinforce the roofo Buy a tarp and rig it over the serverso Buy a tarp and keep it handy
  • Completing Mitigation . . Assign Responsibility LAN Manager - Buying a tarp at Wal-Mart for $9 Develop an Action Plan (if necessary) Do it tomorrow--------------------------------------------------------o Lessen the impact by preparing for the event (even though it is unlikely)o Accept the residual risk
  • Risk Management ExamplesScenario #3 - An Agency Application
  • #3) An Agency Application1) System Characterization - Local Access- based system with PHI sent over the internet2) Threat Identification – From people? From telecommunication?3) Vulnerability Identification – Availability and Integrity risks are low, but Confidentiality risk is high; also, data is sent elsewhere4) Control Analysis – Logical and Physical Access controls, Security Awareness Program, Staff Sensitivity Designations
  • An Application – Continued5) Identify Threat-Source/Vulnerability Pairs – We are sharing PHI with no Business Associate agreement in place6) Likelihood Determination – Sent to another CE, but no BA in place; low likelihood7) Impact Analysis – PHI becoming exposed could hurt image badly – high impact8) Risk Determination – Low (0.1) Likelihood x High (100) Impact = Low (10) Risk
  • An Application – ContinuedControl Recommendation Options: Make sure the receiver of the PHI understands their BA responsibilities Offer training to the Business Associate Request written documentation for the program Establish a written Memorandum of Understanding between the agencies
  • Completing Mitigation . . Assign Responsibility Security Official will contact other Security Official Security Official will develop and offer training show Data Owner will request software documentation Develop an Action Plan (if necessary) --------------------------------------------------------o Lessen the likelihood establishing a HIPAA compliant Business Associate relationshipo Accept the residual risk
  • So Let’s Go! All Set? - We know where we want to go, and we have a map, so we’re ready, right? Hold On – How long is this trip, and how old are we now? Let’s estimate our organization’s risk management maturity, and our readiness
  • What is your Security Risk Management Maturity Level?Based on ISO 17799 Which of these 6 levels best describes your organization?
  • Risk Management Maturity LevelsLevel State Definition 0 Non- Policy is not documented, and previously the Existent organization was unaware of the business risk associated with this risk management; therefore there has been no communication on the issue. 1 Ad-Hoc Some members of the organization have concluded that risk management has value, however, risk management efforts are performed in an ad-hoc manner. There are no documented processes or policies, and the process is not fully repeatable.
  • Risk Management Maturity LevelsLevel State Definition 2 Repeatable There is awareness of risk management throughout the organization. The process is repeatable, but immature, and not fully documented. Implementation is left to individual employees. 3 Defined The organization has made a formal decision Process to adopt risk management wholeheartedly in order to drive its information security program. There are clearly defined goals, and some risk management training is available for all staff.
  • Risk Management Maturity LevelsLevel State Definition 4 Managed There is a thorough understanding of risk management at all levels of the organization. The process is well-defined, broadly communicated, and training is available. Some initial forms of measurement are in place 5 Optimized The organization has committed significant resources to risk management. The process is well-understood and somewhat automated. Training across a range of levels of expertise is available to staff.
  • What is your Security Risk Management Readiness Level?Based on Microsoft’s Security Risk Management Guide – Chapter 3 The following test measures your organization’s readiness level For each of these 17 questions, score your organization on a scale of zero to five, using the previous maturity level definitions as a guide
  • From Microsoft’s Security Risk Management Guide, Chapter 3 Risk Management Readiness Test1) Information security policies and procedures are clear, concise, well-documented, and complete2) All staff positions with job responsibilities involving information security have clearly articulated and well understood roles and responsibilities3) Policies and procedures for securing third-party access to business data are well-documented. For example, remote vendors performing application development for an internal business tool have sufficient access to network resources to effectively collaborate and complete their work, but they have only the minimum amount of access that they need
  • From Microsoft’s Security Risk Management Guide, Chapter 3 Risk Management Readiness Test4) An inventory of Information Technology (IT) assets such as hardware, software, and data repositories is accurate and up-to-date5) Suitable controls are in place to protect business data from unauthorized access by both outsiders and insiders6) Effective user awareness programs such as training and newsletters regarding information security policies and practices are in place7) Physical access to the computer network and other information technology assets is restricted through the use of effective controls
  • From Microsoft’s Security Risk Management Guide, Chapter 3 Risk Management Readiness Test8) New computer systems are provisioned following organizational security standards in a standardized manner using automated tools such as disk imaging or build scripts9) An effective patch management system is able to automatically deliver software updates from most vendors to the vast majority of the computer systems in the organization10) Effective user awareness programs such as training and newsletters regarding information security policies and practices are in place
  • From Microsoft’s Security Risk Management Guide, Chapter 3 Risk Management Readiness Test11) The organization has a comprehensive anti-virus program including multiple layers of defense, user awareness training, and effective processes for responding to virus outbreaks12) User provisioning processes are well documented and at least partially automated so that new employees, vendors, and partners can be granted an appropriate level of access to the organizations information systems in a timely manner. These processes should also support the timely disabling and deletion of user accounts that are no longer needed
