BlogCompliance
January 23, 2023

How do you perform quarterly access reviews?

Savvy organizations usually deploy some type of identity and access management (IAM) solution. IAM solutions leverage the principle of least privilege (POLP), role-based access control (RBAC), or other such mechanisms to manage access to data, applications, and IT infrastructure.

However, every organization's structure and human resources capacity typically change over time as new employees are brought on board and existing ones quit. For large organizations, this can result in hundreds, or even thousands, of employees changing roles or leaving every year.

Without some form of periodic user access review in place, there's a very real risk that former employees may still retain access to sensitive corporate data and systems after being terminated. The same applies to current employees who accumulate user privilege access over time as they move through different roles and departments. 

User access reviews are a great way to prevent these security risks from occurring and transforming into full-blown threats.

What is a user access review?

Access reviews describe the process of monitoring the rights and privileges of everyone who can interact with data and applications. This includes management personnel, employees, vendors, service providers, and other third parties. Also known as entitlement review, account attestation, or account recertification, access reviews are essential to the management, monitoring, and auditing of user account lifecycles.

Access reviews ensure that the access rights to an organization's information system (granted to a user) are authorized and appropriate for that user's role and functions. This review applies to all existing access rights to a company's data, applications, and infrastructure. Reviews pinpoint:

  • which access rights are authorized and approved
  • what level of access each user has
  • who has access to what within the organization

In addition to protecting an organization's data and IT assets, a user access review is an essential prerequisite for the thorough implementation of security and compliance frameworks

It is a mandatory control mechanism used by companies in industries and verticals subject to the following standards: HIPAA, CRBF, Solvency, CMMC, SOC 1 and 2, SOX,  ISAE 3402, ISO 27002, and ISO 27001, among others. It also helps companies adhere to security best practices and risk management by facilitating the separation of duties, the principle of need-to-know, and the principle of least privilege.

How often do you perform access reviews?

Providing unauthorized users with access rights to sensitive corporate data and IT assets can result in risks, inadvertent mistakes, or malicious attacks that are detrimental to an organization's reputation and bottom line. Other risks include:

  • Outdated user access policies
  • Account misconfiguration
  • Internal threats, malicious and accidental
  • Access abuse
  • Fraud
  • Inappropriate or unauthorized access
  • Privilege creep

To prevent these risks from becoming full-blown security incidents, access reviews must be undertaken at regular intervals. Smaller companies may find it easier to frequently review user access due to a manageable number of employees and systems. However, such companies typically don't have high employee turnover, and as such, can afford to review their user access once or twice a year. 

Conversely, larger corporations often have a slew of employees that are constantly leaving, changing roles/departments, or being onboarded as new hires. While frequent access reviews are beneficial from a security standpoint, the vast array of systems, IT assets, and data makes it a challenging task. 

For such organizations, it's a good idea to audit high-risk assets more often than lower-risk systems and then perform biannual access reviews. For best results (regardless of company size or industry), access reviews should be performed quarterly to stay on top of constantly changing access rights and prevent potential security problems.

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Who should perform access reviews?

The first step in performing a quarterly access review is the creation of a report which lists all systems, applications and databases, in addition to users and their access rights. This includes employees, management personnel, and third parties such as consultants, service providers, and vendors. 

This report is sent to asset owners who will determine each department's needs and either approve or reject the access rights of that department. Department managers can then determine if users should be allowed access to the approved data and applications based on their functions.

Although this sounds counterintuitive, performing access reviews and recertifying access rights doesn't automatically fall within the purview of the IT department. Ideally, your organization should have a security lead or asset owner who manages, oversees, and supervises system access across all infrastructure and applications. 

There should also be a dedicated admin to manage access for individual users for any given application and infrastructure. This can be a team lead or departmental manager because they are conversant with employee roles and responsibilities

How automated compliance platforms can help

Access rights and privileges are implicated in an organization's data, servers, applications, and infrastructure. The nature of these rights can change and the type of processes and tools needed to perform quarterly access reviews depends on a myriad of factors, including logic and access delivery mechanisms, reporting requirements, the nature and number of protected assets, and compliance objectives.

Although manual user access reviews can be done through the use of Excel spreadsheets, this adds a layer of complexity and difficulty to an already tedious process. Manually retracing and verifying all assigned access rights is time-consuming and prone to errors. It can quickly become a nightmare if the volume of data and the number of users involved is substantial. In fact, without the right solution to provide an overview of existing permissions, performing quarterly access reviews may seem impossible.

This is why savvy companies leverage robust compliance platforms to automate the access review process. The best automation solutions: 

  • come with reporting tools that provide you with a view of all existing access rights and privileges across your entire IT infrastructure.
  • have an intuitive user interface that enables reviewers to easily confirm or reject access rights. 
  • come with predefined responses to be triggered when data owners don't perform required actions.
  • save time by automating the procedures required in quarterly user access review campaigns.
  • provide auditors with ready-to-use reports at the click of a button.
  • automatically identify and correlate the responsibility of each user with the permissions needed to access specific resources.
  • provide comprehensive mapping of the access rights within the targeted scope.
  • enforce security and compliance policies within your organization by simplifying the performance of quarterly access reviews. 

The right compliance platform can easily implement a single, comprehensive process to meet access review requirements of all major standards, such as ISO, SOC 2, PCI, and HIPAA. The platform should be highly flexible and customizable and provide you with the option to build out access review procedures with custom policies and controls. You should also receive alerts when users, individual departments, or the entire organization is due for user access review.

Vanta’s Access Review

Vanta’s Access Review solution reduces the need for spreadsheets by using automated, pre-built content and intuitive workflows to guide you through the quarterly access review process. With Access Reviews, your team can pass audits and accelerate revenue by gaining attestations and certifications faster. 

Reduce the time and cost of an access review up to 90% with continuous, automated management. Our enhanced solution allows you to proactively reduce the risk of both employees (the main surface area of risk within an organization) and external threats.

Learn more about Vanta’s enhanced Access Review solution.

1

Determine whether the GDPR applies to you and if so, if you are a processor or controller (or both)

Do you sell goods or service in the EU or UK?

Do you sell goods or services to EU businesses, consumers, or both?

Do you have employees in the EU or UK?

Do persons from the EU or UK visit your website?

Do you monitor the behavior of persons within the EU?

If any of the above apply to your business, you’ll need to get GDPR compliant.
2

Create a Data Map by taking the following actions

Identify and document every system (i.e. database, application, or vendor) which stores or processes EU or UK based personally identifiable information (PII)

Document the retention periods for PII in each system

Determine whether you collect, store, or process “special categories” of data

racial or ethnic origins
genetic data
political opinions
biometric data that can uniquely identifying someone
religious or philosophical beliefs
health, sex life or sexual orientation data
trade union membership

Determine whether your Data Map meets the requirements for Records of Processing Activities (Art. 30)

the name and contact details of the controller
the purpose behind the processing of data
a description of the categories of data that will be processed
who will receive the data including data
documentation of suitable safeguards for data transfers to a third country or an international organization
the retention period of the different categories of data
a general description of the technical and organizational security measures

Determine whether your Data Map includes the following information about processing activities carried out by vendors on your behalf

the name and contact details of the processor or processors and of each controller on behalf of which the processor is acting, and, where applicable, of the controller’s or the processor’s representative, and the data protection officer
the categories of processing carried out on behalf of each controller
documentation of suitable safeguards for data transfers to a third country or an international organization
a general description of the technical and organizational security measures
3

Determine your grounds for processing data

For each category of data and system/application have you determined the lawful basis for processing based on one of the following conditions?

consent of the data subject
contract with the data subject
necessary for compliance with a legal obligation
necessary in order to protect the vital interests of the data subject or a third party
necessary for the performance of a task in the public interest or in the exercise of official authority vested in the controller
necessary for the purposes of the legitimate interests pursued by the controller or by a third party, except where such interests are overridden by the rights of data subject
4

Take inventory of current customer and vendor contracts to confirm new GDPR-required flow-down provisions are included

Review all customer contracts to determine that they have appropriate contract language (i.e. Data Protection Addendums with Standard Contractual Clauses)

Review all in-scope vendor contracts to determine that they have appropriate contract language (i.e. Data Protection Addendums with Standard Contractual Clauses)

Do your agreements cover the following items?
vendor shall process the personal data only on documented instructions (including when making an international transfer of personal data) unless it is required to do otherwise by EU or member state law
vendor ensures that persons authorized to process the personal data are subject to confidentiality undertakings or professional or statutory obligations of confidentiality.
vendor have adequate information security in place, technical and organizational measures to be met to support data subject requests or breaches
vendor shall not appoint or disclose any personal data to any sub-processor unless required or authorized
vendor shall delete or return all the personal data after the end of the provision of services relating to processing, and deletes existing copies unless Union or Member State law requires storage of the personal data;
vendor makes available all information necessary to demonstrate compliance and allow for and contribute to audits, including inspections

Have you performed a risk assessment on vendors who are processing your PII?