  • From Microsoft’s Security Risk Management Guide, Chapter 3 Risk Management Readiness Test13) Computer and network access is controlled through user authentication and authorization, restrictive access control lists on data, and proactive monitoring for policy violations14) Application developers are provided with education and possess a clear awareness of security standards for software creation and quality assurance testing of code15) Business continuity and business continuity programs are clearly defined, well documented, and periodically tested through simulations and drills
  • From Microsoft’s Security Risk Management Guide, Chapter 3 Risk Management Readiness Test16) Programs have commenced and are effective for ensuring that all staff perform their work tasks in a manner compliant with legal requirements17) Third-party review and audits are used regularly to verify compliance with standard practices for security business assets
  • Add all 17 scores together< 34 Consider starting slowly by creating a Risk Management team and applying the process to a single business unit of your organization34 to Your organization has taken many significant 50 steps, and is ready to move forward and expose the entire organization to the process> 50 Your organization is well-prepared to begin to use security risk management to its fullest extent
  • Are You Ahead or Behind?80 Blissful70 Ignorance60 Awareness50 Phase40 Corrective30 Phase20 Operations10 Excellence 0 1996 2000 2005 2008According to the Gartner Group, using a population of G2000 type companies
  • So Let’s Go! All Set? - We know where we want to go, and we have a map We know how mature we are, and have an idea about the readiness of our organization to begin risk management Can we kill any other birds with the same stones?
  • Related DHHS Policies “System owners are responsible for determining the sensitivity of data and ensuring that adequate controls are implemented to protect the data.” DHHS Information Systems Review and Auditing Policy “Tests that shall be included in overall security testing strategy for each Division/Offices shall include Vulnerability Scanning and Penetration Testing.” DHHS Security Testing Policy
  • Related DHHS Policies “The BC/DR planning team shall do the following: Identify the types of disasters most likely to occur and the resultant impacts on the agency’s ability to perform its mission.” DHHS Business Continuity and Disaster Recovery Policy “The BC/DR planning team shall do the following: Propose protective measures to be implemented in anticipation of a natural or man-made disaster.” DHHS Business Continuity and Disaster Recovery Policy
  • Related DHHS Policies “Plans shall include: A risk assessment to determine risk priorities and probability of identified risk.” DHHS Business Continuity and Disaster Recovery Policy “Plans shall include: Development of recovery/restoration procedures for time critical systems and applications.” DHHS Business Continuity and Disaster Recovery Policy
  • Related DHHS Policies For each application, classify the risk from loss of confidentiality as “low”, “medium”, or “high For each application, classify the risk from loss of integrity as “low”, “medium” or “high” For each application, classify the availability need level as 1 (2 to 4 days), 2 (5 to 9 days), 3 (10 to 19 days) or 4 DHHS Data Classification, Labeling and Access Control Policy
  • Related DHHS Policies “System Administrators have the responsibility of periodically reviewing user access privileges and notifying management of any access concerns.” “The system owner of each information system shall ensure that all user accounts are reviewed and access rights evaluated at least once per quarter.” DHHS User Authorization, Identification and Authentication Policy
  • More Related DHHS Policies “DHHS Divisions/Offices shall protect data on all sensitive and critical applications/systems by implementing controls that are commensurate with the security level required to protect the data” “If sensitive electronic data resides in a DHHS Division/Office, administrative, physical and technical security controls must be implemented to limit unauthorized access to the data” DHHS Data Protection Policy
  • More Related DHHS Policies “All technology shall be evaluated to ensure that it can provide the level of security required.” “Security risk in the operations environment shall be kept to a level that is considered “acceptable risk” DHHS IT Operations Security Policy
  • Related HIPAA Requirements Application and Data Criticality Analysis – Assess the relative criticality of specific applications and data in support of other contingency plan components HIPAA Section 164.308 (a)(7)(ii)(E) Emergency Mode Operation Plan – Establish procedures to enable continuation of critical business processes for protection of the security of electronic PHI while operating in emergency mode HIPAA Section 164.308 (a)(7)(ii)(C)
  • Final Rule, “Administrative Safeguards” – 45 CFR Part 164.308 HIPAA Security Specifications  Risk Analysis – A covered entity “must conduct an actual and thorough assessment of the potential risks and vulnerabilities of the confidentiality, integrity, and availability of electronic PHI held by the covered entity” Standard (a)(1)(2)(A)  Risk Management – A covered entity “must implement security measures sufficient to reduce risks and vulnerabilities to a reasonable and appropriate level” Standard (a)(1)(ii)(D)
  • 12 Steps Towards YOUR Program1) Educate Management 7) Update Threats list2) Locate all assets 8) Review IS P&P3) Assign all risk 9) Complete4) Complete Network Vulnerability Analysis Risk Analysis forms forms5) Complete 10) RM Committee meets Application Risk and decides on Analysis forms additional controls6) Penetration and 11) Report sent to Director Vulnerability Testing 12) RM mid-year meeting
  • 1) Educate Management Risk Management is one of a half dozen Information Security projects which Management must be educated about Consider an Information Security Training for Management presentation Risk Management MUST be driven by management if it is to be successful Don’t neglect training for “middle” managers, including application owners and supervisors
  • 2) Locate All Assets Hardware and Data - Start listing what you know about, then find the rest Do searches on the network for file types Find out who has been storing data on local hard drives (and stop it) List applications, including which have PHI Determine where Word, Excel, and Access files with PHI are kept
  • 3) Assign all Risk All applications have Data Owners If you created a file (not part of an application program), then you own it If you own a file, you are responsible for protecting it All network components – wiring, router, switches, servers, concentrators – have a person assigned to them who owns the risk
  • For Network Risk Analysis form instructions, click HERE4) Network Risk Analysis Forms Complete one form for each type of component 1) Windows XP Workstations 2) Windows 2000 workstations 3) Windows 98 workstations 4) File Servers 5) Firewall 6) Router 7) Core Switch 8) Workgroup Switches 9) Wireless Segment, etc.