5

Determine if you need to do a Data Protection Impact Assessment

Is your data processing taking into account the nature, scope, context, and purposes of the processing, likely to result in a high risk to the rights and freedoms of natural persons?

Does your processing involve any of the following?
automated processing, including profiling, and on which decisions are based that produce legal effects
special categories of data or data related to criminal convictions and offenses
monitor publicly accessible area on a large scale.
If any of the above are true, you may need to conduct a Data Protection Impact Assessment for existing and new data projects.
6

Review product and service design (including your website or app) to ensure privacy notice links, marketing consents, and other requirements are integrated

Do you have a public-facing Privacy Policy which covers the use of all your products,  services and websites?

Does the notice to the data subject include the following items?

the identity and the contact details of the organization and its representative
the contact details of the data protection officer, if applicable
the purposes to process personal data and its legal basis for the processing
the recipients or categories of recipients of the personal data, if any
the details regarding any transfer of personal data to a third country and the safeguards taken applicable

Does the notice also include the following items?

the retention period, or if that is not possible, the criteria used to determine that period
the existence of the data subject rights (i.e. requests for information, modification or deletion of PII)
the right to withdraw consent at any time
the right to lodge a complaint with a supervisory authority
whether the provision of personal data is a statutory or contractual requirement, or a requirement necessary to enter into a contract, as well as whether the data subject is obliged to provide the personal data and of the possible consequences of failure to provide such data
the existence of automated decision-making, including profiling, and meaningful information about the logic involved, as well as the significance and the consequences

Do you have a mechanism for persons to change or withdraw consent?

7

Update internal privacy policies to comply with notification obligations

Update internal privacy notices for EU employees

Do you have an Employee Privacy Policy governing the collection and use of EU and UK employee data?

Determine if you need to appoint a Data Protection Officer, and appoint one if needed

Have you determined whether or not you must designate a Data Protection Officer (DPO) based on one of the following conditions (Art. 37)?

the data processing is carried out by a public authority
the core activities of the controller or processor require regular and systematic monitoring of data subjects on a large scale
8

If you export data from the EU, consider if you need a compliance mechanism to cover the data transfer, such as model clauses

If you transfer, store, or process data outside the EU or UK, have you identified your legal basis for the data transfer (note: most likely covered by the Standard Contractual Clauses)

Have you performed and documented a Transfer Impact Assessment (TIA)?

9

Confirm you are complying with other data subject rights (i.e. aside from notification)

Do you have a defined process for timely response to Data Subject Access Requests (DSAR) (i.e. requests for information, modification or deletion of PII)?

Are you able to provide the subject information in a concise, transparent, intelligible and easily accessible form, using clear and plain language?

Do you have a process for correcting or deleting data when requested?

Do you have an internal policy regarding a Compelled Disclosure from Law Enforcement?

10

Determine if you need to appoint an EU-based representative, and appoint one if needed

Have you appointed an EU Representative or determined that an EU Representative is not needed based on one of the following conditions?

data processing is occasional
data processing is not on a large scale
data processing doesn’t include special categories or data related to criminal convictions and offenses
doesn’t risk to the rights and freedoms of data subjects
a public authority or body
11

If operating in more than one EU state, identify a lead Data Protection Authority (DPA)

Do you operate in more than one EU state?

If so, have you designated the Supervisory Authority of the main establishment to act as your Lead Supervisory Authority?

12

Implement Employee Trainings to Demonstrate Compliance with GDPR Principles and Data Subject Rights

Have you provided appropriate Security Awareness and Privacy training to your staff?

13

Update internal procedures and policies to ensure you can comply with data breach response requirements

Have you created and implemented an Incident Response Plan which included procedures for reporting a breach to EU and UK Data Subjects as well as appropriate Data Authorities?