  • For Application Risk Analysis form instructions, click HERE5) Application Risk Analysis Forms Complete one form for each application 1) HEARTS 2) MCPlus Pharmacy 3) NC Accounting 4) Personal Planning System 5) NCSnap 6) Restraint Tracking 7) Staff Development Records 8) Staff Vacancies, etc.
  • 6) Penetration and Vulnerability Tests DIRM may be willing to provide penetration and vulnerability testing You may have to hire a firm to provide these services Testing should be done from both inside your firewall, and from outside your firewall If necessary, hire a teenager
  • 7) Update Threats List Consider Natural Threats, Human Threats, and Environmental Threats For Human Threats, consider sources of motivation Your Threats List will not be identical to others, since local factors must be considered Provide this updated list to your Risk Management Committee each year
  • 8) Review IS Policies and Procedures Many risks are inherent in the absence of information security policies and procedures Procedures must evolve as new policies develop and old policies change Your IS Policy and Procedure review should be done by someone other than the agency’s Information Security Official The results of this review are presented at the Risk Management Team meeting
  • For Vulnerability Analysis form instructions, click HERE9) Vulnerability Analysis Forms Complete one form for each vulnerability/ threat-pair combination 1) HEARTS PHI being disclosed to or by the Client Data Warehouse 2) Workgroup switch located in unlocked wiring closet 3) Loss of application availability due to file server running out of disk space
  • 10) Risk Management Team Meets RM Committee should be made up of senior managers, such as the Assistant Director and Business Manager, and at least one information system owner Team reviews all input, and makes decisions as to what additional cost-effective controls should be implemented Educating this team is an important part of improving your risk management process It is the Team’s experience that sets priorities
  • 11) Send RM Report to the Director The Risk Management Report should clearly list the vulnerability/threat-source pairings of concern, and any additional controls which are recommended The report should ideally include a cover letter to the Director, signed by each member of the Committee
  • 12) The Committee’s Mid-Year Meeting The Risk Management Committee should meet at least twice each year The mid-year meeting should be concerned about evaluating the results of the recommendations which emerged from the year’s first meeting, where mitigation measures were discussed and decided upon Minutes of your Risk Management Committee meetings should be saved for 6 years
  • 12 Steps Towards YOUR Program1) Ed 7) Update Threats list uca 8) Review IS P&P te 9) Complete Ma Vulnerability Analysis nag forms em ent 10) RM Committee meets and decides on2) Loc additional controls ate all 11) Report sent to Director ass 12) RM mid-year meeting ets
  • Risk Management Process TimelineRisk Mitigation Meeting Report Sent to Director Implement Additional Controls Risk Management Mid-Year Meeting Penetration Testing Network Risk Forms Application Risk Forms Update Threat List Vulnerability Forms
  • What We Covered Today . . What Risk Management means What NIST says you should do What ISO 17799 says you should do What COBIT says you should do What Microsoft says you should do What HIPAA says you should do What NC ITS says you should do What DHHS says you should do Developing YOUR program in 12 steps
  • Links Found in this Slide ShowNIST ITS Pre-Risk Assessment FormNIST SP 800-12 ITS RA QuestionnaireNIST SP 800-18 Threats ListNIST SP 800-26 Human Motivations ListNIST SP 800-30 Network Risk Analysis FormISO Instructions for above formMicrosoft’s Security Risk Management Guide Application Criticality and Risk AnalysisCOBIT FormDHHS’s Risk Management Instructions for above formITS’s November 2005 Risk Management Vulnerability Analysis Form Policy Instructions for above formMaturity Level Definitions Training for Management ShowHIPAA Security Rule Training for Supervisors ShowITS Risk Management Site Training for Application OwnersITS Risk Management Guide Training for Users Show
  • Any Questions?
  • Developing an Information Technology Risk Management Program
  • Developing an Information Technology Risk Management Program