Do breach reporting policies comply with all prescribed timelines and include all recipients i.e. authorities, controllers, and data subjects?

14

Implement appropriate technical and organizational measures to ensure a level of security appropriate to the risk

This includes pseudonymization/ encryption, maintaining confidentiality, restoration of access following physical/technical incidents and regular testing of measures

Have you implemented encryption of PII at rest and in transit?

Have you implemented pseudonymization?

Have you implemented appropriate physical security controls?

Have you implemented information security policies and procedures?

Can you access EU or UK PII data in the clear?

Do your technical and organizational measure ensure that, by default, only personal data which are necessary for each specific purpose of the processing are processed?

15

Consider streamlining GDPR compliance with automation

Transform manual data collection and observation processes into continuous monitoring

Download this checklist for easy reference

Download now
1

Develop a roadmap for successful implementation of an ISMS and ISO 27001 certification

Implement Plan, Do, Check, Act (PDCA) process to recognize challenges and identify gaps for remediation

Consider ISO 27001 certification costs relative to org size and number of employees

Clearly define scope of work to plan certification time to completion

Select an ISO 27001 auditor

2

Set the scope of your organization’s ISMS

Decide which business areas are covered by the ISMS and which are out of scope

Consider additional security controls for business processes that are required to pass ISMS-protected information across the trust boundary

Inform stakeholders regarding scope of the ISMS

3

Establish an ISMS governing body

Build a governance team with management oversight

Incorporate key members of top management, e.g. senior leadership and executive management with responsibility for strategy and resource allocation

4

Conduct an inventory of information assets

Consider all assets where information is stored, processed, and accessible

  • Record information assets: data and people
  • Record physical assets: laptops, servers, and physical building locations
  • Record intangible assets: intellectual property, brand, and reputation

Assign to each asset a classification and owner responsible for ensuring the asset is appropriately inventoried, classified, protected, and handled

5

Execute a risk assessment

Establish and document a risk-management framework to ensure consistency

Identify scenarios in which information, systems, or services could be compromised

Determine likelihood or frequency with which these scenarios could occur

Evaluate potential impact of each scenario on confidentiality, integrity, or availability of information, systems, and services

Rank risk scenarios based on overall risk to the organization’s objectives

6

Develop a risk register

Record and manage your organization’s risks

Summarize each identified risk

Indicate the impact and likelihood of each risk

7

Document a risk treatment plan

Design a response for each risk (Risk Treatment)

Assign an accountable owner to each identified risk

Assign risk mitigation activity owners

Establish target dates for completion of risk treatment activities

8

Complete the Statement of Applicability worksheet

Review 114 controls of Annex A of ISO 27001 standard

Select controls to address identified risks

Complete the Statement of Applicability listing all Annex A controls, justifying inclusion or exclusion of each control in the ISMS implementation

9

Continuously assess and manage risk

Build a framework for establishing, implementing, maintaining, and continually improving the ISMS

Include information or references to supporting documentation regarding:

  • Information Security Objectives
  • Leadership and Commitment
  • Roles, Responsibilities, and Authorities
  • Approach to Assessing and Treating Risk
  • Control of Documented Information
  • Communication
  • Internal Audit
  • Management Review
  • Corrective Action and Continual Improvement
  • Policy Violations
10

Assemble required documents and records

Review ISO 27001 Required Documents and Records list

Customize policy templates with organization-specific policies, process, and language

11

Establish employee training and awareness programs

Conduct regular trainings to ensure awareness of new policies and procedures

Define expectations for personnel regarding their role in ISMS maintenance

Train personnel on common threats facing your organization and how to respond

Establish disciplinary or sanctions policies or processes for personnel found out of compliance with information security requirements

12

Perform an internal audit

Allocate internal resources with necessary competencies who are independent of ISMS development and maintenance, or engage an independent third party 

Verify conformance with requirements from Annex A deemed applicable in your ISMS's Statement of Applicability

Share internal audit results, including nonconformities, with the ISMS governing body and senior management

Address identified issues before proceeding with the external audit

13

Undergo external audit of ISMS to obtain ISO 27001 certification

Engage an independent ISO 27001 auditor

Conduct Stage 1 Audit consisting of an extensive documentation review; obtain feedback regarding readiness to move to Stage 2 Audit

Conduct Stage 2 Audit consisting of tests performed on the ISMS to ensure proper design, implementation, and ongoing functionality; evaluate fairness, suitability, and effective implementation and operation of controls

14

Address any nonconformities

Ensure that all requirements of the ISO 27001 standard are being addressed

Ensure org is following processes that it has specified and documented

Ensure org is upholding contractual requirements with third parties

Address specific nonconformities identified by the ISO 27001 auditor

Receive auditor’s formal validation following resolution of nonconformities

15

Conduct regular management reviews

Plan reviews at least once per year; consider a quarterly review cycle 

Ensure the ISMS and its objectives continue to remain appropriate and effective

Ensure that senior management remains informed

Ensure adjustments to address risks or deficiencies can be promptly implemented

16

Calendar ISO 27001 audit schedule and surveillance audit schedules

Perform a full ISO 27001 audit once every three years

Prepare to perform surveillance audits in the second and third years of the Certification Cycle

17

Consider streamlining ISO 27001 certification with automation

Transform manual data collection and observation processes into automated and continuous system monitoring

Identify and close any gaps in ISMS implementation in a timely manner

18

Learn more about achieving ISO 27001 certification with Vanta

Book an ISO 27001 demo with Vanta

Download this checklist for easy reference

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1

Determine which annual audits and assessments are required for your company

Perform a readiness assessment and evaluate your security against HIPAA requirements

Review the U.S. Dept of Health and Human Services Office for Civil Rights Audit Protocol

2

Conduct required HIPAA compliance audits and assessments

Perform and document ongoing technical and non-technical evaluations, internally or in partnership with a third-party security and compliance team like Vanta

3

Document your plans and put them into action

Document every step of building, implementing, and assessing your compliance program

Vanta’s automated compliance reporting can streamline planning and documentation

4

Appoint a security and compliance point person in your company

Designate an employee as your HIPAA Compliance Officer

5

Schedule annual HIPAA training for all employees

Distribute HIPAA policies and procedures and ensure staff read and attest to their review

6

Document employee trainings and other compliance activities

Thoroughly document employee training processes, activities, and attestations

7

Establish and communicate clear breach report processes
to all employees

Ensure that staff understand what constitutes a HIPAA breach, and how to report a breach

Implement systems to track security incidents, and to document and report all breaches

8

Institute an annual review process

Annually assess compliance activities against theHIPAA Rules and updates to HIPAA

9

Continuously assess and manage risk

Build a year-round risk management program and integrate continuous monitoring

Understand the ins and outs of HIPAA compliance— and the costs of noncompliance

Download this checklist for easy reference

Download Now
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Access Review Stage Content / Functionality
Across all stages
  • Easily create and save a new access review at a point in time
  • View detailed audit evidence of historical access reviews
Setup access review procedures
  • Define a global access review procedure that stakeholders can follow, ensuring consistency and mitigation of human error in reviews
  • Set your access review frequency (monthly, quarterly, etc.) and working period/deadlines
Consolidate account access data from systems
  • Integrate systems using dozens of pre-built integrations, or “connectors”. System account and HRIS data is pulled into Vanta.
  • Upcoming integrations include Zoom and Intercom (account access), and Personio (HRIS)
  • Upload access files from non-integrated systems
  • View and select systems in-scope for the review
Review, approve, and deny user access
  • Select the appropriate systems reviewer and due date
  • Get automatic notifications and reminders to systems reviewer of deadlines
  • Automatic flagging of “risky” employee accounts that have been terminated or switched departments
  • Intuitive interface to see all accounts with access, account accept/deny buttons, and notes section
  • Track progress of individual systems access reviews and see accounts that need to be removed or have access modified
  • Bulk sort, filter, and alter accounts based on account roles and employee title
Assign remediation tasks to system owners
  • Built-in remediation workflow for reviewers to request access changes and for admin to view and manage requests
  • Optional task tracker integration to create tickets for any access changes and provide visibility to the status of tickets and remediation
Verify changes to access
  • Focused view of accounts flagged for access changes for easy tracking and management
  • Automated evidence of remediation completion displayed for integrated systems
  • Manual evidence of remediation can be uploaded for non-integrated systems
Report and re-evaluate results
  • Auditor can log into Vanta to see history of all completed access reviews
  • Internals can see status of reviews in progress and also historical review detail
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